Paediatrics Upper and Lower GI Disorders

Question 1

What is chronic constipation?

Answer 1

This is infrequent passage of stool, but varies person to person:

• Normal stool frequency ranges from 4 per day to 1 per week, depends on age and diet

Question 2

What does normal stool frequency range between, and depend on?

Answer 2

• Normal stool frequency ranges from 4 per day to 1 per week, depends on age and diet

Question 3

Describe the bristol stool chart?

Answer 3

Question 4

What are signs and symptoms seen with constipation?

Answer 4

• Type 1/2 Bristol stool chart
• Poor appetite
• Irritable
• Lack of energy
• Abdominal pain or distension
• Withholding or straining
• Diarrhoea

Question 5

What are possible causes of constipation?

Answer 5

• Social
  
  • Poor diet
    
    • Insufficient fluid
    • Excessive milk
  • Potty training/school toilet
• Physical
  
  • Intercurrent illness
  • Medication
• Psychological (secondary)
• Organic

Question 6

Describe the psychological viscous cycle of paediatric constipation?

Answer 6

Question 7

Constipation - treatment

Answer 7

• Social
  
  • Explain treatment to parents
  • Diet – increase fibre, fruit, vegetables, fluids, decrease milk
• Psychological
  
  • Reduce aversive factors – make going toilet pleasant experience
  • Reward good behaviour – general praise, STAR charts
• Soften stool and stimulate defication
  
  • Osmotic laxatives (lactulose)
  • Stimulant laxatives (senna, picosulphate)
  • Isotonic laxatives (movicol/laxido)
• For severe constipation (megarectum)
  
  • Empty impacted rectum
  • Empty colon
  • Maintain regular stool passage

Question 8

What are different kinds of laxatives?

Answer 8

• Osmotic laxatives (lactulose)
• Stimulant laxatives (senna, picosulphate)
• Isotonic laxatives (movicol/laxido)

Question 9

What are examples of:

• osmotic laxatives
• stimulant laxatives
• isotonic laxatives

Answer 9

• Osmotic laxatives (lactulose)
• Stimulant laxatives (senna, picosulphate)
• Isotonic laxatives (movicol/laxido)

Question 10

What is a complication of severe constipation?

Answer 10

Megarectum

Question 11

What is megarectum and what can it cause?

Answer 11

• Megarectum
  
  • Lots of faeces collected in rectum, causing it to dilate and push forward on urethra
  • Can cause urinary retention or urinary tract infections

Question 12

What are the conditions that form inflammatory bowel disease?

Answer 12

• Crohn’s disease
• Ulcerative colitis

Question 13

Describe how the epidemiology of inflammatory bowel disease differs between children and adults?

Answer 13

Question 14

How does the location of ulcerative colities different between adults and children?

Answer 14

• Different areas of ulcerative colitis
  
  • Proctitis
    
    • 40% adults
    • 4% <5 years, 17% 5-17 years
  • Left sided colitis
    
    • 40% adults
    • 14% children
  • Pancolitis
    
    • 20% adults
    • >60% children

Question 15

How does the location of Crohn’s disease involvement differ between children and adults?

Answer 15

• Different areas of Crohn’s disease
  
  • Isolated ileal
    
    • 36% adults
    • 6% children
  • Ileocolonic
    
    • 50% adults
    • 45% children
  • Upper GI/panenteric
    
    • Extremely rare adults
    • 51% children

Question 16

What is the main difference between the presenting features of ulcerative colitis and Crohn’s disease?

Answer 16

• Main difference is ulcerative colitis usually always presents with diarrhoea, rectal bleeding and abdominal pain
• Crohn’s is more varied depending on where it is located

Question 17

Compare and contrast the features of Crohn’s disease and ulcerative colitis:

• diarrhoea
• rectal bleeding
• abdominal pain
• fever
• weight loss
• growth failure
• arthritis
• mass

Answer 17

Question 18

How is the diagnosis of inflammatory bowel disease made?

Answer 18

• History and examination
• Intestinal symptoms
• Extra-intestinal manifestations
  
  • Erythema nodosum
  • Oral changes – rolled edge ulcer
  • Perianal changes – tags and fissures
• Exclude infection
• Family history
• Growth and sexual development
• Nutritional status

Question 19

Inflammatory bowel disease - investigations

Answer 19

• FBC and ESR
  
  • Anaemia
  • Thrombocytosis
  • Raised ESR
• Biochemistry
  
  • Stool calprotectin
  • Raised CRP
  • Low albumin
• Microbiology
  
  • No stool pathogens

Definitive investigations:

• Radiology (especially Crohn’s disease)
  
  • MRI
  • Barium meal and follow through
• Endoscopy
  
  • Colonoscopy and upper GI endoscopy
  • Mucosal biopsy
  • Capsule enteroscopy
  • Enteroscopy

Question 20

What is seen in the following for IBD:

• FBC and ESR
• biochemistry
• microbiology

Answer 20

• FBC and ESR
  
  • Anaemia
  • Thrombocytosis
  • Raised ESR
• Biochemistry
  
  • Stool calprotectin
  • Raised CRP
  • Low albumin
• Microbiology
  
  • No stool pathogens

Question 21

What radiology is done for IBD?

Answer 21

MRI

Barium meal and follow through

Question 22

What are the aims of treatment for IBD?

Answer 22

• Induce and maintain remission
• Correct nutritional deficiencies
• Maintain normal growth and development

Question 23

IBD - treatment

Answer 23

• Medical
  
  • Anti-inflammatory
  • Immuno-suppressive
  • Biologicals (Infliximab)
• Nutritional
  
  • Immune modulation
  • Nutritional supplementation
• Surgical

Question 24

Describe the “bottom up” treatment approach for Crohn’s disease?

Answer 24