As the stomach turns…Pediatric GI Gems

Barb Bancroft, RN, MSN, PNP

Group A beta hemolytic strep

• “I have a sore throat and I can’t swallow…”• “…and, my tummy hurts…”

• Dehydration with drooling in young kids• How do you look at a toddler’s throat?• Digression: saliva

Enlarged tonsils

• EBV infection of tonsils• Waldeyer’s ring (tonsils and adenoids)• Kids and sleep apnea; kids, lack of sleep and

growth hormone• ?hypertension in kids?• Behavior disorders? ADHD? In kids?• Non-Hodgkin’s lymphoma

Oral signs of an eating disorder

• The frequent vomiting and nutritional deficiencies often associated with eating disorders can severely affect health

• 89% of bulimic patients have signs of tooth erosion; over time, loss of tooth enamel can be considerable

• Hypertrophy of the parotid gland in women with eating disorders (serum amylase will be elevated)

• Dry and cracked lips• Chronic dry mouth

The immunocompromised patient

• Candida albicans (inhaled steroids in asthmatics)

• Diabetics with hyperglycemia• Fungal infections and TNF-α antagonists

(infliximab/Remicade; adalimumab/Humira; certolizumab/Cemzia etanercept/Enbrel)

• HSV-1, HSV-2

Salivary glands—parotid, sublingual, submandibular

• Parotid gland—MUMPS (kids and vaccines)

• Acetylcholine innervates the salivary glands to produce saliva

OPEN Wide

• Aphthous ulcers and celiac disease• Mouth clues to vitamin deficiencies• Vitamin C—gingivitis, dental erosion• Vitamin B2 (riboflavin)—stomatitis, cheilosis,

geographic tongue• Vitamin B3 (niacin), B6 (pyridoxine), B12

(cobalamin), folic acid (B9)—glossitis

Say “ah”…

• Soft palate and the uvula• Relationship of the pharyngeal musculature with

CN IX (Glossopharyngeal) and X (Vagus)

• Swallowing• What is the hardest thing to swallow?

Causes of nasal speech

• Cleft palate (folic acid!!)

• Glossopharyngeal nerve palsy—(viral)• Guillain-Barré syndrome with bulbar onset

(cranial nerve onset vs. ascending paralysis beginning with the longest nerves first—ie. the feet)

• #1 cause of Guillain-Barré?

Let’s go back to the tonsils, shall we?

• Waldeyer’s ring—adenoids and tonsils

• Lymphatic tissue

• Growth hormone is produced at night

• Adenoiditis/tonsilitis

• Enlarged? Sleep apnea? Behavior disorders? ADHD?

Is it GER or is it GERD?

• GER—Gastroesophageal reflux (regurgitation and vomiting are a normal part of infant life—physiologic reflux)

• Passage of gastric contents into the esophagus—peak at 4-6 months (41%); decline after the first birthday with less than 5% aged 13-14 months)

• 1.8% to 22% in children aged 3 to 18

What is GERD?

• ACID is the bad guy• Physiologic sphincter (LES)—DA/ACH• With GERD--decreased pressure in the lower

esophageal sphincter due to drugs*, nicotine, alcohol, fatty foods, obesity, increased pressure in stomach (late evening meal)

• So, how about a pizza, cold beer and a cigarette before bedtime?

• *What drugs? Beta agonists (bronchodilators in kids with asthma)

Digression

• Biological rhythms—normal input to LES at night and to bronchioles

• GERD and acid reflux—stimulates vagus nerve to release acetylcholine to tighten LES

• Vagus also tightens bronchioles—cough, dyspnea, wheezing in patients with OPD (ROAD, COPD)

• RX?

What are non-drug ways to reduce GERD?

• Dietary changes? For infants with GERD—smaller, more frequent feeds; thickened feeds with rice cereal or carob bean gum thickener

• Don’t overfeed• Consider intolerance to cow’s milk for “GERD-

like” symptoms• Upright feeding position; supine to sleep; small

pillow or a folded blanket where infant sits in car seat to extend hips and decrease intraabdominal pressure

Pharmacology of GERD for kids

• H2 RA (receptor antagonists)—over-the-counter• Tagamet (cimetidine)(≥16 yo), Zantac (ranitidine) (1

month to 16), Pepcid (famotidine)(1 year to 16), Axid (nizatidine)(≥12)(take at bedtime)

• PPIs (Proton Pump Inhibitors) are more potent acid suppressors than H2RA—the “prazoles”; take 30 minutes before breakfast

• Omeprazole (Prilosec)(2-16), lansoprazole (Prevacid)(1-17), and “the purple pill”—esomeprazole (Nexium)(12-17)**

Has your patient been on the “prazoles” for longer than 5 years?

