Digestive system

Common signs, symptoms and diseases

Posseting, regurgitation, vomiting• posseting- non-forceful return of small amounts of

milk with swallowed air, physiological• regurgitation- larger, more frequent loses,

effortless, presence of gastro-esophageal reflux It may be present in infants up to 6 months; if the

appetite and stools are proper, regurgitation does not contribute to malnutrition. Sometimes may cause pneumonia and otitis if is excessive.

• vomiting - forceful ejection of gastric contents Violent descent of diaphragm and constriction of the

abdominal muscles with relaxation of gastric cardia force gastric contents back up the oesophagus. This is coordianated by the vomiting center in medulla.

- is a common problem in infancy and childhood- usually is a result of mild gastroenteritis and gastro-

oesophageal reflux

Causes of vomiting – alimentary tract

• Congenital defects: esophageal (duodenal, ileal, colonic) atresia or stenosis, malrotation of the intestines– Ladd’s syndrom, meconium ileus, Hirshprung disease, hiatus hernia

• Pyloric stenosis• Chalasia (cardio-esophaeal relaxation), achalasia

(cardiospasm)• Peptic ulcer, duodenal ulcer• Food allergy• Ileus (intussusception, intestinal torsion, testis torsion,

advanced abdominal malignancies, paralytic ileus, incarceration of hernia)

• IBD

Causes of vomiting – infectious diseases

• Respiratory tract infections: pharyngitis, laryngitis, bronchitis, pneumonia, pertussis, scarlet fever

• Alimentary tract infections: gastritis, duodenitis, gastroenterocolitis, appendicitis, hepatitis, peritonitis, pancreatitis, cholecystitis

• Otitis media• Urinary tract infections: pyelonephritis• CNS infections: meningitis, encephalitis• Sepsis

Causes of vomiting – non- infectious diseases

• Brain tumor• Hydrocephalus• Cerebral edema• Subdural hygroma• Epidural and subdural hemorrhage• Brain contusion• Migrene• Sunstroke

Causes of vomiting – metabolic and endocrine diseases, intoxiacations, others

• Adrenogenital syndrom• Inborn errors of metabolism: galactosemia, fructosemia• Hypercalcemia• Severe hyperbilirubinemia• Diabetic coma, hepatic coma, uremic coma• Acetonemic vomiting• Exogenic toxins: mediacations (cytostatics,antibiotics,

digitalis, salicylates, anesthesia), narcotics, and chemicals• Overfeeding and eating disorders (anorexia nervosa,

bulimia nervosa)• Violent fits of coughing• After surgery (postoperative nausea and vomiting)

Vomiting of special attention

• excessive, especially in newborns and infants

• fever( meningismus, meningeal signs)• green coloured (ileus)• coffee-grounds (hemorrhage from gastrointestinal tract,

ususally gastric ulcer or gastritis)• morning, persistent, without nausea (brain tumor)• persistent, without diarrhea (various medical conditions)

Complications of vomiting

• aspiration pneumonia• dehydration, alkalosis, hypokalemia,

hypochloremia• malnutrition• renal insufficiency• destruction of tooth enamel• Mallory-Weiss tear (erosions to the esphagus or

small tears in the esophageal mucosa)

Vomiting- laboratory findings

• metabolic alkalosis- hypertrophic pyloric stenosis• metabolic acidosis- diabetes• barium upper gastrointestinal series, 24-hour pH probe,

a technetium -99m scan of gastric emptying, endoscopy esophageal biopsy- GER

• pyuria- urinary tract infection• purulent, lymphocytic, bloody cerebrospinal fluid-

meningitis, cns bleeding• leucocytosis- septicaemia

Vomiting – additional testing when specific etiology is suspected

• USG (CNS, abdomen, testes): pyloric stenosis, appendicitis, gallstones, renal stones, pylonephritis, hydronephrosis, biliary obstruction, intususception, malrotation, acute pancreatitis, pregnancy, tortion of the testis, CNS abnormalities, trumas, and infections)

• barium upper gastrointestinal series, 24-hour pH probe, endoscopy esophageal biopsy- GER

• CT – observation of structures thet cannot be visualized by ultrasound• Barium studies- obstructive or inflammatory lesions of the gut;

therapeutic in intussusception• Blood and urine culture• Otoscopy• Toxicology tests• Esophageal pH monitoring • Allergy testing

