GI, Vomiting, Malabsorption, Lower GI disorders, Paediatric Liver Disease

Question 1

What are some signs and symptoms of constipation?

Answer 1

Poor appetite
Irritable
Lack of energy
Abdominal pain or distension
Withholding or straining

Question 2

Why do children become constipated?

Answer 2

Social (poor diet, insufficient fluids, excessive milk, potty training / school toilet)
Physical (intercurrent illness, medication)
Family history
Psychological (secondary)
Organic

Question 3

How can constipation be treated with diet?

Answer 3

Increase fibre
Increase fruit and vegetables
Increase fluids
Decrease milk

Question 4

How can constipation be treated psychologically?

Answer 4

Make going to toilet a good experience (correct height, not cold, school toilets)
Avoid punitive behaviour from parents

Question 5

What treatments can soften stool and stimulate defecation?

Answer 5

Osmotic laxatives (lactulose)
Stimulant laxatives (senna, picolax)
Isotonic laxatives (movicol)

Question 6

What are the advantages of laxatives?

Answer 6

Non invasive

Given by parents

Question 7

What are the disadvantages of laxatives?

Answer 7

Non compliance

Side effects

Question 8

What is the treatment for impaction?

Answer 8

Empty impacted rectum
Empty colon
Maintain regular stool passage
Slow weaning off treatment

Question 9

What are the presenting features for Crohn’s ad ulcerative colitis?

Answer 9

Diarrhoea 
Rectal bleeding 
Abdominal pain 
Fever 
Weight loss 
Growth failure 
Arthritis 
Mass

Question 10

What lab investigations are used in crohn’s and ulcerative colitis?

Answer 10

FBC and ESR (anaemia, thrombocytosis, raised ESR)

Biochemistry (stool calprotectin, raised CRP, low albumin)

Question 11

What other investigations can be used for Crohn’s and ulcerative colitis?

Answer 11

MRI 
Barium meal 
Colonoscopy 
Upper GI endoscopy 
Mucosal biopsy 
Capsule endoscopy 
Enteroscopy

Question 12

What are the methods of treatment for Crohn’s and ulcerative colitis?

Answer 12

Medical (anti-inflammatory, immunosuppressive, biologics)
Nutritional (immune modulation, supplements)
Surgical

Question 13

What are the different types of vomiting?

Answer 13

Vomiting with Retching
Projectile vomiting
Bilious vomiting
Effortless vomiting

Question 14

What are the different phases of vomiting with retching?

Answer 14

Pre-ejection phase (pallor, nausea, tachycardia)
Ejection phase (retch, vomit)
Post-ejection phase

Question 15

What can stimulate the vomiting centre?

Answer 15

Enteric pathogens
Intestinal inflammation
Metabolic derangement
Infection
Head injury
Visual stimuli
Middle ear stimuli

Question 16

What are the symptoms of pyloric stenosis?

Answer 16

Projectile non-bilious vomiting
Weight loss
Dehydration +/- shock
Electrolyte disturbance (Metabolic alkalosis ↑pH, ↓Cl, ↓K)

Question 17

What type of vomiting is associated with gastroesophageal reflux?

Answer 17

Effortless vomiting

Question 18

What are the presenting symptoms for gastroesophageal reflux?

Answer 18

Vomiting 
Haematemesis 
Feeding problems 
Failure to thrive 
Apnoea 
Cough
Wheeze 
Chest infections

Question 19

What are the investigations for pyloric stenosis?

Answer 19

Test feed
US
Blood gases

Question 20

What is the management for pyloric stenosis?

Answer 20

Fluid resuscitation

Refer to surgeons (Ramstedts pyloroyotomy)

Question 21

What investigations are used for gastroesophageal reflux?

Answer 21

Barium swallow 
Video fluoroscopy 
pH study 
Oesophageal impendance monitoring 
Endoscopy

Question 22

What is the treatment for gastroesophageal reflux?

Answer 22

Feeding advice
Nutritional support (calorie supplements, exclusion diet, NG tube, gastrostomy)
Drugs (feed thickener, pro kinetic drugs, H2 receptor blockers, PPI)
Surgery

Question 23

What are the indications for gastroesophageal reflux surgery?

Answer 23

Failure of medical treatment

Persistent failure to thrive, aspiration and oesophagiitis

Question 24

What are the causes of bilious vomiting?

Answer 24

Intestinal atresia (in newborn babies only)
Malrotation +/- volvulus
Intussusception
Ileus
Crohn’s disease with strictures

Question 25

What are the investigations for bilious vomiting?

Answer 25

Abdominal x-ray Consider contrast meal Surgical opinion re exploratory laparotomy

Question 26

What is chronic diarrhoea?

Answer 26

4 or more stools per day more than 4 weeks

Question 27

What are the causes of diarrhoea?

