Paediatric gastroenterology Flashcards
(80 cards)
1
Q
Coeliacs in children : Definition
A
Sensitivity to gluten - repeated exposure leads to villous atrophy which in turn causes malabsorption
2
Q
Coeliacs in children : Age of presentation
A
Before 3 years old - following introduction of cereals into diet
3
Q
Coeliacs in children : Clinical features
A
- Failure to thrive - low BMI, height
- Abdominal pain and distention
- Diarrhea
4
Q
Coeliacs in children : Diagnosis
A
- Biopsy of the jejunum : subtotal villous atrophy
- Bloods : Anti-endomysial and anti-gliadin antibodies
5
Q
Constipation in children : average BO for children
A
< 6 months : average 3 times a day
+3 years : Once a day
6
Q
Constipation in children : Life style causes
A
- Habitually not opening the bowels
- Low fibre diet
- Poor fluid intake and dehydration
- Sedentary lifestyle
- Psychosocial problems such as a difficult home or school environment
7
Q
Constipation in children : Secondary causes
A
Diet : Low fibre diet and dehydration, Cow’s milk intolerance
Anal stenosis : Anal fissure, IBD
Hirschsprung’s disease
Hypothyroidism
8
Q
Constipation in children : Most common cause
A
Idiopathic - majority of children, cause is unknown
9
Q
Constipation : Diagnosis in children
A
2 or more symptoms of the following:
-
Stool pattern
1. Less than 3 stools a week
- Hard large stool which is difficult to pass
- ‘Rabbit dropping stool’
- Overflow soiling - Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
-
Symptoms associated with defecation
1. Pain
1. Straining and painful passages of stools
1. Abdominal pain and poor appetite which improved with passage of stool
1. Rectal bleeding associated with hard stool -
Signs
1. Holding an abnormal posture, referred to as retentive posturing
1. Hard stools may be palpable in abdomen
1. Loss of the sensation of the need to open the bowels
10
Q
Constipation : Diagnosis of Idiopathic Constipation
A
- Step 1 : Diagnosis of Constipation
- Step 2 : Rule of secondary causes of constipation by considering the following symptoms
- > 48 hours for meconium passage
- ‘Ribbon’ stool : indicates anal stenosis - may be secondary to anal fissure/ IBD
- Failure to thrive - low weight, height
- Neurological weakness/development delay
- Step 3 : If ruled out - can diagnose idiopathic constipation
11
Q
Constipation : Faecal incontinence
A
Considered pathological > 4 years
1. Sign of chronic constipation
2. Rectum becomes stretched chronically and looses sensation
3. Hard stool remains and only loose stool are able to bypass the blockage - leaking out without sensation
4. ‘Overflow soiling’
12
Q
Constipation : Faecal impaction
A
- Habit of not opening bowels and ignoring sensation of full rectum
- Lose sensation to open bowels - reduced frequency of bowel opening
- Retention of faeces .
