Paediatrics: Gastroenterology and surgery in children

🧒 Gastroenterology and surgery in children -vomiting, tummy pain and constipation are everyday problems, and most are benign. The skill is spotting the surgical emergencies: bilious vomiting (malrotation with volvulus), intussusception, appendicitis (often atypical and perforated in young children), and testicular torsion. Age is a powerful clue to the cause.
Your four questions for every child: Is the vomit green (bilious) -a surgical emergency? Is the child growing normally? Is there blood in the stool, a mass, or peritonism? In boys with abdominal pain, have I examined the testes?

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The Vomiting Child -Approach

Age	Common and important causes
Newborn	Possetting; feeding problems; bilious -malrotation and volvulus, duodenal atresia, Hirschsprung's, meconium ileus, NEC; sepsis; metabolic disorders; CAH
Infant	Reflux; gastroenteritis; pyloric stenosis (2–8 weeks); CMPA; UTI; intussusception; meningitis; overfeeding
Older child	Gastroenteritis; infections (UTI, otitis, tonsillitis, pneumonia); appendicitis; DKA; raised intracranial pressure (brain tumour -morning vomiting with headache); migraine; poisoning; pregnancy; eating disorders

• Red flags:
  • Bilious (green) vomiting -surgical emergency (malrotation with volvulus until proven otherwise).
  • Projectile vomiting in a 2–8 week old (pyloric stenosis).
  • Blood in vomit (haematemesis) or stools.
  • Abdominal distension, tenderness, or a mass.
  • Dehydration, lethargy, bulging fontanelle, seizures, headache, early morning vomiting.
  • Faltering growth.

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Reflux and GORD

• Gastro-oesophageal reflux (GOR) -very common in babies (immature lower oesophageal sphincter, liquid diet, lying flat). Effortless regurgitation ("possetting"), starting before 8 weeks; usually resolves by 12 months. The baby is thriving -no treatment needed.
• GORD -reflux causing complications or troublesome symptoms.
• Features of GORD -distress, back arching and crying with feeds, feed refusal, faltering growth, chronic cough, hoarseness, recurrent pneumonia (aspiration), Sandifer syndrome (abnormal head and neck posturing).
• Higher risk -preterm, neurodisability (cerebral palsy), repaired oesophageal atresia or diaphragmatic hernia, obesity.
• Red flags (another cause likely) -bilious or projectile vomiting, haematemesis, starting after 6 months or persisting after 1 year, bloody stools, abdominal distension, fever, bulging fontanelle, faltering growth.
• Management (NICE NG1):
  • Reassurance -common, harmless, improves with time.
  • Feeding review -avoid overfeeding; smaller, more frequent feeds; keep upright after feeds; check breastfeeding technique.
  • Breastfed -trial of alginate (Gaviscon Infant) for 1–2 weeks.
  • Formula-fed -trial of thickened feeds (or anti-reflux formula), then alginate if no better.
  • PPI or H2 blocker (4-week trial) -only for unexplained feeding difficulties, distress or faltering growth with suspected oesophagitis, or in older children with heartburn.
  • Don't use positional treatment (raising the cot) -sleep flat on the back.
  • Consider CMPA (trial of hydrolysed formula) if other allergic features.
  • Severe cases -pH or impedance studies, endoscopy, fundoplication.

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Pyloric Stenosis

• What it is: Thickening of the pyloric muscle, blocking the stomach outlet.
• Who: Babies aged 2–8 weeks; boys (4–5 times more), often first-born; family history.
• Features:
  • Projectile, non-bilious vomiting straight after feeds, getting worse.
  • Hungry after vomiting ("hungry vomiter").
  • Weight loss, dehydration, constipation.
  • Olive-shaped mass in the right upper abdomen (felt during a test feed); visible peristalsis.
• Blood gas -hypochloraemic, hypokalaemic metabolic alkalosis (loss of stomach acid).
• Diagnosis -ultrasound (thickened, elongated pylorus).
• Management:
  • Correct dehydration and electrolytes first (IV 0.9% saline with glucose and potassium) -anaesthesia is unsafe with alkalosis (breathing depression).
  • Stop feeds; NG tube.
  • Pyloromyotomy (Ramstedt -laparoscopic or open); feeding restarts within hours; excellent outcome.

