Paediatrics Gastroenterology Flashcards

Question

What are the **red flags** for **constipation**?

Answer 1

**Not passing meconium within 48 hours of birth** (cystic fibrosis or Hirschsprung’s disease) **Neurological signs** particularly in the lower limbs (cerebral palsy or spinal cord lesion) **Vomiting** (intestinal **obstruction or Hirschsprung’s** disease) **Ribbon stool** (anal **stenosis**) **Abnormal anus** (anal stenosis, inflammatory bowel disease or sexual abuse) **Abnormal lower back or buttocks** (spina bifida, spinal cord lesion or sacral agenesis) **Failure to thrive** (coeliac disease, hypothyroidism or safeguarding) **Acute severe abdominal pain and bloating** (obstruction or intussusception)

Answer 2

**Pain** **Reduced sensation** Anal **fissures** **Haemorrhoids** **Overflow** and soiling **Psychosocial morbidity**

Answer 3

Without investigations, provided **red flags are considered**

Answer 4

- Correct any reversible contributing factors, recommend a high fibre diet and good hydration - Start laxatives (**movicol** is first line) - **Disimpactation regimen** for faecal impactation with high doses of laxatives at first - Encourage and praise visiting the toilet (**schedule visits, bowel diary** and **start charts**) Laxatives continued long term and slowly weaned off as child develops normal, regular bowel habit

Answer 5

Contents from stomach **reflux** through the **lower oesophageal sphincter**

Answer 6

**Immaturity** of the **lower oesophageal sphincter** (90% of infants stop having reflux by 1 year)

Answer 7

- Chronic cough - Hoarse cry - Distress, crying or unsettled after feeding - Reluctance to feed - Pneumonia - Poor weight gain

Answer 8

Similar to adults with **heartburn**, **acid regurgitation**, **retrosternal** or **epigastric pain**, **bloating** and **nocturnal cough**

Answer 9

Overfeeding Gastro-oesophageal reflux Pyloric stenosis (projective vomiting) Gastritis or gastroenteritis Appendicitis Infections such as UTI, tonsillitis or meningitis Intestinal obstruction Bulimia

Answer 10

**Not keeping down any feed** (pyloric stenosis or intestinal obstruction) **Projectile or forceful vomiting** (pyloric stenosis or intestinal obstruction) **Bile stained vomit** (intestinal obstruction) **Haematemesis or melaena** (peptic ulcer, oesophagitis or varices) **Abdominal distention** (intestinal obstruction) **Reduced consciousness, bulging fontanelle or neurological signs** (meningitis or raised intracranial pressure) **Respiratory symptoms** (aspiration and infection) **Blood in the stools** (gastroenteritis or cows milk protein allergy) **Signs of infection** (pneumonia, UTI, tonsillitis, otitis or meningitis) **Rash, angioedema and other signs of allergy** (cows milk protein allergy) **Apnoeas** are a concerning feature and may indicate serious underlying pathology and need urgent assessment

Answer 11

- Small, frequent meals - Burping regularly to help milk settle - Not over-feeding - Keeping baby upright after feeding (i.e. not lying flat)

Answer 12

**Gaviscon mixed with feeds** **Thickened milk or formula** (specific anti-reflux formulas are available) **Omeprazole** where ranitidine is inadequate (not ranitidine as its banned)

Answer 13

**Barium meal** and **endoscopy**

Answer 14

**Surgical fundoplication**

Answer 15

Rare condition causing **brief episodes** of **abnormal movements** associated with GORD in infants - normally **neurologically normal** - **Torticollis** - **Dystonia** (abnormal muscle contractions causing twisting movements, arching of the back or unusual postures) Condition resolves as reflux is treated or improves

Answer 16

**Infantile spasms** (West syndrome) and seizures

Answer 17

Ring of smooth muscle between **stomach and duodenum**?

