Childhood Gastrointestinal problems in General Practice

1. Childhood Gastrointestinal problems in General Practice Aimee Lettis ST4 in General Practice

2. Normal RR values

3. Normal HR values

4. Normal temperature values

5. Colic • Very common up to 3/12 age • Characterised by recurrent bouts of intense, unsoothable crying • Baby’s body goes rigid and tense, face goes red and knees draw up • Usually occurs in early evening • Cause unknown, resolves spontaneously over time • Examination normal • Management • Try gripe water/colic drops • No evidence that change to soya-based formula helpful • Refer if: • Doubtful about diagnosis • Severe symptoms or signs, eg. Failure to thrive, severe eczema • Not better by 4/12 age

6. Possetting • Common • Baby effortlessly brings back 5-10ml of each feed during or soon after feed • Only of concern if baby unwell/not thriving • If thriving, advise parents to keep propped up and slow down rate of feed

7. Gastro-oesophageal reflux • Similar to possetting but greater proportion feed brought back • May result in failure to thrive • More common if have cerebral palsy • Rare complications-oesophageal stricture/aspiration pneumonia • Management • Prop baby up whilst feeding/afterwards • Thickening agents may help • Gaviscon Infant sachets +/- ranitidine • Usually grow out of it once weaned +/- more upright

8. Pyloric stenosis • Usually develops in 1st 3-6 weeks of life, rare after 12 weeks • Failure of pylorus to relax leads to hypertrophy of adjacent pyloric muscle • Typically affects first born males, can run in families, more common in Turner’s syndrome, PKU & oesophageal atresia • Presents with projectile non-bilious vomiting, child still hungry after vomiting & feeds again, rarely haematemesis. • May be FTT, dehydration & constipation (but late signs) • Examination – pyloric mass (olive) in right upper abdomen (95%) especially after vomiting • After test feed, visible peristalsis may be seen • Management • Refer Paediatric surgery for investigations • Bloods typically show a hypokalaemic, hypochloraemic metabolic alkalosis • USS can help with diagnosis • Surgery curative

9. Intussusception • Invagination of one part of bowel into lumen of immediately adjoining bowel • Most common cause intestinal obstruction in young children • Incidence 2/1000 live births • Peak age 5-18 months • Male:female = 2:1 • Associations - ?viral cause, polyps, Meckel’s diverticulum, HSP • Presentation – variable, have high index of suspicion • Colic symptoms – paroxysms of pain during which child draws up legs, often screams in pain and becomes pale • Episodes usually are 10-15 mins apart and last 2-3 mins, increase in frequency • Vomiting occurs early • Rectal bleeding – blood (‘redcurrant jelly stool’) or slime PR is late sign • Sausage shaped mass RUQ not always present • Child can become toxic/ill

10. Constipation • Common problem amongst all age groups • Differentiate between normal & constipation • Normal can vary between every 3/7 to following feeds • Constipation characterised by hard infrequent stools • Infants • Considerable variation according to their diet (or mother’s if breastfeeding) • Change from breast to bottle feeds and weaning can change stools • Check having enough feeds/hydration • Can lead to pain and withholding of stool, can be hard to break this cycle • Rare causes – Hirschsrprung’s disease, congenital abnormalities • Always ask re when bowels first opened after birth (?1st 24hrs) & examine spine

11. Constipation • Older children • Can accompany febrile illness • If causes tear, can get cycle of faecal retention • Symptoms include abdominal pain, anorexia, vomiting, failure to thrive & predisposition to UTI’s • Can lead to soiling due to overflow diarrhoea • Management • Ensure adequate fluids/fibre in diet • Lactulose (+/- senna once stools soft) to start • May need movicol if soiling/longstanding symptoms

12. Rectal bleeding • Common • Usual causes: • Constipation • Anal fissure • Threadworms • Rectal prolapse (think ?CF) • Meckel’s diverticulum • Only refer if profuse/associated symptoms/simple treatment fails

