1
Q
Abdominal pain can be split into medical causes, surgical causes and non-organic/functional causes; state some medical causes
A
- Constipation
- Coeliac disease
- IBD
- IBS
- Mesenteric adenitis
- Abdominal migraine
- UTI
- Pyelonephritis
- DKA
- Henoch-Schonlein purpura
- Infantile colic
- Tonsillitis
Additional causes in adolescent girls….
- Dysmenorrhea
- Mittelschmerz (ovulation pain)
- Ectopic pregnancy
- PID
- Ovarian torsion
- Pregnancy
2
Q
Abdominal pain can be split into medical causes, surgical causes and non-organic/functional causes; state some surgical causes
A
- Appendicitis
- Intussusception (colicky, non-specific, redcurrant jelly stools)
- Bowel obstruction (pain, distension, absolute constipation, vomiting)
- Testicular torsion (sudden onset, unilateral testicular pain, N&V)
3
Q
Abdominal pain can be split into medical causes, surgical causes and non-organic/functional causes. What is non-organic/functional abdominal pain?
A
- No disease process/underlying pathology can be found to explain abdominal pain
- Common children >5yrs
- Often corresponds to stressful life events
4
Q
State some red flags for abdominal pain in children
A
- Persistent or bilious vomiting
- Severe chronic diarrhoea
- Rectal bleeding
- Weight loss or faltering growth
- Dysphagia
- Nighttime pain
5
Q
State some initial investigations you may do for a child with abdominal pain
A
- Urine dipstick (for UTI)
- Faecal calprotectin (for IBD)
- FBC (anaemia in IBD or coeliac)
- CRP/ESR (for IBD)
- Anti-TTG or anti-EMA (for coeliac)
6
Q
For recurrent abdominal pain, discuss:
- What it is
- Triggers/associations
- Management
A
- Repeated episodes of abdominal pain with no identifiable cause (pain is non-organic/functional). Thought that is is due to increased sensitivity & inappropriate signals from visceral nerves in gut
- Often associated with stressful life events e.g. bullying, bereavement
- Management:
- Education & reassurance
- Encourage parents not to ask about or focus on pain
- Distract child from pain
- Advice about sleep, healthy eating, hydration, exercise, reducing stress
- Address any psychosocial triggers/factors
- Support from school counsellor or child psychologist
- Avoid NSAIDs
- Probiotic supplements for IBS symptoms
7
Q
What are abdominal migraines/how do they present?
A
Episodes of central abdo pain lasting >1hr, may have similar triggers to head migraines, which may be associated with:
- Nausea & vomiting
- Headache
- Photophobia
- Aura
- Pallor
- Anorexia
8
Q
How often should children open their bowels?
A
Normal stool frequency in children ranges from an average of four per day in the first week of life to two per day at 1 year of age. Passing between three stools per day and three per week is usually attained by 4 years of age.
9
Q
Discuss the management of abdominal migraines, consider:
- Management of an acute attack
- Preventative management
A
Acute attack
- Low stimulus environment
- Paracetamol
- Ibuprofen
- Sumatriptan (NASAL, PO not licensed in children)
Preventative medications must be started by specialist
- Pizotifen (serotonin agonist)
- Propanolol
- Cyproheptadine (antihistamine)
- Flunarazine (calcium channel blocker)
*Pizotifen= main preventative medication. Must be withdrawn slowly due to withdrawal symptoms (depression, anxiety, poor sleep, tremor)
10
Q
Most cases of paediatric constipation are idiopathic/functional (no underlying cause found other than simple lifestyle factors); however, sometimes it may be secondary to another condition. State some secondary causes of constipation (not including lifestyle factors)
A
- Hirschsprung’s disease
- Hypothyroidism
- Cystic fibrosis
- Hypercalcaemia
- Learning disabilites
- Anal fissure
11
Q
State some typical features in history & examination that suggest constipation
A
- <3 stools a week
- Hard stools
- Stools difficult to pass- straining, painful
- ‘Rabbit droppings’
- Abdominal pain
- Retentive posturing (posture to avoid passing stool- typically straight legs, on tip toes with arched back)
- Rectal bleeding associated with hard stools
- Overflow soiling (encopresis= faecal incontinence)
- Hard stools palpable in abdomen
- Loss of sensation of need to open bowels
12
Q
What 3 symptoms/signs indicate faecal impaction?
