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PAEDIATRICS 2 Flashcards

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1
Q

What is the prevalence of asthma in children?

A

15-20%, 20 deaths a year

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2
Q

What is transient early wheeze in preschool children likely to be?

A

Episodic viral wheeze, due to tendency of airways to narrow and inflame with viruses

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3
Q

What is persistent wheeze likely to be?

A

IgE response to allergens

Recurrent wheeze associated with evidence of allergy is atopic asthma

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4
Q

What is the pathophysiology of asthma?

A

Environmental triggers/allergens lead to bronchial inflammation (oedema, mucous) and hyperresponsiveness, leading to airway narrowing an symptoms of cough/wheeze/SoB/tightness

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5
Q

What are the causes of asthma?

A 
Genetic predisposition (family history)
Atopy
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6
Q

Symptoms of asthma? (7)

A 
Wheeze
Symptoms worse at night and in early morning
Cough
Shortness of breath
Triggered by allergens/environment
Interval symptoms between exacerbations
Positive response to therapy
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7
Q

Signs of asthma? (3)

A

Chest hyperinflation
Eczema
Harrison’s sulcus

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8
Q

How is asthma diagnosed? (5)

A 
Clinically
Skin prick test for common allergies
CXR to exclude other 
Peak expiratory flow rate recording - diurnal pattern
Check if response to bronchodilator
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9
Q

Management of asthma? (6)

A

Allergen avoidance
1 - inhaled SHORT acting beta 2 agonist (salbutamol)
2 - ADD an inhaled STEROID (beclometasone, budenoside)
3 - ADD a leukotriene receptor antagonist LTRA (montelukast)
4 - Stop LTRA, refer if under 5, if over 5 add LABA (formeterol)
5 - increase ICS dose
6 - Trial of theophylline

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10
Q

What is the management of acute asthma? (4)

A

Salbutamol
Oral prednisolone/IV hydrocortisone
Nebulised ipratropium bromide
Oxygen

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11
Q

What is the most common cause of pneumonia in younger and older children?

A

Viruses in younger children, bacteria in older

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12
Q

Common causative organisms of pneumonia in the newborn?

A

Group B strep, enterococci

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13
Q

Common causative organisms of pneumonia in infants/young children?

A

Respiratory syncytial virus
Strep pneumoniae
H.influenzae
Staph aureus is serious

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14
Q

Common causative organisms of pneumonia over 5 years?

A

M.pneumoniae

Strep pneumoniae

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15
Q

What vaccines are there to prevent pneumonia in children?

A

Strep pneumoniae

H.influenzae type b

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16
Q

Symptoms of pneumonia? (6)

A 
Fever
Difficulty breathing
Cough
Lethargy
Poor feeding
Chest/abdo/neck pain
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17
Q

Signs of pneumonia? (4)

A

Tachypnoea
Nasal flaring
Chest recession
End inspiratory crackles

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18
Q

What is pneumonia usually preceded by?

A

URTI

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19
Q

Investigations for pneumonia? (4)

A

CXR
Nasophyaryngeal aspirate to identify cause
FBC
Acute reactants

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20
Q

What may be seen on CXR in pneumonia?

A

Lobar consolidation
Effusion
Empyema

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21
Q

General management of pneumonia? (5)

A 
Admit if severe
Oygen
Analgesia
IV fluids
Abx
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22
Q

What antibotics are used for newborns with pneumonia?

A

Broad spectrum IV

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23
Q

What antibiotics are used for older children with pneumonia?

A

Oral amoxicillin

Co-amoxiclav if complicated

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24
Q

Why are children mostly not infectious for TB?