- Faecal impaction : large, hard stool block the rectum
Symptoms are : severe constipation, overflow soiling, faecal mass in abdomen
13
Q
Constipation : Management of faecal impaction
A
First line : Polyethylene glycol + Movicol } both osmotic laxatives
If no disimpaction in 2 weeks
Second line : Add stimulant laxative (Senna)
14
Q
Constipation : Maintainance therapy
A
- First line : Movicol
If no response - Second line : Add stimulant laxative (Senna)
15
Q
Appendicitis : Incidence in children
A
- Occurs in children > 4 years
- If < 4 years : Presents with perforation
16
Q
Hirschsprung’s disease : Definition
A
congenital condition characterised by partial or complete colonic functional obstruction associated with the absence of ganglion cells
17
Q
Hirschsprung’s disease : Pathophsyiology
A
- Development failure results in lack of parasympathetic plexus innervation of a segment of the bowel
- Aganglionic segment of the bowel results in uncoordinated peristalsis of the bowel
- Functional obstruction
18
Q
Hirschsprung’s disease : Risk factors
A
- 3x more common in males
- Down’s syndrome
19
Q
Hirschsprung’s disease : Incidence
A
new-born period to 1 year of age
20
Q
Hirschsprung’s disease : Clinical features
A
Neonatal period
-Delay of > 48 hr or failure to mass meconium
Older children
-Constipation and abdominal distention
-Vomitting
-Failure to thrive
21
Q
Hirschsprung’s disease : Investigations
A
- Rectal biopsy : Gold standard for diagnosis
- Abdominal X-ray
22
Q
Hirschsprung’s disease : Management
A
- Initial management
- Rectal washout/ Bowel irrigation : poor peristalsis means stool/flatus is not completely cleared - Definitive management
- Surgery to affected segment of the colon
23
Q
Cow’s milk protein allergy/intolerance : Definition
A
- Immune-mediated allergic response to proteins in the milk
- It is one of the most common childhood food allergies
- Allergy : Immediate IgE mediated
- Intolerance : Delayed, non IgE mediated
24
Q
Cow’s milk protein allergy/intolerance : Incidence
A
< 3 month old infants - formula fed infants,
Very rare in breast fed infants
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Cow’s milk protein allergy/intolerance : Risk factors
Formula fed infants
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Cow’s milk protein allergy/intolerance : Clinical features
1. After feeds ;
* Regurgitation and Vomiting
* Diarrhoea
2 . Atopy symptoms `; Urticaria, Ectopic eczema, wheeze
3 . Colic symptoms : Irritability, crying
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Cow’s milk protein allergy/intolerance : Diagnosis
1. Clinical diagnosis : Improvement with cow’s milk protein elimination
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Cow’s milk protein allergy/intolerance : Investigations
* Skin prick/patch testing
* Total IgE and specific IgE (RAST) for cow’s milk protein
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Cow’s milk protein allergy/intolerance : Management
**Formula fed**
1. First line
* Mild-moderate sx : Extensive hydrolysed formula milk
2. Second line
* Severe sx or no response to eHF : Amino acid-based formula
**Breast fed**
1. Eliminate cow’s milk from maternal diet
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Cow’s milk protein allergy/intolerance : Prognosis
Resolves on its own in most children
* IgE mediated - 55% will be milk tolerant by 5 years old
* Non-IgE - Most will be milk tolerant by age 3
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Paediatric GORD : definition
Pathological regurgitation of oesophageal contents - regurgitation is not physiological and is associated with other symptoms
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Paediatric GORD : Incidence
< 8 week infants
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Paediatric GORD : Clinical features
1. Vomiting / Regurgitation
-Milky vomits after feeds
-May occur after being laid flat
2. Failure to thrive
3. Distressed behaviour / Feeding aversion - excessing crying especially when feeding, refusing to feed, gagging
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Paediatric GORD : Diagnosis
Clinical diagnosis
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Paediatric GORD : Management
1. Feeding position : -30 degrees, head up
2. Avoid overfeeding : Smaller, more frequent feeds
3. Trail - not at the same time
* Aligante : Gaviscon
* Thickening agent
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Paediatric GORD : Management with PPI
Trail PPI only if one of the following symptoms apply with regurgitation;
1. Feeding aversion : refusing feeds, gagging, choking
2. Distressed behaviour
3. Failure to thrive
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Paediatric GORD : Complication
1. Failure to thrive
2. Aspiration : Pneumonia
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Intussusception : Definition
1. Inversion of one portion of the intestine with another
1. Commonly in ileo-caecal region
1. Most common cause of bowel obstruction in children
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Intussusception : Incidence
* 6 months - 1 1/2 year olds
* Mainly Boys x2 as often
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Intussusception : Clinical features
1. Abdominal pain ;
* Intermittent, severe, crampy abdominal pain
* During episode - Infant will draw knees up and turn pale
2 . Insonsolable crying (due to pain)
3 . Vomitting
4 . Bloodstained stool - ‘Red-currant jelly’
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Intussusception : Clinical sign
* sausage-shaped mass in the right upper quadrant
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Intussusception : Investigation
US Abdomen : Target-like mass
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Intussusception : Management
First line : **Reduction by air insufflation** } creates pressure within the intestines and seperate them
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Pyloric stenosis : Definition
Condition where the muscle passage (pylorus) between the stomach and small bowel (duodenum) becomes hypertrophied and narrows.