A
- Symptoms of severe constipation
- Overflow soiling
- Faecal mass palpable in abdomen (only specialists should do DRE)
13
Q
Describe how desensitisation of rectum and encoperesis develop
A
- Develop habit of not opening their bowels when need to or ignore sensation of full rectum
- Stretches rectum
- Lose sensation
- Open bowels less frequently
- Retain faeces in rectum
- Faecal impaction
- … vicious cycle
- Only lose stools are able to bypass blockage and leak out leading to encopresis
14
Q
State some red flags in a constipation history
A
If red flags present must refer urgently to specialist:
- Not passed meconium
- Neurological signs or symptoms- particularly lower limbs (may be cerebral palsy or spinal cord lesion)
- Vomiting (intestinal obstruction or hirschsprungs)
- Ribbon stool (anal stenosis)
- Abnormal anus (anal stenosis, IBD, sexual abuse)
- Abnormal lower back or buttocks
- Acute severe abdominal pain & distension (obstruction or intussusception)
*NOTE: failure to thrive (coeliac, hypothyroidism) is an amber flag as is constipation triggered by introduction of cows milk and concerns about possibility of child maltreatment
15
Q
Does functional constipation require any investigations?
A
As long as have ruled out red flags, then can make diagnosis of idiopathic or functional constipation based on history.
16
Q
Discuss the management of functional & idiopathic constipation
A
- Advise on diet: high fibre & plenty of fluids
- Advise regular exercise
- Encourage & praise for using toilet e.g. have scheduled visits, keep a bowel diary, toileting reward charts (e.g. ERIC toilet tool)
- Laxatives
- First line= movicol
- Second line= add stimulant e.g. senna, picosulphate
- Others e.g. lactulose, docusate if stool is hard
- Continue then gradually reduce once regular bowel habits established
- Faecal impaction may require disimpaction regimen (with increasing doses of laxatives over a period of 7-10 days)
*NOTE: don’t just give lifestyle advice on it’s own
17
Q
State some potential complications of constipation
A
- Pain
- Anal fissures
- Haemorrhoids
- Reduced sensation in rectum
- Overflow & soiling
- Rectal prolapse
- Megarectum
- Distress for child & family (discomfort, missed school, social isolation etc…)
18
Q
Summary of NICE guidance for diagnosing constipation in children
A
19
Q
It is normal for babies to reflux feeds; true or false?
A
TRUE: their lower oesophageal sphincter is immature hence allows stomach contents to easily reflux into oesophagus,(and throat and mouth). Provided they are growing and well it is not a problem. It is called GOR if it is asymptomatic. It is called GORD if it is symptomatic or there are complications. 90% stop refluxing by 1yr of age.
20
Q
What is posseting?
A
Most reflux is swallowed back into the stomach, but occasionally babies will vomit it out of their mouth (which is sometimes called posseting or regurgitation.
21
Q
State some risk factors for GORD
A
- Prematurity
- Obesity
- FH of GORD
- Hiatus hernia
- Neurodisability (e.g. cerebral palsy)
- History of repaired diaphragmatic hernia
22
Q
State some signs of problematic reflux in infants
A
- Distress or unsettled after feeding
- Reluctance to feed
- Poor weight gain
- Hoarse cry
- Chronic cough
- Pneumonia
Children >1yr may experience similar symptoms to adults (retrosternal, epigastric pain, bloating, nocturnal cough)
23
Q
Discuss the management of GORD- consider differences for breast fed and formula fed babies, children >1yrs and severe cases
A
- General advice:
- Small, frequent meals
- Burp/wind regularly
- Don’t overfeed
- Feed with head at 30 degrees
- Keep baby upright after feeding
Breast fed
- 1-2 week trial of gaviscon (mixed with water after feed)
- If successful continue treatment but stop every 2 weeks to see if symptoms improve and treatment can be stopped
- If unsucessful, 4 week trial or omeprazole or ranitidine
Formula fed (1-2 week trial of each of the following)
- Reducing feeds (shouldn’t have more than 150ml/kg/day)
- Decrease feed volume each sitting and increase frequency of feeds
- Thickened feeds (thickener or pre-thickened formula e.g. carobel)
- Stop thickener and add alginate to formula
- If unsuccessful, 4 week trial omeprazole or ranitidine
Children >1yrs/not breast or formula fed and still experiencing GORD
- 4 week trial omeprazole or ranitidine
Severe cases
- Surgical fundoplication
24
Q
State some potential complications of GORD in infants
A
- Aspiration leading to pneumonia
- Failure to thrive
- Frequent otitis media
- Dental erosion in older children
- Apnoea (rare)
25
What is coeliac disease?
