Paediatric Paediatric GastroenterologyGastroenterology

Dr Shoana QuinnDr Shoana Quinn

September 2009September 2009

Trinity College DublinTrinity College Dublin

Paediatric GastroenterologyPaediatric Gastroenterology

Recurrent Abdominal Pain of Recurrent Abdominal Pain of ChildhoodChildhood

ConstipationConstipation Gastroesophageal RefluxGastroesophageal Reflux

Recurrent Abdominal Pain of Recurrent Abdominal Pain of ChildhoodChildhood

Very CommonVery Common Especially 7-14 yearsEspecially 7-14 years PeriumbilicalPeriumbilical Present all the timePresent all the time Missing schoolMissing school Sensitive, perfectionistic childrenSensitive, perfectionistic children

RAPRAP

Severe, doubled overSevere, doubled over PallorPallor Persistent for monthsPersistent for months Well in between episodesWell in between episodes No nocturnal symptomsNo nocturnal symptoms ReassuranceReassurance Minimal InvestigationMinimal Investigation

ConstipationConstipation

Very CommonVery Common Hard, sore stoolsHard, sore stools Frequency prior to toilet training is Frequency prior to toilet training is

very variablevery variable WithholdingWithholding Faecal overload and overflowFaecal overload and overflow Perianal tearsPerianal tears

History and ExaminationHistory and Examination Withholding behaviour often mistaken Withholding behaviour often mistaken

for strainingfor straining Bright red blood on stool or on wipingBright red blood on stool or on wiping Children unaware of stool, not Children unaware of stool, not

behaviouralbehavioural Faecal masses on palpation of abdomenFaecal masses on palpation of abdomen Perianal inspection. Rectal examination Perianal inspection. Rectal examination

should never be performed in paediatricsshould never be performed in paediatrics

Constipation treatmentConstipation treatment

Child needs to gain confidenceChild needs to gain confidence Get rid of hard impacted stoolGet rid of hard impacted stool Soften stool adequately so not soreSoften stool adequately so not sore Regular toileting with foot supportRegular toileting with foot support Continue treatment through toilet Continue treatment through toilet

training as this is often a time of training as this is often a time of trouble.trouble.

Star charts and reinforcementStar charts and reinforcement

Constipation treatmentConstipation treatment

Bisacodyl (Dulcolax) for 3 days AMBisacodyl (Dulcolax) for 3 days AM Liquid Paraffin at nightLiquid Paraffin at night Lactulose if younger than 1 yearLactulose if younger than 1 year MovicolMovicol Suppositories should only be used as Suppositories should only be used as

last resortlast resort Diet in children not a big Diet in children not a big

contribution, excess milk can cause contribution, excess milk can cause constipation and iron deficiencyconstipation and iron deficiency

Ddx ConstipationDdx Constipation

Hirschsprung Disease aganglionosis Hirschsprung Disease aganglionosis in intramuscular and submucous in intramuscular and submucous plexuses of the bowelplexuses of the bowel

Always involves anus and extends Always involves anus and extends proximallyproximally

Surgical treatmentSurgical treatment Risk of enterocolitisRisk of enterocolitis

Gastroesophageal RefluxGastroesophageal Reflux

GOR a normal physiological eventGOR a normal physiological event 50% children in first 3 months50% children in first 3 months Fewer than 5% age 1 yearFewer than 5% age 1 year Well, thriving, happy childWell, thriving, happy child Happy to feed post vomitHappy to feed post vomit

GORGOR

Clinical diagnosisClinical diagnosis pH probe probably only useful pH probe probably only useful

investigation but need consistent investigation but need consistent operator and acidic refluxateoperator and acidic refluxate

Barium studies are never appropriateBarium studies are never appropriate

Management of GORManagement of GOR

Parental reassurance and centilesParental reassurance and centiles Lie flat after a feedLie flat after a feed Feed thickeners?Feed thickeners? No medicationsNo medications

Gastrooesophageal Reflux Gastrooesophageal Reflux Disease

Completely different conditionCompletely different condition Characterised by food refusal, Characterised by food refusal,

haematemesis, irritability and failure haematemesis, irritability and failure to thriveto thrive

Clinical diagnosis unless suspicion of Clinical diagnosis unless suspicion of obstructionobstruction

Trial of PPI then endoscopy and biopsyTrial of PPI then endoscopy and biopsy Fundoplication vs longterm PPIsFundoplication vs longterm PPIs