Answer 27

``` Motility disturbance (Toddler Diarrhoea, Irritable Bowel Syndrome) Active secretion (Acute Infective Diarrhoea, Inflammatory Bowel Disease) Malabsorption of nutrients (Food Allergy, Coeliac Disease, Cystic Fibrosis) ```

Question 28

What is osmotic diarrhoea?

Answer 28

Movement of water into the bowel to equilibrate osmotic gradient

Question 29

What can cause fat malabsorption?

Answer 29

``` Pancreatic disease (cystic fibrosis) Hepatobiliary disease (chronic liver disease, cholestasis) ```

Question 30

What is secretary diarrhoea?

Answer 30

Associated with toxin production from E coli | Intestinal fluid secretion is driven by active CL secretion via CFTR

Question 31

What are the causes of motility diarrhoea?

Answer 31

Irritabel bowel syndrome | Congenital hyperthyroidism

Question 32

What is inflammatory diarrhoea?

Answer 32

Malabsorption due to intestinal damage Secretory effect of cytokines Accelerated transit time in response to inflammation Protein exudate across inflamed epithelium

Question 33

What are the investigations for diarrhoea?

Answer 33

History Consider growth and weight gain of child Faeces analysis

Question 34

What are the signs of coeliac disease in children?

Answer 34

``` Abdominal bloatedness Diarrhoea Failure to thrive Short stature Constipation Tiredness Dermatitis herpatiformis ```

Question 35

Who are the susceptible asymptomatic groups for coeliac disease?

Answer 35

Type 1 diabetes Autoimmune thyroid disease Down's syndrome First-degree relatives of people with coeliac disease

Question 36

What are the screening tests for coeliac disease?

Answer 36

Serology screens (anti-tissue transglutaminase, anti-endomysial, concurrent IgA deficiency) Duodenal biopsy Genetic testing

Question 37

What are the histological features of coeliac disease?

Answer 37

Villous atrophy Crypt hyperplasia Lymphocytic infiltration of surface epithelium

Question 38

What is the treatment for coeliac disease?

Answer 38

Strict gluten free diet

Question 39

What is the risk of azathioprine?

Answer 39

Lymphoma risk

Question 40

What are the advantages of breast milk?

Answer 40

``` Well tolerated Less allergenic Low renal solute load Improves cognitive development Reduces infection ```

Question 41

What is included in liver function tests?

Answer 41

Bilirubin ALT/AST Alkaline phosphatase Gamma glutamyl transferase (GGT)

Question 42

What liver function tests will be elevated in biliary disease?

Answer 42

Alkaline phosphatase | GGT

Question 43

What liver function tests will be elevated in hepatocellular damage?

Answer 43

ALT/AST

Question 44

What are some other tests which can assess liver function?

Answer 44

``` Coagulation (prothrombin time) Albumin Bilirubin Blood glucose Ammonia ```

Question 45

What are the signs of chronic liver disease in children?

Answer 45

``` Ascites Portal hypertension Clubbing Splenomegaly Cholestasis Brusing and petechiae Spider neavi Muscle wasting Jaundice Hypotonia Growth failure ```

Question 46

What are the early causes of neonatal jaundice?

Answer 46

Haemolysis | Sepsis

Question 47

What are the intermediate causes of neonatal jaundice?

Answer 47

Breast milk Sepsis Haemolysis

Question 48

What are the prolonged causes of neonatal jaundice?

Answer 48

Extrahepatic obstruction Neonatal hepatitis Hypothyroidism Breast milk

Question 49

What are the features of physiological jaundice?

Answer 49

``` Shorter RBC lifespan in infants Relative polycythaemia Relative immaturity of liver function Unconjugated jaundice Develops after first day of life ```

Question 50

What are the features of great milk jaundice?

Answer 50

Unconjugated jaundice | Can persist up to 12 weeks

Question 51

What is kernicterus?

Answer 51

Unconjugated bilirubin is fat soluble and crosses the BBB | Neurotoxic and deposits in the brain

Question 52

What are the early signs of kernicterus?

Answer 52

Encephalopathy Poor feeding Lethargy Seizures

Question 53

What are the consequences of kernicterus?

Answer 53

Severe choreoathetoid cerebral palsy Learning difficulties Sensorineural deafness

Question 54

What type of jaundice can phototherapy treatment be used?

Answer 54

Unconjugated jaundice

Question 55

What types of biliary obstruction can cause prolonged neonatal jaundice?

Answer 55

``` Biliary atresia (Conjugated jaundice, pale stools) Choledochal cyst (Conjugated jaundice, pale stools) Alagille syndrome (Intrahepatic cholestasis, dysmorphism, congenital cardiac disease) ```

Question 56

What is the treatment for biliary atresia?

Answer 56

Kasai portoenterostomy