Paediatrics – Mosler revision

1. Paediatrics –Mosler revision By Thomas Tay

2. Paediatrics - Intestinal Obstruction By Thomas Tay

3. Intestinal Obstruction • Divided into small bowel obstruction and large bowel obstruction • Small bowel obstruction • Duodenal atresia/ stenosis • Jejunal/ ileal atresia/ stenosis • Malrotationwith volvulus • Meconium ileus • Meconium plug • Large bowel obstruction • Hirschprung disease • Rectal atresia • High lesion (above levatorani, fistula to bladder, urethra, vagina) • Low lesion (below levatorani)

4. Intestinal obstruction • Px: • Bile stained vomitus (unless obstruction above ampulla of Vater) • Delayed/ absent passing of meconium (may have meconium initially) • Abdominal distension (more obvious the more distal the obstruction) • High obstruction present soon after birth, lower obstruction present in days • Aetiology • Congenital malformation (duodenal atresia common in Down Syndrome) • Cystic fibrosis: causes meconium ileus • Hirschprung Disease: caused by absence of myenteric nerve plexus at rectum • Ix: • AXR – Double bubble in duodenal atresia • Upper GI contrast study • Mx: • Surgery

5. Paediatrics – Constipation and soiling By Thomas Tay

6. Constipation and soiling • Constipation can mean many things • Infrequent passing of bowels • Hard stools • Pain during defecation • In a child presenting with constipation, beware of red flag sings • Soiling can occur: • With rectal impaction • Without rectal impaction

7. Constipation and soiling – Red flag sings • Not passing meconium within 24 hours of birth • Hirschprung disease • Failure to thrive • Hypothyroid • Coeliac disease • Gross abdominal distension • Hirschprung disease/ rectal atresia • Abnormal lower limb neurology/ morphology • Lumbosacral pathology • Sacral dimple • Spina bifida occulta • Abnormal appearance/ position/ patency of anus • Abnormal anorectal anatomy • Perianal bruising/ multiple fissures • Sexual abuse • Fistula/ abscess/ fissure • Perianal Chron’s disease

8. Constipation and soiling • If soiling, do abdominal exam, feel for faecal mass • If present, treat like constipation • Ix: • Coeliac screen • Thyroid function test • Mx: • Stool softener (Polyethylene glycol 3350) + electrolytes • Escalating dose for 1-2 weeks • Titrating dose for minimum of 6 months • Simulant laxative (sodium picosulphate/ senna)

9. Paediatrics – Recurrent abdominal pain By Thomas Tay

10. Recurrent abdominal pain • In 90% of cases, no organic cause is found • Goal of management is to identify serious conditions without subjecting the child to unnecessary investigations • Conditions where no organic cause is found • Abdominal migraine • Irritable bowel syndrome • Functional dyspepsia

11. Recurrent abdominal pain • Investigations to rule out serious condtions • Urine microscopy and culture – UTI • Ultrasound of gall bladder and kidneys - gall stones, pelvic-ureteric junction obstruction • Coeliac antibodies – coeliac disease • TFT - hypothyroidism

12. Recurrent abdominal pain – Abdominal migraine • Px: • Abdominal pain + headache • Associated with facial pallor and vomiting • Weeks of no symptoms, 24-48 hours of abdominal pain • Tx: • Migraine medications

13. Recurrent abdominal pain - IBS • Px: • Abdominal pain, diarrhoea, constipation, boating, feeling of incomplete defecation

14. Recurrent abdominal pain – Functional dyspepsia • Px: • Abdominal pain • Waking them up at night • Radiating to the back • FHx of peptic ulcer (first degree relative) • Aetiology • H. Pylori • Ix: • Carbon-13 labelled urea breath test • H. Pylori antigen in stool • Gastric antral biopsy • Mx: • PPI (omeprazole) • Antibiotics if H. Pylori present (amoxicillin + metronidazole/ clarithromycin) • If fail to respond to treatment or symptoms recur after treatment, do endoscope • If endoscopy normal, diagnose functional dyspepsia

15. Paediatrics – Gastroenteritis By Thomas Tay

16. Gastroenteritis • Diagnosis should be: • AGE without clinical dehydration • AGE with clinical dehydration • AGE with shock • Px: • Abdominal pain, diarrhoea, vomiting, fever • Aetiology: • Viral: Rotavirus, adenovirus, norovirus, calicivirus, coronavirus, astrovirus • Bacterial: • Severe abdominal pain: Campylobacter jejuni • Bloody diarrhoea: Salmonella, Shigella • Profuse diarrhoea: Cholera, E. Coli • Protozoal: Cryptosporidium, giardia

17. Gastroenteritis • Ix: • None routinely • If septic/ bloody diarrhoea: stool culture • If IV fluids are to be given: U&E, creatinine, blood glucose • If antibiotics are to be given: blood culture • Mx: • If clinical dehydration: ORS • If shock/ deteriorating/ vomiting: IV fluids • IV antibiotics not routinely given. Given if salmonella in child < 6 months/ immunocompromised/ malnourished; Clostridium, Shigella, Cholera, Giardia

18. Gastroenteritis – Signs of dehydration • Clinical dehydration • Irritable/ lethargic • Sunken eyes • Dry mucosa • Tachycardia • Tachypnoea • Reduced skin turgor • Reduced UO • Shock • Reduced consciousness • Grossly sunken eyes • Capillary refill > 2 sec • Weak pulse • Cold peripheries • Pale/ mottled skin • Hypotension (decompensated shock)

