GI

Question 1

When might an abdominal XR be indicated on a child?

Answer 1

1. Abdominal distension e.g. obstruction.
2. Abdominal pain of unknown cause.
3. Constipation.

Question 2

Give 3 gastrointestinal causes of abdominal pain.

Answer 2

1. IBS.
2. Constipation.
3. Gastritis.
4. Peptic ulcer.
5. Malrotation.
6. Appendicitis.
7. IBD.
8. Abdominal migraine.

Question 3

Give 3 gynaecological causes of abdominal pain.

Answer 3

1. Dysmenorrhoea.
2. PID.
3. Ectopic pregnancy.
4. Ovarian torsion.

Question 4

Give 3 hepatobiliary/pancreatic causes of abdominal pain.

Answer 4

1. Hepatitis.
2. Gall stones.
3. Pancreatitis.

Question 5

Give 2 urinary causes of abdominal pain.

Answer 5

1. UTI.

2. Pelvic ureteric junction obstruction.

Question 6

Give 5 signs of appendicitis.

Answer 6

1. Anorexia.
2. Pyrexia.
3. Abdominal pain - initially central as the appendix is a mid gut structure but then localises to R side as the appendix irritates peritoneum.
4. Vomiting.
5. RIF rebound tenderness.

Question 7

Why is central trauma and bruising to the abdomen a concern?

Answer 7

Mid-line structures such as the pancreas, spleen, bowel and liver may be damaged.

Question 8

If you suspect trauma and abdominal organ damage what investigation might you do?

Answer 8

CT abdomen

Question 9

Give 5 differentials for abdominal pain + rectal bleeding.

Answer 9

1. Anal fissures.
2. Haemorrhoids.
3. Polyps.
4. Proplapse.
5. Infective causes.
6. Meckel diverticulum. If melaena, suspect gastritis or duodenal ulcer.

Question 10

What is Meckel diverticulum a remnant of?

Answer 10

omphalomesenteric duct

Question 11

Give 3 signs of Meckel diverticulum.

Answer 11

1. Severe rectal bleeding.
2. Intussusception.
3. Volvulus.

Question 12

How would you treat Meckel diverticulum?

Answer 12

Surgical resection.

Question 13

Give 3 differentials for abdominal mass.

Answer 13

1. Constipation.
2. Appendicitis.
3. Organomegaly.
4. Nephroblastoma/Wilm’s tumour.

Question 14

Give 5 differentials for vomiting.

Answer 14

1. GORD.
2. Infection e.g. gastroenteritis.
3. Food allergy/intolerance.
4. Intestinal obstruction.
5. Appendicitis.
6. Coeliac disease.
7. Over-feeding - common in bottle-fed infants.
8. Necrotising enterocolitis.
9. Malrotation - biliary vomit.
10. DKA.

Question 15

Give 3 causes of intestinal obstruction that can cause vomiting.

Answer 15

1. Pyloric stenosis.
2. Duodenal atresia.
3. Intussusception.
4. Hirschsprung’s.

Question 16

What is pyloric stenosis?

Answer 16

A disease characterised by hypertrophy of the pyloric muscle causing gastric outlet obstruction.

Question 17

Give 3 signs of pyloric stenosis.

Answer 17

1. ‘projectile’ vomiting, typically 30 minutes after a feed
2. constipation and dehydration may also be present
3. a palpable mass may be present in the upper abdomen
4. hypochloraemic, hypokalaemic alkalosis due to persistent vomiting

Question 18

You suspect pyloric stenosis in a neonate. What investigations might you do?

Answer 18

1. U+E.
2. Blood gas.
3. Dx: USS - hypertrophy of pyloric sphincter.

Question 19

You do a blood gas on a neonate with pyloric stenosis. What would it show?

Answer 19

Metabolic Alkalosis - low K+ and Cl-. The baby has vomited up all the HCl and the kidneys go into overdrive - increased K+ secretion.

Question 20

How would you manage a neonate with pyloric stenosis?