Vomiting- treatment

• depends on underlying problem• management of fluid, gasometry and electrolyte

imbalances: Fluid resuscitation: oral or iv electrolyte solutions Therapy of acidosis (8,4% NaHCO3) Treatment of underlying causes Antiemetic medications – controversial

Not until the etiology is known Only for severe symptoms

Gastroesophageal reflux (GER)

Definition: effortless regurgitation of gastric contentsEtiology: transient relaxation of the lower esophageal tone,

unrelated to swallowing, large hiatal hernias and delayed gastric emptying

Complications: apnea, bradycardia, failure to thrive, esophagitis- irritability, bleeding and anaemia, strictures, Barret’s esophagus, respiratory disease- chronic cough, asthma, aspiration pneumonia, nocturnal cough

Gastroesophageal reflux (GER)- diagnosis and treatment

• Diagnosis

barium upper gastrointestinal series,

24-hour pH probe,

a technetium -99m scan of gastric emptying,

endoscopy esophageal biopsy• Tratment- controversial- head-up prone position therapy

(30° prone upright), prokinetics (bethanecol?, metoclopropamide?, cisapride, histamine receptor type-2 blockers, omeprazole)

• Surgery- Nissen fundoplication wrap procedure ( Barret's esophagus, respiratory complications, GER+ neurologic disabilities)

Gastroesophageal reflux

Reflux esophagitis – grade A (left), B (right)

Barret’s esophagitis

Intussusception- a surgical abdomen

• invagination of one part of intestine into itself• age < 1 year, neonates seldom• etiology: 90% idiopathic = unknown

(2-7%)- viral infection with Peyer’s patches enlarged, Meckel’s diverticulum, polyps, enteric duplications, Henoch-Schonlein purpura, tumors (lymphoma),

• patomechanism: mesentery entrapped venous compression cessation of arterial circulation ischemia necrosis

• localisation: usually ileum pass into the caecum 75%, 15% ileo-ileocolic, 10% ileoileal, colocolic

Intussusception- a surgical abdomen

• symptoms: colicky abdominal pain with intervals of wellness, bloody stools- characteristic „redcurrant jelly”, projectile vomiting

• asymptomatic- altered states of consciousness BE SUSPICIOUS !!!

• physical examination: „sausage shaped” mass often palpable in the abdomen, intensic peristaltic movements ahead, silence behind the intussusception

• diagnosis: usg, X- ray of the abdomen: barium enema + treatment (hydrostatic reduction/ air insufflation reduction )- exclude peritonitis-5% reccurent

• surgical reduction-3% recurrence rate

Intussusception- radiology, ultrasonography images

Intussusception- barium enema

Pyloric stenosis• Hypertrophy of the pyloric muscle causing gastric

outlet obstruction• Present at between 2 and 7 weeks of age• More common in boys• Signs: visible persistalsis, palpable abdominal

mass, increasing vomiting, dehydratation and weight loss if presentation is delayed

• Associated with hyponatraemia, hypokalaemia, hypochloraemic alkalossis

• Diagnosis: ultrasound examination• Management: treated by surgery (pyloromyotomy

incision – open procedure/ laparoscopy)

Pyloric stenosis- surgery

Infantile colic

• affects 10-20% of infants, first few months of life (up to 4 months of age usually)

• paroxysmal crying accompanied by drawing up of the knees, several times a day, particularly in the evening

• etiology unknown• benign unless all reasons of abdominal pain excluded• therapy: cow's milk-free diet and others

Irritable bowel syndrome (IBS)- a functional disorder

• definition: intestinal dysmotility with intervals of diarrhea or constipation

• late adolescence, school absences• pain dull, crampy, bloating located in lower quadrant or

periumbilical region• etiology unknown, no organic cause• exogenous factors: infections, medications, stress,

emotions, diet• positive family history (spastic colon), infant colic, chronic

nonspecific diarrhea until 3 yrs→ then constipation • symptoms: diarrhoea/ constipation with/without abdominal

pain, occur during awaken hours

IBS - a functional disorder

• diagnosis: history + physical examination + routine laboratory research

• management: education, dietary factors (lactose elimination, fiber addition, stress management techniques

• medications- no improvement, symptomatic• psychologic consultations

Constipation

Constipation is generally described as the infrequent passage of stools (bowel

movements) or the passage of hard stools. There is no universally accepted or precise

definition of this symptom.• infrequent stools (less than 3/week)• hard stools• difficult passage of stools• feeling of incomplete evacuation

Parents say about:

• Straining with defecation• Hard stool consistency• Large stool size• Decreased stool frequency• Fear of passing stools• Combination of any

Constipation – pathophysiology

• Childhood constipation develops usually when the baby starts to associate pain with defecation.

