Jaundice, diarrhoea and other gastroenterological symptoms in childhood AGNIESZKA WEGNER

KL INIKA NEUROLOGI I DZIECIĘCEJ

WARSZAWSKI UNIWERSYTET MEDYCZNY

Gastrological symptoms in children q Vomi%ng

q Jaundiceq Abdominalpain

q Diarrhoeaq Cons%pa%on

VomiJng 1.  Vomi%ngisthemeansbywhichtheuppergastrointes%naltractridsitselfofitscontents

whenalmostanypartoftheuppertractbecomesexcessivelyirritated,overdistended,orevenoverexcitable.Vomi%ngisasymptom,presen%ngcomplaintinmul%tudeofdisorders.Rangefromgastrointes%nalpathologytodiseaseindistantorgan(o%%smediaorintracraniallesion)

2.  Nausea:Theunpleasantsensa%onoftheimminentneedtovomit,usuallyreferredtothethroatorepigastrium;asensa%onthatmayormaynotul%matelyleadtotheactofvomi%ng

3.  Regurgita%on:Theactbywhichfoodisbroughtbackintothemouthwithouttheabdominalanddiaphragma%cmuscularac%vitythatcharacterizesvomi%ng.

VomiJng- causes Infant Child Adolescent

Common •  Gastroenteri%s•  Gastroesophageal

reflux•  Overfeeding•  Anatomic

obstruc%on•  Systemicinfec%on•  Pertussissyndrome•  O%%smedia•  Pyloricstenosis

•  Gastroenteri%s•  Gastri%s•  Reflux(GERD)•  Systemicinfec%on•  Pertussissyndrome•  Sinusi%s•  O%%smedia

•  Gastroenteri%s•  GERD•  Gastri%s•  Inflammatorybowel

disease•  Appendici%s•  Systemicinfec%on•  Sinusi%s•  Migraine•  Pregnancy

VomiJng- causes Infant Child Adolescent

•  Rare • CAH• Inbornerrorofmetabolism• Braintumor(increasedintracranialpressure)• Subduralhemorrhage• Foodpoisoning• Renaltubularacidosis

• Reyesyndrome• Hepatitis• Pepticulcer• Pancreatitis• Braintumor• IncreasedICP• Middleeardisease• Achalasia• CyclicvomitingEsophagealstricture• Duodenalhematoma• Inbornerrorofmetabolism

• Reyesyndrome• Hepatitis• Pepticulcer• Pancreatitis• Braintumor• IncreasedICP• Middleeardisease• Cyclicvomiting• Biliarycolic• Renalcolic

Interview q Ageofthepa3entq Dura3on/Frequency

q Onset

q Associatedwithfoodintakeü  instantly:esophagealobstruc%onü ATerawhile:stomachorduodenalobstruc%on

q Nature(projec3le/nonprojec3le)

q Colorandcontentsü Nondigestedfood:proximalobstruc%onü Semidigestedfood:distalobstruc%onü Billouscontent:distalto2ndpartofduodenumü Fecalmaterial:obstruc%onatthelargeintes%ne

q Associatedsymptomsü Fever/AbdominalPain/Diarrhea/cons%pa%on/dysphagia

q Respiratory–cough,chestdiscomfort

q Urinary–dysuria,hematuria

q CNS–irritability,alteredsensorium,drowsy,necks%ffness,headache,visualdisturbance

q PastmedicalhistoryAnyknownmedicalillnesssuchasmetabolicinbornerror,cerebral

palsy,downsyndrome,neurologicaldeficit

q Drugandallergyhistory

q Birthhistory

q Nutri%onalhistoryRecentlychangeintocowmilk/foodallerrgy/typeoffood

q OtherrelevanthistoryRecentea%ngoutside,recenttravelling,familymemberorfriendsin

schoolhavesimilarillness

VomiJng- examinaJon q Generalcondi%on§  Comparisonofpa%ent’sweightbeforeandaTeronsetofillness

q Hydra%onstatus§  Sunkenfrontanelle§  Eyessunkenandtearless§  Drymucousmembrane§  Prolongedcapillaryrefill%me§  Reducedskinturgor§  Tachycardia,tachypnea

q AbdominalExamina%on◦  Distension,Visibleperistalsis,Tenderness,hepatospelnomegaly,abdominalmasses,Bowelsounds

q CNSExamina%on Power,Tone,reflexes Changesinvisionq RespiratoryExamina%on,Earexamina%on Rehydrateaccordingly-encourageoralintake Correctelectrolyteimbalances Treataccordingtotheunderlyingcause

