TREAT PEDIATRIC GI CONDITIONS

1. TREAT PEDIATRIC GI CONDITIONS Unit 4: Part 1 Module 3

2. REFERENCES C290- Nelson’s Essentials of Pediatrics C 306- Dipchand, A., The Hospital for Sick Kids Manual C277- Toronto Notes C291-primary care for the PA Class handout

3. OUTLINE Dehydration/Fluid Requirements Vomiting Diarrhea Constipation Acute/chronic Abdominal Pain GERD Abdominal Masses Intussusception Pyloric stenosis

4. DEHYDRATION Causes in children - Gastroenteritis (most common cause in childhood) - Inadequate fluid intake - Diabetes mellitus - Burns - Pyloric stenosis - GI obstruction GENERAL INFORMATION Newborns and young children have a much higher water content than adolescents and adults and are therefore more prone to loss of water, sodium and potassium during illness Newborn Total body water congent is 0.75 ,,older child 0.65 Maintenance fluid is the amount of fluid the body needs to replace usual daily losses from the respiratory tract, the skin, and the urinary and GI tracts. A well child usually drinks more than maintenance requirements. If a child takes in significantly less than maintenance requirements, he or she will gradually become dehydrated. The requirement for maintenance fluids varies with the weight of the child (Table 4-1). Infants need more fluid per kilogram of body weight than do older children. Various medical conditions will also affect these requirements Infants < 3-4 months usually do not produce tearsGENERAL INFORMATION Newborns and young children have a much higher water content than adolescents and adults and are therefore more prone to loss of water, sodium and potassium during illness Newborn Total body water congent is 0.75 ,,older child 0.65 Maintenance fluid is the amount of fluid the body needs to replace usual daily losses from the respiratory tract, the skin, and the urinary and GI tracts. A well child usually drinks more than maintenance requirements. If a child takes in significantly less than maintenance requirements, he or she will gradually become dehydrated. The requirement for maintenance fluids varies with the weight of the child (Table 4-1). Infants need more fluid per kilogram of body weight than do older children. Various medical conditions will also affect these requirements Infants < 3-4 months usually do not produce tears

5. DEHYDRATION HISTORY - Fever - Vomiting - Diarrhea - Decreased urine output - Lethargy - Irritability NB** All body systems must be reviewed to ascertain underlying cause! Changes in weight Known renal/cardiac diseaseChanges in weight Known renal/cardiac disease

6. CLINICAL ASSESSMENT OF DEGREE OF DEHYDRATION

7. CLINICAL ASSESSMENT OF DEGREE OF DEHYDRATION Severe (> 10%) - Signs of moderate dehydration plus any of the following: - Rapid weak pulse/hypotension - Cold extremities - Oligo-anuria, coma

8. Investigations CBC,BUN, creatinine, electrolytes, glucose( high in hypernatremia), calcium( low in hypernatremia, akalemia,hyperphosphotemia), Investigations CBC,BUN, creatinine, electrolytes, glucose( high in hypernatremia), calcium( low in hypernatremia, akalemia,hyperphosphotemia),

10. *Daily maintenance fluids should be increased by 12% for every degree Celsius body temperature above 37.5°C (rectal). *Daily maintenance fluids should be increased by 12% for every degree Celsius body temperature above 37.5°C (rectal).

12. FLUID REHYDRATION Decide if child is mildly, moderately or severely dehydrated. Weigh child (without clothes) Once you have determined the degree of dehydration, calculate the fluid deficit When you have calculated the deficit, add maintenance requirements Oral rehydration Therapy ( ORT) is safer, effective DIAGNOSTIC TESTS CBC, Bun, Lytes, creatinine Urinalysis to check for ketones Blood glucometry to rule out diabetes (if no diarrhea) MANAGEMENT Goals of Treatment Correct dehydration using oral rehydration therapy (ORT) with or without IV fluids Treat shock or impending shock Prevent complications (e.g., seizures or edema) DIAGNOSTIC TESTS CBC, Bun, Lytes, creatinine Urinalysis to check for ketones Blood glucometry to rule out diabetes (if no diarrhea) MANAGEMENT Goals of Treatment Correct dehydration using oral rehydration therapy (ORT) with or without IV fluids Treat shock or impending shock Prevent complications (e.g., seizures or edema)

13. FLUID REHYDRATION Oral replacement solution (ORS) may be administered by nasogastric tube if necessary Use an ORS such as Rehdralyte to replace the calculated deficit Pedialyte or Gastrolyte are maintenance solutions IV therapy should usually be used only for severe dehydration or intractable vomiting Intraosseous access can be life saving ORS need 75- 90 mmol/L of sodium Pedialyte or Gastrolyte are maintenance solutions and are Ok if child is continuing to feed on formula/ breast mils as well Otherwise need a rehydrating solution WHO or rehydralyte which contains higher concentrations of electrolytes General Comments about Fluid Management: If the child is vomiting, he or she will usually tolerate fluids by mouth if given in small amounts (one sip at a time). If child will not suck, try giving sips frequently by spoon. Allow mother and other family members to administer fluid. Increase daily maintenance fluids by 12% for every degree Celsius body temperature above 37.5°C (rectal). ORS need 75- 90 mmol/L of sodium Pedialyte or Gastrolyte are maintenance solutions and are Ok if child is continuing to feed on formula/ breast mils as well Otherwise need a rehydrating solution WHO or rehydralyte which contains higher concentrations of electrolytes General Comments about Fluid Management: If the child is vomiting, he or she will usually tolerate fluids by mouth if given in small amounts (one sip at a time). If child will not suck, try giving sips frequently by spoon. Allow mother and other family members to administer fluid. Increase daily maintenance fluids by 12% for every degree Celsius body temperature above 37.5°C (rectal).

