12/2/2010

1

PEDIATRICSPEDIATRICSPEDIATRICSPEDIATRICS

GASTROENTEROLOGYGASTROENTEROLOGYGASTROENTEROLOGYGASTROENTEROLOGY

Atan Baas SinuhajiSub Division of Pediatrics Gastroentero-Hepatology

Department of ChildHealth

School of Medicine

University of North Sumatera

CONTENTS

1.GIS K1.GIS K--12 :=Introduction12 :=Introduction

=Vomiting=Vomiting

2.GIS K2.GIS K--17 :=Diarrhoea (1)17 :=Diarrhoea (1)

3.GIS K3.GIS K--21 :=Diarrhoea (2)21 :=Diarrhoea (2)

4.GIS K4.GIS K--27 :=Food Allergy27 :=Food Allergy

5.GIS K5.GIS K--33:=Necrotizing Enterocolitis 33:=Necrotizing Enterocolitis

=Abdominal distention=Abdominal distention

6.GIS K6.GIS K--34:=Tuberculous peritonitis34:=Tuberculous peritonitis

=Abdominal pain=Abdominal pain

=Disorder of ingestion=Disorder of ingestion

12/2/2010

2

7. GIS K-35:=Jaundice

8. GIS K8. GIS K--36:=Encephalopathy36:=Encephalopathy

=Gastrointestinal hemorrhage=Gastrointestinal hemorrhage

9. GIS K9. GIS K--37:=Constipation37:=Constipation

=Failure to thrive ( 1 )=Failure to thrive ( 1 )

10.GIS K10.GIS K--38:=Failure to thrive ( 2 )38:=Failure to thrive ( 2 )

11.GIS K11.GIS K--39=Body fluid balance39=Body fluid balance

PEDIATRICS PEDIATRICS PEDIATRICS PEDIATRICS

GASTROENTEROLOGYGASTROENTEROLOGYGASTROENTEROLOGYGASTROENTEROLOGY

SYSTEMATIC PROBLEM

BASEDFUNCTION

DIGESTIVE

SYSTEM

MAJOR SIGNS

&

SYMPTOMS

12/2/2010

3

DIGESTIVE SYSTEMDIGESTIVE SYSTEMDIGESTIVE SYSTEMDIGESTIVE SYSTEM

PERITONEUM

- ORAL CAVITY

- GI TRACT (ESOPHAGUS ANAL)

DIGESTIVE GLANDS

•SALIVARY GLANDS

•LIVER & BILE DUCT

•PANCREAS

DIGESTIVE TRACT

MAJOR SIGNS & SYMPTOMSMAJOR SIGNS & SYMPTOMSMAJOR SIGNS & SYMPTOMSMAJOR SIGNS & SYMPTOMS

1. DIARRHOEA

2. VOMITING

3. FAILURE TO THRIVE

4. JAUNDICE

5. ENCEPHALOPATHY

6. DISORDERS OF INGESTION

7. ABDOMINAL PAIN

8. ABDOMINAL DISTENSION

9. CONSTIPATION

10. GASTROINTESTINAL HEMORRHAGE

12/2/2010

4

FUNCTIONFUNCTIONFUNCTIONFUNCTION

1. EATING & DRINKING

2. DIGESTION & ABSORPTION

3. SECRETION

4. MOTILITY

5. ENDOCRINE

6. DEFENCE

7. EXCRETION

DIGESTION

BREAK DOWN

DIETARY FOOD

- PHYSIS

- CHEMICAL

- MECHANICAL

SMALLER PARTICLES

&

CAN BE ABSORBED

12/2/2010

5

DIGESTIONDIGESTIONDIGESTIONDIGESTION

INTRALUMINAL

-PANCREAS

-LIVER

-STOMACH

INTRACELLULAR

- PEPTIDASE

- LIPASE

MEMBRANE- SUCRASE- MALTASE- LACTASE- GLUCOAMYLASE

ABSORPTION

TRANSPORT OF WATER OR

DIGESTIVE PRODUCTS

LUMEN

MUCOSA

VESSELSBLOOD

LYMPH

12/2/2010

6

DIGESTION DIGESTION DIGESTION DIGESTION ---- ABSORPTIONABSORPTIONABSORPTIONABSORPTION

INTRALUMINAL DIGESTION

PARACELLULAR

INTERCELLULAR

SPACE

TRANSCELLULAR

MEMBR. DIGESTION

CELLULAR UPTAKE

INTRACELL. DIGESTION

BASOLAT. MEMBRANE

INTERCELLULAR SPACE

BASEMENT MEMBRANE

INTERSTITIAL SPACE

(LAMINA PROPIA)