Answer 20

• IV fluids.
• Repeat gases to monitor alkalosis.
• NBM.
• Pyloromyotomy once stable.

Question 21

How might malrotation in a neonate present?

Answer 21

Obstruction with bilious vomiting.

Abdominal pain and tenderness.

Question 22

Any child presenting with dark green vomiting needs what urgent investigation?

Answer 22

An urgent upper GI contrast study to assess intestinal rotation.

Question 23

Give a potential consequence of malrotation.

Answer 23

SMA blood supply to the small intestine can be compromised -> infarction.

Question 24

What is duodenal atresia?

Answer 24

A congenital absence or complete closure of the duodenum. It causes intestinal obstruction in neonates.

Question 25

You do an AXR on a neonate with duodenal atresia. What would you expect to see?

Answer 25

A double bubble sign.

Question 26

What syndrome is associated with duodenal atresia?

Answer 26

20-40% have Down's syndrome.

Question 27

What is intussusception?

Answer 27

Where proximal bowel telescopes into a distal segment -> obstruction, inflammation, bloody stools.

Question 28

Give 2 signs of intussusception.

Answer 28

paroxysmal abdominal colic pain during paroxysm the infant will characteristically draw their knees up and turn pale vomiting bloodstained stool - 'red-currant jelly' - is a late sign sausage-shaped mass in the right upper quadrant

Question 29

What investigations might you do on a child who you suspect has an intussusception?

Answer 29

USS - 'target sign'. | AXR.

Question 30

Describe the treatment for intussusception.

Answer 30

reduction by air insufflation under radiological control, | if this fails, or the child has signs of peritonitis, surgery is performed

Question 31

Give 5 causes of bilious vomiting in children.

Answer 31

1. Volvulus. 2. Hirschsprung's. 3. Necrotising enterocolitis. 4. Intussusception. 5. Bowel obstruction. 6. Strangulated hernia. 7. Adhesions.

Question 32

What biochemical derangement might you see in a patient with pyloric stenosis?

Answer 32

Metabolic alkalosis.

Question 33

What is the name of the surgery that can be used to treat pyloric stenosis?

Answer 33

Pyloromyotomy.

Question 34

What area of the brain does high levels of unconjugated bilirubin affect?

Answer 34

The basal ganglia.

Question 35

What can you see on X-ray of necrotising enterocoliris?

Answer 35

Dilated bowel loops (often asymmetrical in distribution) Bowel wall oedema Pneumatosis intestinalis (intramural gas) Portal venous gas Pneumoperitoneum resulting from perforation Air both inside and outside of the bowel wall (Rigler sign) Air outlining the falciform ligament (football sign)

Question 36

What is the dx criteria for constipation?

Answer 36

<1y: ``` 1. Stool pattern: Fewer than 3 complete stools per week (type 3 or 4 on Bristol Stool Form Scale) (this does not apply to exclusively breastfed babies after 6 weeks of age) Hard large stool 'Rabbit droppings' (type 1) ``` 2. Symptoms associated with defecation: Distress on passing stool Bleeding associated with hard stool Straining 3. History Previous episode(s) of constipation Previous or current anal fissure >1y 1. Stool pattern: Fewer than 3 complete stools per week (type 3 or 4) Overflow soiling (commonly very loose, very smelly, stool passed without sensation) 'Rabbit droppings' (type 1) Large, infrequent stools that can block the toilet 2. Symptoms associated with defecation: Poor appetite that improves with passage of large stool Waxing and waning of abdominal pain with passage of stool Evidence of retentive posturing: typical straight legged, tiptoed, back arching posture Straining Anal pain 3. History Previous episode(s) of constipation Previous or current anal fissure Painful bowel movements and bleeding associated with hard stools

Question 37

List 10 causes of constipation.