14. FLUID REHYDRATION If the child is breast-feeding and is able to nurse, then breast-feeding should be continued for maintenance requirements; supplement with Pedialyte or Gastrolyte to make up the deficit Increase the amount of maintenance fluids if there are ongoing fluid losses (e.g., if diarrhea continues) If a marked increase in diarrhea occurs when a bottle-fed child returns to his or her usual cow’s milk formula, consult a physician about changing to a soy-based formula (e.g., Prosobee or Isomil) Switch back to regular cow’s milk formula within 7–10 days. Do not go back to Pedialyte unless there is a marked increase in stools while on soy formula. Some increase in stools does not matter, as long as the child takes in enough to keep up with losses. In other words, treat on the basis of the child’s condition, not on the basis of the stoolsIf a marked increase in diarrhea occurs when a bottle-fed child returns to his or her usual cow’s milk formula, consult a physician about changing to a soy-based formula (e.g., Prosobee or Isomil) Switch back to regular cow’s milk formula within 7–10 days. Do not go back to Pedialyte unless there is a marked increase in stools while on soy formula. Some increase in stools does not matter, as long as the child takes in enough to keep up with losses. In other words, treat on the basis of the child’s condition, not on the basis of the stools

15. MANAGEMENTDEHYDRATION Mild Dehydration (<5%) - Assessment and treatment under close observation is recommended - Rehydration phase: oral replacement solution (e.g., Pedialyte), 10 mL/kg per hour, with reassessment q4h - Rehydration should be achieved over 4 hours - Breast-feeding should continue - For bottle-fed children, usual formula should be re-started within 6–12 hours - Extra oral replacement solution (at 5–10 mL/kg) given after each diarrheal stool

16. MANAGEMENTDEHYDRATION Moderate Dehydration (5% to 10%) - Rehydration phase: oral replacement solution (e.g., Pedialyte), 15–20 mL/kg per hour, under direct observation - Frequent reassessment, including weight and state of hydration, is required during the rehydration phase (q1–2h) - Rehydration should be achieved over 4 hours Continue breast feedings if applicableContinue breast feedings if applicable

17. MANAGEMENTACUTE DIARRHEA Moderate Dehydration (5% to 10%)( cont’d) - If dehydration is corrected, continue fluid therapy for maintenance and to make up for ongoing losses Extra oral replacement solution (at 5–10 mL/kg) given after each diarrheal stool - If dehydration persists, repeat rehydration phase - Breast-feeding should continue - For bottle-fed children, usual formula should be re-started within 6–12 hours

18. MANAGEMENTDEHYDRATION Severe Dehydration (>10% or Signs of Shock) - Requires IV therapy, in addition to oral rehydration. - Start IV therapy with Normal saline or Ringer’s lactate - Give a bolus of 20 mL/kg over 20 minutes - Reassess status and repeat bolus (to a maximum of three boluses in 1 hour) if shock or other signs of severe dehydration persist Do not use Ringers with renal failure!Do not use Ringers with renal failure!

19. MANAGEMENTDEHYDRATION Severe Dehydration ( cont’d) - Once a response occurs, calculate the remaining deficit; - Replace 50% of the deficit over 8 hours and remainder over the next 16 hours; - Be sure to include maintenance requirements in total IV therapy - Intraosseous infusion should be used if an IV line cannot be established !

20. TYPES OF DEHYDRATION Isotonic- Na 135 - Rx - IV 2/3+1/3 or D5:0.45 saline with 20 mEq/L KCl (mmol/L) Hypotonic hyponotremic) - Na 110 Rx - IV 2/3+1/3 or D5:0.45 saline with 20 mEq/L KCl (mmol/L) Hypertonic (hypernotremic) - Na 150 - Rx. D5.0.2 saline with 40 mEq/L KCl (mmol/L) Hypotonic Dehydration Symptomatic earlier than isotonic or hypertonic dehydration Usually results from replacing losses (vomiting and diarrhea) with low-solute fluids, such as dilute juice, cola, weak tea Lethargy and irritability are common, and vascular collapse can occur early Need to correct hyponatremia as well as volume deficit Isotonic Dehydration Symptoms less dramatic than in hypotonic dehydration Hypertonic Dehydration Usually occurs as a result of using inappropriately high solute load as replacement, or because of renal concentrating defect with large free-water losses or heat exposure with large insensible losses Typical symptoms include thick, doughy texture to skin (tenting is uncommon), tachypnea, intense thirst, CNS disturbances- e.g irritability, jitteriness, Avoid too rapid rehydration as risk of cerebral edema, seizures possible If sodium dropped to quickly---> water intoxication can occur Shock is very late manifestation Source; IV solutions choices - Sick Kid’s Manual, TorontoHypotonic Dehydration Symptomatic earlier than isotonic or hypertonic dehydration Usually results from replacing losses (vomiting and diarrhea) with low-solute fluids, such as dilute juice, cola, weak tea Lethargy and irritability are common, and vascular collapse can occur early Need to correct hyponatremia as well as volume deficit Isotonic Dehydration Symptoms less dramatic than in hypotonic dehydration Hypertonic Dehydration Usually occurs as a result of using inappropriately high solute load as replacement, or because of renal concentrating defect with large free-water losses or heat exposure with large insensible losses Typical symptoms include thick, doughy texture to skin (tenting is uncommon), tachypnea, intense thirst, CNS disturbances- e.g irritability, jitteriness, Avoid too rapid rehydration as risk of cerebral edema, seizures possible If sodium dropped to quickly---> water intoxication can occur Shock is very late manifestation Source; IV solutions choices - Sick Kid’s Manual, Toronto

