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Specialties > Paeds Written - Gastro > Flashcards

Paeds Written - Gastro Flashcards

1
Q

Features of severe cow’s milk allergy

A

Failure to thrive
Severe atopic dermatitis
Laryngo-oedema / angioedema
Anaphylaxis

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2
Q

Management of cow’s milk allergy

A

Severe Sx –> refer to Paeds

FORMULA FED

  • swap to extensively hydrolysed formula
  • if no response –> amino acid formula

BREASTFED

  • continue breastfeeding
  • eliminate cow’s milk from maternal diet
  • +/- calcium supplements for mum
  • THEN extensively hydrolysed formula when breastfeeding stops until 12 months old / for at least 6 months
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3
Q

Prognosis of cow’s milk allergy

A

IgE mediated - 55% are tolerant at 5yo

Non IgE mediated - most children tolerant by 3yo

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4
Q

Risk factors for GORD

A

Pre-term delivery

Neurological disorders

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5
Q

1st line for GORD

A

1-2 week trial Alginate suspension (Gaviscon)

- should NOT be used at same time as thickeners

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6
Q

2nd line for GORD

A

4 week trial of PPI (omeprazole)

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7
Q

Alternative/Later Tx for GORD

A

Metoclopramide - only with specialist advice

Fundoplication - if severe complications + medical Tx ineffective

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8
Q

Conservative advice for babies with reflux/regurgitating feeds

A

Position during feeds - 30 degrees, head up

Sleep on back as per standard SIDS guidance

Ensure not being overfed

Consider trial of smaller + more frequent feeds

Trial of thickener e.g. rice starch, cornstarch

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9
Q

Distinguishing mesenteric adenitis from appendicitis?

A

Both - central or RIF pain

Mesenteric:

  • no anorexia
  • lack of rebound tenderness
  • shifting tenderness (if child turns to left side)
  • preceded by URTI or gastroenteritis

Appendicits
- high grade fever

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10
Q

Definitive Dx for mesenteric adenitis

A

Large mesenteric lymph nodes seen at laparoscopy (with normal appendix)

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11
Q

Tx for mesenteric adenitis

A

Analgesia

Antipyretics

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12
Q

Delivery requirements if exomphalos found on USS

A

C section

to reduce risk of sac rupture

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13
Q

Clinical features of Exomphalos

A

Abdominal contents protrude from anterior abdominal wall

Covered by amniotic sac (formed from amniotic membrane + peritoneum)

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14
Q

Associations with Exomphalos

A

Beckwith Wiedemann syndrome
Down syndrome
Cardiac & kidney malformations

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15
Q

Principles of surgery for exomphalos

A

Staged closure preferred to primary closure (Esp for large defect)

Sac granulates + epithelialises over weeks - months

Once infant has grown (enough for sac contents to fit inside abdomen) - shell removed + abdomen closed

Completed by 6-12 months

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16
Q

Clinical features of Gastroschisis

A

Abdominal contents outside of body (via anterior paraumbilical abdominal wall)

without peritoneal covering

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17
Q

Delivery requirements for Gastroschisis

A

If found on antenatal USS can still attempt vaginal delivery

BUT

Cling film to protect bowel + go to theatre ASAP after delivery (within 4 hours)

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18
Q

Examination findings in Pyloric stenosis

A

Olive shaped mass in RUQ/epigastric region
Succussion splash on auscultation of stomach
Visible peristalsis

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19
Q

Typical age for pyloric stenosis

A

4-6 weeks old

Range 1-10 weeks

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20
Q

Diagnostic Ix for pyloric stenosis

A

Abdo USS or Test feed

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21
Q

VBG findings in pyloric stenosis

A

Hypochloraemic
Hypokalaemic
Metabolic alkalosis (High bicarb)

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22
Q

Definitive Tx for pyloric stenosis

A

Ramstedt pyloromyotomy

  • Does NOT open GI tract (i.e. enter lumen)
  • Vertical cut across pylorus –> increases lumen diameter
  • Open or laparoscopic
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23
Q

Management of appendicitis

A

GAME

  • Group & Save
  • Abx IV
  • MRSA screen
  • Eat & drink - NO, NBM

+ Appendicectomy

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24
Q

Epidemiology of appendicitis in children

A

most common cause of abdo pain in child

BUT rare before 3yo

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25
Q

Pathophysiology of Mecekls’s diverticulum

A

Continued latency of vitelline duct (omphalomesenteric duct / vitelliointestinal duct)

Normally disappears at 6 weeks gestation

Results in ectopic site of gastric, pancreatic or ileal epithelial tissue

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26
Q

Rule of 2s (Meckel’s)

A

2 feet from ileocaecal valve
2 inches long
Affect 2% population

(Male: female = 2:1)

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27
Q

Most common cause of painless rectal bleeding in children?