Jaundice  Jaundiceisayellowishpigmenta%onoftheskin,theconjunc%valmembranesoverthesclerae(whitesoftheeyes),andothermucousmembranescausedbyhighbloodbilirubinlevels.

q  Thecondi%onforthecrea%onofjaundiceisanincreasedbilirubinserum.

q  Normallevelsofbilirubininthebloodserumrangesfrom0.3-1.0mg/dl,withnearly90%ofconjugatedbilirubin.

q  Bilirubiniscreatedinliver,spleenandbonemarrowasaproductofthecatabolismof:

q  hemoglobinfromerythrocytes80-85%

q  othercombina%onsofcompoundscontainingheme/myoglobin,cytochromes,especiallyCP-450,otherenzymescontainingheme

q  hemoglobinderivedfromineffec%veerythropoiesis/maturingerythrocytes/

ClassificaJon of jaundices  Liverplaysamailroleinbilirubinmetabolism.Therearethreestagesofbilirubinmetabolisminliver:1.  uptakeofbilirubin2.  conjuga%onwithglucuronicandsulfericacid3.  excre%onofconjugatedbilirubinintobile

Classifica%onofthejaundice Pre-hepa%c/hemoly%c-Intrinsicdefectsinredbloodcellsorextrinsiccausesexternaltoredbloodcells Hepa%c/hepatocellular–liverdisease Post-Hepa%c/cholesta%c-obstruc%onofbiliarypassage

HemoliJc jaundice Ø Structuralerythrocytesanomalies-defectsinmembrane/sicklecellanemia/,enzymopa%e,hemoglobinopathies,thalassemia

Ø extrinsiccauseshaemolysis

-  immunological/auto-,izoan%bodies/

-  chemical/intoxica%onPb,Cu,drugs/

-  mechanical/valvularprosthesis/

-  infec%on/bacterialsespis/-  Hipersplenizm,metabolicaldisorders/uricemia/

DiagnosisØ FamilyhistorY,drugs,

Ø weakness,worseexercisetolerance

Ø normalurine,darkstools,strawyellowdiscolora%onoftheskin

Ø tachycardia,hypersplenism

Ø predominanceofindirectbilirubin/unbound/

Ø anemia,re%culocytosis

Ø amarkedincreaseinLDH,aslightincreaseintransaminases

Ø lackofserologicalmarkersofviralinfec%ons

Unconjugated bilirubin predominance Ø Increasedproduc%on-  Intra-andextravascularhemolysis-  Ineffec%veerythropoiesis

Ø Impaireduptakebilirubinbyhepatocytes-  Sepsis,drugs,long-termhunger,hyperthyroidism

Ø Imapiredconjuga%onofbilirubin-  Gilbert'ssyndrome,Crigler-Najjarsyndrome,neonataljaundice

Jaundice caused by congenital enzymaJc defects of hepatocytes Ø GilbertSyndromeØ abnormalbindingofbilirubinwithglucuronideacid–deficiencyofUDPG

Ø Familycharacter,thepredominanceofindirectbilirubin,normallevelsofliverenzymes,noevidenceofhemolysis,bilirubinrarelyexceeds5mg/dl

Ø Crigler-NajjarSyndromeØ bilirubinmetabolismdefectassociatedwithdeficiencyofUDPG

Ø TypeI-childrendieinthefirst2yearsoflifeØ TypeII-normallevelsofenzymes,<20mg/dlbilirubin

Ø predominanceofindirectbilirubin

Ø Dubin-JohnsonSyndromeØ secre%ondisorderassociatedbilirubinpolegallhepatocytes

Ø familycharacter,thepredominaneofconjugatedbilirubin,

Ø bilinubinuria,thepresenceofthedyeinhepatocytesmelanin-like

Ø RotorSyndromeØ VarietyofDubin-Johnsonsyndrome,theabsenceofthedyedepositsinhepatocytes

Ø NewbornsjaundiceØ immaturityofenzyma%chepatocytes-deficiencyUDPGtransferase

HepaJc jaundice- causes Ø Infec%onØ viral:HAV,HBV,HCV,HDV,HEV,EBV,TORCH,Echo,Parvo,

