GI/Liver Flashcards
(81 cards)
1
Q
What are the differential diagnoses for acute abdominal pain in children? (5)
A
- Appendicitis
- Intussusception
- Mesenteric adenitis
- HSP - Henoch-Schonlein purpura
- Peptic ulceration
2
Q
What are the causes of jaundice in a child (not a newborn)?
A
- Viral hepatitis
2. Hepatic cirrhosis
3
Q
What are the differentials for blood in the stool, in children? (6)
A
- Anal fissure
- Dysentery and salmonella
- Milk allergy
- Intussusception
- IBD
- HSP
4
Q
What are the differentials for a child vomiting? (5)
A
- Gastroenteritis
- GORD
- Pyloric stenosis
- Systemic infection
- Migraine
5
Q
What are the differentials for acute diarrhoea?
A
- Viral gastroenteritis
- Bacterial gastroenteritis
- Non-GI infections
6
Q
What are the causes of chronic diarrhoea in children? (9)
A
- Toddler diarrhoea
- Lactose intolerance
- Cow’s milk protein allergy
- Cystic fibrosis
- Coeliac disease
- Ulcerative colitis
- Crohn’s disease
- Overflow in constipation
- Parasites
7
Q
What are the causes of constipation in children? (4)
A
- Functional constipation
- Hirschsprung’s disease
- Fluid depletion
- Bowel obstruction
8
Q
What are the worrying features in a vomiting child? (6)
A
- Bile-stained vomit
- Blood in the vomit
- Drowsiness
- Refusal to feed
- Malnutrition
- Dehydration
9
Q
How does gastroenteritis present?
A
- Sudden onset vomiting and diarrhoea
- Fever
- Blood in stool
- Tender abdomen, distension
10
Q
Causes of gastroenteritis in children?
A
Viral: rotavirus
Bacterial: campylobacter, shigella, salmonella, E.coli
11
Q
What is the most common cause of GORD?
A
Reduced lower oesophageal tone
12
Q
What are the risk factors for GORD?
A
- Premature birth
13
Q
Presentation of GORD?
A
- Recurrent vomiting after feeds
- Arching back due to discomfort
- Irritable
- Reduced growth/failure to thrive
14
Q
What is the management of GORD?
A
- Sitting baby up during feeds
- Ensure not overfeeding (150ml/kg)
- Can thicken milk
- Gaviscon
- PPI
- Nissen’s fundoscopy
15
Q
What is constipation?
A
A decrease in the frequency of bowel movements, characterised by the passing of hard stools, which may be large and associated with straining or pain.
16
Q
Why can soiling of clothes occur in constipation?
A
This may be a result of overflow from the overloaded bowel
17
Q
On average how many stools a day do babies have in the first week of life?
A
4 a day
18
Q
How many stools on average do babies have at one years old?
A
2 a day
19
Q
What is the normal adult range for producing stools, and by what age is this attained in children?
A
Anything between 3 stools per day to 3 stools per week, usually attained by 4 years of age
20
Q
How is chronic constipation classed?
A
Constipation lasting for longer than 8 weeks
21
Q
What are the causes/contributing factors for developing constipation? (7)
A
- Inadequate fluid intake
- Reduced dietary fibre intake
- Toilet training issues
- Pain or fever
- Psychosocial issues
- Drugs such as antihistamines or opiates
- Family history of constipation
22
Q
Constipation is more common in children with which impairments?
A
Impaired mobility (cerebral palsy) or with neurodevelopment disorders (Down’s syndrome or ASD)
23
Q
What is the prevalence of childhood constipation in the UK?
A
10-20% (children aged 4-11, 30% will have constipation lasting <6 months)
24
Q
When is the peak incidence of constipation in children?
A
During toilet training, around the age of 2-3 years
25
Why is constipation largely under-reported?