Remind yourself of the pathophysiology
* **Autoimmune reaction to the gliadin fraction of gluten**
* The antibodies, **anti-tissue transglutaminase** (anti-TTG) and a**nti-endomysial** (anti-EMA), target the **epithelial cells of the intestine** causing inflammation
* **Inflammation** mainly affects **small bowel**- particularly **jejunum**
* Causes **atrophy of intestinal villi** leading to malabsorption and symptoms
26
State some conditions associated with coeliac disease
* T1DM
* Thyroid disease
* Autoimmune hepatitis
* Primary biliary cirrhosis
* Primary sclerosing cholangitis
* Down's syndrome
27
Coeliac disease is often asymptomatic so must have low threshold for testing. If symptomatic, state some potential symptoms
* Failure to thrive
* Diarrhoea
* Abdominal distension
* Mouth ulcers
* Fatigue
* Weight loss
* Anaemia (secondary to Fe, B12 or folate deficiency)
* Dermatitis herpetiformis (itchy, blistering skin rash typically on abdomen)
* Neurological symptoms (e.g. peripheral neuropathy, cerebellar ataxia, epilepsy- RARE)
28
How do we diagnose coeliac disease?
Investigations must be done while patient is eating gluten:
* _Antibodies (must check total IgA levels to exclude IgA deficiency as both anti-TTG and anti-EMA are IgA)_:
* **First line: anti-tissue transglutaminase**
* Anti-endomysial antibodies
* If IgA deficient, test for IgG version of the above or IgG deamidated gliadin peptide antibodies (anti-DGPs)
* _If serology positive do duodenal biopsy (=GOLD STANDARD)_
29
Antibodies, anti-TTG and anti-EMA, correlate with disease activity in coeliac disease; true or false?
True; rise in more active disease
30
We always test for coeliac disease when we diagnose what other endocrine autoimmune condition?
T1DM
31
What two genes is coeliac disease strongly associated with?
HLA-DQ2 (95%)
HLA-DQ8 (80%)
32
What findings, on duodenal or jejunal biopsy, would support diagnosis of coeliac disease
* Villous atrophy
* Crypt hyperplasia
* Increase in intraepithelial lymphocytes
* Lamina propria infiltrated with lymphocytes
33
Discuss the management of coeliac disease
* Life long gluten free diet
* Immunisations (due to hyposplenism. Offer pneumococcal to all and give influenza on individual basis)
34
State some complications of untreated coeliac disease
* Vitamin deficiency
* Hyposplenism
* Anaemia
* Osteoporosis
* Subfertility
* Enteropathy associated T-cell lymphoma (EATL) of the intestine
* Non-Hodgkin lymphoma
* Small bowel adenocarcinoma (rare)
35
Compare and contrast Crohn's and UC in terms of:
* Symptoms
* Extra-intestinal symptoms
* Complications
* Pathology
* Histology
* Endoscopy
* Radiological findings
36
Another summary of symptoms for Crohn's & UC
37
State some potential extra-intestinal features of IBD
* Erythema nodosum
* Pyoderma gangrenosum
* Episcleritis & iritis
* Inflammatory arthritis
* Finger clubbing
* PSC (UC)
38
What investigations would you do if you suspected IBD?