A

Disease is paucibacillary

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25
How to children commonly catch TB?
From an infected adult in same household, more likely to progress to active disease than in adults Mycobacterium tuberculosis
26
Why do 50% of infants and 90% of children show minimal signs of TB?
Inflammation limits progression of disease so it remains latent
27
What are symptoms of TB? (5)
``` Fever Anorexia, weight loss Cough CXR changes i.e. hilar lymphadenopathy Older children: fatigue, night sweats, chest pain, bloody sputum ```
28
What is the primary Ghon complex and what may it lead to in TB?
Lesion of lung calcification and regional nodes May lead to bronchial obstruction, lung collapse, pleural effusion May involve gut, skin
29
What is post primary TB?
Asymptomatic or symptomatic infections may become dormant and reactivate to post primary TB May be widely disseminated
30
What is a complication of post primary TB in infants
Wide dissemination with CNS involvement leading to meningitis
31
How is TB diagnosed? (5)
``` Sputum culture Urine sample CSF sample CXR Lymph node excision ```
32
Management of suspected TB?
Mantoux test - if positive, treat
33
Management of TB
Quadruple therapy with rifampicin, isoniazid, pyrazinamide, ethambutol (6 months) Rifampicin and isoniazid only after 2 months Longer course if disseminated/meningitis
34
What is a side effect of isoniazid and how is it prevented? Which TB drug causes red urine? Which can cause visual problems?
Weekly pyridoxine after puberty to prevent peripheral neuropathy Red urine - rifampicin Visual - ethambutol
35
What is prevention of TB?
BCG vaccine at birth for high risk groups | Screen contacts
36
What is bronchiolitis?
Most common serious respiratory infection of infancy
37
When are children commonly affected by bronchiolitis?
1-9 months | Winter
38
What is the most common pathogen for bronchiolitis?
Respiratory syncytial virus in 80% | Others - parainfluenza, rhinovirus
39
Symptoms of bronchiolitis? (5)
``` Coryzal features Dry cough Increasing breathlessness Feeding difficulty Recurrent apnoea ```
40
Signs of bronchiolitis? (7)
``` Tachypnoea Sub and intercostal recession Hyperinflation End-inspiratory crackles Wheeze Tachycardia Pallor/cyanosis ```
41
Diagnosis of bronchiolitis?
Clinical | Virus on PCR of nasopharyngeal swab
42
Management of bronchiolitis?
Supportive - humidified oxygen nasal cannulae | IV fluids
43
Prevention of bronchiolitis?
Palivuzumab for high risk - preterm infants, CF
44
What is the proper name for croup and what is it?
Laryngotracheobronchitis - mucosal secretions and inflammation affecting the airway, and oedema of the subglottic area which can result in critical narrowing
45
What is the most common cause of croup?
Parainfluenza viruses
46
When does croup occur?
From 6 months-6 years Peak at 2 years Autumn
47
Symptoms of croup? (5)
``` Barking cough Harsh stridor Hoarseness Usually preceded by fever/cold Worse at night ```
48
How is croup treated?
``` Oral dexamethasone (/prednisolone/nebulised budenoside) If severe, nebulised adrenaline and oxygen ```
49
What is bacterial tracheitis?
Similar to severe croup but high fever and rapid obstruction
50
What causes bacterial tracheitis?
Staph aureus
51
How is bacterial tracheitis treated?
IV antibiotics - penicillin
52
What is epiglottitis?
Emergency - obstruction risk due to intense epiglottal swelling, associated with septicaemia DO NOT EXAMINE THROAT
53
What causes epiglottitis?
H influenzae type B
54
Symptoms of epiglottitis? (4)
``` Acute onset High fever Drooling Soft stridor NO COUGH ```
55
Treatment of epiglottitis?
Intubated IV cefuroxime rifampicin for close contacts
56
What is cystic fibrosis?
Most common life limiting (average life expectancy 30-40s) autosomal recessive condition in the Caucasian population
57
What is the cause of cystic fibrosis?
Defective protein of the cystic fibrosis transmembrane conductance regulator (CFTR) on chromosome 7
58
What are some risk factors that may moderate severity of cystic fibrosis?
Passive smoking Social deprivation Modifier genes
59
What features does the defective protein in cystic fibrosis cause? (6)
Impaired ciliary function Increased retention of secretions Chronic bronchial infection - psued aerug Thick meconium in infants - meconium ileus Blocked pancreatic ducts leading to enzyme deficiency, malabsorption Excessive Na and Cl in sweat
60
What is a common bronchial infection in cystic fibrosis?
Pseudomonas aeruginosa
61
Screening for cystic fibrosis?
Guthrie test - heel prick
62
How may cystic fibrosis present in infants? (5)
``` Recurrent infections Failure to thrive Malabsorption Meconium ileus Prolonged neonatal jaundice ```
63
How may cystic fibrosis present in young children? (4)
Bronchiectasis Nasal polyps Sinusitis Rectal prolapse
64
How may cystic fibrosis present in older children? (5)
``` Diabetes Cirrhosis Intestinal obstruction Pneumothorax Male infertility ```
65
How is cystic fibrosis diagnosed?