A

Meckel’s diverticulum

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28
Q

Diagnostix Ix for Meckel’s diverticulum

A

Technetium-99m scintigraphy / pertechenate study of GI tract - shows ectopic uptake by gastric mucosa

Mesenteric arteriography (if severe i.e. needing transfusion)

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29
Q

Surgical management of Meckel’s diverticulum

A

Wedge excision OR

Formal small bowel resection + anastomosis

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30
Q

key clinical feature of malrotation / volvulus

A

Bile stained vomiting

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31
Q

Ix required in suspected malrotation/volvulus

A

upper GI contrast study - urgent

  • assess patency
  • done if bilious vomiting

USS

32
Q

Pathophysiology of Hirschprung’s disease

A

Absence of ganglion cells from Auerbach (myenteric) and Meissner (submucosal) plexuses
In distal colon & rectum
Causing uncoordinated peristalsis + functional obstruction

33
Q

Gold standard IX for Hirschprung’s disease

A

(Suction assisted) Full thickness rectal biopsy

34
Q

Complications of Hirschprung’s disease

A

Meconium plug syndrome

Hhrsicprung’s enterocolitis - life threatening C. diff, perforation

35
Q

Treatment options for Hirschprung’s

A

Rectal washout/bowel irrigation

Surgery - anorectal/endorectal pull through

36
Q

Conditions associated with meconium ileus

A

Cystic fibrosis

Biliary atresia

37
Q

Management of meconium ileus

A

PR contrast studies e.g. Gastrograffin enema, N-acetylcysteine
- diagnostic + potentially therapeutic (1st line)

2nd line if no response = surgical decompression

38
Q

Causes of Intussusception

A

Idiopathic

Enlarged Peyer’s patch - acts as lead point, after gastroenteritis

Hypertrophy in CF

39
Q

Symptoms & signs of Intussusception

A

Intermittent colicky pain - may draw legs up
Diarrhoea
Vomiting - may be bile stained
Red current jelly stool = late sign, emergency!

Abdo distension
Sausage shaped mass in RUQ
Dance’s sign - emptiness on palpation of RLQ

40
Q

1st line imaging in suspected Intussusception

A

Abdo USS –> target sign

41
Q

Management options in Intussusception

A

1st line = air insufflation (or contrast enema)

2nd line (or if perforation) = surgical reduction

+ Broad spectrum Abx e.g. clindamycin + gentamicin

42
Q

What should be done in recurrent intussusception?

A

Investigate for pathological lead point

  • Meckel diverticulum
  • Polyp
43
Q

Red flag features in constipation

A

Failure to pass meconium in first 24h = Hirschsprung’s

Faltering/failure of growth = Hypothyroid, Coeliac

Gross abdo distension = Hirschsprung’s

Abnormal LL neurology or deformity = lumbosacral pathology

Cutaneous marker above natal cleft/on spine = Spina bifida occulta

Abnormal appearance/position/patency of anus = anorectal malformation

Perianal bruising or fissures = sexual abuse

Perianal fistulae, abscesses or fissures = Crohn’s

44
Q

Behavioural interventions for constipation

A

Scheduled toileting - after meals to utilise gastrocolic reflex

Bowel habit diary

Reward system

Daily physical activity

Diet & fluid intake - fruit & veg, high fibre bread

45
Q

Medical management of disimpaction

A

1st line = Mocivol paediatric plain (Polyethylene glycol 3350 + electrolytes)

  • escalating dose regimen
  • e.g. 4 sachets on day 1 –> increase by 2 sachets each day to max 12
  • review within 1 week

2nd line = add stimulant (e.g. Senna)
- if not disimpacted within 2 weeks

If not tolerating Movicol, switch to stimulant +/- osmotic (lactulose)

46
Q

Medical maintenance for constipation

A

Polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain)

  • aim for 1 soft stool per day
  • can be used long term - no danger!
  • THEN gradually reduce over months
47
Q

Associations with umbilical hernia

A

Afro-Caribbean
Down’s syndrome
Mucopolysaccharide storage disease

48
Q

Elective repair of umbilical hernia - indications & timeline

A

Large (>1.5cm) or symptomatic = elective repair at 2-3 years

Small and asymptomatic = elective repair at 4-5 years

49
Q

Acute emergencies of umbilical hernias

A

Incarceration during observation period

  • needs manual reduction
  • THEN surgery within 24 hours

Irreducible –> emergency surgery

50
Q

Risk factors for indirect inguinal hernia

A

Male
Premature
Connective tissue disorders

51
Q

Management of indirect inguinal hernia

A

High risk of strangulation / incarceration –> urgent surgery

  • <6w old = within 2 days
  • <6m old = within 2 weeks
  • <6yo old = within 2 months
52
Q