VESSELS

- BLOOD

- LYMPH

12/2/2010

7

TRANSCELLULERTRANSCELLULER

Tight

Junction

Basolateral

Membrane

Intercelluler

space

E

n

t

e

r

o

c

y

t

e

Luminal

Membrane

Basal

MembraneLamina

propia

PARACELLULERPARACELLULER

Vessel

VOMITING

Atan Baas Sinuhaji

Department of ChildHealth

School of Medicine,University Of Sumatera Utara

Medan

12/2/2010

8

Vomiting

overt reflux

passage of gastric contents into

the mouth

Reflux

Movement of gastric contents retrogradeInto esophagus or more proximal

Food/Drink

Gases -Gastric acid

-Pancreatic juice

12/2/2010

9

REFLUX

OVERT OCCULT

INTO THE MOUTH

VOMITING

INTO THE

ESOPHAGUS

RESPIRATORY

TRACT

LARYNGITIS PNEUMONIAASPIRATION

REFLUX

GASTRIC PRESS. = ESOPH. PRESS.

FUNCTION HIATAL

HERNIA

GASTRIC PRESS. > ESOPH. PRESS.

OBSTRUCTION PERISTALSIS

IN OUT Lower Esophageal

Sphincter (LES)RELAXATION

GastricOutlet

Obstruc.

Pyloric

Stenosis

AbdomInal Tumor

12/2/2010

10

LES RELAXATION

TRANSIENT CONTINOUS

“Gastroesophageal

reflux”Chalasia

HIATAL

HERNIA=

PARTIAL

THORACICSTOMACH

SLIDING HIATUSHERNIA

PARAESOPHAGEAL

HERNIA = ROLLING

12/2/2010

11

REFLUX

GASTRIC ACID

= ACID REFLUX

FOOD/DRINK GASES

ERUCTATION HICCUP

= SINGULTUS

= “CEKUKAN”

HEART BURN

= PYROSIS

= “SENDAWA”

Metaplasia

Epithel of

esophagus

Barret’s

esophagus

ULCUS

stricturebleeding

CONSEQUENCES OF REFLUX

1.- SINGULTUS- ERUCTATION

2. HEART BURN = “SENDAWA”3. ESOPHAGITIS & BARRET’S ESOPHAGUS4. CHRONIC PNEUMONIA ASPIRATION5. FAILURE TO THRIVE (FTT)6. LARYNGITIS7. RUMINATION8. SANDIFER’S SYNDROME9. FOOD REFUSAL

12/2/2010

12

VOMITING

RETURN OF FOOD/DRINK

FROM THE STOMACH TO THE MOUTH

TRUE

VOMITINGREGURGITATION

= SPITTING

= “MINTAR”

= “GUMOH”

PHYSIOLOGICPATHOLOGIC

COMPLICATION (GASTROESOPHAGEAL

DISEASE = GER Disease)

GER

Gastroesophageal reflux (GER)

Physiologic passage of gastric

content to esophagus

Transient LES relaxation

12/2/2010

13

Gastroesophageal reflux

- 50% of infant 0-3 months of age

- 25% of infant 3-6 months of age

- 5% of infant 10-12 months of age

Resolving in most by 12 months and

nearly all by 24 months

Gastro Gastro –– Esophageal Reflux DiseaseEsophageal Reflux Disease

(GERD) (GERD)

GER that causes symptoms or complications that GER that causes symptoms or complications that

effect quality of lifeeffect quality of life

12/2/2010

14

GERD GERD ≠ ≠ VOMITINGVOMITING

-- Not all vomiting are GERDNot all vomiting are GERD

-- Many GERD children do not vomitMany GERD children do not vomit

TRUE VOMITING

�� NAUSEANAUSEA

�� RETCHINGRETCHING

�� FORCEFUL GASTRIC CONTENTS/ FORCEFUL GASTRIC CONTENTS/

INTRA ABDOMINAL PRESSURE INTRA ABDOMINAL PRESSURE ↑↑↑↑

�� SYMPTOMS OF AUTONOMIC SYMPTOMS OF AUTONOMIC

NERVUS SYSTEM (+)NERVUS SYSTEM (+)

12/2/2010

15

REGURGITATION

�� THE YOUNG BABYTHE YOUNG BABY

�� NOT MATURE NOT MATURE L.E.S.L.E.S.