Sweat test - elevated chloride level | Genetic testing - abnormalities in CTFR protein
66
How is cystic fibrosis managed?
MDT approach to suppress lung disease, maintain nutrition and growth
67
What is treatment of bacterial chest infections in cystic fibrosis? (4)
Physiotherapy to clear secretions Prophylactic oral flucloxacillin with rescue antibiotics in exacerbations Daily nebulised pseudomonal antibiotics Nebulised DNAse/hypertonic saline
68
What is treatment of severe/end stage respiratory disease in cystic fibrosis?
If severe - regular IV abx, portacath | Bilateral lung transplant
69
How is pancreatic insufficiency in cystic fibrosis managed?
Pancreatic replacement medication after food High calorie diet Fat soluble vitamin supplements
70
What is the prevalence of significant cardiac malformations in infants?
8/1000, 1/10 stillborn
71
Give 3 left to right shunts and what the main symptom is
Breathless Ventricular septal defect (most common) Patent ductus arteriosus Atrial septal defect
72
Give 2 right to left shunts and what the main symptom is
Blue Tetralogy of Fallot Transposition of the great arteries
73
Give an example of a common mixing heart defect and what the symptoms are
Breathless and blue | Atrioventricular septal defect
74
Give two types of outflow obstruction in a well child and what the symptoms are
Asymptomatic with murmur Pulmonary stenosis Aortic stenosis
75
Give a type of outflow obstruction in the sick neonate and what the symptoms are
Collapse with shock | Coarctation of the aorta
76
What causes congenital heart defects? (5)
``` Rubella infection Diabetes SLE Fetal alcohol syndrome Genetics - Down's, Edwards's, Patau, Turner's ```
77
How does congenital heart disease present and which is most common? (5)
``` Picked up antenatally by USS Detection of heart murmur clinically - most common Heart failure Shock Cyanosis ```
78
What are the hallmarks of an innocent murmur? (4)
``` 30% of children have an innoSent murmur aSymptomatic patient Soft blowing murmur Systolic only left Sternal edge ```
79
When are innocent (flow) murmurs often heard?
When a child has a fever or is anaemic, due to increased cardiac output
80
What are the two main types of atrial septal defect?
Secundum (80%) | Primum (partial atrioventricular septal defect)
81
What is secundum ASD?
Defect in the centre of the atrial septum involving the foramen ovale
82
What is partial AVSD?
Defect of the atrioventricular septum - either between the atrial septum and atrioventricular valves or abnormal atrioventricular valves which leak
83
What are the symptoms of atrial septal defects? (3)
Commonly asymptomatic May have recurrent chest infections Arrhythmias when adults
84
Signs of atrial septal defects? (3)
Ejection systolic murmur (upper left sternal edge) Fixed, widely split second heart sound If partial - apical pansystolic murmur
85
Investigations for atrial septal defects? (3)
CXR shows cardiomegaly, enlarged pulmonary arteries ECG - partial right bundle branch block in secundum, abnornal QRS axis in primum Echocardiography for anatomy
86
How are atrial septal defects treated if significant?
Secundum - cardiac catheterisation with insertion of occlusion device Primum - surgical correction at around 3-5 years
87
What are ventricular septal defects?
Defect anywhere in the ventricular septum, perimembranous (next to tricuspid valve) or muscular Categorised by size - smaller or larger than the aortic valve
88
Symptoms of small VSDs?
None
89
Sign of small VSDs?
Loud pansystolic murmur at lower left sternal edge - loud murmur = smaller defect
90
Investigations of small VSDs?
CXR and ECG normal | Echocardiogram shows anatomy
91
Management of small VSDs?
Will close spontaneously
92
Symptoms of large VSDs? (4)
Heart failure Breathlessness Failure to thrive Recurrent chest infections
93
Signs of large VSDs? (6)
``` Tachypnoea Tachycardia Hepatomegaly Active precordium Soft pansystolic murmur or no murmur Apical mid-diastolic murmur ```
94
Investigations of large VSDs?
CXR shows cardiomegaly, enlarged pulmonary arteries, pulmonary oedema ECG biventricular hypertrophy, upright T wave shows pulmonary hypertension Echocardiogram - anatomy and pulmonary hypertension
95
Management of large VSDs?
Diuretics Captopril - ACEi Extra calories Surgery at 3-6 months to prevent permanent damage from pulmonary hypertension and high blood flow
96
What is patent ductus arteriosus?
When ductus arteriosus fails to close within 1 month after due date due to a defect in constrictor mechanism of duct. Connects pulmonary artery to descending aorta so after birth blood flows from aorta to P.A. Common in prematurity
97
Symptoms and signs (3) of patent ductus arteriosus?
Continuous murmur below left clavicle Pulse pressure increased - collapsing/bounding pulse If large, heart failure and pulmonary hypertension Normally asymptomatic
98
Investigations of patent ductus arteriosus?
CXR and ECG normal - if large same appearance as VSDs | Duct identified on echocardiogram
99
Management of patent ductus arteriosus?
