Level 1 - GI COPY COPY

Question 1

What is constipation?

Answer 1

• A decrease in the frequency of bowel movements characterized by the passing of hard stools, which may be large and associated with straining and pain

Question 2

What is soiling?

Answer 2

• Soiling of the clothes (the involuntary passage of fluid or semi-solid stool) may result from overflow from the overloaded bowel, and stool retention (faecal impaction) may occur

Question 3

What is normal stool frequency in children?

Answer 3

• In the UK, normal stool frequency in children ranges from an average of 4 per day in the first week of life to 2 per day at 1 year of age.

Question 4

What is normal stool frequency in adult?

Answer 4

• The normal adult range (between 3 stools per day and 3 stools per week) is usually attained by 4 years of age.

Question 5

What is idiopathic constipation?

Answer 5

• Constipation is termed idiopathic (functional) if it cannot be explained by any anatomical or physiological abnormality

Question 6

Define chronic constipation?

Answer 6

• Chronic constipation lasts >8 weeks

Question 7

Epidemiology of constipation?

Answer 7

• Around 3% of paediatric consultations
• In the UK, 30% of children aged 4–11 years will have constipation lasting less than 6 months
• Peak incidence is at time of toilet training (2-3 years of age)

Question 8

Risk factors for constipation?

Answer 8

o Pain, fever, inadequate fluid intake, reduced dietary fibre intake, toilet training issues

o Drugs (sedating antihistamines, opiates)

o Psychosocial issues and family history

o Sexual Abuse

o Physically inactive (cerebral palsy)

Question 9

Pathological causes of constipation?

Answer 9

o Hirschsprung disease

o Coeliac disease

o Anorectal disorders

o Hypothyroidism

o Hypercalcaemia

o Neurodegenerative disorder (Down’s/ASD)

Question 10

Symptoms of constipation?

Answer 10

o <3 complete stools per week

o Hard. Large stools

o Rabbit droppings stools

o Overflow soiling

o Distress or pain on passing stool

o Bleeding

o Straining

o Poor appetite

Question 11

What is overflow soiling?

Answer 11

 Typically very loose, smelly stools which are passed without sensation or awareness

 Overdistended rectum loses feeling of need to defecate

 As newer, looser stool continues to be made in the intestines, it leaks around the large chunk of hard stool

Question 12

Signs of constipation?

Answer 12

o Rectal tears etc

o Palpable mass felt in LIF

Question 13

Red flags in constipation?

Answer 13

o Failure to pass meconium in 48 hours (Hirschsprung disease)

o Failure to thrive (hypothyroidism, coeliac disease)

o Gross abdominal distension (Hirschsprungs)

o Sacral dimple over spine (Spina bifida)

o Perianal fistulae, abscesses (Crohns disease)

Question 14

Investigations needed in constipation?

Answer 14

• No specific investigations if no pathology suspected

Question 15

If pathology suspected, what investigations should be done in constipation?

Answer 15

o FBC

o Coeliac antibody screen

o TFTs o Serum calcium

o Abdominal x-ray

o Rectal biopsy (Hirschsprung’s disease)

o Spinal imaging

Question 16

General management of constipation?

Answer 16

• Aim is to achieve disimpaction and then maintenance therapy:
• Reassure patient and child that it is common, and soiling is involuntary

Question 17

Dietary advice in constipation?

Answer 17

o Increase fibre (fruit, vegetables, bread, baked beans)

o Advise normal daily physical activity

o Increase fluid intake

Question 18

Behavioural therapy in constipation?

Answer 18

o Reward child for good toilet routine

o Go at similar time each day

o 5 mins after meals for toilet time, star charts and rewards for passing stools

Question 19

Acute disimpaction medication for constipation?

Answer 19

o Movicol stool softener

o If fails after 2 weeks then add stimulant laxative (Senna)

Question 20

Maintenance laxative treatment in constipation?

Answer 20

o Movicol stool softener

o If constipation persists, add stimulant laxatives (Senna)

o If diarrhoea occurs, then reduce dose suitably

o Continue for several weeks until regular soft stools achieved

Question 21

Complications of constipation?

Answer 21

• Anal Fissure
• Haemorrhoids
• Rectal Prolapse
• Megarectum
• Faecal impaction and soiling

Question 22

Define gastroenteritis?

Answer 22

• Gastroenteritis is a transient disorder due to enteric infection with viruses, bacteria, or parasites
• Characterized by the sudden onset of diarrhoea, with or without vomiting

Question 23

What is acute diarrhoea?

Answer 23

 >3 episodes of watery stool in a day lasting for <14 days

Question 24

What is persistent diarrhoea?

Answer 24

 Diarrhoea lasts >14 days

Question 25

What is dysentery? What organisms responsible for dysentery?

Answer 25

 Loose stools with blood and mucus  Organisms that cause bloody diarrhoea include campylobacter, entamoeba histolytica, E.coli, salmonella serotypes and Shigella

Question 26

What is Traveller's diarrhoea?

Answer 26

 Diarrhoea starting during or shortly after foreign travel  Organism most commonly E.coli, Salmonella, Viruses, Cryptosporidium, Giardia

Question 27

Epidemiology of gastroenteritis?

Answer 27

- Major cause of mortality in developing countries - 10% of under 5 year olds have gastroenteritis - Rotavirus part of childhood vaccination schedule

Question 28

Viral causative organisms in gastroenteritis?

Answer 28

 Rotavirus  Norovirus  Adenovirus

Question 29

Bacterial causative organisms in gastroenteritis?

Answer 29

 Campylobacter jejuni (severe abdominal pain)  E.coli (profuse, rapidly dehydrating diarrhoea)  Salmonella (dysentery)  Shigella (dysentery, high fever)  Yersinia enterocolitica

Question 30

Sources of infection in gastroenteritis?