• Pain due to bowel movements the child begins to withhold stools in attempt to avoid discomfort the rectum gradually accommodates the normal urge to defecate disappears.

• The infrequent passage of very large and hard stools reinforces the child's association of pain with defecation worsening stool retention more abnormal defecation dynamics with anal sphincter spasm.

• Chronic rectal distension :– loss of rectal sensitivity– loss of urge to defecate– fecal incontinence (ie, encopresis).

Constipation - causes• Dietetic factors: inproper fiber and fluid consumption, cow’s milk

intolerance, overuse of coffee, tea, or alcohol• Psychological problems, change in lifestyle (immobilization,

travel, kindergarten)• Medicines: antiepileptic, antiacida (calcium and magnesium),

antidepressants, antihypertensives, diuretics, opiates psychotropic and antycholinergic drugs

• Post radiotherapy• Diseases:

– Metabolism change: K, Ca – Endocrine: diabetes, hypothyroidism, uremia– Nervous system: SMA, neuropathies, CP, CNS tumors, spinal

cord injury, head injury, multiple sclerosis– Abdominal tumors– Cystic fibrosis

Constipation - causes

Colonic obstructionextraluminal (neoplasm, hernias) luminal (neoplasm, stricture)

Colonic dysmotility IBS

Diverticular disease (acquired condition characterized by multiple herniations or outpouchings of layers of the colonic wall outside the colonic lumen)

Hirschsprung's disease Anorectal disorders

Rectocele Intussusception Prolapse of rectal mucosa Fissures, fistulae Anorectal ring spasm (junction where the anal canal meets the rectum), Anal stenosis

Constipation – physical examination

• Examination the abdomen for any sign of a hardened mass

• Digital rectal exam (DRE), the most important part, regardless of age – size of the anal canal– size of rectum– whether any intrarectal masses are present– consistency of stool, presence of blood– sphincter tension ( increased in Hirshprung disease, decreased

in functional constipation)– any anorectal abnormalities (fissures, fistulae, dermatitis,

perianal abscess, hemorrhoids)– empty rectum is typical for Hirshprung disease, whereas great

amount of stools is characteristic for habitual constipation

Constipation – imagine studies

• plain abdominal radiograph - presence of significant fecal retention • barium enema –in Hirshprung disease - assessment of colonic diameter

from the narrow aganglionic segment to more dilated ganglionic segment• rectoscopy or colonoscopy – presence of organic changes (tumors,

constriction)

• rectal biopsy – may reveal:– Neoplasms– strictures from Crohn disease– Diverticulitis– Ischemia– agangliosis of Hirschsprung disease.

• anorectal manometry –measurement of the anal sphincter pressure and defecate reflex (in Hirshprung disease - lack of internal sphincter relaxation in response to increased pressure in rectum)

Constipation-laboratory investigations

• Electrolytes (K, Ca)• Thyroid hormones• Glucose, creatinine• Fecal occult blood • Leukocyte count - patients presenting with

abdominal pain or fever (ileus)

Constipation - managementAppropriate treatment depends on accurate diagnosis• Congenital abnormalities - surgery• Metabolic disorders - treatment of the underlying condition• In all cases - intestinal cleaning: enema

• In order to avoid recurrence of stool retention:– laxatives (Lactulose); abuse may lead to addiction, withdrawal can

provoke return of symptoms– diet rich in fiber: fruits with small seeds, brown bread, big amounts of

vegetables, bran added to meals– large amount of fluid– excluding sweets and products containing cacao

• Toilet training – child should have enough time for defecation in peace and hygienic environment. It is indicated to chose the same time every day in order to create habitual physiological defecation

Hirschprung's disease

Etiology- congenital abnormality- inheritance pattern autosomal dominant, mutations inactivating RET gene cause a susceptibility to HD