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Malrotation and Volvulus

• What it is: The gut doesn't rotate properly in development, leaving the small bowel on a narrow mesentery that can twist (volvulus) and cut off its blood supply. The whole midgut can die within hours.
• Who: Usually in the first month (most in the first year), but can occur at any age.
• Features:
  • Sudden bilious (green) vomiting -the key sign.
  • Abdominal pain, irritability, distension (may be absent early).
  • Blood in stools, shock and peritonitis (late -bowel ischaemia).
  • Older children -intermittent pain and vomiting.
• Diagnosis -urgent upper GI contrast study (abnormal position of the duodenojejunal flexure; "corkscrew" duodenum); ultrasound may show whirlpool sign. Don't delay surgery for imaging if the child is unwell.
• Management -resuscitation, NG tube, IV antibiotics, emergency laparotomy (Ladd's procedure).

⚠️ Safety Pearl: Bilious vomiting in a baby is malrotation with volvulus until proven otherwise -refer immediately to paediatric surgery. Delay can mean losing the entire small bowel.

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Intussusception

• What it is: One segment of bowel telescopes into the next -usually the ileum into the caecum (ileocolic), causing obstruction and ischaemia.
• Who: 6 months to 2 years (peak 6–18 months); boys more than girls; often after a viral illness (enlarged lymphoid patches act as the lead point).
• Features:
  • Episodes of severe colicky pain -the child screams, draws up the legs, goes pale, then may be quiet or lethargic between episodes.
  • Vomiting (bilious later).
  • "Redcurrant jelly" stools (blood and mucus) -a late sign.
  • Sausage-shaped mass in the right upper abdomen; empty right iliac fossa.
  • Lethargy (may be the main feature); shock.
• Diagnosis -ultrasound ("target" or "doughnut" sign).
• Management:
  • Resuscitation (fluids), NG tube, antibiotics if unwell.
  • Air (pneumatic) enema reduction under X-ray guidance -successful in most.
  • Surgery if peritonitis, perforation, shock, or failed reduction.
  • Recurrence in about 10%.
• Older children (over 3) -look for a pathological lead point: Meckel's diverticulum, polyp, lymphoma, IgA vasculitis (HSP), CF.

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Acute Abdominal Pain

• Surgical causes -appendicitis, intussusception, malrotation, bowel obstruction (adhesions, hernia), testicular torsion, ovarian torsion, Meckel's diverticulitis, trauma (including NAI -liver, spleen, duodenal haematoma).
• Medical causes:
  • Gastroenteritis; constipation (very common).
  • Mesenteric adenitis -swollen abdominal lymph nodes after a viral illness; mimics appendicitis.
  • UTI and pyelonephritis.
  • Lower lobe pneumonia; tonsillitis (abdominal pain is common in young children).
  • DKA -always check glucose.
  • IgA vasculitis (HSP); sickle cell crisis; HUS.
  • Pancreatitis, gallstones (haemolytic disease), hepatitis; pregnancy and ectopic in teenagers.
• Examine -chest, throat, abdomen, hernial orifices and testes; urine dipstick; glucose; pregnancy test in girls after menarche.

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Appendicitis

• The commonest surgical emergency in children (peak 10–20 years; rare under 3).
• Features:
  • Central (periumbilical) pain moving to the right iliac fossa.
  • Loss of appetite, nausea, vomiting (usually after the pain starts).
  • Low-grade fever; pain on walking, jumping or coughing; lying still.
  • Tenderness and guarding at McBurney's point; rebound; Rovsing's sign.
• Young children (under 5) -atypical, harder to examine, and perforation is common at presentation (diffuse peritonitis, vomiting, fever, irritability, limp).
• Tests -FBC and CRP (raised but not diagnostic), urine (exclude UTI -mild pyuria can occur in appendicitis), pregnancy test; ultrasound; scoring tools (e.g. Paediatric Appendicitis Score, Alvarado).
• Management -analgesia (morphine is fine -doesn't mask signs), IV fluids, antibiotics, laparoscopic appendicectomy; antibiotics alone for selected uncomplicated cases (specialist decision). Perforated -longer antibiotics; abscess may need drainage.
• Mesenteric adenitis -recent viral illness, high fever, less localised tenderness; ultrasound shows enlarged nodes; self-limiting.