Answer 18

**Hypertrophy** (thickening) of the pylorus

Answer 19

**Projectile vomiting** (due to increasing power peristalsis of the stomach as it tries to push food into the duodenum)

Answer 20

- First few weeks of life - Baby is **pale, thin** and **failing to thrive** - **Projectile vomiting** - Lump like **large olive** in upper abdomen caused by **hypertrophic muscle** of the **pylorus**

Answer 21

**Hypochloric** (low cholride) **metabolic alkalosis** as the baby is vomiting the **hydrochloric acid** from the stomach

Answer 22

**Abdominal ultrasound** to visualise the thickened pylorus

Answer 23

**Laparoscopic pyloromyotomy** (aka Ramstedt's operation) - incision is made in the smooth muscle of the pylorus to widen the canal - **prognosis is excellent**

Answer 24

**Inflammation** of the **stomach** presenting with nausea and vomiting

Answer 25

Inflammation of the **intestines** and presents with diarrhoea

Answer 26

Inflammation from the stomach to the intestines, presents with nausea, vomiting and diarrhoea

Answer 27

Viral (easily spread)

Answer 28

**Isolated** room

Answer 29

**Dehydration** - are they able to keep themselves hydrated / do they need admission for IV fluids Abx are generally not required

Answer 30

Greasy stool with excessive fat content (suggest pancreatic insufficiency e.g. cystic fibrosis)

Answer 31

**Infection** (gastroenteritis) IBD **Lactose** intolerance **Coeliac** disease **Cystic fibrosis** **Toddler’s diarrhoea** **IBS** **Medications** (e.g. antibiotics)

Answer 32

**Rotavirus** **Norovirus** Adenovirus (presents with more subacute diarrhoea)

Answer 33

Normal intestinal bacteria - certain strains cause gastroenteritis - spread through contact with **infected faeces, unwashed salads** or **contaminated water**

Answer 34

**Shiga toxin** which causes abdo cramps, bloody diarrhoea and vomiting - destroys red blood cells and leads to **haemolytic uraemic syndrome**

Answer 35

Antibiotics

Answer 36

Campylobacter jejuni

Answer 37

"Curved bacteria"

Answer 38

**Gram negative** with curved or spiral shape

Answer 39

Raw / improperly cooked poultry Untreated water Unpasteurised milk

Answer 40

3 to 6 days

Answer 41

- Abdo cramps - Diarrhoea often with blood - Vomiting - Fever

Answer 42

Severe symptoms / other risks e.g. HIV or heart failure **azithromycin** or **ciprofloxacin**

Answer 43

Faeces contaminated drinking water, swimming pools and food

Answer 44

1 to 2 days Resolve in 1 week without treatment

Answer 45

Blood diarhoea, abdo cramps and fever

Answer 46

The **shiga toxin** causes **haemolytic uraemic syndrome**

Answer 47

**Azithromycin** or **ciprofloxacin**

Answer 48

Eating **raw eggs** or **poultry** or **food contaminated** with the **infected faeces** of small animals

Answer 49

Incubation is 12 hours to 3 days Symptoms resolve within 1 week

Answer 50

**Watery diarrhoea** which can be associated with mucus / blood Abdo pain Vomiting

Answer 51

Severe cases and **guided by stool culture** and **sensitivities**

Answer 52

**Gram positive rod** spread through inadequately cooked foods

Answer 53

**Fried rice** left out at room temperature

Answer 54

**Cereulide**

Answer 55

**Abdo cramping** and **vomiting** within 5 hours of ingestion

Answer 56

**Gram negative bacillus**

Answer 57

**Pigs** (eating raw / undercooked pork can cause infection)

Answer 58

**Children** with watery / bloody diarrhoea

Answer 59

Lymphadenopathy Fever Abdo pain

Answer 60

4 to 7 days, **illness can last longer than other casues of enteritis** with symptoms lasting 3 weeks or more

Answer 61

Older children or adults present with right sided abdominal pain due to **mesenteric lymphadenitis** (inflammation of the intestinal lymph nodes) and fever

Answer 62

**Severe cases** and guided by stool cultures and sensitivities

Answer 63

Produces **enterotoxins** when growing on foods such as **eggs**, **dairy** and **meat** when eaten these cause small intestine inflammation

Answer 64

Diarrhoea Perfuse vomiting Abdo cramps Fever

Answer 65

Within hours of ingestion and settle within 12 to 24 hours

Answer 66

Type of **microscopic parasite** living in the **small intestines of mammals** (pets, farmyard animals or humans)