21. VOMITING Common childhood symptom Not always a GI problem Characteristics - Frequency, duration,, projectile, occur at night - Volume, color, consistency,bile or blood ( visible/occult) - Relationship to food/fluid intake - Associated S&S - ? any medications, home remedies used - Any signs of localizing infection i.e. otitis media, UTI Associated S&S - nausea, abdominal pain, anorexia, diarrhea, headache, fever, myalgias, joint pain/inflammation Associated S&S - nausea, abdominal pain, anorexia, diarrhea, headache, fever, myalgias, joint pain/inflammation

22. DIFFERENTIAL Dx. VOMITING Newborn Ingestion of maternal blood/mucus Inborn errors of metabolism Congenital adrenal hyperplasia Sepsis Atresia/stenosis of the GIT Over feeding 50% of infants have physiological regurgitation - effortless spitting up of 1-2 mouthfuls without distress or discomfort Rumination a form of auto-stimulation is the voluntary induction of regurgitation, most often seen in infants 3-6 months, occurs in infants with developmental retardation or disturbed mother -infant relationship 50% of infants have physiological regurgitation - effortless spitting up of 1-2 mouthfuls without distress or discomfort Rumination a form of auto-stimulation is the voluntary induction of regurgitation, most often seen in infants 3-6 months, occurs in infants with developmental retardation or disturbed mother -infant relationship

23. DIFFERNTIAL Dx. VOMITING Older Infants/children Overfeeding****** GERD Infection – gastroenteritis, otitis media, UTI Pyloric stenosis Intussusception Volvulus Vomiting related to obstructive conditions does not have nausea, infant eager to eat right after emesis Vomiting with raised ICP also is not associated with nauseaVomiting related to obstructive conditions does not have nausea, infant eager to eat right after emesis Vomiting with raised ICP also is not associated with nausea

24. DIFFERENTIAL Dx. VOMITING Older Infants/children Appendicitis Food allergies Diabetes CNS infection – meningitis, brain tumour Reyes syndrome Medications- erythromycins, digitalis

25. DIFFERENTIAL Dx. VOMITING Adolescents – any of above list plus think about: - Ingestion of illicit drugs/alcohol Pregnancy Eating disorders

26. VOMITING CPX - look for localizing signs e.g. infection, abdominal tenderness Assess urine output, other S&S dehydration DX tests: - CBC, differential - Electrolytes - BUN - Creatinine - Urinalysis - SG, ketones, infection - Blood gases, radiology/imaging as indicated

27. VOMITING Management Prevention and RX of fluid /electrolyte imbalances Bowel rest ( depends on cause) Anti-emetics use with caution- r/o surgical cause first

28. ACUTE DIARRHEA Causes in Infants - Necrotizing enterocolitis( NEC) – preterm infants with RDS - Hirschsprung’s disease (congenital megacolon) - Overfeeding (in newborns) - Viral /bacterial infections ( gastroenteritis) - Parasitic/ fungal infection - Systemic infection - Adverse reaction to antibiotic therapy (C. difficile infection) Common problem in children –    Viral gastroenteritis: 80% of cases in children <2 years old –    Bacterial gastroenteritis: 20% of cases in children <2 years old Viruses Rotavirus: most common cause in children 6–24 months of age Norwalk virus: affects older children Enteric adenovirus: common in children <2 years old Bacteria –    Salmonella –    Shigella –    Escherichia coli –    Campylobacter Parasites –    Giardia, cryptosporidiosis, ameibiasis Worrisome because children especially infants can dehydrate quickly Common problem in children –    Viral gastroenteritis: 80% of cases in children <2 years old –    Bacterial gastroenteritis: 20% of cases in children <2 years old Viruses Rotavirus: most common cause in children 6–24 months of age Norwalk virus: affects older children Enteric adenovirus: common in children <2 years old Bacteria –    Salmonella –    Shigella –    Escherichia coli –    Campylobacter Parasites –    Giardia, cryptosporidiosis, ameibiasis Worrisome because children especially infants can dehydrate quickly

29. ACUTE DIARRHEA Causes in older child Gastroenteritis ( viral/bacterial) ***** common Fungal/parasitic infection Food poisoning Systemic infection Antibiotic associated Toxic ingestion

30. ACUTE DIARRHEA Causes in Adolescents Gastroenterirtis Food poisoning Antibiotic associated Hyperthyroidism

31. MECHANISMSACUTE DIARRHEA Secretory < absorption, > secretion, electrolyte transport Stools watery, normal osmolality Examples- E.coli, C. difficile, cryptosporidiosis Persists during fasting No leukocytes in stool

32. MECHANISMSACUTE DIARRHEA Osmotic Maldigestion, transport defects Stools watery, increased osmolality Examples – lactase deficiency, glucose-galactose malabsorption, laxative abuse Stops with fasting No leukocytes in stool

33. MECHANISMSACUTE DIARRHEA Increased motility Decreased transit time Loose to normal appearing stool Stimulated by gastro-colic reflex Examples – irritable bowel syndrome, thyrotoxicosis Some infections may also contribute to > motility

34. MECHANISMSACUTE DIARRHEA Decreased surface area ( osmotic motility) Decreased functional capacity Stools watery Examples - rotavirus infection, celiac disease

35. MECHANISMSACUTE DIARRHEA Mucosal invasion Inflammation, decreased colonic re-absorption, increased motility Stool loose, blood and mucus( leukocytes) Examples- salmonella, shigella, amebiasis, yersinia campylobacter Dysentry- blood/mucus/WBC’s

36. ASSESSMENT OF ACUTE DIARRHEA History - Onset – acute, gradual - Duration - Frequency, consistency - Relation to food intake - Any blood/mucus - Any fever/vomiting - Signs of localizing infection- e.g URI, UTI, OM Relation to food intake – if food increased diarrhea += osmotic diarrhea, if it occurs even if child is fasting = secretory diarrhea Relation to food intake – if food increased diarrhea += osmotic diarrhea, if it occurs even if child is fasting = secretory diarrhea

