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Paediatric Gastroenterology

Paediatric Gastroenterology. Dr Jessica Daniel ST8 Paediatrics. A huge subject!. Vomiting Diarrhoea Constipation Abdominal pain Nutrition. Vomiting. Infection – Gastroenteritis Rotavirus, Norovirus , Bacterial Gastroesophageal Reflux (GOR) Obstruction Pyloric Stenosis

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Paediatric Gastroenterology

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  1. Paediatric Gastroenterology Dr Jessica Daniel ST8 Paediatrics

  2. A huge subject! • Vomiting • Diarrhoea • Constipation • Abdominal pain • Nutrition

  3. Vomiting • Infection – Gastroenteritis • Rotavirus, Norovirus, Bacterial • Gastroesophageal Reflux (GOR) • Obstruction • Pyloric Stenosis • Malformations – Malrotation, atresias

  4. Case Discussion A B • 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 • 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

  5. 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)

  6. Gastroenteritis • NICE guidance for management <5yrs • Fluid & electrolyte replacement • Assess dehydration • Red flags • Appears unwell / Altered consciousness • Tachycardia / Tachypnoea • Sunken eyes • Reduced skin turgor

  7. 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

  8. Pyloric Stenosis • 2-4 in 1000 newborns • Present age 2-8 weeks, projectile vomiting, poor wt gain • Hypochloraemic, hypokalaemic alkalosis • USS abdomen • Pylorotomy

  9. 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

  10. GI Malformations Imperforate Anus Meckel’s Diverticulum Beware the bilious vomit!!! Duodenal Atresia Double bubble Malrotation

  11. 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

  12. 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

  13. IBD - Diagnosis • Clinical assessment • exclude infectious aetiologies • Upper endoscopy • Colonoscopy (incl. ileoscopy) • +/- Barium follow-through/ MR enteroclysis

  14. IBD – Aims of management • Minimise impact of disease on: • Linear growth • Psychosocial development • Pubertal development • The family • ie Multidisciplinary specialised therapy

  15. 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

  16. 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)

  17. 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

  18. Coeliac Disease

  19. 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

  20. 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

  21. Abdominal Pain • Very common symptom • Good history essential • Acute vs Chronic • Any associated features to indicate pathology? • Social / family / school history

  22. Abdo Pain - Acute • Appendicitis • Malrotation • Intussusception • Abdominal migraine • UTI • Mesenteric Adenitis

  23. Abdo Pain - Chronic • Constipation • IBD • Coeliac disease • GOR • Functional • Non-specific

  24. 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

  25. Organic Causes • Anorectal malformation • Anal fissure • Hirschprung’s • Spinal cord disorders • Coeliac disease • Cow’s Milk Protein Allergy • Hypothyroidism • Hypocalcaemia • Cystic Fibrosis

  26. 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

  27. 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

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