Parents may not be aware of the link between soiling and constipation, and the signs and symptoms sometimes go unrecognised - for example withholding behaviours due to painful passage of stools may be mistaken for straining
26
What are the complications of idiopathic constipation? (7)
1. Anal fissure (vicious cycle then of stool withholding and ongoing constipation)
2. Haemorrhoids
3. Rectal prolapse
4. Megarectum
5. Faecal impaction and soling
6. Volvulus
7. Distress for the child and family, poor school performance, social isolation, reduced involvement in group activities
27
What are the NICE criteria for diagnosing constipation in children, in terms of stool patterns? (4)
1. Fewer than three complete stools a week (unless exclusively breastfed, when stools may be infrequent)
2. Hard, large stool
3. Rabbit droppings stools (type 1 Bristol stool form)
4. Overflow soiling in children older than the age of 1 year (typically very loose, smelly stools which are passed without sensation or awareness; may also be thick or sticky, or dry and flaky)
28
What are the NICE criteria for diagnosing constipation in children, in terms of symptoms associated with defecation? (7)
1. Distress or pain on passing stool
2. Bleeding associated with hard stool
3. Straining
4. Poor appetite that improves with passage of large stool
5. Waxing and waning of abdominal pain with passage of stool
6. Posture - straight legged, on tiptoes, with an arched back
7. Anal pain
29
When is faecal impaction diagnosed? (3)
1. A history of severe symptoms of constipation
2. The presence of overflowing soiling
3. Faecal mass palpable on abdominal examination
30
What are the red/amber flags for constipation that need to be excluded before a diagnosis of idiopathic constipation? (10)
Red flags
1. Symptoms occurring from birth or during first weeks of life (Hirschsprung's disease)
2. Delay in passing meconium for more than 48 hours after birth, in a full-term baby (can indicate Hirschsprung's or cystic fibrosis)
3. Abdominal distension with vomiting (intestinal obstruction or Hirschsprung's)
4. Family history of Hirschsprung's
5. Ribbon stool pattern - anal stenosis
6. Leg weakness or motor delay (neurological or spinal cord abnormality)
7. Abnormal appearance of the anus - bruising, fissures, tight or patulous (widely patent) anus, absent anal wink)
Amber flags
8. Evidence of faltering growth, developmental delay, or concerns about wellbeing
9. Constipation trigged by an introduction to cows milk
10. Concern of possible child maltreatment
31
When is it acceptable not to refer a child with constipation from the GP to secondary care?
When the constipation is idiopathic and red flags have been excluded
32
What is the treatment for idiopathic constipation? (6)
1. Give information and advice/reassurance,
2. Treatment using laxatives
3. Behavioural interventions; scheduled toileting e.g. 5 minutes after each meal, bowel habit diary, encouragement and rewards systems e.g. star charts
4. Give diet and lifestyle advice e.g. recommended fluid intake, high fibre diet including fruit, vegetables, baked beans, cereals, daily physical activity
5. Follow up child regularly
6. Consider need for specialist referral
33
What is gastroenteritis?
A transient disorder due to enteric infection with viruses, bacteria or parasites. It is characterised by sudden onset diarrhoea, with or without vomiting
34
How can episodes of diarrhoea be classified? (5)
1. Acute diarrhoea (three or more episodes of partially formed or watery stool in a day, lasting for less than 14 days)
2. Persistent diarrhoea - lasting more than 14 days
3. Dysentery
4. Traveller's diarrhoea
5. Antibiotic associated diarrhoea
35
What is dysentery?
An acute infectious gastroenteritis characterised by loose stools with blood and mucus. It is often accompanied by pyrexia and abdominal cramps.
36
Which organisms can cause blood diarrhoea? (5)
1. Campylobacter
2. E.coli
3. Salmonella
4. Shigella
5. Entamoeba histolytica
37
What is the most common cause of gastroenteritis? (1 - 3)
Viruses - rotavirus, norovirus, adenoviruses
38
Which bacteria are commonly associated with causing food poisoning and gastroenteritis? (3) (not salmonella)
1. Staph aureus - found in cooked meats and cream products
2. Bacillus cereus - reheated rice
3. Clostridium perfringens - reheated meat dishes or cooked meats
39
What is the most common cause of infantile gastroenteritis?
Rotavirus
40
What is offered to prevent gastroenteritis caused by rotavirus?
An oral rotavirus vaccine (Rotarix) - offered as part of the UK national childhood immunisation programme
41
How does rotavirus gastroenteritis typically present?