37. ASSESSMENT OF ACUTE DIARRHEA History ( continued) Dietary/fluid intake since ill Any dietary changes just prior to onset - new food/formula introduced Food intolerances Urinary output - measure of dehydration Recent travel Exposure to other with similar S&S Past medical/family Hx i.e. cystic fibrosis, celiac disease, IBS, IBD

38. ASSESSMENT OF ACUTE DIARRHEA Physical Exam - Vital signs, weight – compare to previous - General appearance – acutely ill VS chronically ill looking Nutrition/hydration status CPX – look for localizing signs of infection e.g ears, respiratory, GIT, GU Diagnostic Tests - Stool for C&S, O&P PRN

39. MANAGEMENTACUTE DIARRHEA Mild Diarrhea without Dehydration - Breast-feeding and normal dietary intake should continue at home, with fluid intake dictated by thirst - Maintenance oral replacement solution (e.g., Pedialyte) should be offered ad libitum - High-osmolality fluids (e.g., undiluted juices or soda pop) and plain water should be avoided

40. MANAGEMENTACUTE DIARRHEA Diarrhea without Dehydration - Antispasmodic and antidiarrheal agents should not be used - There is also a very limited role for antiemetic agents - Antimicrobial agents are indicated for specific infection i.e. Giardia lamblia, shigella, campylobacter - Salmonella in neonates, immunocompromised children and kids with sickle cell is Rx with antimicrobials as well

41. MANAGEMENTACUTE DIARRHEA Monitoring and Follow-Up - Re-evaluate the child with mild symptoms and no dehydration (treated at home) within 24 hours. - Ensure that the parent or caregiver is aware of the signs and symptoms of dehydration - Instruct him or her to return immediately if dehydration occurs or S&S worsen or if the child cannot ingest an adequate quantity of fluid.

42. MANAGEMENTACUTE DIARRHEA Diarrhea with Dehydration - Record vital signs, clinical condition, intake and output, and weight frequently - Rehydrating a child with mild dehydration, under direct observation - Infants or children with mild dehyration who respond after 4 hours of rehydration may be sent home on maintenance therapy - The decision to continue home management should be made in consultation - Admit all children with moderate-severe dehydration

43. CHRONIC DIARRHEA Differential Dx. chronic diarrhea without FTT - Protracted bacterial infection- salmonella, campylobacter - Antibiotic induced- C. Difficile - Parasitic- giardia - Post gastroenteritis- lactase deficiency - Lactase intolerance - Toddler’s dirrhea Diarrhea lasting > 14 daysDiarrhea lasting > 14 days

44. CHRONIC DIARRHEA Differential Dx. chronic diarrhea with FTT - Celiac disease - Milk protein allergy - Inflammatory bowel disease - Cystic fibrosis - Pancreatic insuffciency - Immuodefciency - AIDS

45. CHRONIC DIARRHEA Differential Dx. chronic diarrhea with FTT - Food allergy Metabolic /endocrine- thyrotoxicosis, Addison’s galactosmia - Neoplastic disease- lymphoma of small bowel, pheochromocytoma

46. ASSESSMENT CHRONIC DIARRHEA History and CPX ( complete physical exam) - Serial growth percentiles - weight/height - S&S dehydration If child growing well minimal investigations If FTT consider the following tests - depending on suspected underlying cause: - Stool for consistency, PH, C&S, O&P, reducing substances, occult blood, 3 day fecal fat, C. Difficile

47. ASSESSMENT CHRONIC DIARRHEA If FTT consider the following tests ( cont,d) - CBC, diff, smear, - ESR, electrolytes, total protein, - Immunoglobulins, albumin, carotene, calcium, phosphorous - Mg. Zinc, ferritin, fat soluable vitamins - PT, PTT

48. ASSESSMENT CHRONIC DIARRHEA If FTT consider the following tests ( cont,d) - Sweat chloride, alpha-antitrypsin level - Thyroid function - Urinalysis, urine MVA and hVA - HIV, lead elvels - CXR, upper GI sries+ follow - through - ? Small bowel biopsy, endoscopy/biopsy

49. TODDLER’S DIARRHEA Most common form of chronic diarrhea Peak age 6-36 months Too much fruit juices - overwhelm small bowel resulting in dissacharride malabsorption 4-6 BM’s per day, may contain food particles Dx. of exclusion in a thriving child Self limiting problem, resolves age 2-4 years Rx: reassurance, reduce juices, increase fiber, other fluids, dietary fat ( 35-40%)

50. LACTOSE INTOLERANCE( Lactase Deficiency) Clinically presents as chronic watery diarrhea, abdominal pain/bloating/borborygmi Primary type -older child, Blacks/Orientals prone Secondary- older infant with IBD, post viral/viral gastroenteritis, Celiac disease Dx- trial off milk products, watery stool, acid pH, positive for reducing sugars, positive hydrogen breath test > 6 years Rx- lactose free diet, soy formula, lactaid tabs/drops

51. CONSTIPATION Non- organic causes ( functional) ***** - Inadequate fluid intake - Under-nutrition - Diet high in carbohydrates or protein (or both) Low-fiber diet Faulty toilet training process Associated family history Infrequent passage of hard, often dry stool. In 99% of cases, the cause of the constipation is never proven definitively. The condition is common in children, 20 % of children < 5 years Often (in 60% of cases) occurs during the first year of life Constipation is a symptom, not a diagnosis. In all cases, the underlying cause must be sought, as many of the causes are correctable. Infrequent passage of hard, often dry stool. In 99% of cases, the cause of the constipation is never proven definitively. The condition is common in children, 20 % of children < 5 years Often (in 60% of cases) occurs during the first year of life Constipation is a symptom, not a diagnosis. In all cases, the underlying cause must be sought, as many of the causes are correctable.