�� NAUSEA (NAUSEA (--))

�� NOT FORCEFULNOT FORCEFUL

�� SYMPTOMS OF ANS (SYMPTOMS OF ANS (--))

RUMINATION

- RETURN OF FOODS INTO THE MOUTH

- FOODS RECHEWED

- FOODS REINGESTED

12/2/2010

16

NAUSEA

- UNPLEASANT SENSATION & OFTEN

CULMINATING IN VOMITING

- CONTRACTION OF PYLORIC

ANTRAL

- SYMPTOMS OF ANS (+)

VOMITING IN INCREASE INTRACRANIAL PRESSURE

- PROJECTILE

- NAUSEA (-)

- RETCHING (-)

12/2/2010

17

DIAGNOSIS GER

1. History

2. Body weight ���� poor weight gain ?

3. Diagnostic Test

- Upper GI series ���� rule out anatomical

abnormalities

- pH probe (12-24 hours) ���� Acid reflux����Gold

Standard

- Scintigraphy

- Endoscopy ���� complication

TREATMENT GER

1. Conservative therapy

2. Pharmacotherapy

3. Surgery ���� Nissen Fundoplication

12/2/2010

18

Conservative Therapy

1. Prone position and upright position :

- The infant is awake and observed

SIDS

2. Small frequent feeding

3. Thickening of formula

Pharmacotherapy

1. Acid Neutralization : Antacids

2. Antisecretory ( Cimetidine, Ranitidine,

Omeprazole, etc)

3. Prokinetic

- Metoclopramide ���� Extrapyramidal

Symptoms

- Bethanechole ���� Bronchospasme

- Cisapride : 0,2 mg/kg/dose 3 or 4 x daily

Arrythmia

12/2/2010

19

VOMITING

SURVIVAL VALUE

DEFENSE- UNDERLYING

- COMPLICATION

THREATENINGTOXIC

COMPLICATION OF TRUE VOMITING

1. Body Fluids Imbalance- dehydration- hyponatremia

- hypokalemia- hypochloremia- hypocalcemia ==> tetany

- metabolic alkalosis2. Mallory Weiss Syndrome

3. Pneumonia aspiration4. Intake - hypoglicemia

- starvation- Failure To Thrive- Metabolic acidosis

12/2/2010

20

VOMITING

Na+

WaterCl-H+ K+

Hyponatremia

Met. Alk.

dehydration Hypo-

chloremia

Hypokalemia

hypovolemia

RBF

Renin

Aldosteron ↑↑↑↑

Retention of Na+ & Water

Loss of K+Loss of H+

hypocalcemia

VOMITING

DIGESTIVE TRACTOUTSIDE

Surgery Medical

- obstruction

- inflammation- perforation

- gastritis

- peptic ulcer- Gastroenteritis

- psychogenic- neurogenic:

int.cran. press.↑↑↑↑

- systemic:sepsis- hemodynamic

12/2/2010

21

MANAGEMENT

1. STABILIZATION OF

GENERAL CONDITIONBody Fluids Imbalance

2. PROTECTION AGAINST ASPIRATION

3. CAUSAL

4. CALORI/ PROTEIN

5. COMPLICATIONS

6. ANTIEMETIC DRUGS

ABDOMINAL EMERGENCY

PNEUMONIA ASP.

CEREBRAL EDEMA

NO RECOMMENDED

ANTI EMETIC

1. DOPAMINE receptor antagonist

- metoclopramide

- domperidone2. Cannabinoid (dronabinol)

3. Anticholinergic (Scopolamine)

4. 5HT3 receptor antagonist

- ondansetron

5. Phenothiazine dan anti histamin

- phenergan, benadryl

- largactil

6. Corticosteroid

12/2/2010

22

BOWEL

OBSTRUCTI0N

COMPLETE

PYLORIC STENOSIS

INCOMPLETE

INVAGINATION

INVAGINATION = INTUSSUSCEPTION

PROXIMAL BOWEL

(INTUSSUSCEPTUM)

DISTAL BOWEL

(INTUSSUSCIPIENS)

SPONTANEUS

REDUCTION

CONTINUING

3 months - 3 years

12/2/2010

23

TYPE OF INVAGINATION

- ILEOCOLIC > > >- ILEOILEIC- CECOCOLIC- COLICOCOLIC- ILEOILEOCOLIC

SIGNS & SYMPTOMS- SUDDEN ONSET- PAROXYSMAL PAIN- VOMITING- BLEEDING PERANUM- TUMOR- SIGNE de DANCE- ABDOMINAL DISTENTION - DEFECATION & FLATUS (-)

- WATER & ELECTROLYTES

- HYDROSTATIC

- OPERATIVE

Th / :

12/2/2010

24

DIAGNOSTIC

CLINIC

RADIOLOGIC

PLAIN OF ABDOMINAL PHOTO

SIGN OF OBSTRUCTION

BARIUM ENEMA- CUPPING- COIL SPRING