Answer 67

**Cysts** are released in the stools of infected mammals (these contminate food / water) and **are eaten**

Answer 68

No symptoms or **chronic diarrhoea** - diagnosis is made by **stool microscopy**

Answer 69

**Metronidazole**

Answer 70

Good hygiene

Answer 71

**Barrier nursing** and rigorous **infection control**

Answer 72

**48 hours** after the symptoms have **completely resolved**

Answer 73

**Microscopy**, **culture** and **sensitivities**

Answer 74

Keep hydrated with **fluid challenge** (policy varies with hospital) Recording a **small volume** of fluid given orally every 5-10 minutes (if they can tolerate this then they can be managed at home) **Dioralyte** (rehydration solution) can be used if tolerated Dehydrated children / those which fail the fluid challenge may require **IV fluids** Give dry foods e.g. toast **Antidiarrhoeals/antiemetics are generally not recommended** (loperamide / metoclopramide) **Antidiarrhoeals are particularly not used** in E.Coli 0157 and shigella infections and where there is **bloody diarrhoea/ high fever** Abx only used in patients at risk of complications

Answer 75

Lactose intolerance IBS Reactive arthritis Guillain-Barre syndrome

Answer 76

**Autoimmune** condition where **explosure to gluten** causes an **immune reaction** which creates **inflammation** in the **small intestines**

Answer 77

**Early childhood** (can start at any age)

Answer 78

**Epithelial cells** of the intestine

Answer 79

**Anti-tissue transglutaminase** (anti-TTG) **Anti-endomysial** (anti EMA)

Answer 80

**Correlate with disease activity** and rise with more active diease (may disappear with effective treatment)

Answer 81

**Jejunum** causing **atrophy** of the **intestinal villi**

Answer 82

**Malabsorption of nutrients** and disease related symptoms

Answer 83

Often asymptomatic (so have a low threshold for testing) **Failure to thrive** in young children Diarrhoea Fatigue Weight loss Mouth ulcers Anaemia seconds to **iron**, **B12** or **folate deficiency** **Dermatitis herpetiformis** which is an itchy blistering skin rash that typically appears on the abdomen

Answer 84

Peripheral neuropathy Cerebella ataxia Epilepsy

Answer 85

Type 1 diabetes (all patients with a new diagnosis are tested for coeliacs)

Answer 86

HLA-DQ2 gene (90%) HLA-DQ8 gene

Answer 87

Tissue transglutaminase antibodies (**anti-TTG**) Endomysial antibodies (**EMAs**) Deaminated gliadin peptides antibodies (**anti-DGPs**)

Answer 88

Investigate whilst patient **remains on a diet containing gluten** **Check total immunoglobulin A levels** to exclude **IgA deficiency** before checking for **coeliac disease specific antibodies** * Raised **anti-TTG antibodies** (first choice) * Raised **anti-endomysial antibodies**

Answer 89

**Crypt hypertrophy** **Villous atrophy**

Answer 90

**Type 1 diabetes** **Thyroid disease** **Autoimmune hepatitis** **Primary biliary cirrhosis** **Primary sclerosing cholangitis** **Down’s syndrome**

Answer 91

**Vitamin deficiency** **Anaemia** **Osteoporosis** **Ulcerative jejunitis** Enteropathy-associated T-cell lymphoma (**EATL**) of the intestine Non-Hodgkin lymphoma (**NHL**) **Small bowel adenocarcinoma** (rare)

Answer 92

Lifelong **gluten free diet** is essentially curative (checking coeliac antibodies can be helpful in monitoring of the disease)

Answer 93

**Ulterative colitis** and **Crohn's disease** (causes inflammation of the GI tract)

Answer 94

Periods of **remission** and **exacerbation**

Answer 95

**N – No blood or mucus** (these are less common in Crohns.) **E – Entire GI tract** **S – “Skip lesions”** on endoscopy **T – Terminal ileum most affected** and **Transmural** (full thickness) inflammation **S – Smoking is a risk factor** (don’t set the nest on fire)

Answer 96

Weight loss Strictures Fistulas

Answer 97

**C** – Continuous inflammation **L** – Limited to colon and rectum **O** – Only superficial mucosa affected **S** – Smoking is protective **E** – Excrete blood and mucus **U** – Use aminosalicylates **P** – Primary sclerosing cholangitis

Answer 98

**IBD** should be suspected in children and teenagers presenting with **perfuse diarrhoea**, **abdo pain, bleeding, weight loss** or **anaemia** During flares = fevers, malaise and dehydration

Answer 99

Finger **clubbing** **Erythema nodosum** **Pyoderma gangrenosum** **Episcleritis and iritis** **Inflammatory arthritis** **Primary sclerosing cholangitis** (ulcerative colitis)

