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Paeds Written - Gastro Flashcards

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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
Pathophysiology of Mecekls's diverticulum
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
26
Rule of 2s (Meckel's)
2 feet from ileocaecal valve 2 inches long Affect 2% population (Male: female = 2:1)
27
Most common cause of painless rectal bleeding in children?
Meckel's diverticulum
28
Diagnostix Ix for Meckel's diverticulum
Technetium-99m scintigraphy / pertechenate study of GI tract - shows ectopic uptake by gastric mucosa Mesenteric arteriography (if severe i.e. needing transfusion)
29
Surgical management of Meckel's diverticulum
Wedge excision OR | Formal small bowel resection + anastomosis
30
key clinical feature of malrotation / volvulus
Bile stained vomiting
31
Ix required in suspected malrotation/volvulus
upper GI contrast study - urgent - assess patency - done if bilious vomiting USS
32
Pathophysiology of Hirschprung's disease
Absence of ganglion cells from Auerbach (myenteric) and Meissner (submucosal) plexuses In distal colon & rectum Causing uncoordinated peristalsis + functional obstruction
33
Gold standard IX for Hirschprung's disease
(Suction assisted) Full thickness rectal biopsy
34
Complications of Hirschprung's disease
Meconium plug syndrome Hhrsicprung's enterocolitis - life threatening C. diff, perforation
35
Treatment options for Hirschprung's
Rectal washout/bowel irrigation Surgery - anorectal/endorectal pull through
36
Conditions associated with meconium ileus
Cystic fibrosis | Biliary atresia
37
Management of meconium ileus
PR contrast studies e.g. Gastrograffin enema, N-acetylcysteine - diagnostic + potentially therapeutic (1st line) 2nd line if no response = surgical decompression
38
Causes of Intussusception
Idiopathic Enlarged Peyer's patch - acts as lead point, after gastroenteritis Hypertrophy in CF
39
Symptoms & signs of Intussusception
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
1st line imaging in suspected Intussusception
Abdo USS --> target sign
41
Management options in Intussusception
1st line = air insufflation (or contrast enema) 2nd line (or if perforation) = surgical reduction + Broad spectrum Abx e.g. clindamycin + gentamicin
42
What should be done in recurrent intussusception?
Investigate for pathological lead point - Meckel diverticulum - Polyp
43
Red flag features in constipation
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
Behavioural interventions for constipation
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
Medical management of disimpaction
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
Medical maintenance for constipation
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
Associations with umbilical hernia
Afro-Caribbean Down's syndrome Mucopolysaccharide storage disease
48
Elective repair of umbilical hernia - indications & timeline
Large (>1.5cm) or symptomatic = elective repair at 2-3 years Small and asymptomatic = elective repair at 4-5 years
49
Acute emergencies of umbilical hernias
Incarceration during observation period - needs manual reduction - THEN surgery within 24 hours Irreducible --> emergency surgery
50
Risk factors for indirect inguinal hernia
Male Premature Connective tissue disorders
51
Management of indirect inguinal hernia
High risk of strangulation / incarceration --> urgent surgery - <6w old = within 2 days - <6m old = within 2 weeks - <6yo old = within 2 months
52
Signs of incarcerated hernia
``` Tender, firm mass Poor feeding Bowel obstruction - no stool Vomiting Overlying skin changes ```
53
Management options for anal fissure
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
Pathophysiology of anal fissure
Tears in skin around anus | Usually due to constipation: sphincter stretched to allow hard, dry stool to pass
55
Dietary interventions for toddler's diarrhoea
Reduce refined sugar | Avoid excessive fluid + fibre intake
56
Most commonly affected sites in Crohn's disease
Distal ileum | Proximal colon
57
Biopsy finding in Crohn's
non-caseating epithelioid cell granulomata
58
Important Ix in Crohn's
FBC - iron, B12, folate CRP, ESR Faecal calprotectin Colonscopy + biopsy Consider anxiety + depression scoring systems to assess impact on life
59
Tx to induce remission in Crohn's
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
Maintaining remission in Crohn's disease
Aminosalicylates (e.g. mesalazine) Immunosuppressive drugs (azathioprine, methotrexate, mercaptopurine) Anti-TNF antibodies (e.g. infliximab)
61
Why should azathioprine NOT be given to?
People with TPMT mutation | - can't metabolise drug --> BM toxicity?
62
Role of surgery in Crohn's?
Is NOT curative - can affect anywhere from mouth --> anus But used for complications: - obstruction - fistula - abscess - severe localised disease unresponsive to medical Tx
63
Colonoscopy & Histology features in Ulcerative colitis
Confluent colitis - extends from rectum proximally Mucosal inflammation / ulceration Crypt damage - abscess, loss, architectural distortion
64
Severity grading system in UC?
Paediatric ulcerative colitis activity index (PUCAI) - severe = >65 points - mild-moderate = 10-64 points Truelove & Witts score
65
Important complications/associations of UC
Enteric arthritis Toxic megacolon Perforation Bowel & liver cancer Primary sclerosis cirrhosis
66
Management of Severe fulminating UC
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
Management of UC
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
Coeliac disease HLA associations
HLA-DQ2 | HLA-DQ8
69
Key clinical features of coeliac disease
Bloating, irritability, diarrhoea Malnutrition - buttock wasting - distended abdomen Dermatitis herpetiformis = pruritic, papulovesicular elbow or knee rash
70
Antibody tests for coeliac disease
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
What Ab can be used to diagnose coeliac disease if IgA deficient ?
IgG deiminated gliadin peptide (DGP)
72
Confirmatory Ix for coeliac disease
Older children --> OGD + jejunal biopsy | Young children --> only Ab & HLA testing
73
Biopsy findings in coeliac disease
Crypt hyperplasia Villous atrophy intraepithelial lymphocytes (IELs)
74
Principles of coeliac disease management
MDT! Strict gluten free diet + Refer to dietician for support Annual 6m-12m review: - height & weight - symptoms - adherence to diet - blood tests?
75
Complications of coeliac disease (poorly treated or untreated)?
Enteropathy associated T cell lymphoma (EATL) Micronutrient deficiencies Hyposplenism
76
Diagnostic biochemical abnormality in rickets
Ca^2+ x PO4^2- = <2.4 | both calcium + phosphate low

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