Transcript 幻灯片 1
The Digestive System Disease Department of Pediatrics Soochow University Affiliated Children’s Hospital Key points ◎ The common symptoms of gastrointestinal disease in childhood, its pathogenesis（发病机制） and management ◎ The presentation of common infections of the gastrointestinal tract ◎ Assessment for dehydration（脱水） in a child with diarrhoea and how to carry out rehydration（纠正脱水） ◎ Chronic gastrointestinal disorders that can lead to malabsorption（吸收不良） and failure to thrive ◎ Infections that can affect the liver Aim and Claim 1. Familiar with the normal features and assessment of digestive system 2. Get hold of the examination of digestive system Normal Features and Assessment Mouth: Foodstuffs（食物） broken down by chewing; saliva（唾 液） added as lubricant（润滑剂） Oesophagus: Conduit（通道） between mouth and stomach Stomach: Digestion of proteins; foodstuffs reduced to liquid form; storage; sterilisation（灭菌） Pancreas: Digestive enzymes（消化酶） for digestion of fats, carbohydrates and proteins Liver: Bile salts for digestion/absorption of fats in small intestine Gallbladder: Stores and concentrates bile Small intestine: Final stages of chemical digestion and nutrient absorption Large intestine: Water absorption, bacterial fermentation（发 酵） and formation of faeces Gastrointestinal Function Sequence of Events Ingestion >> chewing & moistening of food >> swallowing >> peristalsis >> acidifying >> initiation of protein digestion >> neutralization >> digestion >> absorption >> assimilation >> fermentation & putrification >> elimination Severe key points 1. Normal function of the gastrointestinal tract 2. Oral feeding 3. Intestinal microflora（肠道菌群） 4. Stool :meconium（胎粪）, green-brown transition stool, gold-like stool, orange-like stool 5. A palpable liver and a soft spleen tip 6. A protuberant（彭隆的） abdomen in infant and toddlers Intestinal Microflora Metabolic activity of GI flora • Vitamin synthesis – Biotin – Vitamin K • Fermentation of undigested carbohydrates • Development of mucosal immunity – Commensal bacteria colonizing in the first 2 years of life provide the environment for immune development • Production of Short chain fatty acids • Mucous production • Bile acid deconjugation • Detoxification（解毒） • Elimination Examination Of The Gastrointestinal Tract Examination of the gastrointestinal tract （1） Systemic signs of dysfunction ◎Aneamia（贫血） ◎Jaundice （黄疸） ◎Clubbing （杵状指） ◎Oedema （水肿） ◎Distended vein （静脉曲张） ◎Dehydration （脱水） Examination of the gastrointestinal tract （2） Abdominal examination • Examination secquence inspection, palpation, auscultation, percussion • Exposure pelvic region （会阴部） ：don‘t miss torsion （扭转） of the testis （睾丸） or incarcerated hernia （嵌顿疝） • Be careful : Hernial orifices region （疝环口区） , Scrotum （阴囊） and anal （肛门） regions • Rectal examination region right lumber region right iliac region left hypochondriac epigastric region umbilieal region hypogastric region region left lumber region left iliac region Abdominal Area: Nine regions right hypochondriac Symptoms of Digestive System Abdominal Pain Aim and Claim • Familiar with the causes acute abdominal pain • Get hold of the causes of recurrent abdominal pain（再发性腹痛） Acute Abdominal Pain • Trauma（外伤） • Inflammation （炎症） – – – – Acute gastroenteritis Appendicitis Pancreatitis Henoch-Schonlein Purpura （过敏性紫癜） • • Anatomic – – – – – • Extra-abdominal Bowel obstruction Intussusception （肠套叠） Volvulus （扭转） Incarcerated hernia Gallbladder disease – – – – – Lower lobe pneumonia Strep pharyngitis DKA (diabetic ketoacidosis) UTI/pyelonephritis （肾盂肾炎） Renal stones Gynecologic （妇科） – PID (pelvic inflammatory disease) – Mittelschmerz （经间痛） – Dysmenorrhea （痛经） – Ovarian cyst （卵巢囊肿） – Ectopic pregnancy （异位妊娠） Acute Abdominal Pain Evaluation • Careful history - Quality/location/timing - Relieving/aggravating • Associated symptoms • Physical – Abdominal exams – serial • Distention/BS • Rebound （反跳痛） /rigidity （强直） /guarding （肌紧张） • Tenderness （压痛） – Rectal exam – Pelvic exam • Abdominal X-ray – Flat：obstruction （梗阻） – Upright： perforation （穿 孔） • Specific imaging – CT scan – Ultrasound （超声波） • Lab tests – CBC/diff, ESR, CRP – Urinalysis – Serum amylase （淀粉酶） /lipase （脂肪激酶） Recurrent Abdominal Pain • Inflammatory – Crohn’s Disease – Ulcerative Colitis – Celiac disease • Acid peptic disease – – – – Esophagitis（食管炎） Gastritis Gastric/duodenal ulcer GE Reflux • Anatomic – Intrabdominal tumor (Wilms, neuroblastoma) – Meckel’s diverticulum （麦克尔 憩室） – Malrotation （旋转不良） • Bloating/gas/diarrhea – Lactose intolerance – Giardiasis （鞭毛虫病） • Functional （90%） – Irritable Bowel Syndrome – FRAP （功能性再发性腹痛） Symptoms of Digestive System Vomiting Aim and claim • Understand the causes of vomiting • Familiar with the evaluation of vomiting Vomiting • Anatomic – Pyloric stenosis（幽门肥 厚性狭窄） – Bowel obstruction – Malrotation – Intussusception – Ulcer – GE Reflux（胃食管反流） • Inflammatory – – – – – – Gastroenteritis Systemic infection Appendicitis Pancreatitis Hepatitis Milk protein allergy • Metabolic – Inborn errors – DKA • CNS – Increased ICP（颅压） – Migraine（腹型偏头痛） • Post-tussive（咳嗽诱 发） • Toxic ingestion • Chemotherapy • Pregnancy（妊娠） Vomiting Evaluation • Bile-stained vomiting suggests obstruction distal to ampulla of Vater • Abdominal plain film – Flat: look for dilated loops of bowel – Upright: look for free air under diaphragm（横膈） • Contrast radiograph (UGI series, barium enema) • Electrolyte panel – look for acidosis, disturbance • Other labs: UA（尿素氮）, amylase/lipase, LFT（肝 脏功能检查） • Appendicitis: CBC/diff, CT w/contrast Gastro-Esophageal Reflux Aim and claim • Familiar with the clinical features of gastroesophageal reflux • Get hold of the diagnosis of gastro-esophageal reflux • Understanding management of gastroesophageal reflux Introduction • Definition Gastroesophageal reflux (GER), passage of gastric materials into the esophagus, is a normal physiologic process that can progress to gastroesophageal reflux disease (GERD) when the expelled gastric materials produce undesirable symptoms and complications GER as a normal GERD, a pathologic process Pathophysiology 1. A decrease in lower esophageal sphincter (LES) tone –-- the most important factors 2. Changes in the pressure gradients between the esophagus and stomach 3. Stress maneuvers include straining, crying, coughing, eating, or the valsalva maneuver 4. Other factors include gastric distention, delayed esophageal clearance and gastric emptying, neurologic disease, and hiatal hernia Pathophysiology The pathogenesis of GERD is involving • The frequency of reflux • Gastric acidity and gastric emptying • Esophageal clearing mechanisms • The esophageal mucosal barrier • Visceral hypersensitivity • Airway responsiveness • PH (<4) in the refluxate Clinical Features • Regurgitation—mild symptoms—no treatment • Oesophagitis—failure to thrive or recurrent aspiration pneumonia—severe and complications—need to treat • Risk of severe GER —premature infants,infants with cerebral palsy,and infants with congenital oesophageal anomalies Complications of gastroesophageal reflux • • • • • • • • • • • Recurrent vomiting Weight loss or poor weight gain Irritability in infants Regurgitation Heartburn or chest pain Hematemesis（呕血） Dysphagia(吞咽困难) or feeding refusal Apnea呼吸暂停 Wheezing or stridor（喘鸣） Hoarseness（声音嘶哑） Cough Diagnosis（１） • Upper GI Series Ｎor specific for the diagnosis of GER, but is useful for the evaluation of the presence of anatomic abnormalities pyloric stenosis malrotation annular pancreas hiatal hernia esophageal stricture Diagnosis （２） Esophageal pH