Flashcards in Paeds 2 Deck (174)
What is the difference between GOR, GORD and regurgitation?
Gastro-oesophageal reflux (GOR) = passage of gastric contents into the oesophagus
Gastro-oesophageal reflux disease (GORD) = presence of troublesome symptoms or complications arising from GOR.
Regurgitation/posseting = is the voluntary and involuntary movement of part or all of the stomach contents beyond the oesophagus
Why are infants prone to reflux?
Short, narrow oesophagus.
Delayed gastric emptying.
Shorter, lower oesophageal sphincter that is slightly above, rather than below, the diaphragm.
Liquid diet and high caloric requirement, putting a strain on gastric capacity.
Larger ratio of gastric volume to oesophageal volume.
What are the risk factors for GORD in infants
FH of heartburn or acid regurg
history of diaphragmatic hernia or congenital oesophageal atresia
What are the features of a child with reflux
crying whilst feeding
abnormal neck postures
feeding difficulties - refusal, gagging, choking
failure to thrive
What age has reflux normally developed by?
if symptoms start after this, probably not reflux!
What are some differentials for reflux and what sets them apart?
pyloric stenosis - projectile vomiting, <2m old
obstruction - bilious vomiting, abdo distension and tenderness
upper GI bleed - heamatemesis
sepsis - unresponsive, focal features of infection
cow's milk protein allergy - blood in stool, atopy, diarrhoea
How is regurgitation managed
reassure parents that it is normal!
make sure they seek help if child becomes distressed, feeding problems develop or faltering growth
How is GORD managed in a breast fed infant
trial giving gaviscon diluted in water after each feed for 1-2 weeks
if helps, continue
if not, try H2 antagonist or PPI for one month
if fails, seek help of paediatrician
How is GORD managed in a bottle fed infant
if feeds are excessive, decrease amount of milk!
1-2 weeks trial of giving smaller feeds more often (maintaining adequate intake)
if not resolved, 1-2 weeks of thickened feed
if not resolved, 1-2 weeks of gaviscon mixed in with feed
if not resolved, try H2 antagonist or PPI for one month
if fails, seek help of paediatrician
What is the daily milk requirement of an infant
150ml/kg per day
What are some complications of GORD
Recurrent aspiration pneumonia.
Recurrent acute otitis media (more than three episodes in 6 months).
Dental erosion in a child with neurodisability (for example cerebral palsy).
What is pyloric stenosis
diffuse hypertrophy and hyperplasia of the smooth muscle cells of the antrum and pylorus leading to narrowing of the pyloric canal and causing gastric outlet obstruction
What are the risk factors for pyloric stenosis
What are the features of pyloric stenosis
infant aged 2-8 weeks
vomiting after feeds - projectile, non-bilious, remians hungry and wants more!
infrequent/absent bowel movements
What might be found on examination in an infant with pyloric stenosis
Stomach wall peristalsis
An enlarged pylorus, classically described as an 'olive', may be palpated in the right upper quadrant or epigastrium of the abdomen.
What is the differential diagnosis for an infant with suspected pyloric stenossi
malrotation - would be bilious vomiting
What investigations would you do in a child with suspected pyloric stenosis
What is classically seen on a blood gas in an infant with pyloric stenosis? Why is this?
hypokalaemia, hypochloraemic metabolic alkalosis
due to the loss of hydrochloric acid with the repeated vomiting of stomach acid causing a hypochloraemia and metabolic alkalosis.
The kidneys will then exchange potassium to retain protons to attempt to compensate, leading to a hypokalaemia
What is the management of pyloric stenosis
correct hydration and electrolyte abnormalities
NG tube - not for feeds, but aspirated at 4 hourly intervals
operatively: Ramstedt’s pyloromyotomy
post op: recommence feeds 6 hours after op
How is Ramstedt’s pyloromyotomy carried out?
open (supra-umbilical incision) or laparoscopic
pyloric muscle divided down to the mucosa
What are some pre op and post op complications of pyloric stenosis
pre op: hypovolaemia, apnoea
post op: infection, bleeding, wound dehisence, perforation, incomplete myotomy leading to persistent vomiting
Why can an infant vomit post Ramstedt’s pyloromyotomy
What is intussusception and why does it lead to obstruction
one section of bowel invaginates into a distal section of bowel
mesentery becomes compressed as it is drawn between the layers
lymphatic and venous obstruction leads to ischaemia
therefore, bowel wall distends and obstructs lumen
peristalsis is disrupted
When is intussusception most common?
aged 5-10 months
What causes intussusception to occur?
90% - non-pathological lead point eg. rotavirus, adenovirus, HHV6, amoeba, shigella
10% pathological eg. Meckel's diverticulum (75%).
Polyps and Peutz-Jeghers syndrome (16%).
Henoch-Schönlein purpura (3%).
Lymphoma and other tumours (3%).
Reduplication - a process by which the bowel wall is duplicated (2%).
An inflamed appendix.
Weight above average.
What are the symptoms of intussusception
sudden onset of colicky abdo pain
paroxysmal - every 20mins
lethargy, irritability, hypotonia, reduced conscious level
What can be found on examination in intussusception
sausage shaped mass in RUQ
lack of bowels in RLQ - Dance's sign
What investigations should be done in suspected intussusception
U+E, FBC, clotting,
What are the management options for intussusception
drip adn suck firstly - for dehydration
radiologist managed reduction by air or barium enema - if no sign of peritonitis, perforation or shock.
if any sign of peritonitis, perforation, pathological lead point >24 history or failed enema, laparotomy is needed!