Coil or occlusion closure via cardiac catheterisation at 1 year to avoid risk of bacterial endocarditis, pulmonary vascular disease
100
What is the most common cause of cyanotic congenital heart disease?
Tetralogy of Fallot
101
What are the 4 features of tetralogy of fallot?
Large VSD Overriding aorta Pulmonary stenosis Right ventricular hypertrophy
102
Symptoms of tetralogy of fallot? (4)
Most diagnosed antenatally or within first 2 months after a murmur identified Severe cyanosis in first few days of life Hypercyanotic spells later in life Squatting on exercise later in life
103
What are hypercyanotic spells? (5)
``` Rapid increase in cyanosis Irritability/crying Hypoxia Breathlessness Pallor ```
104
Signs of tetralogy of fallot?
Clubbing | Harsh ejection systolic murmur at left sternal edge
105
Investigations for tetralogy of fallot?
CXR shows small heart, with uptilted apex and pulmonary artery 'bay' ECG normal at birth, right ventricular hypertrophy when older Echo for anatomy Cardiac catheterisation for anatomy
106
Management of tetralogy of fallot?
Medical Surgery at 6 months to close VSD If cyanosed infant - shunt to increase pulmonary blood flow
107
How are hypercyanotic spells treated? (4)
Sedation, pain relief, fluids IV propranolol Bicarbonate for acidosis Muscle paralysis and artificial ventilation to reduce oxygen demand
108
How is ductal patency maintained in the first few days of life for duct dependant cyanotic infants?
Prostaglandin infusion
109
What is transposition of the great arteries?
Aorta is connected to the right ventricle Pulmonary artery is connected to the left ventricle Deoxygenated blood is returned to the body - incompatible with life unless there is an associated defect that allows mixing (ASD, VSD, PDA)
110
Symptoms of transposition of the great arteries?
Cyanosis - usually day 2 after ductal closure as reduces mixing Less severe if more mixing
111
Signs of transposition of the great arteries?
Loud, single second heart sound | Variable systolic murmur due to increased pulmonary flow
112
Investigations of transposition of the great arteries?
CXR - narrow upper mediastinum, 'egg on side' appearance of cardiac shadow, increased pulmonary vascular markings ECG normal Echo for anatomy and other abnormalities
113
How is transposition of the great arteries managed?
Improve mixing Maintain patency of ductus arteriosus - prostaglandin infusion Balloon atrial septostomy to tear atrial septum and allow mixing Surgery - arterial switch procedure in neonatal period (first few days of life)
114
What is eisenmenger syndrome?
If high pulmonary blood flow due to a large left to right shunt or common mixing is not treated, pulmonary arteries become thick walled and resistance to flow increases At about 10-15 years the shunt reverses and teenager becomes cyanosed Progressive syndrome, death from heart failure in middle age
115
How is eisenmenger syndrome treated?
Prevention by treating heart defects early Transplant Palliative pulmonary hypertension medication to delay transplantation
116
What is atrioventricular septal defect?
Common mixing Seen in Down's syndrome Defect in the middle of the heart with a common valve between the atria and ventricles, which leaks Causes pulmonary hypertension
117
Features of atrioventricular septal defect? (3)
Presents on fetal USS Cyanosis at birth or heart failure after 2-3 weeks No murmur
118
Management of atrioventricular septal defect
Treat heart failure medically | Surgical repair at 2-3 months
119
What causes heart failure in neonates?
``` Obstructed (duct dependant) systemic circulation: Hypoplastic left heart syndrome Critical aortic valve stenosis Severe coarctation of aorta Interruption of aortic arch ```
120
What causes heart failure in infants?
High pulmonary blood flow (left to right shunts): Ventricular septal defect Atrioventricular septal defect Large patent ductus arteriosus
121
What causes heart failure in older children?
Eisenmenger (right heart failure) Rheumatic heart disease Cardiomyopathy
122
Symptoms of heart failure? (4)
Breathlessness Sweating Poor feeding Recurrent chest infection
123
Signs of heart failure? (7)
``` Poor weight gain Tachypnoea Tachycardia Heart murmur - gallop rhythm Enlarged heart Hepatomegaly Cool peripheries ```
124
Signs of right heart failure?
Ankle and sacral oedema Ascites Rare, may be seen with longstanding pulmonary hypertension or rheumatic fever
125
Complications of heart failure?
Progressive heart failure until 3 months, when symptoms may improve due to rise in pulmonary vascular resistance but this then leads to Eisenmenger's when the shunt reverses to right to left.
126
What is sinus arrhythmia?
Normal cyclical change in heart rate with respiration - increasing on inspiration
127
What is supraventricular tachycardia?
Most common childhood arrhythmia Rapid heart rate - 250-300 bpm Premature activation of the atrium via an accessory pathway
128
How does supraventricular tachycardia present?
Symptoms of heart failure Poor cardiac output Pulmonary oedema
129
Investigation of supraventricular tachycardia?