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Recurrent and Functional Abdominal Pain

• Very common in school-age children (about 1 in 10); most is functional (no disease found).
• Functional abdominal pain disorders:
  • Functional abdominal pain -central pain, often linked to stress (school, family), well between episodes, normal growth.
  • Irritable bowel syndrome -pain with change in stool form or frequency.
  • Abdominal migraine -episodes of central pain with nausea, vomiting, pallor, lasting hours; family history of migraine; later migraine headaches.
  • Functional dyspepsia.
• Red flags (look for organic disease):
  • Pain that wakes the child; pain away from the umbilicus (especially right-sided).
  • Weight loss, faltering growth, delayed puberty.
  • Blood in stools, chronic diarrhoea, persistent vomiting.
  • Fever, joint pains, rash, mouth ulcers, perianal disease.
  • Family history of IBD or coeliac disease.
  • Abnormal examination; raised inflammatory markers or calprotectin.
• Organic causes -constipation, coeliac disease, IBD, UTI, H. pylori, lactose intolerance, gallstones, pancreatitis, gynaecological causes in teenagers.
• Basic tests -FBC, CRP/ESR, coeliac serology, urine, faecal calprotectin (if diarrhoea).
• Management of functional pain -explanation that the pain is real but not dangerous; address triggers and school stress; regular routines; CBT and gut-directed hypnotherapy; avoid repeated unnecessary tests.

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Constipation

• Very common; usually functional (idiopathic) -often starts with weaning, toilet training or starting school, or after a painful stool (fissure), leading to withholding.
• Features -infrequent hard stools (fewer than 3 a week), large stools that may block the toilet, straining and pain, "rabbit droppings", overflow soiling (loose, smelly stools leaking -often mistaken for diarrhoea), withholding behaviours (stiff legs, hiding), abdominal pain, poor appetite.
• Red flags (NICE CG99 -possible underlying cause):
  • Starting from birth or the first few weeks.
  • Delayed passage of meconium (over 48 hours in a term baby) -Hirschsprung's, CF.
  • "Ribbon" stools; abnormal anus position.
  • Abdominal distension with vomiting.
  • Abnormal lower limb neurology, gait, or spine (sacral dimple, hair tuft -spinal cord problems).
  • Faltering growth.
  • Possible abuse (perianal bruising, fissures in unusual places).
• Other causes -hypothyroidism, coeliac disease, hypercalcaemia, CMPA (infants), drugs (opioids), Hirschsprung's, anal problems.
• Management (NICE CG99):
  • Disimpaction (if faecal loading) -macrogol (polyethylene glycol, e.g. Movicol Paediatric Plain) in an escalating dose over up to 2 weeks until the impaction clears; add a stimulant (senna or sodium picosulfate) if not effective. Warn about increased soiling at first. Rectal treatments only if oral fails.
  • Maintenance -macrogol (dose adjusted to produce soft stools) for several weeks after a regular pattern is established, then reduce gradually over months; add senna if needed.
  • Behavioural -regular toilet sitting after meals (5 minutes), footstool, reward charts (for sitting, not for clean pants).
  • Diet -adequate fluids and fibre (fruit, vegetables, wholegrain) -but don't rely on diet alone at first.
  • Infants -extra water or fruit juice; lactulose if needed; macrogol from 1 year (off-label under).
  • Review regularly; refer if no response after 3 months.
• Anal fissure -painful stools with streaks of bright red blood; treat constipation; topical anaesthetic or GTN in specialist care.