Ø listeriosis

Ø ToxicØ drugs-cytosta%cs,paracetamol,TPN

Ø Chemicalcompounds-carbontetrachloride

Ø mushrooms-Amannitaphalloides

Ø Alcohol

Ø MetabolicalØ Wilsondisease-disordersofCumetabolism

Ø hemochromatosis-disordersofFemetabolism

Ø alfa-1antytrypsindeficiency

Ø Galactozemia,fructozemia,glycogenosisIV,tyrosinemia,cys%cfibrosis

Ø Autoimmunological/AIH/Ø AIHtypI,IIa,IIb,III

Ø Primarybilliarycirrhosis/PBC/

Ø Primarysclerosingcholangi%s/PSC/

Ø other-Alagille’asyndrome,Aegenessydrome

Diagnosis Ø interview-surgery,bloodtransfusion,alcohol,drugs,chemicalsØ darkurine,stooldiscolora%onØ Cutaneous/vascularspiders,palmarerythema,purpuraflaw/Ø enlargedliverandspleenØ predominanceofdirectbilirubin/connected/Ø asignificantincreaseinthelevelofALT,ASTinserumlesspronouncedFA,GGTØ leukopeniaandthrombocytopenia/hypersplenism/Ø decreaseinalbumin,gammaglobulinincrease

Ø serologicalmarkersofinfec%onHAV,HBV,HCV,HDV,CMV,EBV

Ø autoan%bodiesANA,AMA,ANCA,LKM,SLA

Ø reduc%oninthelevelofceruloplasmin,

Ø highcopperconcentra%onsinserumanddailyurinecollec%on

Ø elevatedlevelsofFeØ Elevetadurobilinogeninurine,bilirubinuria

Jaundice extracellular- cholestasis  Congenitalobstruc%onofextrahepa%croadsżółciowych-biliaryatresia Cystofcommonbileduct

 Narrowingofthebileducts Urolithiasisand/orspontaneousperfora%onofthecommonbileduct

Diagnosis Ø interview-symptomsofbiliarycholelithiasis,itching,weightloss

Ø darkurine,stooldiscolora%onØ enlargementofthegallbladder,Chełmońskisymtome,liverenlarged,hard,withunevenshore

Ø predominanceofdirectbilirubin/related

Ø asignificantincreaseinGGT,FA,smallALT,AST

Ø leukocytosis,increasedESR,anemia

Ø lackofserologicalmarkersofhepa%%sinfec%on

Ø Abdominalultrasound-thelackofgallbladder

Ø Biopsywątroby-to3weeksoflife->GOLDSTANDARDDIAGNOSISbiliaryatresia

Ø ERCP

Ø CT,MR

Ø PTC-percutaneouscholangiografia

Abdominal pain  Abdominalpaininchildrencanbeasymptomofpsychosocialstress,asinadultstensionheadacheintheoccipitalregion.

 Childrenusuallylocalizedpainaroundthenavel. Division•  acute•  chronic•  recurrent

Acute abdominal pain q mayhaveamildstart,thengraduallythepainincreases

q themomentofhisappearancecanbeappliedtoaspecificdate

q painwakesthechildorpreventssleep,interruptsplayq itisnon-recurring

q rarelysubsideswithouttreatment

q oTenaccompaniedbyothersymptoms:nausea,vomi%ng,diarrhea,fever,lackofappe%te

q thepa%entisanxious,unwillingnesstoinves%gate

q posi%onwithcurledlegs-protectsthestomach,decreasingmuscletensionofthestomach

Acute abdominal pain- causes SURGICAL

 appendeci%s

 intussep%on

 cystorovariantorsion

NON-SURGICAL

 cons%pa%on

 gastroenteri%s

 ovulatorypain

 simula%on

 urinarytractinfec%on

 haemoly%curaemicsyndrome

 hepa%%s

Chronic abdominal pain q prevelence20-30%ofchildren5-14q restrictsthenormalac%vityofthechild-only1/10pa%entsregularlygotoschool

q to9yearsofageoccurswithequalfrequencyinboysandingirls,olderchildrenmoreoTeningirls

q maybealsorelapsing

q theremaylastforseveraldaysorweeks

q individualepisodeslastupto3hours,morethanhalfofchildrenabout1hour

q seizuresusuallyoccurindrovesq paininterfereswithfallingasleep,butdoesnotraiseachildq inmostchildrendis%nctperiodswithoutabdominalpain,butoccasionallythepaincanbecon%nuous

q Itcanbeassociatedwithothersymptoms:nausea,vomi%ng,diarrhea,headache,dizziness,fa%gue

