Gastrointestinal Medicine Pyloric stenosis
When the muscular layer of the pylorus hypertrophies gastric outlet obstruction
Presents around 2-8 weeks
RF First-born male Fair skin Family Hx
Necrotising Enterocolitis (NEC) Signs + Symptoms ‘PYLORIC’
Leading cause of death in premature infants Projectile vomiting (30 minutes after feed)
This is inflammatory bowel necrosis Yelling, unhappy child
Aetiology Lethargic child, Loss of weight
Possible hypoxic insult that occurs in premature infants because their immune Olive (pyloric mass) present in RUQ/Epigastric
system is not fully developed hypoxia intestinal sloughing bacteria Rumbling tummy (gastric peristalsis seen from L R on feeding test)
invade inflammation = this leads to more gangrene, risk of perforation and Irritable
NEC Constipation
Signs + Symptoms Ix
Feed intolerance, abdominal distension, bloody stools Feeding test = Positive peristaltic wave
Ix Bloods FBC, WCC, U&Es, LFTs
Bloods FBC, WCC, U&Es (there may be metabolic acidosis) Hypochloraemic, hypokalaemic, metabolic alkalosis due to persistent vomiting
AXR (e.g. football sign = massive pneumoperitoneum, thumbprinting= large Mx
bowel oedema) Correct fluid + electrolyte imbalance w/ IV fluids (0.45% saline + 5% dextrose / potassium
Mx supplements)
Conservative Stop bottle-feeding, admit to NICU + take serial XRs Definitive Ramstedt pyloromyotomy (child can be fed post 6 hours, done either open/peri-
Medical (only consider if no perforation evident) Decompress the large bowel, umbilical)
provide broad-spec Abx, IV fluids and nutrition
Hirschsprung’s Disease
Coeliac disease Intussusception Congenital, aganglionic megacolon
Malabsorption Failure to thrive, abnormal stools + Invagination of one portion of bowel into the From the muscular + mucosal layers of the colon
specific nutrient deficiencies lumen of the adjacent bowel Usually affects recto-sigmoidal region
Enteropathy where gliadin fraction of gluten provoke a Usually ileo-caecal junction Leads to constipation, obstruction megacolon
damaging immunological response in the proximal 6-18 months, M > F (2:1) M > F (3:1)
small intestinal mucosa (duodenum) RF Previous Hx, FHx, intestinal malrotation 1. Serosal layer
Macrophage (MHC) recruits B cells produce anti- Aetiology 2. Longitudinal muscle layer- Myenteric plexus (SM
gliadin, anti-TTG + anti-endomyseal Children Lymphoid hyperplasia (peyers patches relaxation)
villous atrophy + flat mucosa enlarge during infection e.g. rota/norovirus) + 3. Circular muscle layer- Submucosal plexus (helps control
Associations Dermatitis herpetiformis, Type 1 DM, Meckel’s diverticulum bloodflow, absorption + secretion)
autoimmune hepatitis, HLA-DQ2 (95%) HLA-DQ8 (80%) Adult Tumour Aetiology
Signs + Symptoms Signs + Symptoms Neural crest cell migration neuroblasts migrate
Classic presentation @ 8-24 weeks w/ diarrhoea, Paroxysmal abdominal colic pain, during craniocaudally between weeks 8 12 (Proximal colon
abdominal distension, muscle wasting + irritability, IDA episodes, child will draw up knees, become rectum)
Ix pale, vomiting, blood-stained stool- ‘red current The disruption of development is due to dysregulation of RET
Jejunal biopsy villous atrophy, crypt hyperplasia, jelly’, sausage-shaped mass in RLQ and EDNRB genes (control migration)
increased intraepithelial lymphocytes, lamina propria Ix USS 1st line: ‘Target sign’, XR can also show Signs + symptoms
infiltration w/ lymphocytes distended small bowel Neonatal period: failure to pass meconium in the first 24
Immunology TTG (IgA) ✓Endomyseal (IgA) ✓ Anti- Mx hours, explosive stools upon insertion of finger in the rectum
gliadin ✗ Reduction by rectal air insufflation (1 st line) by Older children: constipation, abdominal distension, bile-
Mx radiologist stained vomiting
Wheat, rye + barley removed from diet for life If this fails/ signs of peritonitis surgery Ix Rectal suction biopsy
Have functional hyposplenism- provide pneumococcal Mx Surgery- remove affected region colostomy
vaccine Soave- Boley procedure (endorectal pullthrough)/ Duhamel