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Hirschsprung's Disease

• What it is: Absence of nerve cells (ganglion cells) in a segment of the bowel wall -always starting at the rectum and extending upwards. The affected bowel can't relax, causing obstruction.
• Associations -boys; Down syndrome; family history; MEN2 (RET gene).
• Features:
  • Newborn -delayed passage of meconium (over 48 hours), abdominal distension, bilious vomiting.
  • Older children -chronic constipation from birth, distension, faltering growth.
  • Rectal examination may release an explosive gush of stool and gas.
• Hirschsprung-associated enterocolitis -fever, distension, explosive foul diarrhoea, sepsis -can be fatal (IV antibiotics, rectal washouts).
• Diagnosis -rectal suction biopsy (absent ganglion cells, increased acetylcholinesterase-positive nerve fibres); contrast enema (transition zone).
• Treatment -rectal washouts initially; surgical pull-through (removing the aganglionic bowel); sometimes a temporary stoma.

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Chronic Diarrhoea

• Toddler's diarrhoea -the commonest cause in 1–5 year olds: loose stools with undigested food (peas, carrots), often more in the day; the child is well and growing normally. Advice -normal fat and fibre, limit fruit juice and squash ("4 Fs": fat, fibre, fluid, fruit juice).
• Other causes:
  • Coeliac disease.
  • Cow's milk protein allergy (infants).
  • Lactose intolerance (often secondary after gastroenteritis -temporary).
  • Inflammatory bowel disease.
  • Infection -Giardia, persistent bacterial infection.
  • Cystic fibrosis (steatorrhoea).
  • Overflow from constipation.
  • Laxative misuse; hyperthyroidism; immunodeficiency.
• Red flags -faltering growth, blood in stools, abdominal pain waking the child, nocturnal diarrhoea, weight loss.
• Tests -growth, FBC, CRP, coeliac serology, stool microscopy and culture, faecal calprotectin, faecal elastase (pancreatic insufficiency), sweat test.

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Coeliac Disease

• What it is: An autoimmune reaction to gluten (wheat, barley, rye) damaging the small bowel lining (villous atrophy). About 1 in 100 people; many undiagnosed.
• Features in children:
  • Young children (after gluten is introduced) -diarrhoea, pale bulky smelly stools, distended abdomen, wasted buttocks, faltering growth, irritability.
  • Older children -abdominal pain, constipation, tiredness, short stature, delayed puberty, iron deficiency anaemia, mouth ulcers, dermatitis herpetiformis (itchy blistering rash on elbows, knees, buttocks).
  • Many have few symptoms.
• Who to test -symptoms above; type 1 diabetes; autoimmune thyroid disease; Down syndrome, Turner syndrome, Williams syndrome; first-degree relatives; IBS-type symptoms.
• Tests:
  • tTG IgA (tissue transglutaminase) with total IgA (IgA deficiency gives false negatives -use IgG tests).
  • The child must be eating gluten (in more than one meal a day for at least 6 weeks) before testing.
  • No-biopsy route (ESPGHAN, for children) -tTG IgA 10 times or more the upper limit, with positive endomysial antibodies on a second sample. Otherwise duodenal biopsy.
• Management:
  • Lifelong strict gluten-free diet (dietitian); oats are usually tolerated.
  • Check iron, folate, vitamin D, calcium; growth and puberty monitoring.
  • Yearly review; repeat tTG to check adherence.
• Untreated -poor growth, osteoporosis, anaemia, small increased risk of lymphoma.

