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  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 A B 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 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

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

23. Abdo Pain - Acute  Appendicitis  Malrotation  Intussusception  Abdominal migraine  UTI  Mesenteric Adenitis

24. Abdo Pain - Chronic  Constipation  IBD  Coeliac disease  GOR  Functional  Non-specific

25. 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

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

28. 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

30. 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