When the muscular layer of the pylorus hypertrophies gastric outlet obstruction
Presents around 2-8 weeks
RF First-born male Fair skin Family Hx
Necrotising Enterocolitis (NEC) Signs + Symptoms ‘PYLORIC’
Leading cause of death in premature infants Projectile vomiting (30 minutes after feed)
This is inflammatory bowel necrosis Yelling, unhappy child
Aetiology Lethargic child, Loss of weight
Possible hypoxic insult that occurs in premature infants because their immune Olive (pyloric mass) present in RUQ/Epigastric
system is not fully developed hypoxia intestinal sloughing bacteria Rumbling tummy (gastric peristalsis seen from L R on feeding test)
invade inflammation = this leads to more gangrene, risk of perforation and Irritable
NEC Constipation
Signs + Symptoms Ix
Feed intolerance, abdominal distension, bloody stools Feeding test = Positive peristaltic wave
Ix Bloods FBC, WCC, U&Es, LFTs
Bloods FBC, WCC, U&Es (there may be metabolic acidosis) Hypochloraemic, hypokalaemic, metabolic alkalosis due to persistent vomiting
AXR (e.g. football sign = massive pneumoperitoneum, thumbprinting= large Mx
bowel oedema) Correct fluid + electrolyte imbalance w/ IV fluids (0.45% saline + 5% dextrose / potassium
Mx supplements)
Conservative Stop bottle-feeding, admit to NICU + take serial XRs Definitive Ramstedt pyloromyotomy (child can be fed post 6 hours, done either open/peri-
Medical (only consider if no perforation evident) Decompress the large bowel, umbilical)
provide broad-spec Abx, IV fluids and nutrition
Hirschsprung’s Disease
Coeliac disease Intussusception Congenital, aganglionic megacolon
Malabsorption Failure to thrive, abnormal stools + Invagination of one portion of bowel into the From the muscular + mucosal layers of the colon
specific nutrient deficiencies lumen of the adjacent bowel Usually affects recto-sigmoidal region
Enteropathy where gliadin fraction of gluten provoke a Usually ileo-caecal junction Leads to constipation, obstruction megacolon
damaging immunological response in the proximal 6-18 months, M > F (2:1) M > F (3:1)
small intestinal mucosa (duodenum) RF Previous Hx, FHx, intestinal malrotation 1. Serosal layer
Macrophage (MHC) recruits B cells produce anti- Aetiology 2. Longitudinal muscle layer- Myenteric plexus (SM
gliadin, anti-TTG + anti-endomyseal Children Lymphoid hyperplasia (peyers patches relaxation)
villous atrophy + flat mucosa enlarge during infection e.g. rota/norovirus) + 3. Circular muscle layer- Submucosal plexus (helps control
Associations Dermatitis herpetiformis, Type 1 DM, Meckel’s diverticulum bloodflow, absorption + secretion)
autoimmune hepatitis, HLA-DQ2 (95%) HLA-DQ8 (80%) Adult Tumour Aetiology
Signs + Symptoms Signs + Symptoms Neural crest cell migration neuroblasts migrate
Classic presentation @ 8-24 weeks w/ diarrhoea, Paroxysmal abdominal colic pain, during craniocaudally between weeks 8 12 (Proximal colon
abdominal distension, muscle wasting + irritability, IDA episodes, child will draw up knees, become rectum)
Ix pale, vomiting, blood-stained stool- ‘red current The disruption of development is due to dysregulation of RET
Jejunal biopsy villous atrophy, crypt hyperplasia, jelly’, sausage-shaped mass in RLQ and EDNRB genes (control migration)
increased intraepithelial lymphocytes, lamina propria Ix USS 1st line: ‘Target sign’, XR can also show Signs + symptoms
infiltration w/ lymphocytes distended small bowel Neonatal period: failure to pass meconium in the first 24
Immunology TTG (IgA) ✓Endomyseal (IgA) ✓ Anti- Mx hours, explosive stools upon insertion of finger in the rectum
gliadin ✗ Reduction by rectal air insufflation (1 st line) by Older children: constipation, abdominal distension, bile-
Mx radiologist stained vomiting
Wheat, rye + barley removed from diet for life If this fails/ signs of peritonitis surgery Ix Rectal suction biopsy
Have functional hyposplenism- provide pneumococcal Mx Surgery- remove affected region colostomy
vaccine Soave- Boley procedure (endorectal pullthrough)/ Duhamel