_Bedside_
* Stool culture
* Faecal calprotectin
_Bloods_
* FBC: *anaemia*
* LFTs: *hepatitis*
* U&Es: *renal func*
* CRP: *raised*
* ESR: *raised*
* Ferritin, TIBC, transferrin saturation: *Fe deficiency*
* B12
* Folate
_Imaging_
* Endoscopy (OGD & colonscopy) with biopsy = GOLD STANDARD
* MRI: *look for complications e.g. fistulas, abscesses*
* CT: *look for complications e.g. fistulas, abscesses*
* Ultrasound: *look for complications e.g. fistulas, abscesses*
39
Discuss the general management for both Crohn's and UC
* MDT management *(paediatrician, specialist nurse, dieticians, surgeons)*
* Monitor growth & pubertal development
* Education
40
Discuss the management of crohn's, include:
* Inducing remission
* Maintaining remission
* Surgical
DON'T SMOKE
_Inducing remission_
* First line= enteral feeds/liquid diet
* Second line= steroids (e.g. oral predniosolone or IV hydrocortisone)
* Immunosuppressant e.g. azathioprine, mercaptopurine, methotrexate
* Biologics e.g. infliximab, adalimumab, vedolizumab, ustekinumab
_Maintaining remission_
* First line= azathioprine, mercaptopurine
* Alternatives= methotrexate, infliximab, adalimumab, vedolizumab, ustekinumab
_Surgical_
* Surgery for strictures, fistulas, perianal disease
* Surgery to remove part of bowel
41
State some potential complications of crohn's disease
* Small bowel cancer
* Colorectal cancer
* Osteoporosis
42
Discuss the management of ulcerative colitis, include:
* Inducing remission
* Maintaining remission
* Surgical
_Inducing remission_
* Mild to moderate disease:
* First line drug= aminosalicyclate (e.g. mesalazine oral or rectal)
* Second line= corticosteroids
* Severe disease
* First line= IV corticosteroids (e.g. hydrocortisone)
* Second line= IV ciclosporin
_Maintaining remission_
* Aminosalicyclate
* Aazthioprine
* Mercaptopurine
_Surgery_
* Panproctocolecotmy will remove the disease; either leave with permanent ileostomy or an ileo-anal anastomosis (J-pouch)
43
State some potential complications of ulcerative colitis
* Toxic megacolon
* Colorectal carcinoma
* Osteoporosis
44
What is gastroenteritis?
Is it contagious?
* Inflammation of stomach and intestines presenting with nausea, vomiting & diarrhoea.
* Viral gastroenteritis (which is most common cause) is highly contagious hence family members or contacts are often affected and must isolate if in hospital
45
State some potential causes of gastroenteritis in children, highlighting the most common one
* **Viral**
* **Rotavirus**
* **Norovirus**
* Adenovirus *(more subacute presentation)*
* Escherichia coli *(certain strains e.g. E.coli 0157)*
* Campylobacter jejuni
* Shigella
* Salmonella typhi
* Bacillus cereus
* Yersinia enterocolitica
* Staphylococcus aureus toxin
* Giardia lamblia
46
For E.coli, discuss:
* How it is spread
* What E.coli 0157 produces and what this leads to
* Whether should use abx
* Normal intestinal bacteria and only certain strains cause gastroenteritis. Spread via contact with **infected faeces, unwashed salads or contaminated food**
* E.coli 0157 produces **shiga toxin** which leads to **dysentery** and **haemolytic uraemic syndrome**
* **Use of abx increases risk of HUS** so avoid if suspect E.coli gastroenteritis
47
For campylobacter jejuni, discuss:
* Gram stain & shape
* How it is spread
* Whether abx are given
* Gram **-ve curved/spiral** shape
* Spread: **raw or improperly cooked poultry, untreated water, unpasteurised milk**
* Symptoms usually resolve after 3-6 days but abx may be **considered** after have confirmed diagnosis and pt has **risk factors** (e.g. immunosuppression, co-morbidities) or ***severe symptoms***. Abx are: **azithromycin or ciprofloxacin.**
48
For shigella, discuss:
* Gram stain & shape
* How it is spread
* What it produces and what this can cause
* Whether abx are used
* Gram -ve rod
* Spread via **faeces contaminated water, swimming pools & food.**
* Can produce **shiga toxin causing HUS**
* Usually resvolves in 1 week but may use abx for severe cases e.g. **azithromycin or ciprofloxacin**
49
For salmonella, discuss:
* Gram stain & shape
* How it is spread
* Whether abx are given
* **Gram -ve rod**
* Spread via **raw eggs, poultry or food contaminated with infected faeces** of small animals
* Symptoms usually resolve within 1 week; **abx only given in severe cases**
50
For Bacillus cereus, discuss:
* Gram stain & shape
* How it is spread
* What toxin does it produce
* Typical course of bacillus cereus
* **Gram positive rod**
* Spread via i**nadequately cooked food**; typical food is **rice** left out at room temp
* Produces **cereulide** toxin while growing on food *(when it arrives at intestines produces different toxins)*
* **Abdo cramping & vomiting within 5hrs then diarrhoea after 8 hrs, resolution within 24hrs**
51
For Yersinia enterocolitica, discuss:
* Gram stain & shape
* How it is spread
* How it typically presents in children
* How it typically presents in adults
* Whether abx are used
* **Gram -ve rod**
* Spread by **eating raw or undercooked pork, contamination of food/water with faeces** of other infected small mammals (e.g. rats, rabbits)
* Most frequently affects children causing **watery or bloody diarrhoea, abdo pain, fever & lymphadenopathy**. Incubation 4-7 days. Symptoms can l**ast 3 weeks or more.**
* Older children & adults can present with **right sided abdo pain** due to **mesenteric lymphadenitis** and **fever** (giving impression of appendicitis)
* Abx only in severe cases
52
For Staphylococcus aureus toxin, discuss:
* How it is spread
* Typical course
* S. Aureus can produce enterotoxins when g**rowing on food such as egg, dairy & mea**t. **Toxins** can cause intestinal inflammation.