ECG - narrow complex tachycardia, if severe changes suggestive of myocardial ischaemia (T wave inversion)
130
Management of supraventricular tachycardia?
Circulatory and respiratory support Vagal stimulating manoeuvres - carotid sinus massage IV adenosine breaks re-entry circuit Electrical cardioversion
131
What is maintenance therapy of supraventricular tachycardia?
Flecainide or sotalol
132
What is congenital heart block?
Rare, related to anti-Ro or anti-La antibodies in maernal serum which prevent normal development of the electrical conduction system in the developing heart, with atrophy of the AV node
133
What are the symptoms of congenital heart block?
May cause death in utero May cause heart failure neonatally Most symptom free for a few years May develop presyncope or syncope
134
What is management of congenital heart block?
Insertion of endocardial pacemaker
135
What is coarctation of the aorta?
Arterial duct tissue encircling the aorta just at the point of insertion of the duct When the duct closes the aorta constricts causing obstruction to left ventricular outflow
136
How does coarctation of the aorta present if not antenatally?
Collapse when DA closes at 2 days Severe heart failure and metabolic acidosis Weak femoral pulses
137
Management of coarctation of the aorta?
Resus Prostaglandin infusion Early surgical repair
138
What is hypoplastic left heart syndrome?
Undervelopment of the entire left side of the heart, with small ascending aorta Usually also has coarctation of the aorta
139
How does hypoplastic left heart syndrome present if not antenatally?
Sickest of all neonates Duct dependent systemic circulation No flow through left heart - acidosis and quick cardiovascular collapse Weak or absent peripheral pulses
140
Management of hypoplastic left heart syndrome?
Resus, prostaglandin infusion | Early surgery, followed by another at 6 months and another at 3 years
141
What is rheumatic fever?
Abnormal immune response to a preceding group A beta-haemolytic streptococcus infection Mainly affects 5-15 year olds, most common cause of heart disease worldwide
142
How does rheumatic fever present?
``` Latent interval 2-6 weeks after pharyngeal infection Pancarditis (endo, myo, pericarditis) Polyarthritis Mild fever Malaise ```
143
What is chronic rheumatic fever?
Mitral stenosis usually occurs from long term damage and fibrosis of the valve tissue if repeated attacks of rheumatic fever with carditis Severity of valvular disease related to number of childhood attacks
144
How is acute rheumatic fever treated? (5)
Anti-inflammatory agents - high dose aspirin Limit exercise Corticosteroids if no rapid improvement Diuretics and ACE inhibitors for heart failure Anti-streptococcal antibiotics if persistent infection
145
How is recurrence of rheumatic fever prevented?
Monthly benzathine penicillin injections or oral erythromycin until age of 18-21 years - possibly lifelong
146
What are risk factors for infective endocarditis?
Congenital heart disease - VSD, coarctation of aorta, patent ductus arteriosus Prosthetic material inserted at surgery
147
Symptoms of infective endocarditis?
``` Fever Malaise Raised ESR Anaemua/haematuria Peripheral stigmata - splinter haemorrhages, clubbig, necrotic skin lesions Cerebral and retinal infarcts ```
148
How is endocarditis investigated?
Blood cultures | Echocardiography for vegetations
149
What is the common causative organism of endocarditis?
Streptococcus viridans (alpha haemolytic)
150
Treatment of endocarditis?
High dose penicillin and aminoglycoside for 6 weeks | Possible removal of synthetic shunts etc.
151
Prophylaxis of endocarditis?
Good dental hygiene
152
What is oesophageal atresia?
Usually associated with tracheo-oesophageal fistula and with polyhdramnios in pregnancy
153
How is oesophageal atresia diagnosed?
Antenatally | Wide feeding tube passed down and checked with X ray if it reaches the stomach
154
How does oesophogeal atresia present?
``` Antenatal USS Salivation Drooling Cough/choking when fed Cyanotic episodes Aspiration of saliva ```
155
How is oesophageal atresia treated?
Continuous suction applied to a tube passed to oesophageal pouch Surgical repair
156
What is the VACTERL association?
``` Vertebral Anorectal Tracheo-Esophageal Renal Limb anomalies ```
157
How does small bowel obstruction present? (4)
Antenatal USS Vomiting, possibly bile stained Delayed/absent stool passing Abdominal distension
158
What is bile stained vomit a sign of until proven otherwise?
Bowel obstruction
159
What may small bowel obstruction be caused by?
Duodenal atresia/stenosis - associated with Down's syndrome and other congenital malformations Jejunal/ileal atresia/stenosis - may be atretic bowel
160
How are small bowel atresia/stenosis treated?
Surgical repair | Correct fluid and electrolyte depletion
161
What is malrotation with volvulus?
Type of small bowel obstruction Loop of intestine loops around itself May lead to infarction of large parts of bowel
162
How is malrotation with volvulus treated?