The causes of chronic abdominal pain q Themostcommoncause-func%onalabdominalpain

q Infec%on-yersiniosis,giardiasis,H.pyloriinfec%on,UTIq cons%pa%onq Foodalergyq Foodintolerance-disaccharidoses-fructose,lactose,sucroseq celiacdiseaseq Anatomicalchanges-ovariancyst,pancreasdivided,gastrointes%nalileus/subileus

q Inflammatoryboweldisease-ulcera%vecoli%s,Crohn'sdisease

q Epilepsy,migraine

q Drugs:NSAIDs,steroids,ironprepara%ons

Chronic abdominal pain FUNCTIONALABDOMINALPAIN

 propergrowth lackoflocalizedsymptoms

 painspilled painaroundthenavel

ORGANICABDOMINALPAIN

 painradia%ngtotheback,chest,hips,associatedwiththeintakeoffoodorflushing

 painawakensthechildfromsleep

 painlocated,limited

 inhibi%onofbodyweightgain

 Othersymptoms-fever,vomi%ng,jointpain,gastrointes%nalbleeding,painaroundlumbararea,changesontheskinaroundtheanusoranalfissure,analincon%nence,abdominaltumors,hepatosplenomegaly

Abdominal pain- diagnosJcs  Laboratorytests:bloodcount,ESR,CRP,ALT,AST,amylase,crea%nine

 Urinetest

 Stooltest:culture,viruses,occultblood,parasites,H.pylorian%geninstooltestELISA-Giardiaintes%nalis

 abdominalultrasound

Diarrhoea- diagnosis  Thehigherthannormalnumberofstoolsperday(oTenmorethentwice),orchangeinthenatureofstool(theyarewateryorsemi-liquid),orthechild'sstoolscontainmucus,bloodorsputum

 WHO-acondi%oninwhichachild<2yearsofage,ar%ficiallyfedormixedhas

 threeormoreliquidorsemi-liquidstoolsper24hours

 or 1abnormalstoolhavingbloodormucusorpuswithin24hours

Diarrhoea- classificaJon  Divisionduetodura%on:◦  Acutediarrhea<14days(usually3-5days)◦  Prolongeddiarrhoea14-30days◦  Chronicdiarrhea>30days(>14days)

 Thedivisionbecauseofthee%ology◦  Noninfec%ousdiarrhea◦  Infec%ousdiarrhea,fever,bloodinthestool,nauseaand/orvomi%ng,◦  an%bio%cs

 Thedivisionduetothemechanism◦  Osmo%cdiarrheacausedbyintes%nalinabilitytoabsorbexcessiveamountsofsubstancesthatretainwater,therebyincreasingstoolvolume(eg.lactoseintolerance)

◦  Secretorydiarrheacausedbyac%vesecre%onintotheintes%neoflargeamountsofsalt,waterandothersubstances(infec%onagents,laxa%ves)

Acute diarrhoea- causes  Infec%onsenteral->viruses,bacteria,exotoxins,protozoa Infec%onsoutsidethegastrologicaltract->UTI,o%%smedia,pneumonia

 Surgicaldiseases->appendici%s,intussuscep%on,obstruc%on Drugs:->An%bio%cs

Viral diarrhoea  HRV(Rhinoviruses)ofgroupA,BandC◦  infec%onthroughoral-faecal◦  infec%oniscomprisedofsmallintes%ne◦  shortincuba%onperiod(1-3days)◦  oTenexcessivevomi%ng(1-2days)◦  Acutewaterydiarrhea(usually2-7days)◦  oTenfever◦  20-40%-rhini%ssymptomsofupperrespiratorytract

◦  Diagnosis:ELISAoralatexagglu%na%onassay

 Adenoviruses◦  tendencytoprolongthediarrhea◦  OTenaccompaniedbysymptomsofupperrespiratorytractinfec%ons

◦  clinicalcourseisusuallymild◦  severedehydra%on,acidosis-inthecaseofseverevomi%ngand/ordiarrheawithoutpropertreatment

 Rotavirus◦  Themaincauseofseverediarrheainyoungchildren

◦  Europe:-autumn-winterseason◦  Childrenaged6-24months◦  Oralanddroplet◦  OTenasnosocomialinfec%onsandepidemics◦  vaccina%on

Bacterial diarrhoea  Thecourseisself-limi%ng!

