Paed GI Flashcards
Examples of GI issues
-Acute abdomen
-Cows milk protein intolerance
-Gastroesophageal reflux
-IBD
-Coeliac
-Pyloric stenosis
-Intussusception
-Hernia/ hydrocele
-Constipation
-Diarrhoea
-Vomiting
-Feeding problems
-Jaundice
Causes of abdominal pain
-Abdominal conditions
=Colic
=Intussusception
=Mesenteric adenitis
=Constipation
=Inflammatory bowel disease
=Coeliac disease
=Appendicitis
-Extra-abdominal conditions
=Migraine
=Diabetic ketoacidosis
=Infection elsewhere (e.g. throat)
=Pneumonia
=Urinary tract infection
=Stress
-Some causes are rare but serious enough not to be forgotten:
=Malignancy: Neuroblastoma, Wilms tumour
=Testicular torsion
=Bowel obstruction: Incarcerated hernia, Malrotation, Meckel’s diverticulum (bilious vomit green bile, not wanting to eat, severe pain worse on movement)
History of abdominal pain
-An acute or chronic condition
-A medical or surgical problem
-A sign of something serious
-Recent illness
-Easy to miss conditions:
=Urinary tract infection
=Obstruction
=Appendicitis
=Inflammatory bowel disease
-Rare but serious conditions:
=Neuroblastoma
=Wilms tumour
-Causes of acute pain – hours to days:
=Urinary tract infection
=Diabetic ketoacidosis (excessive thirst and polyuria)
=Surgical problems
-Causes of chronic pain – weeks or longer:
=Constipation
=Inflammatory bowel disease
=Malignancy
=Growth (faltering), potential stress
Red flags in GI history
-Life restriction
-Anorexia, early satiety
-Weight loss; decreased height velocity; pubertal delay; slowed pubertal progress
-Family history (e.g. IBD, coeliac)
-Diarrhoea, urgency, tenesmus
-Nocturnal pain
-Blood in stools
-Nocturnal stooling
A weak, abnormally high-pitched, or continuous cry is a red flag which may indicate potentially serious illness.
Other red flags include fever, apnoeic episodes, cyanosis, abnormal breathing pattern, bilious or projectile vomiting, weight loss or faltering growth, and blood in the stool.
Abdo exam
-General observations – what is the child’s behaviour:
=Whilst lying down?
=Whilst climbing on and off the couch?
=Walking and moving comfortably?
-Physiological observations – are there signs of dehydration or sepsis:
=Fever
=Capillary refill
=Heart rate
=Respiratory rate- lower lobe pneumonia can present as abdo pain
-Gather the child’s trust:
=Use distraction techniques
=Ask the child to show you where it hurts
=Away from or near the umbilicus?
-Examine the abdomen for:
=Tenderness
=Guarding
=Peritonism
=Masses (LIF constipation)
=Organomegaly
-Perform urinalysis for:
=Infection
=Glucose
=Ketones
Examine genitalia in all boys, rectal exam considered by surgeon
Abdominal red flags
-Peritonitis
-Intussusception
-Abdominal mass
-Vomiting bile
-Torsion of testis
Abdo emergencies
-Gastrointestinal – severe IBD; coeliac crisis; severe GI bleed
-Hepatological – Acute liver failure; portal hypertensive bleeding
-Nutritional – Severe undernutrition needing refeeding protocol
-Procedural – Bleeding; foreign bodies especially button batteries
Symptoms of malabsorption and maldigestion
-Diarrhoea
-Smelly, floaty stools (fat)
-Watery, explosive stools +/- perianal excoriation +/- distension (CHO)
-Short stature, faltering height growth, weight loss
-Vomiting
-Anorexia, early satiety
-Oedema (hypoalbuminaemia); specific nutrient signs (scurvy, rickets)
Overview of peritonitis
-Severe inflammation of peritoneal cavity
-Look for guarding, dehydration, sepsis
-Most common: perforated appendix
Overview of appendicitis in children
-Appendicitis is one of the most common acute surgical problems facing children. Diagnosis is often made difficult by a presentation which is far from the classically history of:
=central abdominal pain which later radiates to the right iliac fossa
=low-grade pyrexia
=minimal vomiting
-Children who are younger or have a retrocaecal/pelvic appendix are more likely to present in an atypical way
-Appendicitis is uncommon in children under 4 years old but in this group often presents with perforation
Overview of intussusception
-Infants and toddlers; invagination of intestine into lumen of adjacent bowel (collapsible telescope): bowel obstruction. Most commonly around ileo-caecal region (proximal or at level of)
-Infants between 6-18 months, boys x2
-P: Signs of extra-abdominal infection (tonsillitis, otitis media, lead point in Peyer’s patches lymph node swelling, vomiting and diarrhoea)
-Bouts of colicky pain, settled in between (intermittent severe crampy progressive abdo pain)
-Inconsolable crying
-During paroxysm the infant will characteristically draw their knees up and turn pale
-Blood stained stool (red currant jelly late sign)
-A right sided mass (sausage shaped in RUQ)
-Anticipate dehydration (IV fluids)
-I: USS (target like mass)
-M: the majority of children can be treated with reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema
=if this fails, or the child has signs of peritonitis, surgery is performed
Overview of abdominal mass
-Neuroblastoma
-Wilms tumour
-Appendix abscess
-Constipation
-Diagnosed late
Overview of Meckel’s diverticulum
-Congenital diverticulum of the small intestine
-Occurs in 2% of the population, 2 feet from the ileocaecal valve, 2 inches long
-P: usually asymptomatic, abdominal pain mimicking appendicitis, rectal bleeding (most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years), intestinal obstruction
secondary to an omphalomesenteric band (most commonly), volvulus and intussusception
-I: if the child is haemodynamically stable with less severe or intermittent bleeding then a ‘Meckel’s scan’ should be considered, mesenteric arteriography may also be used in more severe cases e.g. transfusion is required
-M: removal if narrow neck or symptomatic
options are between wedge excision or formal small bowel resection and anastomosis
Overview of Mesenteric adenitis
Mesenteric adenitis is inflamed lymph nodes within the mesentery. It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two. It often follows a recent viral infection and needs no treatment
Overview of vomiting bile
-Bilious vomiting is intestinal obstruction until proven otherwise:
=Green colour
=Empty stomach?