Epidemiology: 1/5000 newborn

Result- the absence of ganglion cells from the myenteric and submucosal plexuses of the distal part of the large bowel

spasm and functional obstruction of the aganglionic contracted segment

secondary dilatation of proximal colon

Hirschprung's disease

Symptoms: first 24 hours of life- deleyed meconium passage, abominal distention, bile-stained vomiting, constipation, fever, enterocolitis, dehydratation, death if not treated

Rectal examination- narrow segmentTreatment: surgery

Hirschprung disease- abdomen distention (left), the localisation (right)

Hirschprung disease- megacolon

Hirschprung disease- dilatation of colon, narrow rectum

Gastroenteritis

• Loose or watery stools, often accompanied by vomiting, abdominal pain, fever, dehydratation

• Usually recent contact with person with diarrhoea/ vomiting or travel abroad in the history

• CausesDeveloped countries: rotavirus infection(other

viruses: adenovirus, coronavirus, norovirus)Developing countries: mostly bacterial from

contaminated water and food ( Salmonella, Shigella, Campylobacter jejuni, Cholera, enterotoxigenic E. Coli)

• Bacterial infections: blood/ pus present in the stool, high fever, severe abdominal pain, rapid dehydratation from diarrhoea

Conditions mimicking gastroenteritis

• Systemic infections: septicaemia, meningitis• Local infections: otitis media, respiratory tract

infections, urinary tract infections, hepatitis A• Metabolic disorder: diabetic ketoacidosis• Renal disorder: haemolytic uraemic syndrome• Surgical disorders: pyloric stenosis,

intussusception, acute appendicitis, NEC, Hirschprung disease

• Others: coeliac disease, cow’s milk protein intolerance, adrenal insufficiency

Gastroenteritis - dehydratation

• Can result in shock and death• Infants are particularly susceptible to

dehydratation because of the high surface area to weight ratio

• Clinical features:dry mucosous membranes,eyes sunken and tearless, sunken fontanelle, reduced skin turgor, decreased urine output, tachycardia, tachypnoea

• Shock: hypotension, week peripheral pulse, decreased level of consciousness, pale or mottled skin, cold extermities

Gastroenteritis -investigation

• Usually no investigationse indicated• Stool culture: blood or mucus in the

stool, septic signs, antybiotics• Abnormality electrolytes, urea,

creatinine, glucose: intravenous therapy for rehydratation

Dehydratation – management

No clinically detectable dehydratation ( <5% loss of body weight)Continue breast- feeding/ milk feedsExclude fruit juices and carbonated drinksOral rehydratation solution (ORS) Clinical dehydratation ( 5- 10 % loss of body weight)Continue breast/ formula feedingORS often and in small amountsIf non-effective: intravenous therapy for rehydratation ( give 0.9% sodium chloride solution / 5% glucose) 50

ml/kg Shock (> 10% loss of body weight)Rapid infusion of 0.9% sodium chloride solution Give 0.9% NaCl / 5% glucose 100 ml/kgMonitor plasma electrolytes, urea, creatinine, glucoseConsider intravenous potasium supplementation After rehydratationReintroduce milk and usuall solid food as soon as possibleAvoid friut juices Do not return to school until 48 hours after last episode of diarrhoeaAntibiotics only if there is a bacterial cause

Chronic diarrhoea

• Coeliac disease, cow’s milk protein allergy• Postgastroenteritis syndrome- temporary

lactose intolerance• After bowel resection• Cholestatic liver disease, exocrine

pancreatic disfunction

Peptic disease- etiology, localisation, occurence

• etiology unknown, imbalance between destructive (HCl, pepsin, bile salts, ethanol, drugs, stress) and defensive factors (mucous layer, bicarbonate secretion, mucosal blood flow, prostaglandins) in the stomach

• association of Helicobacter pylori infection• positive family history-30% with peptic ulcer disease, blood

group type O• primary ulcers ( idiopathic) : single, duodenum, gastric

antrum• secondary stress ulcers (injury, sepsis, steroids, NSAID,

burns (Curling’s ulcer), brain injury (Cushing’s ulcer) : single or multiple, stomach

• primary/ secondary 7:1• secondary stress ulcers dominate up to 6 mths• boys> girls (3x)