Answer 30

o Contaminated water, o Poor food hygiene (meat, fresh produce, chicken, eggs, previously cooked rice) o Faecal oral route

Question 31

Symptoms and signs of gastroenteritis?

Answer 31

- Diarrhoea - Dysentery (blood and mucus in diarrhoea) - Vomiting - Cramping abdominal pain - Fever - Dehydration/shock - Electrolyte imbalance - Malaise

Question 32

DDx of gastroenteritis?

Answer 32

- Systemic infection o Sepsis, meningitis - Local Infections o RTI, otitis media, Hep A, UTI - Surgical Disorders o Pyloric stenosis, intussusception, acute appendicitis, necrotising enterocolitis, Hirschsprung disease - Diabetic ketoacidosis - HUS - Coeliac disease, cow’s milk protein intolerance

Question 33

Investigations in gastroenteritis?

Answer 33

- Stool culture - Bloods U&E’s, glucose - Dehydration assessment o No clinical dehydration detectable (usually \<5% of body weight) o Clinical dehydration (usually 5-10%) o Shock (usually \>10% dehydration)

Question 34

What are symptoms of clinical dehydration?

Answer 34

Unwell, irritable, lethargy, decreased urine output, warm extremities, sunken eyes, dry mucous membranes, tachycardia, tachypnoea, reduced skin turgor

Question 35

Symptoms of clinical shock?

Answer 35

Decreased conscious level, pale/mottled, cold extremities, tachycardia, tachypnoea, weak pulses, prolonged cap refill, hypotension

Question 36

Fluid management of gastroenteritis when no signs of dehydration?

Answer 36

 Continue breast-feeding and other milk feeds  Encourage fluid intake to compensate increased losses  Oral rehydration solution (ORS) (50ml/kg over 4h) prescribed as supplemental fluid

Question 37

Fluid management of gastroenteritis when clinical dehydration?

Answer 37

 ORS regularly  Give oral fluid deficit replacement (50ml/kg) over 4 hours, if tolerating oral - PRN/Once only meds  If struggling to feed, consider NG tube  Continue breast-feeding  If deterioration, IV therapy with fluid deficits and maintenance fluids  Monitor plasma electrolytes, U&Es, creatinine and glucose

Question 38

Fluid management of gastroenteritis with shock?

Answer 38

 Rapid IV of 0.9% NaCl bolus infusion, repeat if necessary  If deterioration, IV therapy with fluid deficits and maintenance fluids  Monitor plasma electrolytes, U&Es, creatinine and glucose

Question 39

After rehydration, what management should be given in gastroenteritis?

Answer 39

o Give full strength milk o Avoid fruit juice and carbonated drinks o Advise diligent hand-washing, not to towel share, do not return to school until 48 hours after symptoms stop - DO NOT ANTI-DIARRHOEAL DRUGS AND ANTI-EMETICS

Question 40

When would you give antibiotics in gastroenteritis?

Answer 40

o Indicated for sepsis, extra-intestinal spread, salmonella gastroenteritis if \<6 months old or for specific bacterial or protozoal infections (C.diff with colitis, cholera, shigellosis, giardiasis)

Question 41

Complications of gastroenteritis?

Answer 41

- Malnutrition - Temporary sugar intolerance after D&V - Post-gastroenteritis lactose intolerance common - Post-enteritis enteropathy

Question 42

What is GORD? When does it usually resolve? What is reflux disease?

Answer 42

- GORD is a condition where there is reflux of gastric contents (particularly acid, bile, and pepsin) back into the oesophagus - Usually resolves within first year of life - Non-forceful regurgitation into oesophagus Reflux disease is when you get negative side effects

Question 43

Causes of GORD?

Answer 43

o Transient relaxation (reduced tone) of the LOS – functional immaturity o Increased intra-gastric pressure (for example straining and coughing) o Delayed gastric emptying o Impaired oesophageal clearance of acid Floppy children - Down’s syndrome

Question 44

Risk factors for GORD?

Answer 44

o Fluid diet, horizontal stature and short intra-abdominal length of oesophagus o Cerebral palsy o Preterm infants o Following surgery for oesophageal atresia or diaphragmatic hernia

Question 45

Symptoms and signs of GORD?

Answer 45

- Recurrent regurgitation/vomiting - Possetting - May contain some blood - Increased salivations - Failure to thrive - Chronic cough - Normal weight and otherwise well - often

Question 46

Diagnosis of GORD? When to use other tests?

Answer 46

- Diagnosed is clinical usually Other tests: o FBC o 24-hour oesophageal pH monitoring to quantify degree of reflux o Endoscopy with biopsies o Barium swallow/Oesophageal monometry can exclude underlying abnormalities - If treatment resistant then use other tests to identify cause

Question 47

General management of GORD?

Answer 47

* Reassure, don’t overfeed * Position at 30o head-up prone position after feeds * Dietary: Thickened milk feeds (Carobel), small frequent meals, avoid food before sleep, avoid fatty foods, caffeine, citrus juices, alcohol, smoking

Question 48

Drug therapy in GORD? Surgery?

Answer 48

• Drugs:  Gaviscon added to feeds (antacid and alginate forms viscous layer)  Gastric acid reducing drugs - H2 receptor antagonists (ranitidine) or PPI (omeprazole)  Enhance gastric emptying (domperidone) • Surgery if failed medical therapy  Fundoplication – fundus of stomach wrapped around intra-abdominal oesophagus

Question 49

Complications of GORD?

Answer 49

- Failure to thrive - Oesophagitis – haematemesis and iron deficiency anaemia - Recurrent pulmonary aspiration – pneumonia, wheeze - Dystonic neck posturing (Sandifer syndrome – extension and lateral turning of head)