Paeds - Gastro

Question 1

Define

1) poseting
2) regurgitation
3) vomiting

Answer 1

1) poseting = non-forceful return of small amounts of milk with wind
2) regurgitation = larger + more frequent losses
3) vomiting = forceful ejection of gastric contents

Question 2

What are the main causes of vomiting in infants?

Answer 2

1) feeding problems = GOR / over feeding
2) infection = meningitis, RTI/otitis media, whooping cough, gastroenteritis, UTI
3) intestinal obstruction = pyloric stenosis, intersussception, malrotation, volvulus, Hirschsprung disease

Question 3

Why do babies suffer from GOR?

Answer 3

Their lower oesophageal sphincter is immature and this can lead to inappropriate relaxation of it - leading to back flow of gastric contents.
A fluid diet and horizontal posture also contributes.

Question 4

What complications can GOR cause?

Answer 4

FTT
Oesophagitis - haematemesis
Aspiration - recurrent pneumonia
Parent life threatening events

Question 5

A 4m old presents with a cough and wheeze. He has had 2 recent chest infections. He has been refusing feeds recently and have been increasingly irritable.
You suspect that he has GOR and its aspiration is the cause for the respiratory symptoms.
What investigations do you want to request to prove this?

Answer 5

Ix for GOR

• 24hr oesophageal ph monitoring (unexplained aspiration pneumonia)
• Endoscopy with oesophageal biopsy
• PPI trial

Question 6

A 5 month old presents with refusal to feed and wt loss. He has been arching his back in pain following feeds. He often vomits after feeds.
You suspect that he has GOR.
What are the treatment options?

Answer 6

Rx for GOR
Reassurance
Thickening foods - nestargel/gaviscon
Prone positioning after feeds

Meds:

• Ranitidine = H2antagonists
• Omeprazole = PPI

Surgical:
Nissen fundoplication

Question 7

What are the red flag symptoms for a patient presenting with GOR?

Answer 7

• Frequent forceful vomiting - <2 pyloric stenosis
• Bile stained vomit, abdo distension, tenderness, mass - Intestinal obstruction/ surgical
• Blood - GI bleed
• Late onset >6m UTI

Question 8

What age group suffers from pyloric stenosis?

And what are other risk factors

Answer 8

Pyloric stenosis 
2-7weeks 
M>F 
Caucasion 
FHx

Question 9

What is the classical presentation of pyloric stenosis?

Answer 9

<7 week infant (white boy) with projectile vimiting
Still hungry after feeds and poor weight gain
Risk of dehydration and metabolic alkalosis

Question 10

What causes pyloric stenosis?

Answer 10

Hypertrophy of the pyloric muscle causing gastric outlet obstruction

Question 11

What is infantile colic?

Answer 11

Paroxysmal crying - inconsolable crying several times a day.
Occurs in 40% babies - most resolves around 4m

Question 12

What is Rovsing’s sign?

Answer 12

+ve in appendicitis

If you palpate the LIF you induce pain in the RIF

Question 13

A 15 year old girl presents with acute abdomen pain that has come on today. It is constant and worse when she moves. She has vomited and has a fever.
List the differentials.

Answer 13

Appendicitis 
Ectopic pregnancy 
DKA 
Hepatitis 
Pyelonephritis 
Strangulated inguinal hernia

Question 14

Give the ages and reasons that can cause intussusception to occur.

Answer 14

Intessusception = telescoping of the terminal ileum into the large bowl.
4-18m infant: weeing, increased allergens may cause payers patches to develop.
6-7 FAP or meckles diverticulum.

Both are out pouches that are mistaken by food and are moved along the bowl by peristalsis through the cecum and into the ascending colon

Question 15

How does intussusception present?

Answer 15

Severe intermitted colicky pain - child drawing up legs. Pain increasing in frequency.
Lethargic and pale between episodes.
Vomiting +/- Diarrhoea - RED CURRENT JELLY STOOLS
Abdo distension - sausage shaped mass in RUQ

Question 16

How would you diagnose and treat intussusception?

