Transcript Paediatric Gastroenterology

Paediatric
Gastroenterology
Dr Jessica Daniel
ST8 Paediatrics
A huge subject!
 Vomiting
 Diarrhoea
 Constipation
 Abdominal
 Nutrition
pain
Vomiting
 Infection
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– Gastroenteritis
Rotavirus, Norovirus, Bacterial
 Gastroesophageal
Reflux (GOR)
 Obstruction
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Pyloric Stenosis
Malformations – Malrotation, atresias
Case Discussion
A
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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.
• Palpable epigastric mass,
visible peristalsis
• pH 7.5, pCO2 4.5, BE +2
• K 2.9, Cl 99,
B
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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
• Examination unremarkable,
mild fever
• pH 7.29, pCO2 4.9, BE -5
• Na 148, K 3.5, Ur 10, Cr 30
Gastroenteritis
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10% of children <5yrs present to healthcare
professionals, 16% of A&E attendances
2 million deaths worldwide in under 5’s
Most commonly viral
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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
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Appears unwell / Altered consciousness
Tachycardia / Tachypnoea
Sunken eyes
Reduced skin turgor
Gastroenteritis
 Not
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dehydrated
Continue breastfeeding/usual milk feeds
Avoid carbonated/fruit juice
ORS
 Some
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dehydration
ORS little & often, 50ml/kg/hr
Via NG if refusing / continues to vomit
 Shock
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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
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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
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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 Malformations
Duodenal Atresia
Double bubble
Malrotation
Imperforate Anus
Meckel’s Diverticulum
Diarrhoea
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Acute vs Chronic
Infection
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Appendicitis, Intussusception, Partial obstruction
Malabsorption
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UC, Crohn’s
Surgical
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Rotavirus, E coli 0157, Giardia
Inflammatory
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Bloody vs Non Bloody
CMPI, Lactose intolerance, Coeliac
Overflow incontinence
Toddler’s diarrhoea
Inflammatory Bowel Disease in
Childhood
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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
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Essential inflammatory processes
Mucosal lesion
Differences to adult IBD
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Management emphasis
Growth, puberty, psychosocial
Indications for steroids, surgery
IBD - Diagnosis
 Clinical
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assessment
exclude infectious aetiologies
 Upper
endoscopy
 Colonoscopy (incl. ileoscopy)
 +/-
Barium follow-through/ MR
enteroclysis
IBD – Aims of management
 Minimise
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impact of disease on:
Linear growth
Psychosocial development
Pubertal development
The family
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
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single infusion improved histology / mucosal
inflammation
IBD Treatment Options
 Aminosalicylates
 Nutrition
 Antibiotics
 Corticosteroids
 Immunosuppressants
 Immunologic
 Surgery
Steroids
Avoid when possible in
children
Poor effect on mucosa
Second line agent
relapsing disease
severe exacerbation (i.v.
hydrocortisone)
Reducing course 2mg/kg (max
60mg / day)
Enteral nutrition in IBD
 Highly
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effective first-line therapy
Polymeric formulas more palatable
Reduce pro-inflammatory cytokines
Increase regulatory cytokines
 Animal
 Motivation
models suggest alteration of gut flora
of child and family critical
Coeliac Disease
Diagnosis
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History including family history
Antibodies
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HLA association
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Anti-gliadin – moderate sensitivity- not specific
Anti-reticulin – possibly more specific
Anti-endomyseal/ TTG – sensitive and specific
B8 – first described
DR3 or DR5/7 - Much more predictive
DQ2/DQ8 – actual association
Duodenal biopsy
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Villous atrophy & cyrpt hyperplasia
Cow’s Milk Protein Allergy &
Lactose Intolerance
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CMPA
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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
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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
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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)
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Movicol, Lactulose, Senna,
 Education
/ Toilet training
 Behavioural / pyschosocial support
 Dietary advice
 Investigation / Treat underlying disorder if
indicated
Don’t Forget Nutrition &
Growth
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Normal feed requirements for infants
Importance of nutrition for growth and
development
All illnesses impact on growth, especially
chronic conditions
Failure to thrive
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Primary nutrition problem
Underlying medical condition
Psychosocial
Always check weight & height and plot on
growth chart