 Waterystoolswithmucus,pusorblood

 Thetendencytothreading(Salmonella,Shigella,Yersinia,Campylobacter,EPEC)

 Cancallsep%cemiaandsystemicinfec%ons(Salmonella,Yersinia)

 Traveler'sdiarrhea(ETEC,Shigella,Salmonella,Campylobacterjejuni,Vibriocholerae,Cryptosporidiumparvum,Giardiaintes%nalis,Entamoebahistoly%ca)

ETEC  EnterocytotoxicalE.coli;ETEC,Shiga-liketoxinproducingE.coli;verotoxin-producingE.coli◦  Produc%onverocytotoxins(VT1,VT-2)◦  Clinically:bloodydiarrhea,usuallywithoutfever◦  E.coliO157:H7-afrequentcauseofbloodydiarrheaindevelopedcountries◦  undercookedorundercookedbeef,hamburgers,drinkingwater,unpasteurizedmilk,yogurt,vegetables

◦  Lackofsensi%vitytochemotherapy

◦  Complica%on:Hemoly%curemicsyndrome(upto10%infectedwithE.coliO157:H7

Salmonella q Infec%onofatyphoidcancausebacteremiaandfocusofinfec%onintheGItract(bones,joints,CNS)-S.typhi,S.paratyphiA,B,C

q gastroenteri%s(salmonellosis)-S.enteri%dis,S.typhimurium,S.agonae

q asymptoma%ccarriers

q onsetusually<6yearsofageq oralinfec%on->contaminatedwater,food(icecream,mayonnaise)

q fever,nauseaq many,plen%fulsmellystools(mucus,pus,blood)

q Theywereusuallyself-limited

q sheddinginfecesisusuallyapprox.3weeks.q an%bio%cspromotesprolongedcarriage

Clostridium difficile q ToxinA-enterotoxinsimilartothetoxinsofV.cholerae

q ToxinB-cytotoxinq Approx.50-70%ofnewborns;20-50%<1r.ż.;approx.3%ofadults-contaminatedwithC.difficile

q SymptomsaTeran%bio%cstherapy:clindamycin,ampicillin,amoxicillin,cephalosporins

q Thebroadspectrumofclinicalsymptoms:◦  milddiarrheawithwatery-brownstools◦  severehemorrhagicdiarrhea◦  pseudomembranouscoli%s

q posi%vebacteriologicalexamina%oncannotbethebasisforthediagnosis!

q goldstandard-cellculture,demonstratethecytotoxicityofC.difficiletoxinAandB

Giardia intesJnalis q themostcommoncauseofparasi%cdiarrhea

q developedcountriesapprox.2-5%ofthepopula%on,developingcountriesapprox.20%

q Itisintheformtrofozoitandcysts

q oralinfec%on->intakeofwaterorproductscontainingcysts

q mileagevaries(asymptoma%ccarriers,acuteself-limiteddiarrhea,chronicdiarrheawithmalabsorp%on

q fecesorduodenalcontentstothepresenceofcystsortrophozoites

q ELISAtestforGiardiaintes%nalisantygen

Laboratory test  Specificdiagnos%ctestsimmunosorbentassay(ELISA)orlatexagglu%na%on-detectedinasampleofstoolan%gens:HRVgroupA,adenovirus,rotavirus

 Inmostchildrenwithoutimmunodeficiencymicrobiologicaldiagnosisitisnotnecessary-doesnotchangethebasicprinciplesoftreatment

 Indica%onsformicrobiologicalexamina%on:◦  Bloodydiarrhea(Salmonella,Shigella,Campylobacter,E.coliO157:H7,Yersiniaenteroli%ca,Clostridiumdifficile-toxinAandB)

◦  Diarrheawithveryseveredehydra%on≥10%orseriouscondi%on◦  Prolongeddiarrhea(>10-14days)◦  Alargenumberofleukocytesinthestool(>5hpf)◦  Immunosuppressioninchild◦  epidemiologicalconsidera%ons◦  Suspectedcholera

Diarrhoea treatment  Theresultofdiarrhoea-dehydra%on Lossofwaterandelectrolytesinthefaeces(Na,K,Cl,HCO3)

 Thedegreeofdehydra%onisdefinedasapercentageofweightloss

 Comparisonofcurrentweightandbeforethediarrhoeaonset

 Primarytreatmentofacutediarrheaisoralirriga%on(DPN)orintravenous(dependingontheextentofdehydra%on)andfeeding(earlyrealimenta%on)