Answer 16

Ix: USS showing a target or doughnut sign.
Rx: Air enema reduction

Question 17

What is a meckel’s diverticulum?

Answer 17

Meckel’s diverticulum = an ileal remnant of vitello-intestinal duct (yolk stalk)

Question 18

Explain the features of malrotation

Answer 18

Malrotation = embryological failure of the complete rotation and fixture of the small bowel and its mesentery.
- Mesentaric base is shorter than it should be leading to increased risk of volvulus.
- Cecum displaced to RUQ
Fibrous bands of Ladd - normally attack the cecum to the RLQ but may cause obstruction if in wrong place.

Question 19

What is IBS?

Answer 19

Altered gastric motility and abnormal sensation of intra-abdominal events.

Question 20

What are the causes of chronic constipation in children?

Answer 20

Intollerence/allergy = coeliacs, cow’s milk/soy protein allergy, lactose intolerance
IBD = Chrons/UC
CF
Post infectious secondary lactose deficiency

Question 21

What are the treatment options for constipation?

Answer 21

1) stool softeners: macrogol laxatives = movicol (polyethylene glycol)
2) Stimulant laxatives = senna
3) Osmotic laxatives = lacululose

Question 22

Causes of proteinuria in children?

Answer 22

Transient = normal 
* Physical exercise 
* Postural - when its only found when the child is upright - measure urine protein/creatinine ratio in a morning series of ratios 
Persistant & abnormal 
* UTI 
* Glomerular abnormalities 
    * Minimal change glomerular disease 
    * Glomerulonephritis 
    * Abnormal glomerular basement membrane 
* Renal tubular disease 
* Chronic renal disease 
* HTN

Question 23

Give the features in nephrotic syndrome and how it might present?

Answer 23

Nephrotic syndrome 
1. Proteinuria 
2. Low plasma albumin 
3. Oedema 
Pres: periorbital oedema, scrotal, vulval, leg and ankle oedema, ascites or SOB

Question 24

Primary and secondary causes of nephrotic syndrome

Answer 24

Primary - minimal change disease, focal segmental glomerulosclerosis or membranoproliferative glomerulonephritis

Secondary - Diabetes, henoch-schonlein purpura, hepatitis, SLE, Strep infection,

Question 25

Complications of nephrotic syndrome

Answer 25

Complications * Hypovoleamia abdo pain & feeling faint Rx: IV albumin but caution not to fluid overload * Thrombus Hyper coagulable state - losses of antithrombin & thrombocytosis and increased blood viscosity and increased production of clotting factors * Infection - Esp pneumococcus and H influenzae, * Hypercholesterolaemia -

Question 26

What Ix would you do for nephrotic syndrome?

Answer 26

Bloods - FBC, ESR, U&E’s, creatinine, albumin, complement levels C3&C4 Urine - dipstick for proteins, MC&S, urinary sodium concentrations Hep B&C screen, malaria if recent travel, Antisteptolysin O or anti-DNAase B titres and throat swab

Question 27

What can cause haematuria?

Answer 27

``` Non-glomerular = Renal vein thrombosis, bleeding disorders, infection, SC, stones Glomerular = Acute glomerulonephritis, chronic glomerulonephritis, IgA nephropathy, Alport syndrome ```

Question 28

What can cause acute nephritis?

Answer 28

Acute nephritis * Post strep * Vasculitis - Henoch-Schonlein purpura, SLE, polyarteritis nodosa * IgA nephropathy * Goodpastures syndrome - anti-glomerular basement membrane disease

Question 29

What are the symptoms of Henoch-schonlein purpura?

Answer 29

1. Purpura - buttocks, extensor surfaces, arms & legs - trunk spared Urticarical - maculopapular and purpuric 1. Arthritis 2. Periarticular oedema 3. Abdo pain 4. Glomerulonephritis And fever