13. Diarrhoea & vomiting • Need to know: • Nature & duration of symptoms • ?Blood/mucus in stool • ?Other symptoms • ?Infectious contacts • ?Recent foreign travel • Differential diagnosis • Physiological • Infection – viral (especially rotavirus) /bacterial • Infection elsewhere – eg. UTI/OM/LRTI • Intussusception/pyloric stenosis/ appendicitis • Constipation with overflow • Malabsorption • GORD • Raised ICP • Ketoacidosis • Anorexia/bulimia • Travel/motion sickness

14. Diarrhoea & vomiting • Examination • Hydration status • Look for sources infection • Examine abdomen for masses/distension/tenderness/BS • Management • Stool sample if foreign travel/blood/>7 days duration • Rehydrate – clear fluids +/ dioralyte • Diet – stick to bland diet until diarrhoea settled • If breast fed/not weaned, stick to normal feeds • Avoid loperamide • If dehydrated/not tolerating fluids, admit • Refer urgently/admit if symptoms >3 weeks

15. Coeliac disease • Autoimmune condition diagnosed at any age • Non-gastrointestinal features increasingly recognised • New NICE guidelines 2009 • Should offer serological testing if: • Chronic/intermittent diarrhoea • FTT/ faltering growth (children) • Persistent/unexplained GI symptoms eg. Nausea • Prolonged fatigue • Recurrent abdominal pain/distension • Sudden/unexpected weight loss • Unexplained iron deficiency anaemia +/- other anaemia • If have autoimmune thyroid disease, dermatitis herpetiformis, IBS or Type 1 DM • If first degree relative with coeliac disease

16. Coeliac diseaseNICE • Consider offering testing to following groups: • Addison’s disease • Amenorrhoea • Autoimmune liver conditions/myocarditis • Depression/bipolar disorders • Down’s syndrome • Epilepsy • Low trauma fracture/metabolic bone disease • Lymphoma • Persistent constipation • Persistently raised LFTs of unknown cause • Polyneuropathy • Recurrent miscarriage/unexplained subfertility • Sjogren’s syndrome • Turner’s syndrome • Unexplained alopecia

17. Coeliac diseaseNICE • Advice to patients • Serology only accurate if eating diet containing gluten for at least 6 weeks when tested • If reluctant/unable to reintroduce gluten into diet, refer • Investigations • Do not use IgG/IgA antigliadin Ab • Laboratories should use TTG Ab (IgA) as first choice • Only use EMA testing if TTG Ab equivocal • Check for IgA deficiency if TTG Ab negative • Use IgG TTG or EMA Ab if have IgA deficiency • Refer for biopsy if positive serology or if normal and still clinically suspected

18. Bloody diarrhoea • Often indicates serious gastrointestinal disease • Intestinal bacterial infection most common cause, 15-20 times more likely than IBD • Bacterial gastroenteritis usually self-limiting, antibiotics rarely needed • IBD often presents with bloody diarrhoea & should be considered in all ages • Also, consider IBD if other GI symptoms, weight loss or poor growth • Colitis can occur in infants associated with breast milk/allergy, usually benign & self-limiting • Children with severe bloody diarrhoea (>6/day) or unwell need urgent referral

19. IBD • Diagnosis often prolonged • Do not dismiss in young children • ½ children with IBD present before 11 • May occur in 1st year of life • Persistent (>7/7) or recurrent bloody diarrhoea are indications for Paediatric Gastro referral • Other important signs – clubbing, poor growth, weight loss, oral/perianal symptoms • 45% with Crohn’s have perianal disease • Hb/platelets combined have sensitivity of 92% & specificity of 80% for IBD • But CRP/FBC can be normal

20. Hirschsprung’s disease • Congenital absence of ganglion cells of colon • Affects 1/5000 live births • About 80% present in 1st year life • >90% have delayed passage meconium >24hrs • Classical presentation with constipation • But ¼ present with enterocolitis • Abdominal distension, severe watery and sometimes bloody stools leading to shock/perforation when progresses • Mortality rate of 33% • Early diagnosis therefore essential

21. Further reading • NICE guidance on febrile illness in children • NICE guidance on coeliac disease