Surgically after correction of fluids and electrolytes
163
What is meconium ileus?
Thick meconium becomes compacted in the lower ileum - almost all affected have cystic fibrosis
164
How is meconium ileus treated?
Dislodged using gastrografin contrast medium
165
What is meconium plug?
Plug of thick meconium causes lower intestinal obstruction, passes spontaneously
166
What causes large bowel obstruction?
Hirschprung's disease | Rectal atresia
167
What is rectal atresia?
Absence of anus at the normal site, possible fistula to bladder or vagina Surgical repair
168
What is Hirschprung's disease?
Absence of the ganglion cells from the myenteric and submucosal plexuses in the large bowel results in a narrow, contracted segment Mostly confined to rectosigmoid but in 10% whole bowel affected
169
How does Hirschprung's disease present? (4)
Intestinal obstruction in neonatal period Failure to pass meconium Abdominal distension Bile stained vomit
170
What is Hirschprung enterocolitis?
Severe bowel inflammation during first few weeks of life caused by Clostridium difficile infection
171
How does Hirschprung's disease present in older children? (3)
Chronic constipation Abdominal distension Growth failure
172
How is Hirschprung's disease diagnosed?
Absence of ganglion cells Presence of large acetylcholinesterase positive nerve trunks on rectal biopsy Barium studies to give length of affected segment
173
How is Hirschprung's disease treated?
Surgical | Colostomy then anastomosis of normal bowel to anus
174
What is exomphalos?
(omphalocoele) Abdominal contents protrude through umbilical ring, covered by a sac of amniotic membrane and peritoneum Usually associated with other abnormalities
175
What is gastroschisis?
Bowel protrudes through defect in abdominal wall adjacent to umbilicus, no covering sac Not associated with other abnormalities
176
Complications of gatroschisis?
Carries high risk of dehydration and protein loss
177
How is gastroschisis treated?
Wrap abdomen in layers of clingfilm NG tube IV dextrose Colloid support for lost protein
178
Repair of gastroschisis and exomphalos?
Primary closure of abdomen if small If large, intestine enclosed in a sac sutured to edge of abdominal wall and contents slowly returned to the peritoneal cavity
179
What is intussusception?
Invagination of proximal bowel into a distal segment, commonly ileum into caecum
180
When does intussusception present?
Most common intestinal obstruction after neonatal period | 3 months - 2 years
181
Complications of intussusception?
Stretching and constriction of mesentary resulting in venous obstruction and bowel perforation and necrosis
182
How does intussusception present? (6)
Paroxsymal severe colicky pain and pallor Refusal to feed Vomit, may be bile stained Mass in abdomen Passing of redcurrant jelly stool with blood stained mucous Abdominal distension, shock
183
Investigation of intussusception?
X ray - Distended small bowel, no gas in distal colon or rectum, may show outline
184
Treatment of intussusception?
Reduction by rectal air insufflation | Operative reduction if failed
185
What is Meckel's diverticulum?
Ileal remnant of the vitello-intestinal duct containing ectopic gastric mucosa or pancreatic tissue in 2% of infants
186
Presentation of Meckel's diverticulum? (4)
Most asymptomatic Rectal bleeding Intusssusception Diverticulitis
187
How is Meckel's diverticulum treated?
Surgical resection
188
How does malrotation of the bowel present?
Usually in first 1-3 days with obstruction | Presents at any age with volvulus causing obstruction and ischaemic bowel
189
Symptoms of malrotation?
Bilious vomiting Abdominal pain and tenderness from peritonitis Ischaemic bowel
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Treatment of malrotation?
GI contrast study and urgent surgery
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What is pyloric stenosis?
Hypertrophy of pyloric muscle causing gastric outlet obstruction, presenting between 2-7 weeks and more common in eldest boys
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Symptoms of pyloric stenosis? (4)
Projectile vomiting Dehydration Loss of interest in feeding Weight loss
193
Investigations of pyloric stenosis? (3)
Bloods - hypochloraemic metabolis alkalosis with low sodium and potassium Test feed - visible gastric peristalsis left to right, palpable olive shaped mass in upper right quadrant USS
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Management of pyloric stenosis?
Correct fluid and electrolyte balance - IV fluids, dextrose | Surgery - pyloromyotomy
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Symptoms of constipation? (4)
Decreased frequency of defecation Hard stool Pain Abdominal mass
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What is overflow diarrhoea?
Chronic constipation causes rectum to be over distended and the urge to defecate is lost Involuntary soiling may occur of watery stool
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How is constipation treated? (4)