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Inflammatory Bowel Disease

• About a quarter of IBD starts in childhood; Crohn's disease is more common than ulcerative colitis in children.
• Crohn's disease:
  • Abdominal pain, diarrhoea (may be no blood), weight loss, growth failure and delayed puberty (sometimes the only sign), tiredness, fever.
  • Perianal disease (tags, fissures, fistulas, abscesses), mouth ulcers, lip swelling.
  • Extra-intestinal -joint pains, erythema nodosum, uveitis.
• Ulcerative colitis -bloody diarrhoea, urgency, abdominal pain; often extensive (pancolitis) in children.
• Tests -FBC (anaemia, raised platelets), CRP, ESR, albumin, faecal calprotectin; stool cultures; endoscopy and colonoscopy with biopsies; MRI small bowel.
• Treatment (paediatric gastroenterology):
  • Crohn's -exclusive enteral nutrition (liquid formula only for 6–8 weeks) is first-line induction (as effective as steroids, better for growth); steroids if not suitable; maintenance with azathioprine or methotrexate; anti-TNF (infliximab, adalimumab) for moderate to severe disease; surgery for complications.
  • UC -aminosalicylates (mesalazine); steroids for flares; azathioprine; biologics; colectomy for severe disease.
  • Acute severe colitis -IV steroids, rescue therapy (infliximab), surgery; watch for toxic megacolon.
  • Growth, bone health, nutrition, psychological support, transition to adult services.
• See the Inflammatory Bowel Disease chapter.

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Blood in the Stools

Age	Causes
Newborn	Swallowed maternal blood (from birth or cracked nipples -Apt test); NEC; vitamin K deficiency bleeding; CMPA; malrotation with volvulus; anal fissure
Infant	Anal fissure (the commonest); CMPA (allergic colitis); intussusception; infectious colitis
Toddler and preschool	Anal fissure; infection; Meckel's diverticulum; intussusception; juvenile polyps; HSP; HUS
Older child	Infection (Campylobacter, Salmonella, Shigella, E. coli O157); IBD; polyps; fissure; haemorrhoids (rare); Meckel's

• Meckel's diverticulum -a remnant of the vitelline duct in the small bowel; "rule of 2s" -about 2% of people, 2 feet from the ileocaecal valve, about 2 inches long, often presents under 2 years, may contain 2 types of tissue (gastric, pancreatic):
  • Painless, heavy rectal bleeding (dark red or maroon) in a young child -from ulceration by acid-secreting gastric tissue.
  • Also intussusception, obstruction, diverticulitis (mimics appendicitis).
  • Technetium-99m pertechnetate scan ("Meckel's scan"); surgical removal.
• Juvenile polyps -painless bright red bleeding; usually single and benign; multiple polyps suggest a polyposis syndrome (Peutz–Jeghers -lip freckles; familial adenomatous polyposis).
• Upper GI bleeding -swallowed blood (nosebleed), Mallory–Weiss tear (after vomiting), oesophagitis, gastritis (NSAIDs), varices (portal hypertension -biliary atresia), foreign body (button battery).

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Liver Problems in Children

• Neonatal jaundice and biliary atresia -see the Neonatology chapter.
• Viral hepatitis -hepatitis A (mild in children, often without jaundice), B and C (vertical transmission), EBV, CMV.
• Wilson's disease -consider in any child over 5 with unexplained liver disease (or neurological or psychiatric symptoms): low caeruloplasmin, high urine copper, Kayser–Fleischer rings; chelation (penicillamine, trientine), zinc.
• Autoimmune hepatitis -teenage girls; raised IgG, autoantibodies; steroids and azathioprine.
• Alpha-1 antitrypsin deficiency -neonatal cholestasis, later liver disease.
• Fatty liver (MASLD) -rising with childhood obesity.
• Paracetamol overdose -the commonest cause of acute liver failure in teenagers (often intentional); see the Paediatric Emergencies chapter.
• Gallstones -haemolytic disorders (sickle cell, hereditary spherocytosis), obesity, long-term TPN.
• Hepatoblastoma -liver tumour in young children (raised AFP).
• Signs of chronic liver disease -jaundice, itch, hepatosplenomegaly, ascites, faltering growth, easy bruising, spider naevi.