52. CONSTIPATION Organic causes – Intestinal Milk protein allergy( cow’s milk) Hirschsprung’s disease Neuronal dysgenesis Anal stenosis, stricture Rectal abscess/fissure

53. CONSTIPATION Drug causes Lead Narcotics Antidepressants Psychoactive drugs

54. CONSTIPATION Metabolic causes Dehydration Cystic fibrosis Hypothyroidism Hypokalemia Hypercalcemia Hypermagnesemia

55. CONSTIPATION Neuromuscular causes Infant botulism Absent abdominal muscle Myotonic dystrophy Spinal cord lesions

56. FUNCTIONAL CONSTIPATIONVS HIRSCHSPRUNGS History Functional Hirschsprung’s > 2 yrs. At birth, <1mos. Stool size large Small, ribbon like Abd. Pain – yes Abd. Pain –yes Enterocolitis rare Enterocolitis possible FTT uncommon Common Family Hx variabe Family Hx- yes, not always Hirscprungs- Enterovolitis may be fatal, peak age 2-3 months, toxic megacolon and perforationHirscprungs- Enterovolitis may be fatal, peak age 2-3 months, toxic megacolon and perforation

57. FUNCTIONAL CONSTIPATIONVS HIRSCHSPRUNGS Examination - abdominal/rectal exam Functional Hirschsprung’s - Abd. distention variable Common Poor growth rare Common Anal tone patulous Anal tone tight Rectal – stool ++ Rectal –empty Malnutrition absent Malnutrition possible Important to examine lower back for occult cord lesion (NTD)!

58. FUNCTIONAL CONSTIPATION Risk factors - Inadequate fluid intake - Under-nutrition - Diet high in carbohydrates or protein (or both) Low-fiber diet Faulty toilet training process- withholding stool Associated family history Accounts for 99% of cases of constipation in childrenAccounts for 99% of cases of constipation in children

59. FUNCTIONAL CONSTIPATION Complications Impaction Anal Fissure Rectal bleeding Chronic dilatation with overflow incontinence (encopresis) UTI

60. MANAGEMENT FUNCTIONAL CONSTIPATION Infants Adequate fluids ( , 6 months 150 ml/kg/day) Juices( prune) and fruits in diet Lactulose can be given Older children Mineral oil, lactulose Increased fiber in diet Appropriate toilet training technique Needs attention or it may become severeNeeds attention or it may become severe

61. ACUTE ABDOMINAL PAIN CAUSES- Infants - Infant colic - Hernia - Intussusception (in children 3 months to 2 years old) - Malrotation +/- Volvulus - Duplication of bowel Abdominal pain is a common symptom in children. In very young children, it may be difficult In younger children, abdominal pain may be a non-specific symptom of disease in almost any system. In older children, the symptoms become more specific, but can still be caused by a wide variety of more and less serious conditions. Abdominal pain is often categorized as acute, chronic or recurrent. The latter is usually defined as pain that recurs at least monthly over a 6-month period. Pain that requires surgical intervention is almost always acute. Abdominal pain is a common symptom in children. In very young children, it may be difficult In younger children, abdominal pain may be a non-specific symptom of disease in almost any system. In older children, the symptoms become more specific, but can still be caused by a wide variety of more and less serious conditions. Abdominal pain is often categorized as acute, chronic or recurrent. The latter is usually defined as pain that recurs at least monthly over a 6-month period. Pain that requires surgical intervention is almost always acute.

62. ACUTE ABDOMINAL PAIN CAUSES - Pre-school Children - Tonsillitis - Pneumonia - Hydronephrosis - Urinary tract infection /Pyelonephritis - Appendicitis (especially in children ?3 years old) In younger children, the classic pattern of acute appendicitis is less likely. If the child is older and has a retrocecal or retroperitoneal appendix, the presentation may be confusing, with pain radiating to the back or bladder, or the presence of bowel irritation. Generalized peritonitis is a common presentation of appendicitis in young children In younger children, the classic pattern of acute appendicitis is less likely. If the child is older and has a retrocecal or retroperitoneal appendix, the presentation may be confusing, with pain radiating to the back or bladder, or the presence of bowel irritation. Generalized peritonitis is a common presentation of appendicitis in young children

63. ACUTE ABDOMINAL PAIN CAUSES- 5–18 Years Old - Appendicitis - most common disorder - Mittelschmerz - UTI/Pyelonephritis - Mesenteric adenitis - Meckle’s diverticulum - Functional ( Recurrent abdominal pain) Sickle cell crisis, DKA, an present as abdominal pain Sickle cell crisis, DKA, an present as abdominal pain

64. ACUTE ABDOMINAL PAIN HISTORY - Characteristics of Pain – OPQRST - Associated- N/V, diarrhea/constipation/fever - Review of Systems and Medical History - Respiratory system - Urinary system Vomiting before pain suggests gastroenteriritis Vomiting after pain suggests a surgical conditionVomiting before pain suggests gastroenteriritis Vomiting after pain suggests a surgical condition

65. ACUTE ABDOMINAL PAIN HISTORY - Diet – appetite, fluid intake - Activity level - Sexual history (in female adolescents) - Trauma - Medications/ Allergies

66. ACUTE ABDOMINAL PAIN Diagnostic Tests –    Hemoglobin –    WBC count –    Urinalysis (for blood, protein, nitrates and WBCs) –    Pregnancy test for all reproductive-age females –    Chest x-ray (upright), to rule out pneumonia

67. INITIAL MANAGEMENTACUTE ABDOMINAL PAIN Critical decision medical vs surgical abdomen Consult MO/surgery NPO if ? Surgical IV N/S – maintain hydration ? NG tube ? Foley catheter ? Analgesia- non-narcotic, narcotic