GRADE(weighloss)

GENERALCONDITI

ONEYEBALLS TEAR

S

MOUTH AND

TONGUE

THIRST SKINFOLD

Noorsmall(<5%)

Calm, concious

Propertension + Wet Normal Straighte

nupfast

Intermediate

(5-10%)restless

Sunken ,

dark circles- Dry

drinksgreedilythirsty

Straigtensupslowly

Severe(>10%)

Drowsy

or unconsci

ous , limp

Moresunken - Verydry

Drinks

poorly or unable to

drink independ

ently

Straighte

ns up very slowl

Acute diarrhoea treatment Oralfluids-prepara%onswithalowercontentofsodium(60mmol/l)andalowerosmolarity(245mmol/l)

Smec%te(Smecta)-reducesthedura%onofdiarrheaWed.17-24hrs.,noeffectonfaecaloutput

Probio%cs-LactobacillusrhamnosusGG,Saccharomycesboulardishortensthedura%onofacutediarrheaininfantsandyoungchildrenapprox.for24hours.Efficiencyisstrainspecific.Moreefficientinviraldiarrhea(diarrheainthee%ologyHRV)andinearlyuse.

Notrecommended:

• drugsabsorbingbacterialtoxins(ac%vatedcharcoal).• drugsinhibi%ngperistalsisp.p.(Eg.Loperamide)

• an%secre%ondrugs(bismuthsubsalicylate)

• Torehydratenotuseacommerciallyavailableclearfruitjuices,ordrinkslike"cola"

AnJbioJcs in diarrhoea Inmostcases,acuteinfec%ousdiarrhoea(viralandbacterial)resolvesspontaneouslyanddoesnotrequirean%microbialagents

Indicatedan%bio%ctherapyandmodifica%onoftreatmentaTercollec%ngstoolculturewhen:

fever(>380C)andatleastoneofthefollowingsymptoms:

->Bloodydiarrhea

->Largenumberofleukocytesand/orlactoferrininthestool

Chronic diarrhoea- causes  Frequentcausesofchronicdiarrhoea◦  post-infec%ousdiarrhoea,toddler’sdiarrhoea,foodallergy,coeliacdisease,cys%cfibrosis,disaccharideintolerance

 Rarecausesofchronicdiarrhea◦  diarrhoeachloride,diarrhoeasodium,congenitalatrophyofmicrovilli,epithelialdysplasia,autoimmunediarrhoea

Food allergy  Themostcommonallergens

 Childhood-90%offoodallergiesarecausedbyproteinsofcow'smilk,eggs,peanuts,wheat

 Teens,youngadultsandlaterage-85%peanuts,fish,shellfish

 Allergytocow'smilkproteins

 Formulafeeding:1,9-4,4%

 Breast-feeding:0.5%

Food allergy- causes  Diges%vetract◦  Vomi%ng(approx.25-75%)◦  Acutediarrhea◦  Chronicdiarrhea(approx.25-75%)◦  Lossofbodymass◦  Enteropathy-malabsorp%on◦  Irondeficiencyanemia◦  Abdominalpain,abdominalcolic(babies)◦  Coli%s,proctocoli%s◦  gastroenteropathyeosinophilic◦  cons%pa%on

 Skin Respiratorysystem

Food allergy  DIAGNOSISq Interviewq Oralfodchallenge

•  open•  blind•  double-blind

q skintestsq TotalIgEandspecific

 TREATMENT

q Elimina%ondiet

q Proteinhydrolysates(Bebilonpep%,Nutramigen)

q Dietselementary(Bebilonamino,Neocate)

q Soyformula

Lactose intolerance  Primarylactosedeficiency–veryrare!Secondarylactasedeficiency•  acuteandchronicgastrointes%nalinfec%ons•  foodalergy•  celiacdisease•  an%bio%corchemotherapy•  immunedisorders• malnutri%on

 Hypolactasiaadulttype◦  InPolandapprox.35%

Coeliac disease  Celiacdiseaseisimmune-mediated,causedbygluten,andthegluten-likeprolamins.

