8. GI Disorders

Gastroesophageal reflux (GER)

- Recurrent spitting/vomiting in health infant that resolves spontaneously — Frequently postprandial regurgitation

- Common in young infants!

Gastroesophageal reflux (GER) vs. GERD

GERD with secondary S/S or complications (pain)

Cause of gastroesophageal reflux (GER)

Physiological — Spontaneous relax of LES unaccompanied by swallowing

Factors that promote reflux

- Short esophageal length

- Supine

- Small stomach / large volume feed

Red flag signs of recurrent vomiting (GER, GERD)

- FTT

- Bile-stained emesis

- GI bleed

- Hepatosplenomegaly

- Abd tenderness/distention

- Neurologic changes

Bile-stained emesis is a warning sign for...

Intestinal obstruction

Sandifer syndrome

Combo of GERD w/ spastic torticollis & dystonic body movements w/ OR w/o hiatal hernia

Risk factors for GERD & esophagitis

Asthma, CF, CP, hiatal hernia

S/S of reflux disease in infant

Apnea OR apparent life-threatening events (now known as Brief Resolved Unexplained Events / BRUE)

Extraesophgeal manifestation of reflux disease

- Upper airway — Hoarseness, sinusitis, laryngeal erythema, edema

- Lower airway — Recurrent pneumonia / cough

- Dental erosions

Management of GER in infants

- Small feeding interval

- Thickened feedings w/ rice cereal

- Elevated HOB for 30 mins

- Resolves spontaneously in 85% by 12 months

**NO evidence of benefits of acid suppression

Management of GERD in children

Acid suppression — H2 antagonists, PPI

Risks with long-term PPI therapy

Infection — Pneumonia, C. diff

Pyloric stenosis

Postnatal muscular hypertrophy of pyloric muscle w/GOO

Risk factors of pyloric stenosis

- Male <12 weeks (MC 2-4 weeks)

- Erythromycin in neonatal period (pertussis)

S/S & PE of pyloric stenosis

- Nonbilious, projectile postprandial vomiting

- Dehydration, alkalosis in age <12 weeks

- Infants hungry & feed avidly

- Upper abd distention, prominent peristaltic waves

- Olive on palpation

Diagnostic workup of pyloric stenosis

- Upper GI contrast radiographs OR abd US — Diagnostic

US → Hypoechoic muscle ring >4mm thickness w/ hyper dense center

UGI → String sign (retention of contrast in stomach & long narrow pyloric channel w/ double track of barium)

- Hypochloremic alkalosis w/ K depletion

- Dehydration → Elevated Hb & Hct

Management of pyloric stenosis

- Manage dehydration & electrolyte imbalance PRIOR to treatment

- Ramstedt pyloromyotomy

FYI with ramstedt pyloromyotomy for pyloric stenosis

- Increased risk of chronic abd pain in childhood

- Postop barium radiograph remains abnormal

MCC of bowel obstruction in first 2 years of life

Intussusception

Intussusception

Telescoping of 1 segment of intestine into another — MC just proximal to ileocecal valve

MCC & location of intussusception

Idiopathic — Ileocolic

Risk factors for intussusception

Males age 3-12 months

MCC of intussusception in age >6

Lymphoma

Primary causes of intussusception

Meckels, lipoma, foreign body, viral enteritis, hypertrophy of peyer patches

S/S of intussusception

- Colicky abd pain w/ severe screaming & knees to chest

- Vomiting & diarrhea

- Fatigue & lethargy between paroxysms

- Sausage mass in upper mid abd

- Current jelly stools

Diagnostic workup of intussusception

US — Most sensitive & specific

Management of intussusception

Barium enema & air enema — Both diagnostic & therapeutic

- Decreased success w/ enema if S/S >24hr

Contraindications of barium enema & air enema for intussusception

Strangulated bowel, perforation, toxicity

Management of intussusception with shock / sepsis

- Advantage of ID lead point (mocked diverticulum, lymphoma, small bowel polyp) — Decreased recurrence rate vs. pneumatic reduction

- Increased risk for subsequent boewl resection if S/S >24hrs

Congenital diaphragmatic hernia

Herniation of abd contents through diaphragm generally through posterolateral defect of L side of diaphragm (foramen of bochdalek)