Disimpaction - evacuation of rectum with stool softeners and laxatives and electrolytes (movicol, senna if unsuccessful) Maintenance - polyethylene glycol, reducing dose over a few months Enema if severe Dietary interventions, school support etc.
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How do diaphragmatic hernias present?
Antenatally Failure to respond to resuscitation Respiratory distress
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What is a congenital diaphragmatic hernia?
Defect in the diaphragm so bowel protrudes through and into the lung cavity, compressing the lung Most are left sided
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Signs of congenital diaphragmatic hernia? (2)
Poor air entry on affected side | Apex beat displaced if left sided
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Treatment of congenital diaphragmatic hernia?
Surgical correction | High mortality if large pulmonary hypoplasia
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What is an inguinal hernia and what causes it?
Protrusion of the bowel through the inguinal canal, mostly indirect Due to patent processus vaginalis More common in boys, premature
203
How does an inguinal hernia present? (2)
Groin/scrotal swelling when crying or straining | Possible scrotal oedema
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How are inguinal hernias treated?
Prompt surgical correction to avoid strangulation
205
What is appendicitis?
Inflammation of the appendix, commonest cause of abdominal pain in children needing surgery
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Symptoms of appendicitis? (3)
Anorexia Vomiting Initial central colicky pain then localised to right iliac fossa
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Signs of appendicitis? (4)
Flushed face Fever Pain aggravated on movement Tenderness and guarding at McBurney's point
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Investigations of appendicitis?
FBC for inflammatory markers | USS
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How is appendicitis treated?
Surgery - appendicectomy | Antibiotics if perforation
210
How common is recurrent abdominal pain in children?
10% of school age
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What are some causes of recurrent abdominal pain in children? (13)
``` IBS IBD Constipation Abdominal migraine Ulcers or functional dyspepsia Malrotation Dysmenorrhoea Ovarian cysts PID Hepatitis Gallstones UTI Psychosocial ```
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What are the 3 most common of recurrent abdominal pain in children?
IBS Functional dyspepsia Abdominal migraine
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Management of recurrent abdominal pain?
Exclude serious causes | Reassure - 50% become asymptomatic quickly
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How common is infective diarrhoea (gastroenteritis)?
10% of under 5s annually | Significant cause of mortality in developing countries
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What is the most common cause of gastroenteritis in developed countries?
Rotavirus 60% | Adenovirus, norovirus, coronavirus
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What are bacterial causes of gastroenteritis?
Campylobacter jejuni | Shigella, salmonella
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Symptoms of gastroenteritis? (3)
Loose watery stools Vomiting Dehydration
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Red flags in gastroenteritis? (6)
``` Red flags possibly indicating shock Deteriorating Lethargic Sunken eyes Increased heart rate and respiratory rate Decreased skin turgor ```
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Investigations of gastroenteritis?
Usually none Stool cultures if septic or bloody stools or if prolonged illness Check electrolytes
220
Treatment of gastroenteritis?
Oral rehydration solution IV fluids if shock or ongoing illness Antibiotics if septic, if <6 months, if salmonella or C.difficile, if immunodeficient
221
What is toddler diarrhoea?
Commonest cause of persistent loose stools in preschool children, most grow out of it by 5 but faecal continence may be delayed
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Symptoms of toddler diarrhoea?
Stools of varying consistency | Children are well
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What causes toddler diarrhoea?
Underlying maturational delay in intestinal motility leading to intestinal hurry
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How to manage toddler diarrhoea?
Eat more fat and fibre | If failure to thrive, investigate for cow's milk allergy or coeliac disease
225
What is Crohn's disease?
Inflammatory bowel disease, can affect everywhere from mouth to anus
226
Symptoms of Crohn's disease? (11)
``` Growth failure Delayed puberty Fever Weight loss Abdominal pain Oral lesions Perianal skin tags Uveitis Arthralgia Diarrhoea Erythema nodosum ```
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What is erythema nodosum?