Answer 100

**Faecal calprotectin** (released by intestines when inflammed - useful screening tool) **Endoscopy** (OGD and colonoscopy) with biopsy is the **gold standard investigation** for diagnosis of IBD **Imaging** with ultrasound, CT and MRI can be used to look for complications e.g. **fistulas, abscesses and strictures** (Blood tests for anaemia, thyroid, kidney and liver function - raised CRP indicates active inflammation)

Answer 101

Referral to secondary care for assessment Managed by **multi-disciplinary team** (paediatricians, specialist nurses, pharmacists, dieticians and surgeons) Monitoring of **growth** and **pubertal development** (particularly when flaring or on steroids) Inducing remission during flares and then maintaining

Answer 102

**Steroids** (oral prednisolone or IV hydrocortisone) If steroids alone dont work then add immunosuppressants: **Azathioprine** **Mercaptopurine** **Methotrexate** **Infliximab** **Adalimumab**

Answer 103

**First line:** * Azathioprine * Mercaptopurine **Alternatives:** * Methotrexate * Infliximab * Adalimumab

Answer 104

Disease only affects the **distal ileum** (possible to resect this area to prevent further flares) Treat **strictures** and **fistulas**

Answer 105

**_Mild to moderate disease_** First line: **aminosalicylate** (e.g. mesalazine oral or rectal) Second line: corticosteroids (e.g. prednisolone) **_Severe disease_** **First line: IV corticosteroids** (e.g. hydrocortisone) Second line: IV ciclosporin

Answer 106

**Aminosalicylate** (e.g. mesalazine oral or rectal) ## Footnote **Azathioprine** **Mercaptopurine**

Answer 107

**Panproctocolectomy** (removing colon and rectum as UC only usually affects here) Patient is left with **ileostomy** or **ileo-anal anastomosis** (j-pouch) = ileum is folded back on itself and fashioned into a larger pouch **like a rectum** which is then attached to the anus

Answer 108

Congenital condition where a section of the bile duct is **narrowed** or **absent** resulting in **ch****olestasis**

Answer 109

Conjugated bilirubin

Answer 110

Shortly after birth with significant **jaundice** due to **high conjugated bilirubin levels** (more than 14 days in term babies and 21 days in premature babies)

Answer 111

**Conjugated** and **unconjugated bilirubin -** high proportion of **conjugated bilirubin** suggests the liver is processing the bilirubin for excretion by conjugating it - but not able to excrete

Answer 112

**Benign** e.g. **breast milk jaundice**

Answer 113

**Sugery** - Kasai portoenterostomy - a section of the small intesting is attached to the opening of the liver where bile duct normally attaches **Full liver transplant**

Answer 114

Patient is unable to pass stools or wind

Answer 115

**Meconium ileus** **Hirschsprung’s** disease **Oesophageal atresia** **Duodenal atresia** **Intussusception** **Imperforate anus** **Malrotation of the intestines with a volvulus** **Strangulated hernia**

Answer 116

**Persistant vomiting** (bilious = bright green bile) **Abdo pain and distention** **Failure to pass stools** or wind **High pitched / tinking bowel sounds** early in the obstruction and **absent** later

Answer 117

**Abdo x-ray** showing **dilated loops of bowel** proximal to the obstruction and **collapsed loops of bowel** distal to the obstruction ## Footnote **Absence of air in the rectum**

Answer 118

Reffered to **paediatric surgical unit** as an emergency with inital mangement of **nil by mouth** and inserting a **NG** tube to drain the stomach **IV fluids** to correct dehydration / electrolyte imbalances

Answer 119

**Congenital condition** where nerve cells of the **myenteric plexus** are **absent in the distal bowel and rectum**

Answer 120

Forms the **enteric nervous system** - brain of the gut aka **Auerbach's plexus**

Answer 121

Web of **neurons, ganglion cells, receptors, synapses** and **neurotransmitters** - responsible for stimulating **peristalsis** of the large bowel

Answer 122

**Absence of parasympathetic ganglion cells** (during development these cells start higher in the GI tract and gradually migrate down to the distal colon and rectum - here they dont travel all the way down)

Answer 123

**Total colonic aganglionosis** the aganglionic section of the colon doesnt relax causing it to become constricted causing loss of movement of faeces