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Hernias and Hydroceles

• Inguinal hernia:
  • An indirect hernia -the processus vaginalis stays open, letting bowel (or an ovary in girls) into the groin or scrotum.
  • More common in boys and preterm babies.
  • A groin or scrotal swelling that comes and goes, more obvious when crying or straining; you can't "get above" it.
  • High risk of incarceration (trapped bowel) in infants -irritability, vomiting, a tender, firm, irreducible lump: emergency (reduce if possible, then surgery).
  • Refer for surgery promptly -urgently for infants (within days to weeks; within 2 weeks for babies under 6 weeks old); herniotomy.
• Umbilical hernia -very common in babies (especially Black and preterm babies); soft, reducible; rarely strangulates; most close by 3–5 years; surgery if still present at about 4–5 years or very large.
• Hydrocele -fluid around the testis:
  • Painless, soft scrotal swelling that transilluminates; you can get above it; the testis is often hard to feel.
  • Communicating (patent processus vaginalis) -size changes during the day.
  • Most resolve by 1–2 years; surgery if persistent after 2 years.
  • New hydrocele in an older boy -exclude underlying causes (torsion, tumour, infection) with ultrasound.
• Epigastric hernia -small midline lump above the umbilicus; surgery if symptomatic.

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Undescended Testes

• Cryptorchidism -a testis not in the scrotum. About 3–5% of term boys (more in preterm); many descend by 3 months.
• Types:
  • Retractile testis -can be brought down into the scrotum and stays there briefly (active cremaster reflex) -normal; review yearly (can "ascend").
  • Undescended -palpable in the groin (most) or impalpable (in the abdomen, or absent).
  • Ectopic -outside the normal path (perineum, femoral).
• Management:
  • Bilateral undescended testes at birth -urgent senior review (within 24 hours) -exclude disorders of sex development (e.g. CAH in a virilised girl -salt-wasting risk).
  • One undescended testis -review at 6–8 weeks; if still undescended at 3 months, refer to paediatric surgery.
  • Orchidopexy -ideally at 6–12 months (and before 18 months).
  • Impalpable testes -laparoscopy.
• Risks if untreated -reduced fertility, testicular cancer (risk higher even after surgery -teach self-examination), torsion, trauma, psychological effects, inguinal hernia.

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The Acute Scrotum

Cause	Features
Testicular torsion	Sudden severe testicular pain (may be lower abdominal pain only), nausea and vomiting; adolescents (and newborns); high-riding, horizontal testis; very tender; absent cremasteric reflex
Torsion of the testicular appendage (hydatid of Morgagni)	Ages 7–12; gradual pain at the top of the testis; tender nodule; "blue dot" sign; cremasteric reflex present -rest and analgesia (explore if in doubt)
Epididymo-orchitis	Gradual pain and swelling, fever, urinary symptoms; younger boys -UTI or urinary tract abnormality; teenagers -consider STIs; mumps orchitis (with parotitis)
Idiopathic scrotal oedema	Young boys; red, swollen scrotum, often both sides, extending to the groin and perineum; little pain; testes normal; settles in days
Incarcerated inguinal hernia	Irreducible groin and scrotal lump, vomiting
IgA vasculitis (HSP), trauma, tumour	Other features; tumours are usually painless

• Testicular torsion is a surgical emergency:
  • Immediate surgical exploration -the testis can usually be saved if untwisted within 6 hours.
  • Don't delay for ultrasound if the diagnosis is likely.
  • Fix both testes (bilateral orchidopexy); remove a dead testis.
  • Analgesia; nil by mouth.

⚠️ Safety Pearl: Teenage boys with "abdominal pain" may be too embarrassed to mention testicular pain. Always examine the testes in a boy with lower abdominal pain or vomiting -torsion can cost a testis within hours.