Diagnosis of congenital diaphragmatic hernia

Prenatally via secreening US

Postnatal challenges associated with congenital diaphragmatic hernia

Pulmonary hypoplasia & CV dysfunction

Long-term health implications of congenital diaphragmatic hernia

Chronic pulm disease, pulm HTN, neurodevelopment delays, hearing loss, GERD

Associations of congenital diaphragmatic hernia

Congenital malformations — CV structural defects

Malrotation

Failure of normal embryologic gut rotation & attachment

What is one of the MC indications for small bowel transplant in children?

Volvulus

Average age of diagnosis of malrotation (+/- volvulus)

1st year of life

Associations of malrotation

Cardiac congenital anomalies

S/S of malrotation

- Intrauterine volvulus causing intestinal obstruction / perf @ birth

- Neonate w/ ascites or meconium peritonitis

- Bile-stained vomit / Overt SBO during first 3 weeks of life

- Later S/S: Intermittent intestinal obstruction, malabsorption, protein-losing enteropathy

Diagnostic workup & findings of malrotation

- UGI series (gold standard), confirmed by barium enema

- XR — Double bubble sign (BUT pathognomonic for duodenal atresia)

- CT abd & US — Whirlpool sign with midgut volvulus

Classic location of malrotation

Duodeno-jejunal junction & jejunum on RIGHT side of spine

Management of malrotation

LADD procedure — Mobilization of duodenum, short mesenteric root extended, bowel fixed

Management of volvulus

SURGICAL EMERGENCY — Resect necrotic bowel (d/t occlusion of SMA)

**Guarded prognosis

Diagnostic workup & findings of sigmoid volvulus

Coffee bean sign (kidney bean sign / bent inner tube sign) / Closed loop SBO

Sigmoid volvulus vs. cecal volvulus

Cecal → Only 1 gas-fluid level (rather than several w/ sigmoid)

Complications of delayed diagnosis of malrotation

Ischemic injury, perf, peritonitis

What chart is used to assess stool type?

Bristol stool chart

Bristol stool chart (important ones)

1: Deer poopy

3: Dry sausage

4: Smooth sausage

7: Entirely liquid

Diagnosing chronic constipation in childhood

2+ following for 2 months:

- <3 BM/week

- >1 encopresis/week

- Impaction of rectum

- Stool so large it obstructs toilet

- Retentive posturing / fecal witholding

- Pain w/ defectation

Chronic constipation in childhood can result in...

Encopresis — Overflow incontinence

Most constipation in childhood is a result of...

Voluntary / involuntary retentive behavior

Risk factors for childhood constipation

- Males

- Diet — Undernutriton, excessive milk

S/S of normal passing of stools in infants <3 months

Grunting, straining, turning red in face (NOT constipation)

Diagnosis of childhood constipation

- Clinical — Mass in suprapubic area, anal fissures, soiled garments

- XR — Fecal loading / impaction +/- bowel dilation of rectosigmoid region

Management of childhood constipation

- Polyethylene glycol

- Milk of magnesia for ≥2 years

- High residue diet — Bran, WW, fruit, veg

- Stimulant laxatives (Senna / bisacodyl) — 2nd line

What medication used for constipation should NOT be given to non-ambulatory children? Why?

Mineral oil — Risk of aspiration → Lipid PNA

Hirschsprung disease AKA

Congenital ganglionic megacolon

MC chromosomal abnormality associated with Hirschsprung disease

Trisomy 21

Risk factors for Hirschsprung disease

Males

S/S of Hirschsprung disease

Failure of newborn meconium in 1st 24hrs

PE findings with Hirschsprung disease

DRE w/ NO fecal material despite retained stools on abd exam / XR

Diagnostic workup & findings of Hirschsprung disease

Barium enema — Ganglion cells absent in submucosal & mucosal layers of bowel (represented via transition zone); "String sign" (non-peristaltic bowel)