• The parietal cell that pumps acid also pumps out intrinsic factor (IF)

• Intrinsic Factor is necessary for the absorption of B12 from food

• If you stop pumping the acid into the stomach, you also stop pumping intrinsic factor for B12 absorption

• May also be caused by an autoimmune disease with antibodies against IF (pernicious anemia); kids with type 1 diabetes may also have pernicious anemia

• No acid, no calcium (kids and bones)• No acid, no iron (check for iron deficiency anemia)

Selected conditions

• Gastroenteritis—peri-umbilical pain• Acute diarrhea—watery—think viral? Bloody—

think more invasive, bacterial?• Acute appendicitis—no more than a 5-day

disease; periumbilical pain followed by pain in the RLQ; increased WBC with left shift; fever; psoas sign; “the walk”

Selected conditions

• Child abuse injuries• The second most common cause of death from

child abuse is injury to abdominal organs• Small intestine, especially the duodenum,

followed by mesenteric hemorrhage and liver lacerations

• Accidental abdominal injury—spleen, kidney

Child abuse and bruises

• “The skin and the bones tell a story that the child is either too young or too frightened to tell.”

• Normal bruises are facial scratches, one bruise on forehead (toddler), knee and chins

• French proverb: “The mother of a child who elects to re-wed, has taken the enemy into her bed.”

• A child living with a stepparent is 100 times as likely to suffer fatal abuse.

Age of bruise

• Is it red, purple, blue?• Green, yellow, brown?• Reddish/blue less than 1 day, immediate• Blue/purple 1-5 days• Green 5-7 days• Yellow 7-10 days• Brown 10-14 days • Resolution 2-4 weeks

Normal bruises in kids…

• Facial scratches in babies from long fingernails• Knee and shin bruises due to usual wear and

tear of playing rough and tumble• Single bruise on the forehead of a toddler• Bruises on bony prominences such as the knees

and elbows

The stomach

• “Whoever said the way to a man’s heart is through his stomach flunked geography…”

--anonymous

• The stomach is a saccular organ with a volume of 1200 to 1500 ml but a capacity of greater than 3000 ml

Gastric acid

• At maximal secretory rates, the stomach intraluminal concentration of hydrogen ion is 3 million times greater than that of the blood and tissues

• The mucosal barrier protects the gastric mucosa from autodigestion and is created by:

1) mucus secretion; 2) bicarbonate secretion 3) epithelial barrier and, 4) mucosal blood flow

• Truly a physiological marvel, or gastric walls would suffer the same fate as a T-bone

Peptic ulcer disease• Usually solitary lesions less than 4 cm in diameter• Duodenum, first portion• Stomach, antrum• GE junction, in the setting of GERD• 4 million people have peptic ulcers; 350,000 new cases per year,

100,000 hospitalized, 3000 die• Male/female for duodenal = 3:1; male/female for gastric = 1.5 to 2:1• Imbalance between the gastroduodenal mucosal defense

mechanisms and the damaging forces—gastric acid and pepsin• Hyperacidity is NOT a prerequisite• H. pylori is present in 100% of duodenal ulcers and about 70% of

patients with gastric ulcers

Gastric ulcers (peptic ulcer disease)

• Helicobacter pylori—the most common infection worldwide

• Elaborates urease and produces ammonia which buffers gastric acid in the immediate vicinity

• Gastric ulcers• Chronic inflammation (gastritis) and regeneration of the

antrum• The only bacteria known to be “oncogenic”• Is it normal flora?• How do you “catch” it?• How do you treat it?• Is H. pylori a good thing?

Gastric ulcer caused by NSAIDS

• 2.74 RR of any GI complication

• If over 50, RR is 5.57

• RR 12.7 with NSAIDS and warfarin; 4.76 with NSAIDS and steroids

• PPIs decrease ulcer/ bleed by 4-fold

The duodenum (12 fingerbreadths), —the organ of nausea

• 5-HT3 (serotonin) receptors)• Serotonin release causes nausea--Makes ya’

sick to your duodenum• 5-HT3 blockers--The “setrons”—ondansetron

(Zofran), granisetron (Kytril), doasetron (Anzemet), palonosetron

• Adding ondansetron to oral rehydration in kids reduces nausea and vomiting and decreases the need for IV fluids by greater than 50%

• Bariatric surgery, Type 2 DM, and kids

Celiac disease and the duodenum

• 1 in 250 in U.S.; greater prevalence in 1st and 2nd degree relatives; ?duration of breast feeding; age at which a person ingests gluten; cigarette smoking

• Autoimmune disease—HLA-DQ2; HLA-DQ8• Ingested gluten crosslinks with tissue transglutaminase

released in the lamina propria and epithelium of the small intestine

• Immune system helper T cells (CD4 cells) release cytokines IF-γ and IL-4 which damage villi; flattened villi and malabsorption

• Anti-transglutaminase antibodies

Celiac disease

• Absorption problems result in anemias—iron deficiency (growth problems in kids); folate deficiency; calcium absorption problems (osteopenia)

• Always check for osteopenia and osteoporosis in your long-term patients with celiac disease!

