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UON Paediatric Society Teaching Series - Week 6 – Gastroenterology Made by: Nishant and Ameera Feedback Form:Warm up 01 02 03 What are some red Can you think of congenital diseases flags in children? causes forchronic associated with GI? abdominal pain? Types of Gastroenterological (Abdominal) Conditions UKMLA RECAP: What defines “lower” and “upper” GI? Clinically (bleed) → above and below the duodenojejunal junction Diagnostically (endoscopic imaging) → also above and below duodenojejunal junction Conventionally → upper (mouth to ileum) and lower (caecum to anus)Presentation: VomitingBiliary Atresia KEY FACTS CLINICAL S&S OVERVIEW • Because CFC1 gene mutations • Jaundice can also lead to this, • Impaired liver function • Blockage/absence of the bile duct in dextrocardia, situs inversus and newborns (unique) -> cholestasis asplenia may also present in the • Dark urine (why?) • No definitive cause but typically congenital patient • Portal hypertension -> hepatomegaly with or due to inflammation soon after birth splenomegaly • Potential viral or toxic substances can • Patient can also take hydrophilic cause this destruction or aggravate any bile acid • Cardiac murmurs if associated cardiac inflammation abnormalities • CFC1 gene mutation – responsible for left- • On ultrasound, a “triangular cord” sign is right embryonic development observed due to the absent common bile duct (credit: Radiopaedia), 1/10000—15000 MANAGEMENT live births • Intraoperative cholangiogram -> gold standard to confirm obstruction • Kasai surgical procedure* to address neonatal jaundice (only exists for biliary atresia) -> involves joining INVESTIGATIONS COMPLICATIONS small intestine directly to liver (effective but inevitable • Ultrasound • Liver cirrhosis, portal hypertension, slowly progressing liver hepatic encephalopathy disease in infants) • Oral cholecystogram • Liver transplant if all fails • Recurrent cholangitis, cirrhosisPyloric Stenosis KEY FACTS CLINICAL S&S OVERVIEW • 2-4 week of life, 4/1000 live • Vomiting -> at 2-6 weeks increases in births, 4x more common in intensity until projectile vomiting and non- • Sometimes also known as HYPERTROPHIC PS males bilious (why?) (HPS) (congenital) • depletes CL- (similar logic for hypokalemia) • Pylorus of stomach thickens and reduces lumen diameter entering duodenum • Metabolic Alkalosis -> less K+ and CL- in • Obstruction from HPS can cause peristalsis blood leads to less H+ and thus decreased impairment and further gastric wall hypertrophy acidity of blood or an increased blood pH • Cause is unknown (epigenetic), although more • Visible peristalsis likely in young boys and first born (autosomal dominant) and due to exposure to macrolide antibiotics MANAGEMENT • Hydration, electrolyte correction INVESTIGATIONS COMPLICATIONS • Ramstedt’s Procedure (pyloromyotomy) -> cutting • Enlarged pylorus can be felt as an • Dehydration muscle of pylorus region and “olive” in RU quadrant or epigastric • Malnourishment pass more easilylowing food to region • Ultrasound and X-ray • Acid-base imbalance • Lab tests for ions (metabolic alkalosis) • FluoroscopyQuestion time!Q/A A 6 week old formula fed baby has been admitted to the paediatric ward. His mother says he has been projectile vomiting and it is white in colour. His appetite has not changed but seems to be more tired. On examination, he appears to be pale and there seems to be visible peristalsis in LUQ. What is the diagnosis? a) Pyloric stenosis b) Cows milk protein allergy c) Duodenal atresia d) Malrotation e) GORDQ/A A 6 week old formula fed baby has been admitted to the paediatric ward. His mother says he has been projectile vomiting and it is white in colour. His appetite has not changed but seems to be more tired. On examination, he appears to be pale and there seems to be visible peristalsis in LUQ. What is the diagnosis? a) Pyloric stenosis b) Cows milk protein allergy c) Duodenal atresia d) Malrotation e) GORDQ/A A 5-week-old previously healthy male infant presents to the Emergency Department with progressive and forceful vomiting. The parents inform you that it started from 3 weeks of age but has now become more projectile and occurs commonly after feeding. He has been treated for formula intolerance and gastro-oesophageal reflux, with very little benefit. On examination, he is distressed and crying. He has dry mucous membranes. Abdominal examination is difficult to perform but appears normal. Given the likely diagnosis, which of the following is a risk factor for this condition? a) Abnormal rotation and fixation of the midgut b) Advanced maternal age c) Firstborn status d) Prematurity e) Female genderQ/A A 5-week-old previously healthy