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GI Disorder Part 1 of 4 Lawrence M. Formoso, M.D..

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1 GI Disorder Part 1 of 4 Lawrence M. Formoso, M.D.

2 Normal Digestive Tract Phenomena
A fetus can swallow AF as early as 12 wk of gestation nutritive sucking in neonates 1st develops at about 34 wk of gestation The coordinated oral and pharyngeal movements necessary for swallowing solids develop within the 1st few months of life By 1 mo of age, infants appear to show preferences for sweet and salty foods

3 Infants’ interest in solids increases at about 4 mo of age
The recommendation to begin solids at 6 mo of age is based on nutritional and cultural concepts rather than maturation of the swallowing process Infants swallow air during feeding, and burping is encouraged to prevent gaseous distention of the stomach

4 Regurgitation, the result of gastroesophageal reflux, occurs commonly in the 1st year of life
volumes of emesis are commonly ≈15–30 mL but may occasionally be larger Most often, the infant remains happy, although possibly hungry, after an episode of regurgitation Episodes may occur from less than one to several times per day resolves in 80% of infants by 6 mo of age and in 90% by 12 mo. Complications of gastroesophageal reflux include failure to thrive, pulmonary disease (apnea or aspiration pneumonitis), and esophagitis with its sequelae

5 The earliest stools after birth consist of meconium, a dark, viscous material that is normally passed within the 1st 48 hr of life With the onset of feeding, meconium is replaced by green-brown transition stools, often containing curds, and, after 4–5 days, by yellow-brown milk stools Stool frequency is extremely variable in normal infants and may vary from none to seven per day Breast-fed infants may have frequent small, loose stools early (transition stools), and then after 2–3 wk, may have very infrequent soft stools.

6 Toddler's diarrhea A pattern of intermittent loose stools
occurs commonly between 1 and 3 yr of age These otherwise healthy growing children often drink excessive carbohydrate-containing beverages The stools typically occur during the day and not overnight The volume of fluid intake is often excessive limiting sugar-containing beverages and increasing fat in the diet often leads to resolution of the pattern of loose stools.

7 Nondigestive Tract Causes of Gastrointestinal Symptoms in Children
ANOREXIA Systemic disease (inflammatory, neoplastic) Cardiorespiratory compromise Iatrogenic—drug therapy, unpalatable therapeutic diets Depression Anorexia nervosa VOMITING Inborn errors of metabolism Medications (erythromycin, chemotherapy) Increased intracranial pressure Brain tumor Infection (urinary tract) Labyrinthitis Adrenal insufficiency Pregnancy Psychogenic Abdominal migraine Toxins

8 Nondigestive Tract Causes of Gastrointestinal Symptoms in Children
DIARRHEA Infection (otitis media, urinary) Uremia Medications (antibiotics, cisapride) Tumors (neuroblastoma) Pericarditis CONSTIPATION Hypothyroidism Spina bifida Psychomotor retardation Dehydration (diabetes insipidus, renal tubular lesions) Medications (narcotics) Lead poisoning Infant botulism ABDOMINAL PAIN Pyelonephritis, hydronephrosis, renal colic   Pneumonia   Pelvic inflammatory disease   Porphyria   Angioedema   Endocarditis   Abdominal migraine   Familial Mediterranean fever  Sexual or physical abuse   Systemic lupus erythematosus   School phobia   Sickle cell crisis   Vertebral disk inflammation   Medications (NSAIDs)   Pelvic osteomyelitis

9 Nondigestive Tract Causes of Gastrointestinal Symptoms in Children
ABDOMINAL DISTENTION OR MASS Ascites (nephrotic syndrome, neoplasm, heart failure) Discrete mass (Wilms tumor, hydronephrosis, neuroblastoma, mesenteric cyst, hepatoblastoma, lymphoma) Pregnancy JAUNDICE Hemolytic disease Urinary tract infection Sepsis Hypothyroidism Panhypopituitarism

10 Major Symptoms and Signs of Digestive Tract Disorders
Dysphagia, or difficulty swallowing, may be caused by a structural defect or motility disorder Structural defects that cause a fixed impediment to the food bolus arise from narrowing within the esophagus stricture, web, or tumor Most nonstructural causes of dysphagia are caused by motility abnormalities of the oropharynx or the esophagus transfer dysphagia - Dysphagia during the oropharyngeal phase of swallowing usually associated with neuromuscular disorders (cerebral palsy) The sensation that something is stuck in the upper esophagus is globus (formerly termed globus hystericus) associated with GER