 This disease affects people with a gene%c predisposi%on, and is characterized by clinicalsymptomsglutenodependant,enteropathyandan%bodiesspecificforcoeliacdisease:

•  %ssuetransglutaminasean%bodies–tTGA•  endomysialan%bodies–EMA•  deamidatedgliadinpep%de–DGP•  histocompa%bilityan%gensHLA-DQ2orDQ8

Coeliac disease- classificaJon 1.  Theclassicformofthedisease

2.  Hiddenrefractoryanemiaandrecurrentshortstaturedelayedpubertyandinfer%lityenamelhypoplasiarecurrentaphthousinmouth

3.  Latent4.  Thepoten%al(onlyHLA)

Coeliac disease – classical form  Arich,smelling,fa{ystools Inhibi%onofweightgainordecrease Growthretarda%on Childsad,apathe%c,irritable Lipoatrophy Alargeprotrudingbelly,thinlegs

Toddler’s diarrhoea  Themostcommoncauseofchronicdiarrhoea!

 Painlesspassingthreeormoreunformedstoolsforatleast4weeks

 Onsetbetween6a36m.ż.

 Stoolsonlyduringtheday%me

 Nodisturbancesofweightgain(ifsufficientcaloricintake)

 Children◦  treatmentisnotnecessary◦  increasingthedoseoffatandreducedamountsofjuices

 Parents◦  explainthenatureofthedisease◦  persuadingparentsaboutthebenignnatureofthedisease

ConsJpaJon Defeca%onoccursless1per3daysand/orthebigeffortsisnecceserybecausehard,thoughstoolconsistencyinchildrenaTerinfancy.

Func%onalcons%pa%onaccordingtoRomeIIICriteria:

*≤2stools/week

*≥1episodeoffecalinconinenec/week

*fecalmassesinrectalampulla

*ininterview:reten%onbehaviours,hard,toughstools,largediameterofthestools

*Diagnosis-2ormoresymptomsoccursatleastfor2months

Organic causes of the consJpaJon q Surgical:•  Hirschsprungdisease•  Anusandrectaldiseases•  Acuteabdomen

q Metabological•  dehydrata%on•  Cys%cfibrosis(meconiumobstruc%on)•  Hipothyroidism,adrenalinsufficiency•  Hipercalcemia

q neuromuscular•  hypotensionabdominalmuscles(Downsyndrome,MPD)•  musculardystrophy•  spinalinjury(tumors,spinabifida)•  Congenitalmuscularlimpness

q ATerdrugsintake•  narco%cs•  an%depressants•  psychotropmedicines•  vincris%ne

q Psychiatric:anorexianervosa,depression

q Inolderinfantsexclusivelybreas~ed

ConsJpaJon INTERVIEWq Childageq Dura%on%meofilnessq Frequencyofbowelmovement,stoolsconsistency,effortduringdefeca%on,bloodinstools,fecalincon%nenceq TimeaTerbirthwhenmeconiumappearsq drugsq VitD3supplementa%onq dietq Otherdiseases

 Physicalexamina%onq assessmentofnutri%onalstatusq abdominaldistensionq palpa%onassessmentoffaecalimpac%onintheleTandsome%mesrightiliacfossa%meq rectalexamina%on-evalua%onvoltageofsphincter,thepresenceoffecalmassesinarectum

AddiJonal tests q Ultrasoundofabdominalcavityandthyroidq electrolytesq Thyroidhormonesq Sweatchloridetestq Vitamin25OHD3q Anorectalmanometryq enemaq rectoscopyq transit%meq Rectalbiopsy:histologicalexamina%onandhistochemical

Treatment q Coloncleansingfromdefaul%ngfecalmasses

q Drugs:laxa%ves,drugsaffec%nggastrointes%nalmo%lity

q High-fiberdietq Increasedphysicalac%vity

q Psychologicalexamina%on

q Surgicaltreatment

Literature Ø  Pediatria,Kawalec,Grenda,PZWL,Warszawa2013

Ø  IllustratedtextbookofPediatrics,4thEdi%onØ  EuropeanSocietyforPediatricGastroenterology,Hepatology,andNutri%onGuidelinesfor

theDiagnosisofCoeliacDisease.JPGNVolume54,Number1,January2012

Ø  DrossmanDA.Thefunc%onalgastrointes%naldisordersandtheRomeIIIprocess.Gastroenterology.2006;130:1377-90.

Ø  SummaryandRecommenda%ons:Classifica%onofGastrointes%nalManifesta%onsDuetoImmunologicReac%onstoFoodsinInfantsandYoungChildrenSampson,HughA.;Anderson,JohnA.JPGN,2000,30,S87-S94

Ø  Google.com

Ø  Slideshare.net