male infant presents to the Emergency Department with progressive and forceful vomiting. The parents inform you that it started from 3 weeks of age but has now become more projectile and occurs commonly after feeding. He has been treated for formula intolerance and gastro-oesophageal reflux, with very little benefit. On examination, he is distressed and crying. He has dry mucous membranes. Abdominal examination is difficult to perform but appears normal. Given the likely diagnosis, which of the following is a risk factor for this condition? a) Abnormal rotation and fixation of the midgut b) Advanced maternal age c) Firstborn status d) Prematurity e) Female genderQ/A A 20 year old baby is brought to A&E by her parents. She is visibly jaundiced and the parents say she has been irrtable and off her feeds since yesterday morning. On examination, there is hepatomegaly. Blood test show normal FBC and thyroid function test, but raised liver transaminases and a very high conjugated bilirubin level. A diagnosis of biliary atresia is suspected. Which of the follwing is the most appropriate first-line management for this condition? a) Reassure and discharge b) Intravenous antibiotics c) Surgical intervention d) Liver transplantationQ/A A 20 year old baby is brought to A&E by her parents. She is visibly jaundiced and the parents say she has been irritable and off her feeds since yesterday morning. On examination, there is hepatomegaly. Blood test show normal FBC and thyroid function test, but raised liver transaminases and a very high conjugated bilirubin level. A diagnosis of biliary atresia is suspected. Which of the following is the most appropriate first-line management for this condition? a) Reassure and discharge b) Intravenous antibiotics c) Surgical intervention d) Liver transplantationPresentation: Abdominal painIntussusception KEY FACTS CLINICAL S&S • Most common intestinal obstruction in infants/young • Intermittent Abdominal Pain -> gets worse OVERVIEW children (2/3 in infants <1 year old) with peristalsis, may cause child to guard • Part of the intestine folds in on itself resulting in but can also occur in adults abdomen or draw knees to chest obstruction a.k.a. “telescoping” • Most cases are idiopathic (guarding) • Typically in ileocaecal region and almost all caecumusceptions happen when ileum folds into the • Vomiting • leading edge causing such a foldsis) can “grab” • (RUQ) -> less K+ and CL- in blood leads to less H+ and thus decreased acidity of • to this foldinglasia in Peyer’s patches can lead blood or an increased blood pH • Meckel’s diverticulum -> abnormal outpouching of • Pressure -> on trapped bowel walls GI tissue that sticks out into the peritoneal cavity leading to ischemia -> infarction -> • Risk factors include having had one previously, sloughing of mucosa/blood/mucus -> red weeks development)nd intestinal malrotation (~12 currant jelly stool COMPLICATIONS MANAGEMENT • Due to sudden development, rapid • Intestinal tearing (due to infarction) treatment is necessary! cavity -> sepsis and fevero body INVESTIGATIONS • Barium or air enema can unfold an • Large mass in abdomen collects -> intussusception • In children can be felt during rectal exam volvulus • Surgery -> telescoped intestine is • Ultrasound, X-ray and CT -> reveals • Peritonitis freed, obstruction is cleared and classic “Bull’s-eye” representing the dead tissue is removed telescoped intestine on end Appendicitis KEY FACTS CLINICAL S&S • 10% of population develops OVERVIEW this, most common surgical • Rebound tenderness -> pain in abdominal intervention in the abdomen RLQ when pressure is released • Most common cause: obstruction by fecalith (poop rock), undigested • Cystic fibrosis comorbidity in • Abdominal Guarding -> may cause child to seeds, pinworm infection children, male guard abdomen or draw knees to chest • Abdominal Pain -> abdomen's right lower- • Lymphoid follicle growth peaks at quadrant; 1/3 distance from ASIS to adolescence and can cause umbilicus (McBurney’s Point) inflammation (this compounds with viral infection) • Continuous natural mucous secretions build up in small appendix region due to blockage -> fills up and expands -> visceral nerve fibres -> RLQ pain (McBurney’s point) *appendicolith MANAGEMENT INVESTIGATIONS COMPLICATIONS • Ultrasound and Physical Examination • Fever • effects sometimes done without appendicitis prophylactically • Further pushing affects nearby blood vessels -> compression -> ischemia -> ruptured appendix -> bacteria into peritoneum -> peritonitisViral Gastroenteritis KEY FACTS CLINICAL S&S • Self-limiting illness, temporary • Vomiting = viruses -> epithelium damage -> OVERVIEW disorder due to an enteric osmotic diarrhoea -> >3 stools daily -> infection vomiting • GI tract viral infection (from stomach to • Watery Diarrhoea = vomiting -> loss of HCL intestines) [lasts 12h-3d], 1º transmission is -> depletes CL- (similar logic for faecal-oral route hypokalemia) • Rotavirus most common in children • Nausea, Abdominal Cramps, Pain, Fever, (norovirus in adults) Malaise • Children, elderly, immunocompromised individuals are vulnerable COMPLICATIONS • Contaminated food/water, public areas • Severe dehydration (daycare, cruise ships) “Traveller’s DIA” • Altered mental health status • Unintended weight loss MANAGEMENT • Hydration, electrolyte INVESTIGATIONS correction, fluid replacement • Stool sample • Hygiene practices, rotavirus • PCR and ELISA for stool and vomit lab vaccine testing • Elevated CRP Peritonitis KEY FACTS CLINICAL S&S • Fever, chills, tachycardia • Patient/child may need OVERVIEW paracentesis if ascites • Ascites, abdominal ridigity present • of abdominal cavity and organs (AKAing • Jaundice peritoneum) • Absent Bowel Sounds • dull -> severe pain (from early to later • Proximal GI tract perforation -> GPB and stages) negative -> GNB • Encephalopathy; delirium, confusion and cognitive decline • formation of fibrinopurulent (fibrin and pus) exudate COMPLICATIONS • Dehydration MANAGEMENT • Sepsis • Medication -> typically systemic INVESTIGATIONS antibiotics such as third generation cephalosporins/quinolones • Supine, upright abdominal films • Lab results: leukocytosis and acidosis Mesenteric CLINICAL S&S KEY FACTS Lymphadenitis • Pain in stomach area -> often at RLQ but • Appendicitis is an acute cause pain can radiate to other nearby regions OVERVIEW of MA • IBD, SLE, HIV infection and • General tenderness to stomach area • Mesenteric adenitis, aka mesenteric tuberculosis are chronic lymphadenitis -> inflammation of lymph causes of MA • Fever nodes found in the mesentery • Enlarged mesenteric lymph nodes • Typically a paediatric condition, can be 1º or 2º • DIA, N&V • 1º -> lymphadenopathy without an whereas 2º is a known causetory cause • Acute and chronic causes exist, usually an infection of the intestines or infection of the lymph nodes themselves -> swelling affects mesentry INVESTIGATIONS • Ultrasound is the gold standard as it can MANAGEMENT differentiate this condition from others where a shape is more apparent • Pain relief medications • Hydration COMPLICATIONS • Typically no complicationsQuestion time!Q/A A 16 year old female presents with a 2 day history of right lower quadrant pain, anorexia and fever. Physical examination reveals right lower quadrant tenderness, guarding and rebound tenderness. Which of the following options is the most likely diagnosis? a) Splenic rupture b) Mesenteric ischaemia c) Ovarian torsion d) Acute appendicitisQ/A A 16 year old female presents with a 2 day history of right lower quadrant pain, anorexia and fever. Physical examination reveals right lower quadrant tenderness, guarding and rebound tenderness. Which of the following options is the most likely diagnosis? a) Splenic rupture b) Mesenteric ischaemia c) Ovarian torsion d) Acute appendicitisQ/A A previously well 9 year old boy presents to A&E with acute, diffuse abdominal pain. It started overnight and has been constant since.There has been no episdoes previosuly. He has recently been off school with a cough and sore throat; his siblings have also been unwell with similar symptoms. On examination, there is gneeralised abdominal tenderness. He is not peritonitic. He is McBurney's point negative. Observations are as follows: HR 89, RR 18 and temp is 38. What is the most appropriate first line investigation? a) CT thorax, abdomen and pelvis b) Barium enema c) Full blood count d) Abdominal ultrasound e) Helicobacter pylori breath testQ/A A previously well 9 year old boy presents to A&E with acute, diffuse abdominal pain. It started overnight and has been constant since.There has been no episdoes previosuly. He has recently been off school with a cough and sore throat; his siblings have also been unwell with similar symptoms. On examination, there is gneeralised abdominal tenderness. He is not peritonitic. He is McBurney's point negative. Observations are as follows: HR 89, RR 18 and temp is 38. What is the most appropriate first line investigation? a) CT thorax, abdomen and pelvis b) Barium enema c) Full blood count d) Abdominal ultrasound e) Helicobacter pylori breath testQ/A A 10 month old male infant is brought to A&E with sudden onset of inconsolable crying episodes which involve drawing up the knees to their chest during these episodes. The parents mention he seems to be normal in between the episodes. He is refusing feeds and passing looser stools which appear 'reddish' since yesterday. On