68. CHRONIC ABDOMINAL PAIN Definition - 3 episodes of pain , severe enough to affect activities occurring in a child > 3 years of age over a period of 3 months Incidence - Affects 10-15 % of children

69. CHRONIC ABDOMINAL PAIN Red Flags For Organic Etiology - Age < 5 years - Pain away from the midline - Localized pain, awakens child at night - Prominent vomiting, diarrhea - Joint pain

70. CHRONIC ABDOMINAL PAIN Red Flags For Organic Etiology - Rectal bleeding - Fever - Anemia - Rash - Weight loss - Travel history

71. CHRONIC ABDOMINAL PAIN Differential Diagnosis Organic (< 10 %) - Constipation/functional - IBD - PUD - Lactose intolerance - Esophagitis - Anatomic anomalies/masses

72. CHRONIC ABDOMINAL PAIN Differential Diagnosis Organic (< 10 %) - Hepatobiliary disease- gallstones - GU disease - Gynecological - Cardiovascular - Neoplastic

73. RECURRENT ABDOMINAL PAIN(RAP-FUNCTIONAL) School age - peak 8-10 years Occurs in < 10 % of school age kids Female > male Pain characteristics - Vague, crampy, periumbilical or epigastric - Describes pain with vivid imagery - Episodes occur in clusters - Pain seldom interferes with sleep - Pain made worse by exercise/improved with rest RAP accounts for 90% of cases of chronic abdominal painRAP accounts for 90% of cases of chronic abdominal pain

74. RECURRENT ABDOMINAL PAIN(RAP- FUNCTIONAL) Associated with: - School avoidance - Absence of organic features - e.g fever, vomiting.diarrhea/weight loss - Psychological factors - Psychiatric co-morbidity;: anxiety, somatization, mood changes, learning disorders, eating disorders, sexual abuse, elimination disorders- enuresis, encopresis

75. RECURRENT ABDOMINAL PAIN(RAP- FUNCTIONAL) Must exclude organic disorders ( e.g. IBD, renal disease) Thorough history - look for psychosocial issues Thorough CPX CBC, ESR, Urinalysis, Stool OP/C&S, Occult blood

76. RECURRENT ABDOMINAL PAIN(RAP- FUNCTIONAL) RX: - Ensure continued attendance at school - Trial of high fiber and / or lactose free diet - Reassurance +++ - Referral to appropriate resource for emotional /family issues e.g. social worker, psychiatry etc., Pain resolves in 30-50 % in 2-6 weeks of Dx. 30-50 % go on to have functional pain e.g IBD as adultsPain resolves in 30-50 % in 2-6 weeks of Dx. 30-50 % go on to have functional pain e.g IBD as adults

77. CASE HISTORY Ashley, born at 37 weeks , BW 3700 Gms Regurgitation +++ after feedings as an infant Growth parameters- weight gain at 10th percentile during infancy, height and head circumference at 50 % Frequent infections as infant/toddler- otitis, UTI, bronchiolitis, pneumonia, Dx. at one point as asthmatic

78. CASE HISTORY Age 2-3, picky eater, mother reported frequent vomiting after meals Mom had lots of psycho-social issues ongoing, parenting issues - child ran household Public health nurse /home support worker from CAS into home to monitor Weight dropped to 5th , then 3 rd percentile, height/head stayed at 50th percentile, anemia FTT- referred to Pediatrics for Dx.work up

79. GERD IN CHILDREN Pathologic Regurgitant Reflux Differs from physiologic reflux in two ways: Abnormally large quantity of material refluxed 2. High frequency or long duration of episodes (or both) DEFINITION Physiologic or pathologic reflux of an abnormal quantity of gastric contents into the esophagus, which results in GI, respiratory or neurobehavioral manifestations. The prevalence is unknown. In children, the peak age at onset is 1–4 months of age. Physiologic Regurgitant Reflux Reflux occurs occasionally in all infants and children, and brief episodes of reflux (small quantities) after meals are normal. It is important to differentiate physiologic from pathologic reflux. Pathophusiology- Gastric Dysfunction - Large volume of gastric contents - High abdominal pressure (because of obesity or tight clothes) Dysfunction of Lower Esophageal Sphincter (LES) - Transient relaxation of LES (major cause of reflux) - Basal relaxation of LES (minor cause of reflux) Esophageal Dysfunction - Impairment of esophageal clearance of refluxate Predisposing Factors Supine position , Certain foods and medications DEFINITION Physiologic or pathologic reflux of an abnormal quantity of gastric contents into the esophagus, which results in GI, respiratory or neurobehavioral manifestations. The prevalence is unknown. In children, the peak age at onset is 1–4 months of age. Physiologic Regurgitant Reflux Reflux occurs occasionally in all infants and children, and brief episodes of reflux (small quantities) after meals are normal. It is important to differentiate physiologic from pathologic reflux. Pathophusiology- Gastric Dysfunction - Large volume of gastric contents - High abdominal pressure (because of obesity or tight clothes) Dysfunction of Lower Esophageal Sphincter (LES) - Transient relaxation of LES (major cause of reflux) - Basal relaxation of LES (minor cause of reflux) Esophageal Dysfunction - Impairment of esophageal clearance of refluxate Predisposing Factors Supine position , Certain foods and medications

80. GERD IN INFANTS GIT Manifestations - Failure to thrive - Malnutrition - Esophagitis - Feeding problems - Irritability - Hematemesis - Anemia

81. GERD IN INFANTS Respiratory Manifestations - Apnea (obstructive) - Chronic cough - Wheeze - Pneumonia (chronic or recurrent) - Cyanotic spells - Others (e.g., stridor, hiccups, hoarseness) Reflux with respiratory manifestations is more likely to be observed in association with certain disorders in both infants and children (e.g., esophageal atresia, cystic fibrosis, bronchopulmonary dysplasia and tracheo-esophageal fistula). Reflux with respiratory manifestations is more likely to be observed in association with certain disorders in both infants and children (e.g., esophageal atresia, cystic fibrosis, bronchopulmonary dysplasia and tracheo-esophageal fistula).