Answer 124

**Downs** syndrome **Neurofibromatosis** **Waardenburg syndrome** (genetic condition causing pale blue eyes, hearing loss and patches of white skin and hair) **Multiple endocrine neoplasia type II** **Family hx of Hirschsprung's**

Answer 125

**Delay in passing meconium** (more than 24 hours) **Chronic constipation since birth** **Abdo pain** and distention **Vomiting** **Poor weight gain** and failure to thrive Can be gradul / acute presentation

Answer 126

**Inflammation and obstruction of intestine** (occuring in 20% of neonates with Hirschsprung's disease) typically presents within 2-4 weeks of birth with fever, abdo distention, diarrhoea (often with blood) and features of sepsis

Answer 127

Life threatening - leads to **toxic megacolon** and **perforation of bowel** Treated with **abx, fluid reuscitation** and **decompression** of the **obstructed bowel**

Answer 128

**Abdo x-ray** for diagnosing intestinal obstruction and demonstrating features of HAEC **Rectal biopsy** to confirm the diagnosis (histology will demonstate an **absence of ganglionic cells**) Fluid resuscitation and management of **intestinal obstruction** IV abx in HAEC

Answer 129

**Surgical removal** of **aganglionic cells** - most have a normal life after surgery but may be some degree of incontinence

Answer 130

Condition where bowel '**invaginates**' or '**telescopes**' into itself

Answer 131

**Concurrent viral illness** **Henoch-Schonlein purpura** **Cystic fibrosis** Intestinal **polyps** **Meckel diverticulum**

Answer 132

- Severe colicy abdo pain - Pale, lethargic and unwell child - "**Redcurrant jelly stool**" - Right upper quadrant mass (sausage shaped) - Vomiting - Intestinal obstruction

Answer 133

**Ultrasound scan** or **contrast enema**

Answer 134

**Therapeutic enemas** (contrast, water or air are pumped into the colon to force the folded bowel out of the bowel and into the normal position) **Surgical reduction** (if enemas don't work or if bowel becomes gangrenous/perforates)

Answer 135

Obstruction Gangrenous bowel Perforation Death

Answer 136

Inflammation of the appendix (a small thin tube sprouting from the caecum) - becomes inflammed due to infection being trapped there by obstruction at the point where the appendix meets the bowel

Answer 137

**Gangrene** and **rupture** causing **peritonitis**

Answer 138

Patients aged 10-20

Answer 139

**Abdo pain** which migrates from centre to **RIF** Tenderness at **Mc Burney's point** localised area one third from ASIS to umbilicus **Anorexia** (loss of appetite) N&V **Rovsing's sign** (palpation on LIF causes pain in RIF) **Guarding** on abdo palpation **Rebound tenderness** on RIF **Percussion tenderness** which is pain and tenderness when percussing the abdomen

Answer 140

**Peritonitis** caused by **ruptured appendix**

Answer 141

**Clinical presentation** and **raised inflammatory markers** CT scan can be used to **confirm the diagnosis** - particularly when another diagnosis is more likely **Ultrasound** in female to exclude ovarian and gynae pathology

Answer 142

**Diagnostic laparoscopy** to visualise appendix - can then proceed to an **appendicectomy** during same procedure

Answer 143

**Ectopic pregnancy** (take a serum / urine bHCG) **Ovarian cysts** (particularly with rupture / torsion) **Meckel's diverticulum** (malformation of distal ileum in 2 % of population, usually asymptomatic but can bleed, become inflammed, rupture or cause a **volvulus** / **intussusception**) - often removed prophylactically if itendified incidentally during other bado operations **Mesenteric adenitis** (inflammed abdo lymph nodes causing abdo pain in younger children associated with tonsillitis or URTI - not specific treatment required) **Appendix mass** - when **omentum** surrounds and sticks to the inflammed appendix, forming a mass in the RIF - managed conservatively with supportive treatment and abx followed by appendicectomy once condition has resolved

Answer 144

**Emergency admission to hospital** (older children can be managed by adult general surgical teams \>10) **Appendicectomy** **Laparoscopic sugery** = fewer risks and faster recovery compared to open sugery (**laparotomy**)

Answer 145

**Bleeding, infection, pain and scars** **Damage** to bowel, bladder or other organs **Removal of a normal appendix** **Anaesthetic risks** **Venous thromboembolism**

Paediatrics Gastroenterology Flashcards

(171 cards)