• aphthous ulcers are strongly associated w/ celiac disease (This Week in Medicine, MDConsult, 1/31/07)

Celiac disease

• Classic symptomatic presentation characterized by diarrhea, abdominal pain, weight loss, flatulence, and nutritional deficiencies

• Atypical presentation characterized by gait ataxia, seizures, peripheral neuropathy, aphthous stomatitis, arthritis, migraine headaches

• Associated with other autoimmune diseases—Type 1 diabetes, autoimmune myocarditis, primary biliary cirrhosis

• Gluten-free diets and the improvement of symptoms

Gastroenteritis…

• Umbilicus (belly button)—embryologic origins with colon (Homer and Dr. Colón)

Word o’ the day…Omphaloskepsis (om-fuh-lo-SKEP-sis); noun• Definition: Contemplation of one’s navel. (From Geek

omphalos (navel) + skepsis (act of looking, examination)

• Peri-umbilical pain• Causes of gastroenteritis—food poisoning, viral

infections, bacterial infections

Gastroenteritis

• Infectious gastroenteritis—causes more than 12,000 deaths per day from dehydration among children in developing countries and constituting one half of all deaths worldwide before age 5

• Attack rates of one to two illnesses per person per year in U.S.—results in an estimated 99 million acute cases of either vomiting or diarrhea per year—approximately 40% of the population

Viral gastroenteritis

• Rotavirus—140 million cases and 1 million deaths worldwide per year; 6 to 24 months of age; shed 1,000,000,000,000 (10¹² particles)/ml of stool (the minimum infective inoculum is only 10 particles, hence the rampant outbreaks in daycare and pediatric populations in hospitals)

• Norwalk virus (norovirus)—rare in young kids

Noroviruses

• Responsible for majority of nonbacterial food-borne epidemic gastroenteritis in older children and adults;

• Salad bars (cold foods, raw shellfish), person-to-person,water on cruise ships

• Has also been found in the community and in nursing homes

• Vicious cycle of vomiting and diarrhea for an average of 23 hours—known as “shuking”

• start shedding virus before symptoms occur and shed virus for 4 days after symptoms subside (hence, the rapid spread of infection); can shed virus up to 4 to 8 weeks after illness

Bacterial entercolitis

• Ingestion of preformed toxin in food—Staphylococcus aureus, Vibrio species, Clostridium perfringens

• Infection by toxigenic organisms, which proliferate in the gut lumen and elaborate an enterotoxin (Cholera toxin is the prototype secretagogue)

• Infection by enteroinvasive organisms, which proliferate, invade, and destroy mucosal epithelial cells (Salmonella, Yersinia enterocolitica)

Acute appendicitis

• Acute appendicitis presents initially with peri-umbilical pain and subsequently localizes to the right lower quadrant (RLQ)

• High risk occupation for acute appendicitis?

• Pig farmers

Food-borne illness and gastroenteritis

Salmonella in raw or undercooked eggs and chicken

• Pasteurized eggs for “seizure” salad (Caesar salad), eggnog, and guacamole

• Salmonella in chicken

• No more sunny-side up, especially for high-risk patients (unless the eggs are pasteurized)

Digression:

• Salmonella in reptiles—snakes, turtles, iguanas

Campylobacter jejuni

• Undercooked chicken

• Cuddly puppies

• 180º whole chicken

• 170º white meat

• 180º dark meat

E. Coli 0157:H7—the “burger” bug

• 3rd most deadly toxin in the world• 10-100 pathogens to make you ill or kill you• Very young, very old, very immunocompromised• Acute Renal Failure in Kids—hemolytic uremic syndrome• Swimming pools, petting zoos• Mickey D’s—30 outbreaks per year• Supportive Treatment• Prevent—cook burgers to 160º F

Spinach

• Produce is the biggest offender for E.Coli O157:H7

• Parasites and salmon sushi; raw fish

Crohn’s disease—inflammatory bowel disease

• Primarily small bowel, but can include anywhere from the esophagus to the rectum

