GIT Paeds

Question 1

Surgical and medical causes of abdo pain in neonates and infants not to be missed

Answer 1

Surgical:
- testicular/ovarian torsion
- appendicitis
- peritonitis
- necrotising enterocolitis
- volvulus
- intersussecption
- Hirschprungs disease
- incarcerated hernia

Medical
- DKA
- toxic e.g iron ingestion
- sepsis
- haemolytic uraemic syndrome
- UTI

Question 2

How might a Meckel diverticulum present?

Answer 2

• GIT haemorrhage 40% (can be bright red to tarry and may be significant)
• bowel obstruction 30%
• diverticulitis 20% (can perforate)

Question 3

What is the most common cause of significant lower gastrointestinal haemorrhage in children?

Answer 3

Meckel diverticulum

Question 4

What age group is appendicitis most common in?

Answer 4

9 - 12
Uncommon in infants
Very rare in neonates

Question 5

In young children, say under two year old. What are the most common features of appendicitis?

Answer 5

• vomiting 90%
• pain (may not be in RLQ though!) 30 to 70%
• diarrhoea 18 to 45%
• fever 40 - 60%

Question 6

In what conditions may an abdo xray help?

Answer 6

• bowel obstruction of any cause
• bowel perforation ( lateral abdo xray)
• necrotising enterocolitis (bowel wall pneumatosis)

Question 7

Non- IgE mediated food allergy -also referred to as Cow milk protein intolerance consists of what three conditions?

Answer 7

Food protein induced allergic proctocolitis (FPIAP): non-IgE inflammation o rectum. Presents first few months of life with blood +/- mucous in stool in well infant
Food protein induced enteropathy: delayed non-Ige mediated inflammation of small intestine. Presents early infancy with persistent loose stool, vomiting, poor weight gain. Secondary lactose intolerance causes bloating and peri-anal excoriation
Food protein induced enterocolitis syndrome (FPIES) delayed onset repeated vomiting 2-4 hours after eating trigger food. May be associated with pallor, lethargy, loose stools. Presents first year of life following introduction of solids. Common foods: rice, cow milk, soy milk, oats but can be any food

Question 8

Possible investigations for the vomiting infant?

Answer 8

• VBG (hypochlorhaeia hypokalaemic alkaosis of pyloric stenosis
• ABX (bowel obstruction from interussception/malroations, volvulus, mencoium plug)
• USS: hypetrophic pyeloric stenosis, intersussecption
• Urine: MCS (while all infections can cause vomiting, UTI is common cause)
• LP (MCS for meningitis, openingn pressure but below age 2 as uses high volume of CSF to check pressure)
• BC if unwell, sepsis

Question 9

What symptoms may make you concerned about an unwitnessed button battery ingestion?

Answer 9

• airway obstruction or wheezing
• drooling
• vomiting
• chest discomfort
• difficulty swallowing, decreased appetite, refusal to eat
• coughing, choking, or gaggin when eating or drinking

Question 10

what is an oral treatment as a temporising measure for a child with an eosophageal button battery < 12 hours ago?

Answer 10

• honey 10ml every 10 minutes up to 6 doses if child > 12 months

There is a button battery national hotline you can call for assitacne with battery identification and treatment
Battery must be removed within 2 hour to avoid complications

Question 11

A child has an eosophageal button battery removed 2 weeks ago. What are delayed complications?

Answer 11

• tracheosophageal fistula
• eosphageal perforation
• mediastinitus
• vocal cord paralysis
• tracheal stenosis or tracheomalacia
• aspiration pneumonia
• empyema
• lung abcess
• pneumothorax
• spondylodiscitis
• exsanguation from large vessel erosion

Question 12

Ingestion of what foreign bodies may need specialist input/treatment

Answer 12

• button batteries
• coins in eosphagus
• symptomatic ingestion
• sharp objects
• large objects
• 2 x magnet or magnet + metal FB

no xray needed and expectant management if:
- < 2cm diameter and < 6cm long
- not sharp or pointed
- not a magnet or battery
- not expandable
- non toxic
- able to eat and drink
- no known GI abnormality

Question 13

You do bloods on a drowsy 5 year old and unexpectly find she may be in liver failure. Exposure to what hepatotoxins are more likely in Australia?

Answer 13

• paracetamol
• anticonvulsants
• aspirin
• mushrooms

important to ask as may have specific treatment available

Question 14

Initial resus for a child with suspected intusseption?

Answer 14

• IVC
• 20ml/kg 0.9 % sodium chloride
• anaglesia e.g morphine 0.05 - 0.1mg/kg 4 hourly IV, paracetamol

Question 15

How much NG fluid, what NG fluid and over what time frame for rehydration for 10kg child with
-mild dehydration
- moderate dehydration

Answer 15

mild: 50ml/kg ORS via NG over 4 hours = 500ml
moderate: 100ml/kg ORS via NG over 4 hours = 1000ml

QCH guideline says 50ml/kg for all children as doctors tend to overestimate level of dehydration
If age > 2 IV rehydration may be more appropriate

Question 16

When should slower (8-12 hours)NG rehydration be considered for a child with gastroenteritis?

Answer 16

• significant co-morbidities (renal, cardiac, diabetes, on diuretics)
• infants < 6 months to avoid fluid overload
• who continue to vomit during rehydration
• are being admitted overnight

Question 17

A 10kg child is moderately dehydrated and you wish to rehydration intravenously over 24 hours. How do you calculate your fluid and which fluid do you use?

Answer 17

10% dehydration x 10kg x 10
= 10 x 10 x 10
= 1000ml
Maintenance = 4 x 1 = 40ml/hr
Hourly rate =1000/24 = 41 ml + 40ml = 81 ml/hr

Note, generally moderate dehydration is repaced over 48 hour period
Moderate = 5 - 10%
Maintaince rule is
4 x first 10kg i.e 4 x 1 not 4 x 10
2 x 2nd 10kg ie 2 x 1
1 x every other 10 kgs i.e 1 x 2 if child 40kg
= ml/hour

Question 18

How is rapid IV rehydration done for gastroenteritis?

Answer 18

10ml/kg/hr of 0.9% sodium chlordie + 5% glucose for 4 hours

Question 19

What organ systems are affecteid with Henoch-Schonlein purpura?

Answer 19

Skin: extensor surface petechiae and maculopapules in lower limbs and buttoks
Joints: acral arthritis, but more commonly arthralgia and limb swelling
Kidney: micro or macroscopic haematuria, with or without proteinurea, may present with frank nephritis
Gastrointestinal: abdominal pain with submucosal vasculitis presenting with intussusception, per rectum bleeding, malaena or peritoneal irritation

leucocytoclastic vasculitis disorder of uncertain aetiology