82. GERD IN INFANTS Neurobehavioral Manifestations - Arching and stiffening of back - Hyperextension of the neck or marked flexion of the neck to one side (torticollis)

83. GERD - OLDER CHILDREN/ADOLESCENTS Gastrointestinal Manifestations (Esophagitis) - Chest pain (heartburn) - Dysphagia (difficulty swallowing) - Halitosis (due to refluxate in mouth) - Odynophagia (painful swallowing) - Water brash (flow of sour saliva into mouth) - Hematemesis - Anemia (iron-deficient form)

84. GERD - OLDER CHILDREN/ADOLESCENTS Respiratory Manifestations - Recurrent or chronic pneumonia - Recurrent wheeze - Chronic cough - Stridor, hoarseness)

85. GERD Differential Diagnosis - Infection as a cause of vomiting (e.g., gastroenteritis) - Neurologic problem (e.g., hydrocephalus, brain tumor) - Metabolic problem (e.g. phenylketonuria, galactocemia) - Food intolerance (e.g., milk allergy, celiac disease) - Anatomic malformations (e.g., pyloric stenosis, esophageal atresia, intussusception)

86. GERD Complications - Esophagitis - Esophageal stricture - Failure to thrive - Recurrent aspiration pneumonia - Reactive airways disease, asthma - Apnea, near-miss SIDS - Anemia

87. GERD DIAGNOSIS Thorough history CPX including: - Growth /development assessment - Cardio-respiratory - GIT/GU - CNS - Skin- rashes, anemia (bruising)

88. GERD DIAGNOSIS Hemoglobin - concern about anemia Chest x-ray - to rule out aspiration or recurrent pneumonia Upper GI series Esophageal/gastric motility studies

89. MANAGEMENTOF GERD Positioning - Place child in upright positions - Avoid supine or semi-seated position - Elevation of head of bed onto 6-inch (15-cm) blocks may be useful

90. MANAGEMENTOF GERD Feeding - Thicken infant foods (add 1 tbsp dry rice cereal for each ounce of formula) - Fasting for a few hours before child goes to sleep - Avoid large meals (i.e., smaller but more frequent feedings) - Diet for weight loss may be considered in an older child, if he or she is overweight or obese - Avoid foods that decrease LES pressure or increase gastric acidity (e.g., carbonated drinks, fatty foods, citrus fruits, tomatoes) - Avoid tight-fitting clothes - Avoid exposure to tobacco smoke - Avoid tight-fitting clothes - Avoid exposure to tobacco smoke

91. MANAGEMENTOF GERD Medications Acid-Reducing Agents - aluminum-magnesium-simethicone suspension (e.g., Mylanta)0.5-1.0 mL/kg PO 3-6 times per day Histamine Antagonists - ranitidine (Zantac) 2 mg/kg PO tid Prokinetic Agents dopamine antagonist (e.g., domperidone [Motilium] as first-line therapy, before feeding, PPI’s - Losec Acid-Reducing Agents Used more often in older children who have pain associated with esophagitis Prokinetic Agents Mechanism of action of prokinetic agents is to raise the basal LES pressure, improve esophageal clearance and increase the rate of gastric emptying. Such an agent is usually started on a trial basis for 8 weeks. : Acid-Reducing Agents Used more often in older children who have pain associated with esophagitis Prokinetic Agents Mechanism of action of prokinetic agents is to raise the basal LES pressure, improve esophageal clearance and increase the rate of gastric emptying. Such an agent is usually started on a trial basis for 8 weeks. :

92. MANAGEMENTOF GERD Reassess monthly while the child is symptomatic Watch carefully for signs of complications (e.g., failure to thrive, recurrent pneumonia, asthma, erosive esophagitis or anemia) Monitor growth and development, hemoglobin level and lung sounds

93. MANAGEMENTOF GERD Surgery may be necessary in severe cases Indications for surgery: - Failure of medical management - Severe or intractable detrimental effects (e.g., failure to thrive, recurrent pneumonia, peptic stricture) - Neurologically impaired children with or without gastrostomy tube Prognosis Most infants with mild or moderate reflux become asymptomatic and can discontinue medical therapy by 1 year of age Of infants with severe reflux, 60% to 65% become asymptomatic without therapy by 2 years of age Children more resistant to complete resolution have good response to medical therapy but experience relapse when medications are discontinued Prognosis Most infants with mild or moderate reflux become asymptomatic and can discontinue medical therapy by 1 year of age Of infants with severe reflux, 60% to 65% become asymptomatic without therapy by 2 years of age Children more resistant to complete resolution have good response to medical therapy but experience relapse when medications are discontinued

94. MANAGEMENTOF GERD Consult Pediatrics if: Conservative measures fail to control reflux There is evidence of complications (e.g., failure to thrive)

95. DIFFERNTIAL DX. OF ABDOMINAL MASSES Benign - Renal - hydronephrosis,polycystic kidneys - Ovarian cysts - Pyloric stenosis - Hernia - Splenomegaly 50% of abdominal masses in the newborn are renal in origin

96. DIFFERNTIAL DX. OF ABDOMINAL MASSES Malignant - Wilm’s tumour - Renal cell carcinoma - Neurobalstoma ( adrenal) - Ovarian tumour - Lymphoma - Retroperitoneal rhabdomyosarcoma

