GI Disorder Part 1 of 4

GI DisorderPart 1 of 4

Lawrence M. Formoso, M.D.

Normal Digestive Tract Phenomena- A fetus can swallow AF as early as 12 wk of gestation- nutritive sucking in neonates 1st develops at about 34 wk of

gestation- The coordinated oral and pharyngeal movements necessary

for swallowing solids develop within the 1st few months of life- By 1 mo of age, infants appear to show preferences for sweet

and salty foods

- Infants’ interest in solids increases at about 4 mo of age

- The recommendation to begin solids at 6 mo of age is based on nutritional and cultural concepts rather than maturation of the swallowing process

- Infants swallow air during feeding, and burping is encouraged to prevent gaseous distention of the stomach

• Regurgitation, the result of gastroesophageal reflux, occurs commonly in the 1st year of life

• volumes of emesis are commonly ≈15–30 mL but may occasionally be larger

• Most often, the infant remains happy, although possibly hungry, after an episode of regurgitation

• Episodes may occur from less than one to several times per day• resolves in 80% of infants by 6 mo of age and in 90% by 12 mo.• Complications of gastroesophageal reflux include failure to

thrive, pulmonary disease (apnea or aspiration pneumonitis), and esophagitis with its sequelae

• The earliest stools after birth consist of meconium, a dark, viscous material that is normally passed within the 1st 48 hr of life

• With the onset of feeding, meconium is replaced by green-brown transition stools, often containing curds, and, after 4–5 days, by yellow-brown milk stools

• Stool frequency is extremely variable in normal infants and may vary from none to seven per day

• Breast-fed infants may have frequent small, loose stools early (transition stools), and then after 2–3 wk, may have very infrequent soft stools.

Toddler's diarrhea

• A pattern of intermittent loose stools • occurs commonly between 1 and 3 yr of age• These otherwise healthy growing children often drink

excessive carbohydrate-containing beverages• The stools typically occur during the day and not overnight• The volume of fluid intake is often excessive• limiting sugar-containing beverages and increasing fat in the

diet often leads to resolution of the pattern of loose stools.

Nondigestive Tract Causes of Gastrointestinal Symptoms in Children

• ANOREXIA- Systemic disease

(inflammatory, neoplastic)

- Cardiorespiratory compromise

- Iatrogenic—drug therapy, unpalatable therapeutic diets

- Depression- Anorexia nervosa

• VOMITING- Inborn errors of metabolism- Medications (erythromycin,

chemotherapy)- Increased intracranial pressure- Brain tumor- Infection (urinary tract)- Labyrinthitis- Adrenal insufficiency- Pregnancy- Psychogenic- Abdominal migraine- Toxins


• DIARRHEA- Infection (otitis media, urinary)- Uremia- Medications (antibiotics, cisapride)- Tumors (neuroblastoma)- Pericarditis

• CONSTIPATION- Hypothyroidism- Spina bifida- Psychomotor retardation- Dehydration (diabetes insipidus, renal

tubular lesions)- Medications (narcotics)- Lead poisoning- Infant botulism

• ABDOMINAL PAIN- Pyelonephritis, hydronephrosis, renal colic - Pneumonia - Pelvic inflammatory disease - Porphyria - Angioedema - Endocarditis - Abdominal migraine - Familial Mediterranean fever - Sexual or physical abuse - Systemic lupus erythematosus - School phobia - Sickle cell crisis - Vertebral disk inflammation - Medications (NSAIDs) - Pelvic osteomyelitis


• ABDOMINAL DISTENTION OR MASS

- Ascites (nephrotic syndrome, neoplasm, heart failure)

- Discrete mass (Wilms tumor, hydronephrosis, neuroblastoma, mesenteric cyst, hepatoblastoma, lymphoma)

• Pregnancy

• JAUNDICE- Hemolytic disease

- Urinary tract infection- Sepsis- Hypothyroidism- Panhypopituitarism

Major Symptoms and Signs of Digestive Tract Disorders

• Dysphagia, or difficulty swallowing, may be caused by a structural defect or motility disorder

• Structural defects that cause a fixed impediment to the food bolus arise from narrowing within the esophagus

• stricture, web, or tumor• Most nonstructural causes of dysphagia are caused by motility

abnormalities of the oropharynx or the esophagus• transfer dysphagia- Dysphagia during the oropharyngeal phase of swallowing- usually associated with neuromuscular disorders (cerebral palsy)• The sensation that something is stuck in the upper esophagus is globus