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Foreskin, Hypospadias and the Penis

• Physiological phimosis -the foreskin normally can't be pulled back in young boys (adhesions to the glans); most become retractable by 5–10 years (some later). Ballooning of the foreskin during urination is normal. Don't force it back.
• Balanitis -inflamed glans and foreskin: hygiene, warm baths, topical antifungal or antibiotics if infected; recurrent episodes may need circumcision.
• Pathological phimosis -scarred, white, tight foreskin (balanitis xerotica obliterans -lichen sclerosus); urinary obstruction. Topical steroids; circumcision.
• Paraphimosis -a retracted foreskin can't be pulled back, causing a painful swollen glans: emergency -analgesia, ice or compression, manual reduction; dorsal slit or circumcision if it fails.
• Hypospadias:
  • The urethral opening is on the underside of the penis (anywhere from glans to perineum); hooded foreskin (incomplete on the underside); chordee (downward curve).
  • About 1 in 300 boys; picked up at the newborn examination.
  • Don't circumcise -the foreskin is used in the repair.
  • Surgical repair at about 6–18 months.
  • Severe hypospadias with undescended testes -consider a disorder of sex development (CAH, karyotype).
• Epispadias -opening on the upper side; linked to bladder exstrophy.
• Circumcision -medical indications: pathological phimosis, recurrent balanitis, recurrent UTIs with urinary tract abnormalities; also done for religious and cultural reasons (consent from those with parental responsibility).
• Labial adhesions (girls) -fused labia minora in young girls; usually harmless and resolve at puberty; topical oestrogen if causing urinary problems.

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Drug Reference Table

Drug	Key points
Alginate (Gaviscon Infant)	Trial for 1–2 weeks in breastfed babies with GORD.
Feed thickeners / anti-reflux formula	Formula-fed babies with GORD.
Omeprazole (or an H2 blocker such as famotidine)	4-week trial for suspected oesophagitis with distress or faltering growth.
Macrogol (Movicol Paediatric Plain)	Constipation -escalating dose for disimpaction, then maintenance for months.
Senna / sodium picosulfate	Stimulant laxatives added if macrogol alone isn't enough.
Lactulose	Osmotic laxative (infants and if macrogol not tolerated).
IV 0.9% saline + glucose + potassium	Correct dehydration and alkalosis before pyloromyotomy.
Polymeric formula (exclusive enteral nutrition)	First-line induction for paediatric Crohn's disease (6–8 weeks).
Mesalazine	Ulcerative colitis.
Azathioprine	IBD maintenance; check TPMT; blood monitoring.
Infliximab / adalimumab	Moderate to severe IBD; TB screening first.
Morphine IV	Analgesia in suspected appendicitis -doesn't mask diagnosis.
Topical steroid (e.g. betamethasone)	Pathological phimosis (BXO).

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Spot the Diagnosis

Clue	Diagnosis
Happy, thriving 3-month-old who brings up small amounts after feeds	Physiological reflux -reassure
5-week-old first-born boy with projectile vomiting, hungry, olive mass	Pyloric stenosis
Hypochloraemic hypokalaemic metabolic alkalosis in a vomiting infant	Pyloric stenosis
Sudden green vomiting in a 2-week-old	Malrotation with volvulus -emergency
9-month-old with screaming episodes, pallor, and redcurrant jelly stools	Intussusception
Target sign on abdominal ultrasound	Intussusception
Periumbilical pain moving to the right iliac fossa with anorexia	Appendicitis
High fever, sore throat and vague abdominal pain, enlarged nodes on ultrasound	Mesenteric adenitis
No meconium for 60 hours, distension, explosive stool on PR, Down syndrome	Hirschsprung's disease
Soiling with hard stools on abdominal palpation in a 6-year-old	Constipation with overflow
Thriving toddler with loose stools containing peas and carrots	Toddler's diarrhoea
Short 10-year-old with iron deficiency and abdominal pain, tTG 15 times normal	Coeliac disease
Teenager with weight loss, delayed puberty and a perianal fistula	Crohn's disease
Painless maroon rectal bleeding in a 2-year-old	Meckel's diverticulum
Streaks of bright red blood with painful hard stools in an infant	Anal fissure
Groin lump in a preterm boy when crying	Inguinal hernia -prompt surgery
Painless scrotal swelling that transilluminates in a 6-month-old	Hydrocele
Bilateral impalpable testes at birth	Urgent review -possible DSD/CAH
14-year-old with sudden testicular pain, high-riding testis, no cremasteric reflex	Testicular torsion -explore now
Tender nodule at the top of the testis with a blue dot	Torsion of the testicular appendage
Urethral opening on the underside of the penis with a hooded foreskin	Hypospadias -don't circumcise

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Exam-style Scenarios

1. A 6-week-old boy has had projectile vomiting after every feed for 4 days and seems hungry afterwards. Gas: pH 7.52, chloride 88, potassium 2.9.
Answer: Pyloric stenosis with hypochloraemic hypokalaemic alkalosis.