-Investigate by
=Abdominal X-ray
=Blood tests
-Consider a surgical opinion
Overview of pyloric stenosis
-Pyloric stenosis typically presents in the second to fourth weeks of life with vomiting, although rarely may present later at up to four months. It is caused by hypertrophy of the circular muscles of the pylorus.
-Epidemiology: incidence of 4 per 1,000 live births, 4 times more common in male,10-15% of infants have a positive family history, first-borns are more commonly affected
-P: ‘projectile’ vomiting (non bile stained), typically 30 minutes after a feed, constipation and dehydration may also be present, a palpable mass may be present in the upper abdomen, hypochloraemic, hypokalaemia alkalosis due to persistent vomiting
-I: USS, test feed
-M: Ramstedt pyloromyotomy (open or laparoscopic)
Overview of testis torsion
-Symptoms of testicular torsion include:
=Testicular pain – usually
=Abdominal pain – occasionally
=Crying & being unsettled in infants
=More common in 12 and above
-Check scrotum for
=Swelling
=Tenderness
=Discolouration
-Have a low threshold for urgent referral to surgeons- operation within 6 hours
= Fertility in the testicle concerned may be lost within 4 to 6 hours of interrupted blood flow to the organ
Overview of necrotising enterocolitis
Necrotising enterocolitis is one of the leading causes of death among premature infants.
-P: Initial symptoms can include feeding intolerance, abdominal distension and bloody stools, which can quickly progress to abdominal discolouration, perforation and peritonitis.
Abdominal x-rays are useful when diagnosing necrotising enterocolitis, as they can show:
=dilated bowel loops (often asymmetrical in distribution)
=bowel wall oedema
=pneumatosis intestinalis (intramural gas)
=portal venous gas
=pneumoperitoneum resulting from perforation
=air both inside and outside of the bowel wall (Rigler sign)
=air outlining the falciform ligament (football sign)
M: Increased risk when empirical antibiotics are given to infants beyond 5 days
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
Overview of coeliac disease in children
-Sensitivity to the protein gluten.
-Repeated exposure leads to villous atrophy which in turn causes malabsorption.
-Children normally present before the age of 3 years, following the introduction of cereals into the diet
-Genetics, incidence of around 1:100, it is strongly associated with HLA-DQ2 (95% of patients) and HLA-DQ8 (80%)
-P: Features may coincide with the introduction of cereals (i.e. gluten): failure to thrive, diarrhoea, abdominal distension, older children may present with anaemia, many cases are not diagnosed to adulthood
-I: jejunal biopsy showing subtotal villous atrophy
anti-endomysial and anti-gliadin antibodies are useful screening tests
Overview of IBD
-Paed: Incidence 12/100,000, increasing prevalence and incidence
-CD – granulomatous, transmural inflammation with skip lesions
-UC – mucosal inflammation, continuous and starts in rectum
-IBD unclassified (U) - mucosal inflammation , limited to the colon
-I: height and weight, oral, Abdo and peri-anal exam, EIM’s, stool and blood tests
History and exam findings in PIBD
-Abdominal pain
-Diarrhoea with or without blood
-Pyrexia
-Arthritis
-Rash
-FH
-Abdominal tenderness, mass
-Finger clubbing
-Erythema nodosum (very rarely pyoderma gangrenosum)
-Growth problems: reduced height velocity, height centile/ z-score out with that expected for parental height. Mean final height 2.4cm below target height
-Crohns: perianal exam (abscess, fistula, deep fissures, large inflamed skin tags), perioral (mucogingivitis, buccal tagging, deep ulceration, perioral erythema)