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