Starts with fever and vomiting, followed by diarrhoea, often lasting 3 - 8 days
42
How many children are hospitalised annually in England and Wales due to rotavirus-related disease?
18,000
43
What is the most common virus to cause gastroenteritis in all age ranges - perhaps more so in adults due to its short immunity?
Norovirus
44
Which three parasites can cause diarrhoea disease in humans? (3)
1. Cryptosporidium
2. Entamoeba histolytica
3. Giardia
45
What are the complications of gastroenteritis?
1. Dehydration and electrolyte disturbance
2. Haemolytic uraemia syndrome (HUS)
3. Reactive complications (arthritis, carditis, urticaria, erythema nodosum)
4. Systemic invasion by Salmonella
5. Toxic megacolon
6. Guillian-Barre syndrome
7. Malnutrition
8. IBS
46
What is HUS?
A potentially life threatening complication of gastroenteritis, haemolytic uraemic syndrome is characterised by acute renal failure, haemolytic anaemia and thrombocytopenia. Initial presenting features include decreased frequency of urination, fatigue and pallor
47
What is coeliac disease?
An autoimmune condition in which dietary proteins known as glutens, activate an abnormal mucosal response with chronic inflammation and damage (villous atrophy) to the lining of the small intestine
48
How can coeliac disease present? (13)
1. Abdominal pain
2. Indigestion
3. Diarrhoea
4. Bloating
5. Constipation
6. Fatigue
7. Anaemia
8. Dermatitis
9. Osteoporosis
10. Fertility problems
11. Short statute
12. Delayed puberty
13. Peripheral neuropathy
49
What is refractory coeliac disease?
The persistence or recurrence of unexplained malabsorption symptoms and villous atrophy despite adhering to a gluten free diet
50
In which gender is coeliac disease more common in?
Females
51
What are the common malabsorption complications of coeliac disease? (2)
1. Anaemia due to deficiency of iron, B12 and/or folate
| 2. Osteoporosis due to malabsorption of calcium and/or vitamin D
52
What are the other complications of coeliac disease? (8)
1. Increased risk of fragility fractures
2. Chronic pancreatitis with pancreatic insufficiency
3. Hepatobiliary abnormalities e.g. autoimmune hepatits, primary biliary cirrhosis and primary scleroing cholangitis
4. Splenic dysfunction
5. Subfertility
6. Lactose intolerance
7. Malignancy e.g. Hodgkin's and non-Hodgkin's lymphoma, small intestinal adenocarcinoma and pancreatic cancer
8. Children may have faltering growth and delayed puberty
53
What is the genetic link with coeliac disease?
HLA - not all people with human leukocyte antigens will develop coeliac disease, however the absence of HLA in a person with suspected coeliac disease means they do not have and will never develop coeliac disease.
54
In particular, which HLA is associated with a higher incidence (estimated risk 26%) of developing coeliac disease?
DQ2
55
Which other autoimmune conditions put people at an increased risk of developing coeliac disease? (2)
1. Type 1 diabetes
| 2. Autoimmune thyroid disease
56
When is coeliac disease suspected, and what testing is offered? (10) (not really paediatrics)
Serology testing is offered, in a person with:
1. Persistent, unexplained abdominal or GI symptoms such as indigestion, diarrhoea, abdominal bloating and constipation
2. Faltering growth in children
3. Prolonged fatigue
4. Severe/persistent mouth ulcers
5. Unexplained iron/B12/folate deficiency
6. Type 1 diabetes
7. IBS in adults
8. First degree relative with coeliac disease
9. Unexplained recurrent miscarriage or sub fertility
10. Persistent, unexplained raised LFTs
57
Where are children referred if their coeliac serology screen is positive?
Refer to a paediatric gastroenterologist with a special interest in coeliac disease, for further investigation to confirm or exclude coeliac disease. This may include further serology testing, intestinal biopsy, HLA genetic testing, or a combination of these.
58
If someone tests positive for coeliac disease and is referred for biopsy, what is important to advise them until the biopsy?
To continue eating gluten containing foods at least twice a day, until the intestinal biopsy is performed.