11 Major Symptoms and Signs of Digestive Tract Disorders
Nontransfer Dysphagia Esophageal web, tracheobronchial remnant, or vascular ring may cause dysphagia in infancy. A Schatzki ring, a thin ring of tissue near the lower esophageal sphincter, is another mechanical cause of recurrent dysphagia presenting after infancy An esophageal foreign body or a stricture secondary to a caustic ingestion also causes dysphagia REGURGITATION effortless movement of stomach contents into the esophagus and mouth infants with regurgitation are often hungry immediately after an episode Regurgitation is a result of GER through an incompetent or, in infants, immature lower esophageal sphincter regurgitation or “spitting” resolves with maturity

12 Differential Diagnosis of Emesis During Childhood
Gastroenteritis Gastritis Systemic infection Toxic ingestion Pertussis syndrome Medication (GERD) Sinusitis Otitis media INFANT Gastroenteritis Gastroesophageal reflux Overfeeding Anatomic obstruction Systemic infection Pertussis syndrome Otitis media

13 Differential Diagnosis of Emesis During Childhood
ADOLESCENT Gastroenteritis GERD Toxic ingestion Systemic infection Gastritis Sinusitis Inflammatory bowel disease Appendicitis Migraine Pregnancy Medication Ipecac abuse/bulimia

14 Major Symptoms and Signs of Digestive Tract Disorders
ANOREXIA Hunger and satiety centers are located in the hypothalamus The afferent nerves from the gastrointestinal tract to these brain centers are important determinants of the anorexia that characterizes many diseases of the stomach and intestine Satiety is stimulated by distention of the stomach or upper small bowel, the signal being transmitted by sensory afferents, which are especially dense in the upper gut

15 Major Symptoms and Signs of Digestive Tract Disorders
Vomiting is a highly coordinated reflex process that may be preceded by increased salivation and begins with involuntary retching Violent descent of the diaphragm and constriction of the abdominal muscles with relaxation of the gastric cardia actively force gastric contents back up the esophagus coordinated in the medullary vomiting center, which is influenced directly by afferent innervation and indirectly by the chemoreceptor trigger zone and higher central nervous system (CNS) centers

16 Cyclic vomiting is a syndrome with numerous episodes of vomiting interspersed with well intervals onset is usually between 2 and 5 yr of age the frequency of vomiting episodes is variable (average of 12 episodes per yr) with each episode typically lasting 2–3 days, with four or more emesis episodes per hour Patients may have a prodrome of pallor, intolerance of noise or light, nausea, lethargy, and headache or fever Precipitants include infection, stress, and excitement

17 Cyclic vomiting Laboratory evaluation is based on a careful history and physical examination and may include, if indicated, endoscopy, contrast gastrointestinal radiography, brain MRI, and metabolic studies (lactate, organic acids, ammonia) Treatment includes hydration and ondansetron Prevention may be possible with the antimigraine agent amitriptyline or cyproheptadine

18 Pharmacologic Therapies for Vomiting Episodes
Reflux Dopamine antagonist: metoclopramide (Reglan) (0.1–0.2 mg/kg qid PO/IV) Peripheral dopamine antagonist: domperidone (Motilium) (0.2–0.6 mg/kg tid–qid PO) Chemotherapy Metoclopramide; (0.5–1.0 mg/kg qid IV, with antihistamine prophylaxis of extrapyramidal side effects) Serotoninergic 5-HT3 antagonist: ondansetron (Zofran) (0.15–0.3 mg/kg tid IV/PO) Phenothiazines:(extrapyramidal, hematologic side effects)     Prochlorperazine (Compazine) (≈0.3 mg/kg bid–tid PO) Chlorpromazine (Thorazine) (>6 mo of age: 0.5 mg/kg tid–qid PO/IV) Steroids:dexamethasone (Decadron) (0.1 mg/kg tid PO) Cannabinoids:nabilone (tetrahydrocannabinol) (0.05–0.1 mg/kg bid–tid PO)

19 Pharmacologic Therapies for Vomiting Episodes
Motion sickness/vestibular disorder Antihistamine:dimenhydrinate (Dramamine) (1 mg/kg tid–qid PO) Anticholinergic:scopolamine (Transderm Scōp) (adults: 1 patch/3 days) Adrenal crisis Steroids:cortisol (2 mg/kg bolus IV followed by 0.2–0.4 mg/kg/hr IV [± 1 mg/kg IM])