(formerly termed globus hystericus)• associated with GER


• Nontransfer Dysphagia- Esophageal web, tracheobronchial remnant, or vascular ring may cause dysphagia

in infancy.- A Schatzki ring, a thin ring of tissue near the lower esophageal sphincter, is

another mechanical cause of recurrent dysphagia presenting after infancy- An esophageal foreign body or a stricture secondary to a caustic ingestion also

causes dysphagia

• REGURGITATION- effortless movement of stomach contents into the esophagus and mouth- infants with regurgitation are often hungry immediately after an episode- Regurgitation is a result of GER through an incompetent or, in infants, immature

lower esophageal sphincter- regurgitation or “spitting” resolves with maturity

Differential Diagnosis of Emesis During Childhood

• INFANT- Gastroenteritis- Gastroesophageal reflux- Overfeeding- Anatomic obstruction- Systemic infection- Pertussis syndrome- Otitis media

• CHILD- Gastroenteritis- Gastritis- Systemic infection- Toxic ingestion- Pertussis syndrome- Medication- (GERD) - Sinusitis- Otitis media

Differential Diagnosis of Emesis During Childhood

• ADOLESCENT- Gastroenteritis- GERD- Toxic ingestion- Systemic infection- Gastritis- Sinusitis

- Inflammatory bowel disease- Appendicitis- Migraine- Pregnancy- Medication- Ipecac abuse/bulimia


• ANOREXIA- Hunger and satiety centers are located in the hypothalamus- The afferent nerves from the gastrointestinal tract to these brain centers

are important determinants of the anorexia that characterizes many diseases of the stomach and intestine

• Satiety is stimulated by distention of the stomach or upper small bowel, the signal being transmitted by sensory afferents, which are especially dense in the upper gut


• Vomiting - is a highly coordinated reflex process that may be preceded by increased

salivation and begins with involuntary retching- Violent descent of the diaphragm and constriction of the abdominal

muscles with relaxation of the gastric cardia actively force gastric contents back up the esophagus

- coordinated in the medullary vomiting center, which is influenced directly by afferent innervation and indirectly by the chemoreceptor trigger zone and higher central nervous system (CNS) centers

Cyclic vomiting • is a syndrome with numerous episodes of vomiting interspersed with well

intervals• onset is usually between 2 and 5 yr of age• the frequency of vomiting episodes is variable (average of 12 episodes per

yr) • with each episode typically lasting 2–3 days, with four or more emesis

episodes per hour• Patients may have a prodrome of pallor, intolerance of noise or light,

nausea, lethargy, and headache or fever• Precipitants include infection, stress, and excitement

Cyclic vomiting • Laboratory evaluation is based on a careful history and physical

examination and may include, if indicated, endoscopy, contrast gastrointestinal radiography, brain MRI, and metabolic studies (lactate, organic acids, ammonia)

• Treatment includes hydration and ondansetron• Prevention may be possible with the antimigraine agent amitriptyline or

cyproheptadine

Pharmacologic Therapies for Vomiting Episodes• Reflux Dopamine antagonist:

metoclopramide (Reglan) (0.1–0.2 mg/kg qid PO/IV)

Peripheral dopamine antagonist: domperidone (Motilium) (0.2–0.6 mg/kg tid–qid PO)

• Chemotherapy Metoclopramide; (0.5–1.0 mg/kg

qid IV, with antihistamine prophylaxis of extrapyramidal side effects)

Serotoninergic 5-HT3 antagonist: ondansetron (Zofran) (0.15–0.3 mg/kg tid IV/PO)

Phenothiazines:(extrapyramidal, hematologic side effects)

Prochlorperazine (Compazine) (≈0.3 mg/kg bid–tid PO)

Chlorpromazine (Thorazine) (>6 mo of age: 0.5 mg/kg tid–qid PO/IV)

Steroids:dexamethasone (Decadron) (0.1 mg/kg tid PO)

Cannabinoids:nabilone (tetrahydrocannabinol) (0.05–0.1 mg/kg bid–tid PO)

Pharmacologic Therapies for Vomiting Episodes

• Motion sickness/vestibular disorder Antihistamine:dimenhydrinate (Dramamine) (1 mg/kg tid–qid

PO) Anticholinergic:scopolamine (Transderm Scōp) (adults: 1

patch/3 days)

• Adrenal crisis Steroids:cortisol (2 mg/kg bolus IV followed by 0.2–0.4

mg/kg/hr IV [± 1 mg/kg IM])

