Paediatric Gastroenterology
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Transcript of Paediatric Gastroenterology
Paediatric Gastroenterology
Dr Jessica DanielST8 Paediatrics
A huge subject! Vomiting Diarrhoea Constipation Abdominal pain Nutrition
Vomiting Infection – Gastroenteritis
Rotavirus, Norovirus, Bacterial Gastroesophageal Reflux (GOR) Obstruction
Pyloric Stenosis Malformations – Malrotation, atresias
Case Discussion 6wk old baby, born at
term, bottle fed 2 week history of
increasing vomiting Reduced wet nappies,
BNO 2/7 Mild sunken fontanelle,
Obs normal.
8mth old baby, term delivery, previously well
3 day history of vomiting and reduced feeding
BO 8/day, loose stool with reduced wet nappies
Mild sunken fontanelle, tachycardia
A B
• Palpable epigastric mass, visible peristalsis
• pH 7.5, pCO2 4.5, BE +2• K 2.9, Cl 99,
• Examination unremarkable, mild fever
• pH 7.29, pCO2 4.9, BE -5• Na 148, K 3.5, Ur 10, Cr 30
Gastroenteritis 10% of children <5yrs present to healthcare
professionals, 16% of A&E attendances 2 million deaths worldwide in under 5’s Most commonly viral
50% rotavirus – newly introduced vaccine 25% Campylobacter Salmonella, Norovirus, Shigella, E.coli,
Usually uncomplicated but beware those at risk (immunocompromised, neonates etc)
Gastroenteritis NICE guidance for management <5yrs Fluid & electrolyte replacement Assess dehydration Red flags
Appears unwell / Altered consciousness Tachycardia / Tachypnoea Sunken eyes Reduced skin turgor
Gastroenteritis Not dehydrated
Continue breastfeeding/usual milk feeds Avoid carbonated/fruit juice ORS
Some dehydration ORS little & often, 50ml/kg/hr Via NG if refusing / continues to vomit
Shock IV fluids
Pyloric Stenosis
• 2-4 in 1000 newborns• Present age 2-8 weeks,
projectile vomiting, poor wt gain
• Hypochloraemic, hypokalaemic alkalosis
• USS abdomen• Pylorotomy
GOR
Half of all infants aged 0-3mths will have 1 episode/day of regurgitation
Most common ages 1-4mths, most resolve by 1yr
Risk factors Low birth weight, hiatus hernia,
neurodevelopmental problems, cows milk allergy Investigations may include Barium swallow or
pH study If simple management measures ineffective try
medication – thickener, antacid, PPI Consider milk intolerance – CMPI / Lactose
GI MalformationsDuodenal AtresiaDouble bubble
Malrotation
Imperforate AnusMeckel’s Diverticulum
BEWARE THE BILIOUS VOMIT!!!
Diarrhoea Acute vs Chronic Bloody vs Non Bloody Infection
Rotavirus, E coli 0157, Giardia Inflammatory
UC, Crohn’s Surgical
Appendicitis, Intussusception, Partial obstruction
Malabsorption CMPI, Lactose intolerance, Coeliac
Overflow incontinence Toddler’s diarrhoea
Inflammatory Bowel Disease in Childhood UC – Largely mucosal. Diffuse acute and chronic
inflammation. Essentially confined to colon. Crohn’s – Transmural. Focal chronic
inflammation. Fibrosis. Granulomas. Anywhere along GI tract.
Similarities to adult IBD Essential inflammatory processes Mucosal lesion
Differences to adult IBD Management emphasis Growth, puberty, psychosocial Indications for steroids, surgery
IBD - Diagnosis Clinical assessment
exclude infectious aetiologies
Upper endoscopy Colonoscopy (incl. ileoscopy)
+/- Barium follow-through/ MR enteroclysis
IBD – Aims of management Minimise impact of disease on:
Linear growth Psychosocial development Pubertal development The family
ie Multidisciplinary specialised therapy
IBD Management Try to avoid steroids in children Only 29% of patients with colonic Crohn’s
disease heal with corticosteroids Role of enteral nutrition Healing with azathioprine 70% heal with Infliximab
single infusion improved histology / mucosal inflammation
IBD Treatment Options Aminosalicylates Nutrition Antibiotics Corticosteroids Immunosuppressants Immunologic Surgery
SteroidsAvoid when possible in childrenPoor effect on mucosaSecond line agent
relapsing diseasesevere exacerbation (i.v. hydrocortisone)
Reducing course 2mg/kg (max 60mg / day)
Enteral nutrition in IBD Highly effective first-line therapy
Polymeric formulas more palatable Reduce pro-inflammatory cytokines Increase regulatory cytokines
Animal models suggest alteration of gut flora
Motivation of child and family critical
Coeliac Disease
Diagnosis History including family history Antibodies
Anti-gliadin – moderate sensitivity- not specific Anti-reticulin – possibly more specific Anti-endomyseal/ TTG – sensitive and specific
HLA association B8 – first described DR3 or DR5/7 - Much more predictive DQ2/DQ8 – actual association
Duodenal biopsy Villous atrophy & cyrpt hyperplasia
Cow’s Milk Protein Allergy & Lactose Intolerance
CMPA IgE(rapid,
GI/anaphylactic reactions) or non-IgE mediated (delayed,systemic or GI sympt’s)
Vomiting, colic, bloody diarrhoea, ezcema
Non IgE mediated harder to test (SPT & RAST often neg)
• Lactose Intolerance• Primary lactase
deficiency very rare in infants
• Secondary following gastroenteritis
Abdominal Pain Very common symptom Good history essential Acute vs Chronic Any associated features to indicate
pathology? Social / family / school history
Abdo Pain - Acute Appendicitis Malrotation Intussusception Abdominal migraine UTI Mesenteric Adenitis
Abdo Pain - Chronic Constipation IBD Coeliac disease GOR Functional Non-specific
Constipation 5-30% of children suffer constipation Infrequent defaecation (<3/wk) +/- pain on
defaecation Impaction (palpable large faecal mass) Incontinence / Overflow Often parental anxiety / lack of awareness Common in toilet training / toddlers / school Up to 95% functional
Organic Causes Anorectal malformation Anal fissure Hirschprung’s Spinal cord disorders Coeliac disease Cow’s Milk Protein Allergy Hypothyroidism Hypocalcaemia Cystic Fibrosis
Managment Disimpaction- movicol, enema Maintenance – often need long term
treatment (50% resolve in 1yr) Movicol, Lactulose, Senna,
Education / Toilet training Behavioural / pyschosocial support Dietary advice Investigation / Treat underlying disorder if
indicated
Don’t Forget Nutrition & Growth Normal feed requirements for infants Importance of nutrition for growth and
development All illnesses impact on growth, especially chronic
conditions Failure to thrive
Primary nutrition problem Underlying medical condition Psychosocial
Always check weight & height and plot on growth chart