59
What are the differential diagnoses for coeliac diseases? (5)
1. Crohn's disease
2. UC
3. Malignancy (rare in children)
4. Infections e.g. HIV
5. Cow's milk protein allergy
60
What is the difference between gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease (GORD)?
GOR is the passage of gastric contents into the oesophagus. It is considered physiological in infants when symptoms are absent or not troublesome. GORD is the complications (troublesome symptoms) arising from GOR - pain, oesophagitis, pulmonary aspiration)
61
Why does GOR occur?
It is as a result of transient lower oesophageal sphincter relaxation
62
Why are infants less than 1 years of age more susceptible to GOR than older children and adults? (6)
1. Short, narrow oesophagus
2. Delayed gastric emptying
3. Shorter, lower oesophageal sphincter that is slightly above, rather than below, the diaphragm
4. Liquid diet and high caloric requirement, putting a strain on gastric capacity
5. Larger ratio of gastric volume to oesophageal volume
6. Infants are frequently recumbent
63
What % of infants have regurgitation, and what % have GORD?
40% will have regurgitation, yet only 0.9% have GORD
64
What are the risk factors for children developing GORD? (6)
1. Premature birth
2. Parental history of heartburn or acid regurgitation
3. Obesity
4. Hiatus hernia
5. History of congenital diaphragmatic hernia
6. Neurodisability e.g. cerebral palsy
65
Although most children with GOR or regurgitation do not develop complications, what are the complications linked to GORD? (5)
1. Reflux oesophagitis
2. Aspiration pneumonia
3. Acute otitis media
4. Dental erosion
5. Apnoea
66
Why does GORD and GOR resolve in 90% of infants before the age of one? (4)
1. An increase in length of the oesophagus
2. Increase in tone of the lower oesophageal sphincter
3. A more upright posture
4. A more solid diet
67
When is GORD suspected in infants as opposed to GOR? (5)
In any infant with regurgitation and one or more of the following:
1. Distressed behaviour shown e.g. excessive crying, crying while feeding, unusual neck postures
2. Hoarseness and/or chronic cough
3. A single episode of pneumonia
4. Unexplained feeding difficulties
5. Faltering growth
68
How may children over the age of 1 present with GORD? (3)
1. Heartburn
2. Retrosternal pain
3. Epigastric pain
69
What is the pathophysiology of necrotising enterocolitis?
Mucosal damage leads to an invasion of bacteria which results in inflammation, ischaemia, necrosis and perforation.
70
What are the findings of NEC on an abdominal x-ray? (4)
1. Bowel dilatation
2. Intramural gas (pneumatosis)
3. Portal venous gas
4. Free gas
71
What are the predisposing factors for NEC?
1. Prematurity
2. IUGR
3. Hypoxia
4. Polycythaemia
5. Rapid increase in milk feeding
72
When does NEC most commonly present?
The second week after birth
73
How does NEC tend to present? (4)
1. Non-specific illness
2. Vomiting
3. Blood, mucus, or tissue in stools
4. Abdominal distension
74
What is mesenteric adenitis?
It is inflamed lymph glands in the abdomen causing pain. It is also known as mesenteric lymphadenitis.
75
In what age range is testicular torsion most common?
12-18 years with peak incidence 13-16
76
What is testicular torsion actually torsion of?
The spermatic cord
77
Which anatomical deformity is associated with testicular torsion?
'Bell clapper deformity' - it is an abnormal fixation of the tunica vaginalis to the testicle, which allows the testicle to rotate freely within then tunica vaginalis
78
What are the predisposing risk factors to developing testicular torsion?
1. Testicular tumour
2. Testicles with horizontal lie
3. Spermatic cord with long intra-scrotal portion
79
What are the causes of constipation?
1. Dietary
2. Lack of exercise
3. Hypothyroidism
4. Poor colonic motility
5.
80
What are the signs/symptoms of constipation? (8)
1. Straining
2. Infrequent stools
3. Anal pain on defecation
4. Anorexia
5. Rectal bleeding
6. Involuntary soiling
7. Flatulence
8. Abnormal anal tone
81
First line laxative for children with constipation?
Movicol (Laxido)