20 Pharmacologic Therapies for Vomiting Episodes
Cyclic vomiting syndrome (CVS) Supportive: Analgesic:meperidine (Demerol) (1–2 mg/kg q4–6h IV/IM)  Anxiolytic, sedative: Lorazepam (Ativan) (0.05–0.1 mg/kg q6h IV) Antihistamine, sedative: diphenhydramine (Benadryl) (1.25 mg/kg q6h IV) Abortive: Serotoninergic 5-HT3 antagonist: Ondansetron:(0.15–0.3 mg/kg tid IV/PO) Granisetron (Kytril) (10 μg/kg q4–6h IV) Nonsteroidal antiinflammatory agent (GI ulceration side effect): Ketorolac (Toradol) (0.5–1.0 mg/kg q6–8h IV) Serotoninergic 5-HT1D agonist: sumatriptan (Imitres) (>40 kg; 20 mg intranasally/25 mg PO, one time only) Prophylactic:(if >1 CVS bout/month;taken daily) Antimigraine, β-adrenergic blocker: propranolol (Inderal) (0.5–2.0 mg/kg bid PO) Antimigraine, antihistamine: cyproheptadine (Periactin) (0.25–0.5 mg/kg/day ÷ bid–tid PO) Antimigraine, tricyclic antidepressant: amitriptyline (Elavil) (0.33–0.5 mg/kg tid PO, and titrate to maximum of 3.0 mg/kg/day as needed; obtain baseline ECG at start of therapy, and consider monitoring drug levels) Antimigraine antiepileptic: Phenobarbital (Luminal) (2–3 mg/kg qhs) Erythromycin: Low estrogen oral contraceptives: consider for catamenial CVS episodes

21 Causes of Gastrointestinal Obstruction
ESOPHAGUS Congenital Esophageal atresia   Vascular rings  Schatzki ring   Tracheobronchial remnant Acquired Esophageal stricture   Foreign body   Achalasia   Chagas disease   Collagen vascular disease

22 Causes of Gastrointestinal Obstruction
STOMACH Congenital Antral webs   Pyloric stenosis Acquired Bezoars/foreign body   Pyloric stricture (ulcer)   Chronic granulomatous disease of childhood   Eosinophilic gastroenteritis   Crohn disease   Epidermolysis bullosa

23 Causes of Gastrointestinal Obstruction
SMALL INTESTINE Congenital Duodenal atresia   Annular pancreas   Malrotation/volvulus  Malrotation/Ladd bands   Ileal atresia   Meconium ileus   Meckel diverticulum with volvulus or intussusception   Inguinal hernia  Intestinal duplication Acquired Postsurgical adhesions   Crohn disease   Intussusception   Distal ileal obstruction syndrome (cystic fibrosis)   Duodenal hematoma   Superior mesenteric artery syndrome

24 Causes of Gastrointestinal Obstruction
COLON Congenital Meconium plug   Hirschsprung disease   Colonic atresia, stenosis   Imperforate anus   Rectal stenosis   Pseudo- obstruction   Volvulus  Colonic duplication Acquired Ulcerative colitis (toxic megacolon)   Chagas disease   Crohn disease   Fibrosing colonopathy (cystic fibrosis)

25 Major Symptoms and Signs of Digestive Tract Disorders
DIARRHEA excessive loss of fluid and electrolyte in the stool. Normally, a young infant has ≈5 g/kg of stool output per day; the volume increases to 200 g/24 hr in an adult The greatest volume of intestinal water is absorbed in the small bowel; the colon concentrates intestinal contents against a high osmotic gradient The basis for all diarrhea is disturbed intestinal solute transport

26 Mechanisms of Diarrhea
Secretory Decreased absorption, increased secretion, electrolyte transport Cholera, toxigenic E. coli; carcinoid, VIP, neuroblastoma, congenital chloride diarrhea, Clostridium difficile, cryptosporidiosis (AIDS) Persists during fasting; bile salt malabsorption may also increase intestinal water secretion; no stool leukocytes Osmotic Maldigestion, transport defects ingestion of unabsorbable Lactase deficiency, glucose-galactose malabsorption, lactulose, laxative abuse Stops with fasting; increased breath hydrogen with carbohydrate malabsorption; no stool leukocytes Primary mechanism, Defect, Examples