Answer 37

``` idiopathic (most cases) dehydration low-fibre diet medications: e.g. Opiates anal fissure over-enthusiastic potty training hypothyroidism Hirschsprung's disease hypercalcaemia learning disabilities ```

Question 38

List 3 factors which suggest faecal impaction.

Answer 38

1. symptoms of severe constipation 2. overflow soiling 3. faecal mass palpable in abdomen

Question 39

What is the mx of constipation?

Answer 39

1. polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment 2. add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated

Question 40

What is the school exclusion criteria for whooping cough?

Answer 40

2 days after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )

Question 41

What is the school exclusion criteria for chicken pox?

Answer 41

Cases of chickenpox are generally infectious from 2 days before the rash appears to 5 days after the onset of rash. Although the usual exclusion period is 5 days, all lesions should be crusted over before children return to nursery or school.

Question 42

How is malrotation diagnosed?

Answer 42

Diagnosis is made by upper GI contrast study and USS

Question 43

How is malrotation managed?

Answer 43

Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a Ladd's procedure is performed

Question 44

Describe features of malrotation.

Answer 44

1. High caecum at the midline 2. Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia 3. May be complicated by the development of volvulus, an infant with volvulus may have bile stained vomiting

Question 45

What is Hirschsprung's disease?

Answer 45

Absence of ganglion cells from myenteric and submucosal plexuses

Question 46

How is Hirschsprung's diagnosed?

Answer 46

Full thickness rectal biopsy

Question 47

List 2 features of Hirschsprung's.

Answer 47

1. Delayed passage of meconium | 2. Abdominal distension

Question 48

How is Hirschsprung's managed?

Answer 48

Rectal washouts initially, after that an anorectal pull through procedure

Question 49

List 2 features of meconium ileus.

Answer 49

1. Delayed passage of meconium 2. Abdominal distension The majority have cystic fibrosis

Question 50

What is seen on X-ray of meconium ileus.

Answer 50

X-Rays will not show a fluid level as the meconium is viscid, PR contrast studies may dislodge meconium plugs and be therapeutic

Question 51

What is the mx of meconium ileus?

Answer 51

Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs

Question 52

List 2 features of biliary atresia.

Answer 52

Jaundice > 14 days | Increased conjugated bilirubin

Question 53

How is biliary atresia treated?

Answer 53

Urgent Kasai procedure.

Question 54

What is the main risk factor of necrotising enterocolitis?

Answer 54

Prematurity

Question 55

What are the features of necrotising enterocolitis?

Answer 55

Early features include abdominal distension and passage of bloody stools

Question 56

What is the mx of necrotising enterocolitis?

Answer 56

1. Treatment is with total gut rest and TPN | 2. Babies with perforations will require laparotomy

Question 57

List 5 features of cow's milk protein intolerance (CMPI).

Answer 57

1. regurgitation and vomiting 2. diarrhoea 3. urticaria, atopic eczema 4. 'colic' symptoms: irritability, crying 5. wheeze, chronic cough rarely angioedema and anaphylaxis may occur

Question 58

How is CMPI/CMPA diagnosed?

Answer 58

skin prick/patch testing | total IgE and specific IgE (RAST) for cow's milk protein

Question 59

What is the mx of CMPI?

Answer 59

Management if formula-fed: 1. Mild-moderate - extensive hydrolysed formula (eHF) milk is the first-line replacement formula for infants 2. Severe - amino acid-based formula (AAF) in infants with severe CMPA or if no response to eHF Management if breast-fed: 1. continue breastfeeding 2. eliminate cow's milk protein from maternal diet. 3. Consider prescribing calcium supplements for breastfeeding mothers whose babies have, or are suspected to have, CMPI, to prevent deficiency whilst they exclude dairy from their diet 4. use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months

Question 60

Give 4 Ddx of diarrhoea in infants.

Answer 60

1. most common cause in the developed world is cows' milk intolerance 2. toddler diarrhoea 3. coeliac disease 4. post-gastroenteritis lactose intolerance

Question 61

Describe gastroschisis.

Answer 61

A congenital defect in the anterior abdominal wall just lateral to the umbilical cord

Question 62

Describe exomphalos.

Answer 62

Abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum