Category Archives: Gastro

Proctalgia

Clinical, Gastro, General paediatrics

=anal pain.

Rule out anal fissure (may be hard to see but bleeding or sentinel pile are clues, typically caused by constipation), thrombosed haemorrhoid, infection.

After that, functional (see Rome criteria)- often triggered by defaecation or sitting.

Classifed as acute (less than 20 mins – “fugax”) or chronic (greater than 20 mins episodes). Latter thought to be due to paradoxical pelvic floor contraction.

Biofeedback has best evidence but consider tricyclic antidepressants, Botox, and sacral nerve stimulation (!).

Variceal bleeding

Emergency medicine, Gastro, General paediatrics

Due to portal hypertension from chronic liver disease.

Potential for large losses – may need local major haemorrhage protocol (FFP, platelets etc) – typically if blood loss >150mls/min, or else 20% blood volume loss in <1 hour (normal blood volume is 80ml/kg).

In adults, they try not to transfuse above 80 – thought that excessive transfusion may increase bleeding.

Terlipressin preferred to octreotide – from age 12. IV injection every 4 hours. No evidence for Tranexamic acid!

NG tube may cause more trauma…

In adults, Glasgow-Blatchford score used. Authors are Oliver and Mary Blatchford (couple?) – he was actually in Paisley at the time…

Eosinophilic oesophagitis

Gastro, General paediatrics

=EOE, but in the US EE.

In Danish study, incidence tripled between 2011 and 2018…

Boys predominate!  Young kids non specific (aversion, FTT, vomiting), older may have pain, food bolus impaction. 

70% atopic. Besides eosinophils histologically (>15/hpf), “cat scratch furrowing”, exudates, strictures on endoscopy (“trachealization”).

High dose omeprazole 2-3mg/kg (max 80mg) in split doses (before scope, 8/52).  Then Budesonide syrup (nebules broken open, mixed with linctus), nil orally for 30 mins after.  Some reports of adrenal insufficiency with this regimen.

Elemental diet? Usually Milk free effective, else 2-6 food elimination (80% effective – milk, egg, wheat, soya, nuts, fish).  4 weeks at a time. Re-introduce 1 food per 2/52.  Use SPT to guide, as often positive even if not aware of type 1 reactions! 

Most experience in infants is with amino acid formulas, not clear if extensively hydrolysed would be ok or not.

Generally symptoms recur at 5-6/7, if they are going to.   Not practical to repeat endoscopy after each food but symptoms can settle without microscopic remission.  Egg allergy can get worse with exclusion so shorter time or ignore?

[Diana Flynn]

The Farm effect in allergy

Allergy, Gastro, General paediatrics, Nutrition

Children growing up on farms are less likely to develop allergies and asthma. Farming has been part of human culture for probably 7000 years.

It is widely accepted now that a symbiotic relationship with a diverse population of microbes in the environment, on the skin, in the gut and in the lung is necessary for a healthy immune system (“microbiome“). These microbes influence the balance between inflammation and immune tolerance. That relationship needs to be developed in early life, and nutrition is a major part.

Big European cross sectional studies – PARSIFAL and GABRIEL. Amish and Hutterites in US are genetically similar but Hutterites use industrial rather than traditional farming techniques (and have 4-6x the rate of hay fever and atopic sensitization).

Prenatal maternal exposure to farm animals is protective against eczema in the first 2 years of life, and against asthma symptoms pre-school.

Farm milk consumption in the first year of life is protective against respiratory allergies. Not clear what it is about it – more whey? Higher levels of cytokines or polyunsaturated fatty acids?

In children, exposure to cows and hay was protective against asthma. Some evidence for pigs, but risk seems to go up for sheep.

Mediators thought to potentially be N-gylcolylneuraminic acid (animals/pets) and arabinogalactan (plants).

Lipopolysaccharide (endotoxin) is widespread in the farm environment. Levels in mattresses inversely associated with hay fever, atopic sensitisation and asthma.

Lack of gut microbial diversity in first month of life predicts school age asthma.

Dietary diversity in first 2 years of life protects against asthma and allergic rhinitis. The link between gut microbes and lung health is thought to be short chain fatty acids, such as acetate and butyrate.

[Ped Allergy and Imm 2022]

In a study of 589 children, 1-year microbiota maturation (based on metagenomics – genetic material of a community of micro-organisms – and metabolomics – metabolites in environment) closely related to eczema, asthma, food allergy and allergic rhinitis at age 5 years. Found a core set of “functional and metabolic imbalances” characterized by compromised mucous integrity, elevated oxidative activity, decreased secondary fermentation, and elevated trace amines. [Hoskinson, BC, Canada – Nature communications . 14(1):4785, 2023 08 29.]

Irritable Bowel Syndrome

Common, Gastro, General paediatrics

Rome IV classification gives definition as:

Recurrent abdominal pain, at least once per week for at least 3 months, associated with at least 2 of:

  • Associated with defecation
  • Change in bowel frequency
  • Change in stool form/appearance

Bloating has been removed from diagnostic criteria as it has no predictive value, being common across all kinds of GI issues.

Subtypes then based on stool form on symptomatic days – predominantly constipation, predominantly diarrhoea, mixed constipation/diarrhoea.

Normal physical examination supports diagnosis. Tests should include FBC to exclude iron deficiency anaemia, CRP for IBD, TTG antibody for coeliac disease.

Management

Trial of lactose, fructose and wheat free diet if suspected link to consumption of these foods (non coeliac gluten sensitivity occurs).

Low FODMAP diet is challenging but can help – should be supervised by dietician.

Reassurance – making diagnosis helps justify not investigating fruitlessly.

[J Clin Med 2017]

Microbiome

Allergy, Gastro, General paediatrics, Immunology

Substantial evidence that alterations in the gut microbiome early in life “imprint” gut mucosal immunity, which is probably important for development of food allergy.

Maternal factors, timing and how solids introduced all likely to be important.

Similarly, the “exposome” is the term for external factors influencing epithelial barrier immune balance – damage, inflammation, colonization, dysbiosis, translocation etc.

Great data from studies of Hutterite vs Amish populations in the US (same origin in Austria) – Amish are more traditional farmers, low technology use, v low atopy rates. See more on the farm effect on allergy here.

Transplacental factors discussed by Patrick Holt (Perth, WA) in 2009 (“soothing signals”).

MV130 is heat inactivated cocktail of bacteria – in RCT (n=120, under 3yrs) 6 months SLIT reduces episodes of recurrent wheeze by 40% in children, also lower duration and symptom scores. [Antonio Nieto, Madrid]

COVID 19 has shown how innate immunity isn’t actually fixed, and can be trained (“trained immunity”) esp BCG, LPS.

Experimental studies have shown that faecal transplants or other attempts to modify bacterial commensals can prevent or treat food allergy as well as asthma.

Mechanisms include restoration of gut immune regulatory checkpoints (eg retinoic orphan receptor gamma T+ regulatory T cells), the epithelial barrier, and healthy immunoglobulin A responses to gut commensals.

[Rima Rachid, JACI 2021]

Campylobacter

Gastro, General paediatrics, Infectious disease

Common cause of bloody diarrhoea. As with other causes of bloody diarrhea, often associated with fever and abdominal cramps.

Usually self resolving within a week. Antibiotics help if symptoms severe enough.

Excretion continues for a number of weeks, although risk of spreading infection after diarrhoea has settled of course much less, assuming decent hygiene.

Chronic excretion can occur with continuous symptoms rarely, certainly in immunosuppressed patients. Asymptomatic carriers exist, although seems to be more common in developing countries (so malnutrition probably a factor) and reinfection can also occur, of course.

About 1 in 1000 cases develop Guillain Barre syndrome after the infection. Inflammatory bowel disease seems more common after campylobacter infection?

Acute pancreatitis

Gastro, General paediatrics, Surgical

Incidence increasing, approaching that of adults!? INSPPIRE international study. 

Diagnosis

Amylase 3x upper limit, radiology positive. 

Cullen’s and Grey Turner signs (umbilical and flank bruising respectively).

Amylase level not prognostic. False positive liver/renal impairment, GI inflammation.  False negative in 10%, esp drug induced!

Lipase more specific, only done in Huddersfield?! Stays high for longer.

Low calcium, high glucose seen.

Diagnosis mostly clinical. USS usually sensitive, else CT – more for complications (focal or diffuse enlargement, heterogeneous enhancement, irregular or shaggy outline, oedema of surrounding fat).

AXR may show sentinel loop, free gas (loss of psoas shadow). CXR for effusion.

Causes

I GET SMASHED

  • idiopathic (25% in children)
  • gall stones
  • ethanol
  • trauma
  • steroids – and other drugs, esp anti-epileptics, immunosuppressants eg azathioprine, cancer drugs.
  • mumps (even without parotitis), malignancy
  • autoimmune
  • scorpion sting!

But misses IBD, sepsis, Mycoplasma (early or late), genetic causes! 

Management

Prognosis good in children. Scoring systems in adults eg Modified Glasgow-Imrie not applicable, various paediatric versions, of debatable value. 

Fluid resuscitation then 1.5-2x maintenance requirements (not much evidence – don’t be afraid of positive balance! Keep urine output at 1ml/kg/hr), analgesia, early enteral nutrition if possible (to avoid bacterial translocation) else parenteral.

Antibiotics only for suspected sepsis.

Surgery eg necrosectomy. 

1/3 acute recurrent (defined as recurrence after full recovery). Often anatomical problems. Chronic associated with genetic disorders, metabolic, autoimmune.

ERCP for anatomical causes. Pancreatic enzymes. Non opiate pain management eg tricyclics. 

[NASPGHAN 2018 Guidelines]

Diarrhoea

Clinical, Common, Gastro, General paediatrics

According to NICE, 3 or more loose or liquid stools in a day (or more frequently than is normal for the individual) counts as diarrhoea.

Persisting for more than 14 days makes it chronic.

Acute typically gastroenteritis. Presence of blood and/or mucus suggests more invasive inflammation, viz colitis.

In kids, can occur with pretty much any illness!

Vomiting with diarrhoea makes a primary gut cause more likely, but still not specific.