27 Mechanisms of Diarrhea
Increased motility Decreased transit time Irritable bowel syndrome, thyrotoxicosis, postvagotomy dumping syndrome Infection may also contribute to increased motility Decreased motility Defect in neuromuscular unit(s) Stasis (bacterial overgrowth) Mucosal invasion Inflammation, decreased colonic reabsorption, increased motility Salmonella, Shigella, infection; amebiasis; Yersinia, Campylobacter infections Dysentery evident in blood, mucus, and WBCs Blood and increased WBCs in stool

28 Differential Diagnosis of Diarrhea
INFANT Common: Gastroenteritis Systemic infection Antibiotic associated Overfeeding Rare: Primary disaccharidase deficiency Hirschsprung toxic colitis Adrenogenital syndrome Neonatal opiate withdrawal CHILD Gastroenteritis Food poisoning Systemic infection Antibiotic associated Toxic ingestion ADOLESCENT Hyperthyroidism

29 Major Symptoms and Signs of Digestive Tract Disorders
CONSTIPATION is relative and depends on stool consistency, stool frequency, and difficulty in passing the stool A normal child may have a soft stool only every 2nd or 3rd day without difficulty; this is not constipation A hard stool passed with difficulty every 3rd day should be treated as constipation Constipation can arise from defects either in filling or emptying the rectum A nursing infant may have very infrequent stools of normal consistency; this is usually a normal pattern True constipation in the neonatal period is most likely secondary to Hirschsprung disease, intestinal pseudo-obstruction, or hypothyroidism.

30 Major Symptoms and Signs of Digestive Tract Disorders
ABDOMINAL PAIN Visceral pain tends to be experienced in the dermatome from which the affected organ receives innervation Painful stimuli originating in the liver, pancreas, biliary tree, stomach, or upper bowel are felt in the epigastrium pain from the distal small bowel, cecum, appendix, or proximal colon is felt at the umbilicus pain from the distal large bowel, urinary tract, or pelvic organs is usually suprapubic Parietal pain impulses travel in C fibers of nerves corresponding to dermatomes T6–L1; such pain tends to be more localized and intense than visceral pain.

31 Major Symptoms and Signs of Digestive Tract Disorders
GASTROINTESTINAL HEMORRHAGE Bleeding can occur anywhere along the gastrointestinal tract, and identification of the site may be challenging Evaluation of the small intestine is facilitated by capsule camera endoscopy Erosive damage to the mucosa of the gastrointestinal tract is the most common cause of bleeding, also variceal bleeding secondary to portal hypertension occurs frequently bleeding originating in the esophagus, stomach, or duodenum, it may cause hematemesis

When exposed to gastric or intestinal juices, blood quickly darkens to resemble coffee grounds; massive bleeding is likely to be red Red or maroon blood in stools, hematochezia, signifies either a distal bleeding site or massive hemorrhage above the distal ileum. Moderate to mild bleeding from sites above the distal ileum tends to cause blackened stools of tarry consistency (melena); major hemorrhages in the duodenum or above can also cause melena

33 Differential Diagnosis of Gastrointestinal Bleeding in Childhood
INFANT Common: Bacterial enteritis Milk protein allergy Intussusception Swallowed maternal blood Anal fissure Lymphonodular hyperplasia Rare: Volvulus Necrotizing enterocolitis Meckel diverticulum Stress ulcer, stomach Coagulation disorder (hemorrhagic disease of newborn)

34 CHILD Common: Bacterial enteritis Anal fissure Colonic polyps
Intussusception   Peptic ulcer/gastritis   Swallowed epistaxis   Prolapse (traumatic) gastropathy 2° emesis   Mallory-Weiss syndrome Rare: Esophageal varices Esophagitis Meckel diverticulum Lymphonodular hyperplasia Henoch-Schönlein purpura Foreign body Hemangioma, arteriovenous malformation Sexual abuse Hemolytic-uremic syndrome Inflammatory bowel disease Coagulopathy

35 ADOLESCENT Common: Bacterial enteritis Inflammatory bowel disease
Peptic ulcer/gastritis Prolapse (traumatic) gastropathy 2° emesis Mallory-Weiss syndrome Colonic polyps Rare: Hemorrhoids Esophageal varices Esophagitis Telangiectasia-angiodysplasia Gay bowel disease Graft versus host disease

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