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Pyloric stenosis : Clinical features
1. Projectile vomiting - 30 minutes after feed
High frequency of vomiting leads to;
1. Hypochloraemia, Hypokalaemia Alkalaosis
2. Dehydration —> Constipation
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Pyloric stenosis : Clinical signs
Palpation : 'Olive' Mass in the upper abdomen
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Pyloric stenosis : Incidence
< 4 week old infants
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Pyloric stenosis : Investigation for diagnosis
Abdominal US
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Pyloric stenosis : Management
Ramstedt Pyloromyotomy
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Biliary atresia : definition
Congential abnormality of obstruction of the bile ducts leading from the liver secondary to narrowing.
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Biliary atresia : Pathophysiology
1. Congential abnormality characterised by the narrowing of the bile ducts this leads to
1. Obstruction of the biliary ducts which transport bile from the Liver to the Gall bladder and small intestine.
1. Bile and its components (conjugated bilirubin) back up in tot liver and are released in the blood
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Biliary atresia : Clinical presentation
1. Jaundice peresistent > 14 days after birth
1. High levels of conjugated bilirubin } indicates obstructive disease
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Biliary atresia : Management
Surgery - “*Kasai portoenterostomy*”
-Attach small section of small intestine to opening of the liver
54
Meckel’s diverticulum - definition
A congenital out-pouching - diverticulum present in the small intestine at birth
55
Meckel’s diverticulum - Pathophysiology of development
1. < week 8 of development : The omphalmomesenteric duct delivers nutrients from the yolk sac to the midgut/small intestine for developmen
2. Normally : narrows and disappears before week 8
3. Pathology : Proximal part of the vitelline duct fails to regress and remains a part of the small intestine
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Meckel’s diverticulum - Anatomy
Meckel’s diverticulum contains;
1. Pluripotent embryonic cells from other tissue times : ectopic illeal, gastric or pancreatic mucosa
2. Has its own blood supply : Omphalomesenteric artery } prone to obstruction
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Meckel’s diverticulum : Rule of 2s
1. 2% (of the population)
2. 2 feet (proximal to the ileocecal valve
3. 2 inches (in length)
4. 2 types of common ectopic tissue (gastric and pancreatic)
5. 2 years is the most common age at clinical presentation
6. 2:1 male:female ratio
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Meckel’s diverticulum : Clinical features
Usually asymptomatic
1.**Abdominal pain** - similar to appendicitis
2. **Rectal bleeding** : most common cause of severe painless GI bleeding in children
3. **Vomitting / Constipation**
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Meckel’s diverticulum : Complications
1. Diverticulitis
2. Ulcers : from HCL secretion of gastric mucosa
3. Intestinal obstruction : intussusception, volvulus
4. Perforation
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Meckel’s diverticulum : Investigation
1. Haemodynamically stable : 99M Technetium scan which has an affinity for gastric mucosa (ectopic)
2. Unstable : Mesenteric arteriography
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Meckel’s diverticulum : Management
1) Surgery
-Wedge excision or formal small bowel resection and anastomosis
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Neonatal jaundice : Definition
Jaundice describes the condition of abnormally high levels of *bilirubin* in the blood
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Neonatal jaundice : Physiology
1 . *Red blood cells* contain *unconjugated bilirubin*.