examination, a palpable abdominal mass can be found in the right lower quadrant. Given the history, what is the single most appropriate investigation to diagnose the condition? a) Abdominal ultrasound b) MRI abdomen c) CT scan d) Abdominal X-rayQ/A A 10 month old male infant is brought to A&E with sudden onset of inconsolable crying episodes which involve drawing up the knees to their chest during these episodes. The parents mention he seems to be normal in between the episodes. He is refusing feeds and passing looser stools which appear 'reddish' since yesterday. On examination, a palpable abdominal mass can be found in the right lower quadrant. Given the history, what is the single most appropriate investigation to diagnose the condition? a) Abdominal ultrasound b) MRI abdomen c) CT scan d) Abdominal X-rayQ/A A 14 month old baby girl is brought to A&E because she has had diarrhoea for 3 days and vomiting for 1 day.The diarrhoea has been 4 times a day and watery with no blood. She has vomited yellow fluid 2 times today. The parents are worried because she has been refusing all food and not drinking at all for the last 24 hours. She has had 5 wet nappies today, which is 2 fewer than normal. She is otherwise healthy and takes no regular medicines. On examination, the child appears well and is playing. Her skin is pink and warm with no mottling. Her mucous membranes appear dry and her eyes do not appear sunken. Her respiratory rate is 30 and saturations 99%. Her heart rate is 110, blood pressure is 118/78 and capillary refill is 2 seconds centrally. Her temperature is 37.1 degrees. Her abdomen is soft and non-tender. A urine dip shows no abnormalities What is the most appropriate management for this child? a) IV fluids b) Encourage solid foods c) Refer to surgical team d) Dioralyte oral rehydration e) IV antibioticsQ/A A 14 month old baby girl is brought to A&E because she has had diarrhoea for 3 days and vomiting for 1 day.The diarrhoea has been 4 times a day and watery with no blood. She has vomited yellow fluid 2 times today. The parents are worried because she has been refusing all food and not drinking at all for the last 24 hours. She has had 5 wet nappies today, which is 2 fewer than normal. She is otherwise healthy and takes no regular medicines. On examination, the child appears well and is playing. Her skin is pink and warm with no mottling. Her mucous membranes appear dry and her eyes do not appear sunken. Her respiratory rate is 30 and saturations 99%. Her heart rate is 110, blood pressure is 118/78 and capillary refill is 2 seconds centrally. Her temperature is 37.1 degrees. Her abdomen is soft and non-tender. A urine dip shows no abnormalities What is the most appropriate management for this child? a) IV fluids b) Encourage solid foods c) Refer to surgical team d) Dioralyte oral rehydration e) IV antibioticsPresentation: Constipation Constipation KEY FACTS CLINICAL S&S OVERVIEW • include Hirschsprung’sses • <3 stools/week, hard stools that are hard to disease, cystic pass • Very common problem in paediatric care, fibrosis or hypothyroidism • Rabbit dropping stools most cases are idiopathic • Encopresis -> term for faecal • Many red flags to look out for when a child incontinence, which have rarer • Straining and difficult passage of stools, is constipated, as the underlying condition causes abdominal pain, rectal bleeding associated may be more serious! -> N&V, neuro, with the hard stools bleeding, abnormal rectum/anus/lower back etc. • postureve posturing -> holding an abnormal • Overflow soiling -> incontinence of particularly foul-smelling stools • Hard stools may be palpable, loss of sensation in the need to open bowels MANAGEMENT INVESTIGATIONS COMPLICATIONS • Pain, reduced sensation • High fibre diet and good hydration • Endoscopy, biopsy • Digital rectal exam (DRE) • Anal fissures, haemorrhoids • Laxatives (Movicol is first line) • Overflow, soiling, psychosocial • Bowel diary • Physical exam morbidity Summary • Pyloric stenosis and biliary atresia are typically associated with N&V and have large underlying genetic influences in many cases • Intussusception -> telescoping of intestines, sausage-shaped mass • Peritonitis is a complication from appendicitis • Viral gastroenteritis is most commonly caused by rotavirus and ELISA testing is used for its diagnosis • Mesenteric lymphadenitis causes pain in RLQ • Complications are usually from other abdominal conditions, peritonitis is a common one that can result from other conditions • Ultrasound and physical examination can diagnose most conditions in children • High fibre, good hydration and avoidance of cause is also a ”must-do” for conditions that typically arise in abdominal painFeedback Form: Thank You!