Monitoring • Esophageal pH monitoring is a valid and reliable measure of acid reflux. • Esophageal pH monitoring is useful to establish the presence of abnormal acid reflux, and to assess the adequacy of therapy in patients. • Esophageal pH monitoring may be normal in some patients with GERD, particularly those with respiratory complications. Diagnosis （３） Endoscopy and Biopsy • Endoscopy with biopsy can assess the presence and severity of esophagitis, strictures and Barrett’s esophagus. • Exclude other disorders, such as Crohn’s disease and eosinophilic or infectious esophagitis. • A normal appearance of the esophagus during endoscopy does not exclude histopathological esophagitis; subtle mucosal changes such as erythema. Management （１） Diet Changes in the Infant • There is evidence to support a one to two-week trial of a hypoallergenic formula in formula fed infants with vomiting. • Milk-thickening agents do not improve reflux index scores but do decrease the number of episodes of vomiting. Management （２） Positioning in the Infant • Supine positioning（仰卧位） confers the lowest risk for SIDS（sudden infant death syndrome，婴儿猝死 综合症 ）and is preferred. • Prone positioning（俯卧位） during sleep is only considered in unusual cases. • When prone positioning is necessary, it is particularly important that parents be advised not to use soft bedding, which increases the risk of SIDS in infants placed prone. Management （３） Positioning in the Child & Adolescent • In children older than one year it is likely that there is a benefit to left side positioning during sleep and elevation of the head of the bed. • Lifestyle Changes in the Child & Adolescent • Children and adolescents with GERD avoid caffeine, chocolate and spicy foods that provoke symptoms. Management （４） Acid-suppressant Therapy • Histamine-2 receptor antagonists (H2RAs) produce relief of symptoms and mucosal healing. • Proton pump inhibitors (PPIs), the most effective acid suppressant medications, are superior to H2RAs in relieving symptoms and healing esophagitis. Management （５） Prokinetic Therapy • Cisapride reduces the frequency of symptoms, including regurgitation and vomiting. • The potential for serious cardiac arrhythmias in patients receiving cisapride, appropriate patient selection and monitoring as well as proper use • Other prokinetic agents have not been shown to be effective in the treatment of GERD in child. Management （６） Surgical Therapy • Surgery is often considered for the child with GERD who has persistence of symptoms following medical management or who is unable to be weaned from medical therapy. • Recently experience with laparoscopic procedures has been reported. Summary • Very common during 1st year of life • Reduced LES pressure or greater LES relaxation • GERD = Aspiration (chronic cough or wheeze), Esophagitis, failure to thrive • Dx: Clinical, Esophageal pH probe, UGI series (anatomy) • Medical tx: Thickened feeds, position, acid suppression, pro-kinetic agent • Surgical tx: Nissen fundoplication Quiz • Which one of the following is not organic causes of recurrent abdominal pain： • A. Urinary tract infections B. Inflammatory bowel disease C. Irritable bowel syndrome* D. Obstructive uropathy E. Malrotation True/False: Surgical causes of abdominal pain are much less common than non-surgical causes. True Quiz • Gastroesophageal reflux(GER )is A. GER in infancy is that it is usually abnormal (Pathologic), unlike older children and adults. B. Nature of emesis（呕吐） in GER is effort , and is preceded by nausea (pallor, anorexia, excessive salivation). C. Increased intraabdominal pressure - Cough, physical effort and Slow gastric emptying. D. Complicated GER in infants is termed "physiologic GER" or simply "spitting up".* E. Emesis is not usually post-prandial.