• Stop feeds; IV fluids (0.9% saline with glucose and potassium) to correct electrolytes.
• Ultrasound to confirm.
• Pyloromyotomy once electrolytes are normal.

2. A 10-month-old has episodes of screaming and drawing up his legs every 15 minutes, with pallor and lethargy between. He has vomited twice and passed a bloody stool.
Answer: Intussusception.

• Resuscitation, IV access, NG tube.
• Urgent ultrasound; air enema reduction.
• Surgery if peritonitis or failed reduction.

3. A 7-year-old has opened her bowels twice a week for months with painful large stools and soiling. Abdomen shows a palpable faecal mass. No red flags.
Answer: Functional constipation with impaction and overflow.

• Disimpaction with escalating-dose macrogol over up to 2 weeks (add senna if needed); warn about more soiling at first.
• Maintenance macrogol for months; toilet routine after meals; rewards; fluids and fibre.
• Review regularly.

4. A 13-year-old boy woke at 5 am with severe left testicular pain and vomiting. The left testis lies high and horizontal and is very tender.
Answer: Testicular torsion.

• Analgesia; nil by mouth; immediate urology/paediatric surgical exploration (don't wait for a scan).
• Untwist and fix both testes; remove if non-viable.

5. A newborn boy has the urethral opening on the underside of the penis shaft and an incomplete foreskin. Both testes are in the scrotum.
Answer: Hypospadias.

• Refer to paediatric urology; advise no circumcision.
• Repair at about 6–18 months.

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Key Points

• Bilious vomiting = malrotation with volvulus until proven otherwise -emergency surgical referral.
• Reflux in a thriving baby is normal and settles by 12 months; alginate or thickened feeds before acid suppression.
• Pyloric stenosis: 2–8 weeks, projectile non-bilious vomiting, hungry baby, alkalosis -correct fluids before pyloromyotomy.
• Intussusception: 6–18 months, colicky screaming, pallor, redcurrant jelly stool, target sign -air enema.
• Appendicitis in young children is atypical and often perforated; give analgesia.
• Check glucose, urine and testes in children with abdominal pain.
• Functional constipation: macrogol disimpaction then months of maintenance; red flags include onset from birth and delayed meconium.
• Hirschsprung's: delayed meconium, distension, Down syndrome -rectal biopsy; beware enterocolitis.
• Coeliac: test while eating gluten; tTG IgA with total IgA; no-biopsy route if tTG 10 times normal and EMA positive.
• Paediatric Crohn's: growth failure and delayed puberty; exclusive enteral nutrition first line.
• Meckel's: painless heavy rectal bleeding in young children -technetium scan.
• Inguinal hernias need prompt surgery (incarceration risk); umbilical hernias and hydroceles usually resolve.
• Undescended testis: refer at 3 months; orchidopexy at 6–12 months; bilateral impalpable at birth -urgent (CAH/DSD).
• Torsion: explore within 6 hours; fix both sides.
• Hypospadias: no circumcision; repair at 6–18 months.

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Guidelines and Further Reading

• NICE NG1: Gastro-oesophageal reflux disease in children and young people
• NICE CG99: Constipation in children and young people
• NICE NG20: Coeliac disease; ESPGHAN guidelines for diagnosing coeliac disease
• BSPGHAN / ECCO-ESPGHAN: Paediatric IBD guidelines
• British Association of Paediatric Surgeons and BAUS: guidance on undescended testes and the acute scrotum
• NICE Clinical Knowledge Summaries: Inguinal hernia; Undescended testes; Scrotal pain and swelling
• BNF for Children -for current doses

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