* Symptoms start h**rs after ingestion and resolve in 12-24hrs**
53
For Giardiasis, discuss:
* What it is
* How it is spread
* Presentation
* Whether abx are given
* Caused by **Giardia lamblia** (a **microscopic parasite**) that lives in **small intestine of mammals** (pets, farmyard animals or humans)
* Releases **cysts in stools which then contaminate food or water** (faecal oral transmission)
* May not cause any symptoms or may cause chronic diarrhoea
* Treat with **metronidazole**
54
Discuss the principles of managing gastroenteritis
* **Good hygiene** e.g. regular handwashing, using separate bathrooms, cleaning regularly
* **Isolation & barrier nursing in hospital**
* Children must **stay off school until 48hrs after symptoms completely resolved**
* **Stool culture** for M,C&S
* **Ensuring they remain hydrated** *(can do fluid challenge to see if can tolerate fluids; if can tolerate, can be managed at home with safety net advice. Can use rehydration fluids. If child is dehydrated or fails fluid challenge will need IV fluids)*
* **Light diet can be reintroduced** *(dry foods often better)*
* **Antibiotics may be considered in some cases** *(e.g. if at risk of complications and causative organism confirmed)*
*\*Most children make full recovery with supportive management but beware gastroenteritis can be fatal in at risk groups e.g. very young, immunosuppressed, comorbidities*
55
Are antidiarrhoeal medications (e.g. loperamide) & anti-emetic medications (e.g. metoclopramide) recommended in gastroenteritis in children?
* **Generally not recommended** (but may use in some cases)
* Anti-diarrhoeal are particularly avoided in E.coli 0157, Shigella infections, if there is bloody diarrhoea or high fever
56
State some potential complications of gastroenteritis in children
* Reactive arthritis
* Guillain-Barre syndrome
* HUS
* IBS
* Lactose intolerance
57
State some causes of acute liver failure in children
* Viruses *(e.g. HSV, EBV, CMV, varicella, hepatitis A, B, E)*
* Wilson disease
* Galactosaemia
* Mitochondrial disease
* Toxins *(e.g. paracetamol overdose)*
* Medications *(e.g. valproate, phenytoin, rifampicin, isoniazid, erythromycin)*
* Illicit drugs *(ecstasy, toxic mushrooms)*
* Autoimmune hepatitis
* Heart disease
58
State some causes of chronic liver failure in children
* Chronic hepatitis (e.g. hepatitis C, NAFLD)
* Haemochromatosis
* Biliary atresia
* Alpha-1 antitrypsin deficiency
* Mitochondrial disorders
59
Presentation of liver failure in children & investigations are similar those in adults.
Management of liver failure in children depends on underlying cause.
Management:
* Treat underlying cause
* Supportive e.g. diuretics, vitamins, lactulose for hepatic encephalopathy
* Liver transplant
Yr4: Child Health
flashcards
Decks in class (21)
# Cards
-
Community Paediatrics66
-
Child Development85
-
Safeguarding & Law20
-
Endocrinology100
-
Respiratory 191
-
Respiratory 248
-
ENT45
-
Cardiology121
-
Paediatric Emergencies36
-
Neurology90
-
Infectious Diseases92
-
Gastroenterology59
-
Surgery111
-
Haematology/oncology85
-
Neonatology132
-
Musculoskeletal/Rheumatology107
-
Renal & Urology57
-
Immunology42
-
Paediatric History & Examination19
-
Genetics57
-
Dermatology80