Signs of incarcerated hernia

A 
Tender, firm mass
Poor feeding
Bowel obstruction - no stool
Vomiting
Overlying skin changes
53
Q

Management options for anal fissure

A

Increase dietary fibre

Increase fluid intake

Advise against stool withholding

Pain management

  • simple analgesia
  • sit in shallow warm bath
  • topical anaesthetic e.g. lidocaine, GTN ointment

Consider constipation Tx pathway

54
Q

Pathophysiology of anal fissure

A

Tears in skin around anus

Usually due to constipation: sphincter stretched to allow hard, dry stool to pass

55
Q

Dietary interventions for toddler’s diarrhoea

A

Reduce refined sugar

Avoid excessive fluid + fibre intake

56
Q

Most commonly affected sites in Crohn’s disease

A

Distal ileum

Proximal colon

57
Q

Biopsy finding in Crohn’s

A

non-caseating epithelioid cell granulomata

58
Q

Important Ix in Crohn’s

A

FBC - iron, B12, folate
CRP, ESR
Faecal calprotectin

Colonscopy + biopsy

Consider anxiety + depression scoring systems to assess impact on life

59
Q

Tx to induce remission in Crohn’s

A

Nutritional = Whole protein modular diet

  • 6-8 weeks
  • mostly liquid
  • may need NG tube
  • easily digested products –> put on lost weight

Pharmacological = Steroids (prednisolone)

60
Q

Maintaining remission in Crohn’s disease

A

Aminosalicylates (e.g. mesalazine)

Immunosuppressive drugs (azathioprine, methotrexate, mercaptopurine)

Anti-TNF antibodies (e.g. infliximab)

61
Q

Why should azathioprine NOT be given to?

A

People with TPMT mutation

- can’t metabolise drug –> BM toxicity?

62
Q

Role of surgery in Crohn’s?

A

Is NOT curative - can affect anywhere from mouth –> anus

But used for complications:

  • obstruction
  • fistula
  • abscess
  • severe localised disease unresponsive to medical Tx
63
Q

Colonoscopy & Histology features in Ulcerative colitis

A

Confluent colitis - extends from rectum proximally

Mucosal inflammation / ulceration
Crypt damage - abscess, loss, architectural distortion

64
Q

Severity grading system in UC?

A

Paediatric ulcerative colitis activity index (PUCAI)

  • severe = >65 points
  • mild-moderate = 10-64 points

Truelove & Witts score

65
Q

Important complications/associations of UC

A

Enteric arthritis

Toxic megacolon
Perforation
Bowel & liver cancer
Primary sclerosis cirrhosis

66
Q

Management of Severe fulminating UC

A

MDT - medics, surgeons

IV corticosteroids or ciclosporin

Assess need for surgery. More likely if:

  • stool frequency >8/day
  • tachycardia
  • pyrexia
  • low Albumin, low Hb, high platelets or CRP
  • AXR showing colonic dilatation
67
Q

Management of UC

A

1st line = aminosalicylates
- topical –> oral if no improvement after 4 weeks

2nd line = topical –> oral corticosteroid

3rd line = oral tacrolimus

4th line = biologics e.g. infliximab

5th line - surgery

68
Q

Coeliac disease HLA associations

A

HLA-DQ2

HLA-DQ8

69
Q

Key clinical features of coeliac disease

A

Bloating, irritability, diarrhoea

Malnutrition

  • buttock wasting
  • distended abdomen

Dermatitis herpetiformis = pruritic, papulovesicular elbow or knee rash

70
Q

Antibody tests for coeliac disease

A

IgA tissue transglutaminase (anti TTH) - most sensitive
IgA anti-endomysial cell antibodies - less sensitive

NOTE: send IgA at same time - deficiency can cause false negative

71
Q

What Ab can be used to diagnose coeliac disease if IgA deficient ?

A

IgG deiminated gliadin peptide (DGP)

72
Q

Confirmatory Ix for coeliac disease

A

Older children –> OGD + jejunal biopsy

Young children –> only Ab & HLA testing

73
Q

Biopsy findings in coeliac disease

A

Crypt hyperplasia
Villous atrophy
intraepithelial lymphocytes (IELs)

74
Q

Principles of coeliac disease management

A

MDT!

Strict gluten free diet

+ Refer to dietician for support

Annual 6m-12m review:

  • height & weight
  • symptoms
  • adherence to diet
  • blood tests?
75
Q

Complications of coeliac disease (poorly treated or untreated)?

A

Enteropathy associated T cell lymphoma (EATL)
Micronutrient deficiencies
Hyposplenism

76
Q

Diagnostic biochemical abnormality in rickets

A

Ca^2+ x PO4^2- = <2.4

both calcium + phosphate low

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