Swollen fat under the skin causing bumps and redness
228
What is the classic triad of Crohn's presentation?
Weight loss Diarrhoea Abdominal pain
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Investigations of Crohn's disease? (5)
``` Increased platelets, ESR, CRP Decreased albumin Iron deficiency anaemia Colonoscopy Histology ```
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3 features of Crohn's disease?
Transmural Focal - commonly distal ileum/proximal colon Subacute or chronic
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What does colonoscopy in Crohn's disease show? (4)
Areas of inflamed/thickened bowel Strictures and fistulae Narrowed, fissured bowel Mucosal irregularities
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What does histology in Crohn's disease show?
Non caseating epithelioid cell granulomata
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What is the treatment of Crohn's disease?
Nutritional therapy - replace normal diet with protein feeds for 8 weeks If ineffective, systemic steroids If steroids contraindicated, budenoside or 5-ASAs
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How is relapsed Crohn's disease treated?
Immunosuppressants - azathioprine, methotrexate May need infliximab Surgery if complicated or refractive
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What is ulcerative colitis?
Recurrent inflammatory ulcerating disease affecting colonic mucosa
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Symptoms of ulcerative colitis?
``` Rectal bleeding Diarrhoea Colicky abdominal pain Arthritis Erythema nodosum ```
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How is ulcerative colitis diagnosed?
Bloods - raised inflammatory markers, anaemia Colonoscopy shows colitis extending from rectum proximally Histology
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What is a feature of ulcerative colitis?
In children, more likely to be pancolitis than confined to distal bowel in adults
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What is seen on histology in ulcerative colitis? (4)
Mucosal damage Crypt loss Abscesses Ulceration
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How is ulcerative colitis treated? (4)
5-ASA (aminosalicylates) If only rectum/sigmoid, topical steroids Azathioprine with prednisolone for exacerbations Colectomy if severe
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What is coeliac disease?
Malabsorption syndrome manifesting as abnormal stools, failure to thrive, nutrient deficiencies
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Symptoms of coeliac disease? (4)
Presents between 8-24 months normally, can present less acutely later on Steatorrhoea (greasy, hard to flush, smell) Failure to thrive Abdominal distension Irritability
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What causes coeliac disease?
Gliadin part of gluten provokes damaging immunological response in the proximal small intestine mucosa Villu shorten leaving a flat mucosa
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How is coeliac diagnosed?
Biopsy of small intestine shows villous atrophy and crypt hyperplasia Serology for IgA tissue transglutaminase antibodies, anti-endomysial
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How is coeliac treated?
Lifelong gluten free diet with supervision
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What is marasmus?
Severe protein-energy malnutrition in children, with <70% weight for height compared to average
247
Symptoms of marasmus? (3)
Wasted, wizened appearance Skinfold thickness and mid-arm circumference reduced Withdrawn, apathetic
248
What is Kwashiorkor?
Severe protein malnutrition, common in developing countries where infants are weaned late and diet is high in starch
249
Symptoms of Kwashiorkor? (8)
``` Oedema - weight not be as markedly reduced Distended abdomen Hepatomegaly Angular stomatitis Sparse hair Hyperkeratosis, rash Diarrhoea Hypothermia, hypotension, bradycardia ```
250
Management of severe malnutrition? (7)
``` Correct hypoglyaemia Keep warm Correct dehydration Correct electrolytes Treat infection Give vitamins Initiate small volume feeding frequently ```
251
What is IBS?
Irritable bowel syndrome, associated with altered GI motility and abnormal sensation, stronger peristaltic contractions
252
Symptoms of IBS? (5)
``` Abdo pain relieved by defecation Explosive, loose, mucousy stools Bloating Feeling of incomplete defecation Fluctuating constipation ```
253
Treatment of IBS? (5)
``` Fibre supplements Laxatives Anti-diarrhoeals Antispasmodics - reduce pain Antidepressants - reduce pain ```
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What is colic?
Symptom complex occuring in first few months of life, benign and self limiting
255
Symptoms of colic?
Paroxysmal inconsolable crying/screaming Drawing up of knees Excessive flatus
256
Causes of colic?
Unknown Cows milk allergy GORD

3A REVISION (17 decks)

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