Pharmacologic Therapies for Vomiting Episodes• Cyclic vomiting syndrome (CVS)Supportive: Analgesic:meperidine (Demerol) (1–2

mg/kg q4–6h IV/IM) Anxiolytic, sedative: Lorazepam (Ativan)

(0.05–0.1 mg/kg q6h IV) Antihistamine, sedative: diphenhydramine

(Benadryl) (1.25 mg/kg q6h IV)

Abortive: Serotoninergic 5-HT3 antagonist:• Ondansetron:(0.15–0.3 mg/kg tid IV/PO)

• Granisetron (Kytril) (10 μg/kg q4–6h IV) Nonsteroidal antiinflammatory agent (GI

ulceration side effect): Ketorolac (Toradol) (0.5–1.0 mg/kg q6–8h

IV)

• Serotoninergic 5-HT1D agonist: sumatriptan (Imitres) (>40 kg; 20 mg intranasally/25 mg PO, one time only)

• Prophylactic:(if >1 CVS bout/month;taken daily)

• Antimigraine, β-adrenergic blocker: propranolol (Inderal) (0.5–2.0 mg/kg bid PO)

• Antimigraine, antihistamine: cyproheptadine (Periactin) (0.25–0.5 mg/kg/day ÷ bid–tid PO)

• Antimigraine, tricyclic antidepressant: amitriptyline (Elavil) (0.33–0.5 mg/kg tid PO, and titrate to maximum of 3.0 mg/kg/day as needed; obtain baseline ECG at start of therapy, and consider monitoring drug levels)

• Antimigraine antiepileptic: Phenobarbital (Luminal) (2–3 mg/kg qhs)

• Erythromycin:• Low estrogen oral contraceptives:

consider for catamenial CVS episodes

Causes of Gastrointestinal Obstruction

• ESOPHAGUS Congenital1. Esophageal atresia 2. Vascular rings 3. Schatzki ring 4. Tracheobronchial remnant

Acquired1. Esophageal stricture 2. Foreign body 3. Achalasia 4. Chagas disease 5. Collagen vascular disease

Causes of Gastrointestinal Obstruction

• STOMACH Congenital1. Antral webs 2. Pyloric stenosis

Acquired1. Bezoars/foreign body 2. Pyloric stricture (ulcer) 3. Chronic granulomatous

disease of childhood 4. Eosinophilic

gastroenteritis 5. Crohn disease 6. Epidermolysis bullosa

Causes of Gastrointestinal Obstruction• SMALL INTESTINE Congenital1. Duodenal atresia 2. Annular pancreas 3. Malrotation/volvulus 4. Malrotation/Ladd bands 5. Ileal atresia 6. Meconium ileus 7. Meckel diverticulum with

volvulus or intussusception 8. Inguinal hernia Intestinal

duplication

Acquired1. Postsurgical adhesions 2. Crohn disease 3. Intussusception 4. Distal ileal obstruction

syndrome (cystic fibrosis) 5. Duodenal hematoma 6. Superior mesenteric artery

syndrome

Causes of Gastrointestinal Obstruction• COLONCongenital1. Meconium plug 2. Hirschsprung disease 3. Colonic atresia, stenosis 4. Imperforate anus 5. Rectal stenosis 6. Pseudo- obstruction 7. Volvulus 8. Colonic duplication

Acquired1. Ulcerative colitis (toxic

megacolon) 2. Chagas disease 3. Crohn disease 4. Fibrosing colonopathy (cystic

fibrosis)


• DIARRHEA- excessive loss of fluid and electrolyte in the stool. - Normally, a young infant has ≈5 g/kg of stool output per day;

the volume increases to 200 g/24 hr in an adult- The greatest volume of intestinal water is absorbed in the

small bowel; the colon concentrates intestinal contents against a high osmotic gradient

- The basis for all diarrhea is disturbed intestinal solute transport

Mechanisms of Diarrhea• Secretory- Decreased absorption, increased secretion, electrolyte transport- Cholera, toxigenic E. coli; carcinoid, VIP, neuroblastoma, congenital

chloride diarrhea, Clostridium difficile, cryptosporidiosis (AIDS)- Persists during fasting; bile salt malabsorption may also increase intestinal

water secretion; no stool leukocytes

• Osmotic- Maldigestion, transport defects ingestion of unabsorbable- Lactase deficiency, glucose-galactose malabsorption, lactulose, laxative

abuse- Stops with fasting; increased breath hydrogen with carbohydrate

malabsorption; no stool leukocytes

Mechanisms of Diarrhea• Increased motility- Decreased transit time- Irritable bowel syndrome, thyrotoxicosis, postvagotomy dumping syndrome- Infection may also contribute to increased motility