19. Gastroenteritis – IV fluid management • There are 3 types of fluid • Resuscitation fluid • Replacement fluid • Maintenance fluid • Resuscitation fluid for shock (20ml/kg bolus) • Replacement fluid is either 5% (50ml/kg/24h) for clinical dehydration or 10% (100ml/kg/24h) for shock • Maintenance fluid: • 1st 10 kg: 100ml/kg/24h • 2nd 10 kg: 50ml/kg/24h • Subsequent kg: 20ml/kg/24h

20. Paediatrics – Inflammatory Bowel Disease By Thomas Tay

21. Inflammatory Bowel Disease • Inflammatory Bowel Disease includes • Crohn’s Disease • Ulcerative colitis • Crohn’s vs UC • Crohn can occur from mouth to anus, commonly distal ileum and proximal colon; UC occurs only in the colon • Crohn’s is more common than UC in children • Crohn’s is transmural UC is not • Crohn’s occurs in skipped lesions, UC is continuous

22. Inflammatory bowel disease - Crohn’s disease • Px: • Failure to thrive/ weight loss, fever, abdominal pain, diarrhoea, lethargy. Extra intestinal: uveitis, oral lesions, perianal skin tags, erythema nodosum, arthralgia • Ix: • Diagnosis of condition: Biopsy (non-caseatingepitheloid cell granulomata) • Imaging: Upper GI endoscope, ileocolonoscopy, small bowel imaging • Diagnosis of remission: Raised inflammatory markers: FBC (platelet), ESR, CRP; Iron deficiency anaemia: FBC (Hb), PBF (MCV), Iron study; serum albumin • Mx: • Induce remission: Nutritional therapy (polymeric diet), systemic steroids • Prevent relapse: • Immunosuppressant (azathioprine, mercaptopurine, methotrexate) • If resistant, anti TNF (infliximab, adalimumab) • Complications: fistula and obstruction – surgery

23. Inflammatory bowel disease - UC • Px: • Failure to thrive/ weight loss, fever, colicky abdominal pain, diarrhoea, lethargy, rectal bleeding, extra-intestinal manifestations: erythema nodosum, arthralgia • Ix: • Diagnosis: Biopsy and rule out infective cause (Histology: inflamed mucosa, damaged crypts, ulcers) • Imaging: upper GI endoscopy (nothing), ileocolonoscopy, small bowel imaging (nothing) • Mx: • Remission induction and maintenance (mild disease): Aminosalicylate (mesalazine) • Remission induction: topical or systemic steroids • Remission maintenance (aggressive disease): Immunosuppressant (azathioprine) +- low dose steroid • Resistant disease: anti TNF (infliximab, ciclosporin) • Acute disease: IV fluids, IV steroids, IV ciclosporin • Surgery: Colectomy with colostomy or ileorectal pouch

24. Paediatrics – Coeliac disease By Thomas Tay

25. Coeliac disease • Px: • Age: 8 months to 24 months • Classic: Failure to thrive, abdominal distension, buttock wasting, abnormal stools, irritability • Modern: Failure to thrive, iron or folate deficiency anaemia, abdominal pain, screening (done in high risk group: T1DM, Down syndrome, autoimmune thyroid disease, FHx of coeliac disease) • Aetiology • Wheat, rye and barley triggers an immunological response causing destruction of small intestine villi • Ix: • Diagnosis: biopsy (increased lymphocytes, villous atrophy, crypt hypertrophy) and response to gluten free diet • Serological antibodies (anti-tTg, EMA) • Mx: • Gluten free diet for life

26. Paediatrics – Gastro oesophageal reflux By Thomas Tay

27. Gastro oesophageal reflux • Common benign condition in <12 months • Px: • Vomiting without failure to thrive • Becomes gastro oesophageal reflux disease (GORD) when there is: • Failure to thrive • Oesophagitis • Recurrent pulmonary aspiration • Dystonic neck posturing • High risk for GORD: Cerebral palsy, preterm with bronchopulmonary dysplasia, surgery for oesophageal atresia or diaphragmatic hernia

28. Gastro oesophageal reflux and GORD • Ix: • Usually clinically diagnosed but if uncertain: • 24-hour oesophageal pH monitoring • 24-hour impedance monitoring • Endoscopy + oesophageal biopsy (to look for oesophagitis) • Upper GI contrast study to rule out anatomical abnormality • Mx for GOR: • Reassurance, food thickening agents, more frequent, smaller feeds • Mx for GORD: • H+ receptor antagonist (Ranitidine), PPI (Omeprazole) • Surgical: Nissen fundoplication

29. Paediatrics – Pyloric stenosis By Thomas Tay

30. Pyloric stenosis • Px: • Age: 2 weeks to 8 weeks • Risk factor: “Mommy’s boy” - more common in boys with family history on maternal side • Vomiting increasing in frequency and forcefulness ultimately becoming projectile vomiting • Hunger after vomiting until dehydration leads to loss of interest in feeding • Weight loss if late presentation • Aetiology: • Hypertrophy of pyloric muscle causing gastric outlet obstrution • Ix: • Test feed followed by inspection of peristalsis and palpation of olive-like pyloric mass at RUQ • Diagnosis: Ultrasound • U&E checking for electrolyte imbalance • Mx: • Immediate treatment: IV fluids to correct fluid and electrolyte abnormality • Definitive treatment: Surgery - pyloromyotomy

31. Paediatrics – Testicular torsion By Thomas Tay

32. Testicular torsion • Px: • Age: Any age, most common post-pubertal • Sudden severe abdominal, testicular or scrotal pain, redness and oedema of the scrotum • Aetiology • Rotation of testicle around spermatic cord • High risk: Undescended testes, Clapper bell testes • Ix: • Emergency surgical exploration • Mx: • Correction of affected testicle and contralateral testicle