97. MANAGEMENT -ABDOMINAL MASSES Consult ASAP Refer U/S , CT scan Definitive Dx Definitive Rx depends on Dx

98. INTUSSUSCEPTION Telescoping of one section of bowel into another In children, the most common form of intussusception is prolapse of the terminal ileum into the colon Most common in first year of life Males > females (3:2) Cause is unknown

99. INTUSSUSCEPTION

100. INTUSSUSCEPTION

101. INTUSSUSCEPTION History - Crampy abdominal pain, manifested as regular, intermittent episodes of colic during which the baby draws his or her feet up to the knee–chest position - Vomiting - “Currant jelly” stool: almost pathognomonic when present - Other signs of obstruction, including abdominal distension, may be present - Lethargy: may become extreme, very similar to coma

102. INTUSSUSCEPTION Physical Findings - Vital signs usually normal in the early stages - Abdominal palpation may reveal an empty feeling in the right lower quadrant and a sausage-shaped mass in the area of the transverse colon - Rectal Examination may reveal bloody or currant jelly stool

103. INTUSSUSCEPTION Differential Diagnosis - Infection - Parasitic infestation (e.g., Enterobius) - Tumor - Hirschsprung's disease (congenital megacolon) - Obstruction of the bowel - Meckel's diverticulum - Incarcerated hernia - Malrotation of the gut with incarceration In children who are extremely lethargic, a clinical history, physical examination and high index of suspicion are needed to rule out conditions such as meningitis, various metabolic conditions, enterocolitis caused by coxsackievirus and traumaIn children who are extremely lethargic, a clinical history, physical examination and high index of suspicion are needed to rule out conditions such as meningitis, various metabolic conditions, enterocolitis caused by coxsackievirus and trauma

104. INTUSSUSCEPTION Diagnostic Investigations CBC Lytes Abd. X-ray/ultrasound Barium or air contrast enema

105. INTUSSUSCEPTION Complications - Bowel necrosis - GI bleeding - Bowel perforation - Sepsis - Shock

106. INTUSSUSCEPTION Management - Consult a physician/pediatric surgery - Admit - Start IV therapy with normal saline and run at a rate sufficient to maintain hydration - If there is evidence of hypovolemia or shock, give a bolus of IV fluid (20 mL/kg) over 20 minutes; repeat as necessary until hypovolemia is corrected (up to three times in 1 hour

107. INTUSSUSCEPTION Management - Nothing by mouth - Insert nasogastric tube - Monitor ABCs, vital signs, intake and output, and abdominal findings frequently while awaiting transfer. - Referral to a center where pediatric surgery and radiology can be carried out. If the intussusception has been present for less than 18 hours and there is no free air on x-ray of the abdomen, a barium enema with hydrostatic pressure can be attempted to reduce the intussusception. This procedure is successful in up to 70% of cases and avoids the need for a surgical procedure. If the attempted reduction of the intussusception is unsuccessful or if there appears to be a lead point (e.g., tumor), surgery is required immediately. If the intussusception has been present for less than 18 hours and there is no free air on x-ray of the abdomen, a barium enema with hydrostatic pressure can be attempted to reduce the intussusception. This procedure is successful in up to 70% of cases and avoids the need for a surgical procedure. If the attempted reduction of the intussusception is unsuccessful or if there appears to be a lead point (e.g., tumor), surgery is required immediately.

108. CASE HISTORY Sean, 4 week old male infant Healthy term infant, birth weight 3500 gms Breast fed infant- increased feeding schedule, appears hungry, feeds vigorously but is vomiting after all feedings for 3 days Otherwise seems well, no fever Current weight 4300 gms CPX appeared normal

109. CASE HISTORY Had Mom feed child in clinic- fed hungrily and well Vomited after 5 minutes, projectile ( shoots across room) Vomitus contained curdled milk ( delayed transit of previous feed) Re-examination of abdomen reveals a small mass in the right upper quadrant

110. PYLORIC STENOSIS 1/300 live births Males > females ( 4:1) Some familial tendency A narrowing of the outlet from the stomach to the small intestine (called the pylorus) that occurs in infants Exposure to erythromycin may predispose Presents at age 2-4 weeks - projectile vomiting and possibly dehydration Occurs in 5% of siblings and in 25% of offspring if mother was affected Often called infantile hypertrophic pyloric stenosis Results in hypertrophy and hyperplasia of pyloric sphincter in neonatal period Mainly affects circular muscle fibres of pylorus Pylorus becomes elongated and thickened ? Due to failure of nitric oxide synthesis Results in gastric outflow obstruction, vomiting and dehydration Occurs in 5% of siblings and in 25% of offspring if mother was affected Often called infantile hypertrophic pyloric stenosis Results in hypertrophy and hyperplasia of pyloric sphincter in neonatal period Mainly affects circular muscle fibres of pylorus Pylorus becomes elongated and thickened ? Due to failure of nitric oxide synthesis Results in gastric outflow obstruction, vomiting and dehydration

113. PYLORIC STENOSIS Physical findings Immediately after or during a feeding, an olive shaped mass is palpable to the right of midline in epigastric area Associated visible peristaltic waves progressing from left upper quadrant to the epigastrium

114. PYLORIC STENOSIS Diagnostic tests CBC BUN, Creatinine, Lytes Indirect bilirubin Abdominal U/S - thick ring in the areas of the pylorus Hpokalemia metabolic akalosis with paradoxic aciduria an dehydration indirect hyperbilirubinenmia may be presentHpokalemia metabolic akalosis with paradoxic aciduria an dehydration indirect hyperbilirubinenmia may be present

115. PYLORIC STENOSIS Management Correct dehydration and electrolyte abnormalities with IV fluids ( N/S + KCL0 Surgery- Pyloromyotomy Feeding re-established within 12-24 hours of surgery Recurrence does not occur Feeding re-established within 12-24 hours of surgery Recurrence does not occur