• Decreased motility- Defect in neuromuscular unit(s) - Stasis (bacterial overgrowth)

• Mucosal invasion- Inflammation, decreased colonic reabsorption, increased motility- Salmonella, Shigella, infection; amebiasis; Yersinia, Campylobacter infections

- Dysentery evident in blood, mucus, and WBCs- Blood and increased WBCs in stool

Differential Diagnosis of Diarrhea• INFANTCommon:- Gastroenteritis- Systemic infection- Antibiotic associated- OverfeedingRare:- Primary disaccharidase

deficiency- Hirschsprung toxic colitis- Adrenogenital syndrome- Neonatal opiate withdrawal

• CHILD- Gastroenteritis- Food poisoning- Systemic infection- Antibiotic associated- Toxic ingestion

• ADOLESCENT- Gastroenteritis- Food poisoning- Antibiotic associated- Hyperthyroidism


• CONSTIPATION- is relative and depends on stool consistency, stool frequency, and

difficulty in passing the stool- A normal child may have a soft stool only every 2nd or 3rd day

without difficulty; this is not constipation- A hard stool passed with difficulty every 3rd day should be

treated as constipation- Constipation can arise from defects either in filling or emptying

the rectum- A nursing infant may have very infrequent stools of normal

consistency; this is usually a normal pattern - True constipation in the neonatal period is most likely secondary

to Hirschsprung disease, intestinal pseudo-obstruction, or hypothyroidism.


• ABDOMINAL PAINVisceral pain - tends to be experienced in the dermatome from which the

affected organ receives innervation- Painful stimuli originating in the liver, pancreas, biliary tree,

stomach, or upper bowel are felt in the epigastrium- pain from the distal small bowel, cecum, appendix, or proximal

colon is felt at the umbilicus- pain from the distal large bowel, urinary tract, or pelvic organs is

usually suprapubicParietal pain impulses travel in C fibers of nerves corresponding to

dermatomes T6–L1; such pain tends to be more localized and intense than visceral pain.


• GASTROINTESTINAL HEMORRHAGE- Bleeding can occur anywhere along the gastrointestinal tract,

and identification of the site may be challenging - Evaluation of the small intestine is facilitated by capsule

camera endoscopy- Erosive damage to the mucosa of the gastrointestinal tract is

the most common cause of bleeding, also variceal bleeding secondary to portal hypertension occurs frequently

- bleeding originating in the esophagus, stomach, or duodenum, it may cause hematemesis

• GASTROINTESTINAL HEMORRHAGE- When exposed to gastric or intestinal juices, blood quickly darkens to

resemble coffee grounds; massive bleeding is likely to be red - Red or maroon blood in stools, hematochezia, signifies either a distal

bleeding site or massive hemorrhage above the distal ileum. - Moderate to mild bleeding from sites above the distal ileum tends to

cause blackened stools of tarry consistency (melena); major hemorrhages in the duodenum or above can also cause melena

Differential Diagnosis of Gastrointestinal Bleeding in Childhood

• INFANT• Common:- Bacterial enteritis

- Milk protein allergy- Intussusception- Swallowed maternal blood

- Anal fissure- Lymphonodular hyperplasia

• Rare:- Volvulus- Necrotizing enterocolitis- Meckel diverticulum- Stress ulcer, stomach- Coagulation disorder

(hemorrhagic disease of newborn)

• CHILD• Common:- Bacterial enteritis - Anal fissure - Colonic polyps - Intussusception - Peptic ulcer/gastritis - Swallowed epistaxis - Prolapse (traumatic) gastropathy

2° emesis - Mallory-Weiss syndrome

• Rare:- Esophageal varices- Esophagitis- Meckel diverticulum- Lymphonodular hyperplasia

- Henoch-Schönlein purpura

- Foreign body- Hemangioma, arteriovenous

malformation- Sexual abuse- Hemolytic-uremic syndrome- Inflammatory bowel disease- Coagulopathy

• ADOLESCENT• Common:- Bacterial enteritis

- Inflammatory bowel disease

- Peptic ulcer/gastritis- Prolapse (traumatic) gastropathy

2° emesis- Mallory-Weiss syndrome- Colonic polyps

• Rare:- Hemorrhoids- Esophageal varices- Esophagitis- Telangiectasia-angiodysplasia

- Gay bowel disease- Graft versus host disease

GI Disorder Part 1 of 4

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