2 . RBC breakdown and release of unconjugated bilirubin
3 . Unconjugated bilirubin is *conjugated* in the *liver*
4 . Conjugated bilirubin* is excreted in two ways
* via the *biliary system* into the gastrointestinal tract
* via the *urine*
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Neonatal jaundice : Physiological jaundice
1. Foetal cell break down after birth
2. Increase bilirubin release } rise in bilirubin
3. Less developed liver function : unable to break down excess bilirubin
4. Mild yellowing of sclera 2-7 days
5. Resolves by 10 days
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Neonatal Jaundice : Due to increase bilirubin break down
1. *Increased production of bilirubin:* } Excess RBC breakdown
* Haemolytic disease of new born : Rhesus incompatibility
* Haemorrhage
* Polycythaemia
* Sepsis or DIC
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Neonatal Jaundice : Due to decrease bilirubin clearance
**1**. *Decreased clearance of bilirubin:*
* Prematurity : very immature liver
* Breast milk jaundice
-Components of milk inhibit liver breakdown of bilirubin
-Higher risk of dehydration with inadequate feeding - constipation, and more bilirubin absorption
**2** . Biliary atresia
**3** . Hypothyroidism : lack of T3/T4 inhibits liver enzymes which breakdown bilirubin
**4** . Gilbert’s syndrome
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Neonatal Jaundice : Prolonged jaundice definition
Jaundice lasts longer than if physiological
* More than 14 days in full term babies
* More than 21 days in premature babies
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Neonatal Jaundice : Prolonged jaundice causes
1. G6PD deficiency : Genetic disorder when unable to produce G6PD enzyme which protects RBC from oxidative damage
2. Hypothyroidism
3. Biliary atresia
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Neonatal Jaundice : Investigations for diagnosis
* ***Full blood count*** and *blood film* : polycythaemia or anaemia
* ***Conjugated bilirubin***: elevated levels indicate a *hepatobiliary cause*
* ***Blood type testing*** : ABO or rhesus incompatibility
* ***Direct Coombs Test*** (direct antiglobulin test) for *haemolysis*
* ***Thyroid function***, particularly for *hypothyroid*
* ***Blood and urine cultures*** : if *infection* is suspected. Suspected sepsis needs treatment with antibiotics.
* ***Glucose-6-phosphate-dehydrogenase***: (G6PD) levels for *G6PD deficiency*
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Neonatal Jaundice : Management
1. Treatment threshold chart : age and total bilirubin level monitored - tx commence if threshold reached
2. Phototherapy with blue light
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Neonatal Jaundice : Complication
* **Kernicterus** : Bilirubin deposits in the brain causing CNS damage
May cause : *Cerebral palsy*, *learning disability* and *deafness*
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Necrotising enterocolitis : Definition
Serious medical condition characterised by inflammation and daage to the tissues of the intestine
* Particularly colon and small intestine
* Commonly affects **premature infants with low birth weights**
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Necrotising enterocolitis : Pathophysiology
1. Predominantly affects premature infants (<32 weeks)
2. Bacterial infection of intestine : immature gut barrier makes it more permeable
3. Inflammation of intestine 2nd to bacterial colonisation
4. Intestinal ischaemia —> leads to necrosis of the bowel
* More vulnerable to damage from inflammation and vessels are more susceptible to ischaemia
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Necrotising enterocolitis : Incidence
Occurs 2nd - 3rd week of life
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Necrotising enterocolitis : Clinical features
1. Feeding intolerance
2. Abdominal distention
3. Blood stools
May acutely progress to : perforation and peritonitis
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Necrotising enterocolitis : Investigation
1. Abdominal XR may show
* Dilated bowel loops
* Bowel oedema
**Abnormal air pockets**
* Pnematosis intestinal : gas within the intestinal wall
* Pneumoperitoneal
77
Necrotising enterocolitis : Risk factors
1. Prematurity +++ risk
2. Formula feed - reduces protective factors for gut health
3. Enteral feeding
78
Meconium ileus : Definition
Aspirated meconium **obstructs the small intestine at the level of terminal ileum**
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Meconium ileus : Clinical presentation
1. Intestinal obstruction ***within hours after birth***
2. Billous vomitting during feeds
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Meconium ileus : Investigation
Abdominal Xray - soap -bubble sign in distal small intestine where meconium mixes with swallowed air