• Skip lesions; fistulas; strictures • Cause? Bacteria? Mycobacterium

paratuberculosis?• Autoimmune response

Signs and symptoms

• Usually begins with intermittent attacks of relatively mild diarrhea, fever, and abdominal pain, spaced by asymptomatic periods lasting for weeks to many months

• 1/5th of patients with abrupt onset, with acute RLQ pain, fever, and diarrhea

• Diff dx suggesting acute appendicitis or acute bowel perforation

• Chronic disease with fibrosing strictures, marked loss of albumin, generalized malabsorption, B12 malabsorption, or malabsorption of bile salts leading to steatorrhea

Treatment

• Methotrexate to reduce the immune response

• Inflammation via TNF-alpha

• Drugs that block TNF-alpha include infliximab (Remicade), adalimumab (Humira), etanercept (Enbrel)

• Certolizumab pegol (Cemzia)

Ulcerative colitis—inflammatory bowel disease

• Limited to the colon and affects only the mucosa and submucosa; extends in a continuous fashion proximally from the rectum

• Peak onset between 20 and 25 years of age• Risk for colon cancer—risk is highest in patients with

pancolitis of 10 or more years duration; 30% @ 35 years after dx

• Dysplasia (distortion of the normal orientation and architecture of cells)—low-grade dysplasia vs. high-grade dysplasia and ulcerative colitis

Antibiotic-associated diarrhea

• “the usual, run-of-the-mill diarrhea” vs.

• Clostridium difficile diarrhea (new strain)—the “floxacins” and Clindamycin are the biggest offenders for C. difficile

Clostridium difficile

• Clostridium difficile (difficult to culture, hence, difficile) and soap and water kill spores better than alcohol-based gels

• New strain (2003) produces more toxin and causes more severe outbreaks—produces 16x more toxin A and 23 times more toxin B; characterized by the deletion of a gene that downregulates the production of both toxins

• Major risk factor? Use of the fluoroquinolones; Other antibiotics? Amox/Ampicillin, 2nd/3rd generation cephalosporins

A few more notes on C. diff

• Has the child had dental work with prescribed antibiotics?

• Treatment—vancomycin, metronidazole• Stool transplants in chronic C. diff• High risk of recurrence in patients over 65, patients with

severe underlying disease, and additional antibiotic use after discontinuing therapy for C. diff.

• Surawicz CM. Reining in recurrent Clostridium difficile infection—Who’s at risk? Gastroenterology 2009 Apr;136:1152.

The sheep

• You wanna do WHAT with my intestines?

• Clinical uses of a sheep’s cecum

Chronic constipation—4% of preschoolers; 2% of school-age kids

• Normal number of bowel movements?• 3 per day to 3 per week or fewer than seven bowel

movements over a 2-week period with no medication usage as a precipitating cause

• Pain—avoid passing stools; resist the urge by squeezing buttocks and standing straight

• Causes—drugs (anti-cholinergic agents, opiates including codeine, morphine, meperidine; laxative abuse over the years; too much cow’s milk; not enough fluids; not enough fiber)

Constipation

• Advise parents to try fruit juices with sorbitol like prune, pear and apple

• Miralax is only approved for 17 and over, but more and more pediatricians are using it for young kids after trying dietary changes and the above juices

Kiddie constipation

• Give Miralax before using other osmotic laxatives• 0.7 to 1.5 g/kg/day for kids over 2; but no more than the

adult dose of 17g/day• Takes 1 to 3 days to work; use glycerin suppositories if

help is needed fast• Docusate for hard, dry stools; nasty taste and takes a

few days to kick in• Use stimulants (senna, bisacodyl) for “rescue therapy”

when other treatments fail; stimulants can cause abdominal pain and cramping

• (Prescriber’s Letter, April 2009)

Examination of the belly

• Ticklish? How to relax the abdomen…• Inspection…scars, bruises, distention• Auscultation—are the bowel sounds present or

absent; does it matter where you place the stethoscope?

• Palpation—rebound tenderness for localized peritonitis

• The 6 F’s (fat, flatus, feces, fibroid [tumor], fluid, fetus)

Abdominal distention—the 6 F’s

• Fluid

• Fat

• Flatus

• Feces

• Fibroids (or other tumors)

• Fetus (or other tumors--)

The end.

• Barb Bancroft, RN, MSN, PNP

• www.barbbancroft.com

• bbancr9271@aol.com

Bibliography

• Hay WW et al. Current Diagnosis and Treatment—Pediatrics. 19th ed. McGraw Hill-Lange; 2009