Management of Hirschsprung disease

Surgical resection — Diverting colostomy / ileostomy

Complications of surgical resection of Hirschsprung disease

Fecal retention, incontinence, anastomotic breakdown / stricture

Constipation vs. Hirschsprung disease

Constipation: Onset 2-3 years, abd distention rare, normal nutrition / growth

Hirschsprung disease: Onset at birth, abd distention present, poor nutrition / growth

Imperforate anus

Congenital defect with absent / blocked anus occurring in week 5-7 of GA

Risk factors for imperforate anus

Males w/ syndromic anomalies

Types of imperforate anus

- Low lesion — Rectoperineal malformation

- High lesion

Low lesion imperforate anus (what, S/S, tx)

Anus is narrow, misplaced, covered by membrane

S/S: Failure to pass meconium, greenish bulging membrane, bucket-handle skin tag in males at birth

Simple surgery effective (80-90% continence)

High lesion imperforate anus (what, S/S, diagnosis, tx)

Rectum may connect to urinary / reproductive tract

S/S: NO anal musculature, hypoplastic buttocks, cloacal anomalies, +/- neuro deficits

Diagnosis requires FULL anatomic & neuro eval

Diverting colostomy (only 30% continence)

Cows milk protein intolerance

Non-allergic good sensitivity

Risk factors for cows milk protein intolerance

- Male

- FamHx of atopy

MC S/S / Presentation of cows milk protein intolerance

Healthy infant with flecks of blood in stool OR loose mucoid stools w/ streaks of blood

Diagnosis of cows milk protein intolerance

Clinical; Rectal biopsy can show lymphonodular hyperplasia, mucosal edema, eosinophilia

Presentation of cows milk protein intolerance in older children

Eosinophilic gastroenteritis with protein-losing enteropathy, iron deficiency, hypoalbuminemia, hypogammaglobulinemia

Management of cows milk protein intolerance

BF → Mother eliminate dairy

Formula → Soy or protein hydrolysate

**Generally resolves by 8-12 months

MCC of enteropathy

Milk protein

FYI of milk protein allergy

Rarely proved, especially infants <12 months

Presentations of milk protein allergy

- Severe diarrhea w/ systemic allergic reaction → Food protein-induced enterocolitis syndrome (FPIES)

- Enteropathy secondary to dietary proteins

Food protein-induced enterocolitis syndrome (FPIES)

Life-threatening condition during infancy with large-volume diarrhea, acidosis, hypotensive shock d/t common food proteins (milk / soy)

MCC of enteropathy

Milk protein

Celiac disease

Immune-mediated enteropathy triggered by gluten; Can occur anytime after gluten has been introduced

Gluten products

Wheat, rye, barley

Risk factors for celiac disease

- T1DM

- Down Syndrome

- Turner's syndrome

- IGA deficiency

- AI thyroiditis

- FamHx of CD

Onset & S/S of celiac disease

- 6-24 months

- Anorexia

- Poor weight gain

- Anemia, delayed puberty, short stature, elevated LFTs, arthritis

Diagnostic workup & findings of celiac disease

- IGA antitissue transglutaminase OR IGA antiendomysial antibody tests

- Hypoalbunemia

- Anemia w/ low MCV & iron deficiency

Celiac crisis (S/S & management)

Profound anorexia, abd distention, hypoK+ — Corticosteroids

Poor adherence to GF diet with celiac disease have increased risk of...

Fractures, iron deficiency anemia, infertility, enteropathy-associated T-cell lymphoma

Diagnosis of chronic vomiting

≥3 episodes in 3 months

Common finding secondary to forceful vomiting d/t Mallory Weiss tear

Hematemesis

Leading cause of pediatric morbidity / mortality

Dehydration d/t diarrhea

Dehydration & diarrhea

>10mL/kg/day of fluid lost in stools

Toddler diarrhea is associated with... (& day)

Excessive fruit juice consumption — 6 month to 3 years

Types of diarrhea (4)

- Secretory

- Osmotic

- Motility disorder

- Decreased SA

Acute diarrhea (duration)

<2 weeks

MCC of acute gastroenteritis

Viruses — Rotavirus

Rotavirus S/S & onset

Large volume watery diarrhea in age 3-15 months during winter

Diagnosis of rotavirus

Clinical +/- Rotavirus stool antigens

Management of rotavirus

Supportive +/- IVF