Peptic disease- steps to diagnosis

Abdominal pain in the epigastric or periumbilical area, worsens with meals or at night, nausea, vomiting, anorexia (25%), hematemesis, melena (20%). Acute onset in viral-like ilness

Physical examination- abdominal tenderness, bleeding, abdominal distension, decreased bowel sounds- signs of perforation, weight loss, reflux symptoms

Laboratory findings: anaemia, iron, ferritin and reticulocyte low level and total iron-binding capacity elevated, occult blood in stool

Peptic disease- diagnosis, differential diagnosis

H-pylori-specific IgG antibody serologic test, C-urea breath test

Radiology GI series (frequency of detection 50-89%)Endoscopy- a procedure of choice

Appendicitis, Meckel’s diverticulum, chronic recurrent (functional) abdominal pain, GER, pancreatitis, cholelithiasis, intussusception, inflammatory bowel disease, gastroduodenitis,

Peptic disease- endoscopy a procedure of choice

normal image (left),

Peptic disease- gastric ulcer, gastritis after NSAID treatment

Duodenal ulcers

Bleeding duodenal ulcers

Peptic disease- management

• no prior established peptic history- initiate therapy with H2 blocker twice daily for 4-6 weeks

• poor response upper endoscopy with biopsy• resistant peptic esophagitis or gastritis, failure to

respond to H2 blocker therapy- proton pump inhibitor therapy for 8 weeks

endoscopic confirmation of healing with recurrent or persistent symptoms

Helicobacter pylori gastritis- cobblestoning

Appendicitis- symptoms, treatment

• the most common surgical condition- can be mimicked by many other childhood diseases

• visceral, poorly localised, periumbilical pain secondary to the distention, within 48 hours the pain become parietal, well localised and constant in the right iliac fossa (Mc Burney’s point)

• muscle rigidity, nausea, vomiting, anorexia

• perforation occurs with a much greater frequency (app 25%) in children population

• appendectomy- a treatment of choice

Appendicitis- risk stratification

• Low risk- neutrophils<67%, bands<5%, no guarding on physical examination

• High risk- neutrophils >67%, WBC count > 10000/mm, guarding on physical examination

Ultrasound is a procedure of choice in children to have low or intermediate probability of appendicitis based on clinical findings.

Computed tomography- increasing use• 94-99% accuracy in the diagnosis but potential risks of

radiation

Abdominal pain in childhood-ultrasonography- advanced periappendiceal inflammation

Appendicitis-abscessus

• a

Appendicitis-inflamed with 2 fecoliths

Meckel’s diverticulum

• Most common congenital anomaly involving the small bowel and terminal ileum

• Remnant of omphalomesenteric duct, 2 feet from ileocecal valve, 2 inches in length, 2 types of ectopic tissue inside: gastric and pancreatic

• Symptoms: usually asymptomatic, symptoms- hemorrhage, intussusception, volvulus, diverticulitis may occure

• 2 main complications: bleeding, obstruction• Diagnosis: scintigraphy with technet, diagnostic

laparotomy• Treatment: surgical resection

Meckel’s diverticulum- anatomy (left)

Inflammatory bowel disease (IBD)

• Etiology: unknown- defect in immunoregulations affecting gut-associated lymphoid tissue + antigens?, pathogenes? (viral, bacterial, mycobacterial agents as a trigger)

• Age: adolescence• Epidemiology: North Europe, North America• Symptoms: pain in lower abdomen, crampy in nature,

increases after meal or activityanorexia, bloody diarrhea (urgent), need to defecate during night, perianal lesions !!! (anal tag, anal fistulas and abscesses), ileal mass, anaemia, fever, recurring aphtous ulcers, large joints synovitis or arthritis, growth impairement (2 standard deviations below), delayed puberty

Inflammatory bowel disease (IBD)

Diagnosis: small bowel barium contrast x-ray, upper gastrointestinal series, colonoscopy with biopses, occult blood in stool, growth velocity curves, bone age, lactose breath hydrogen test

Laboratory findings: anaemia (blood loss, Fe), low serum iron, high total-iron binding capacity, hypoalbuminemia, C-reactive protein, low serum cholesterol,

Complications: colorectal cancer Differential diagnosis: amebiasis, giardiasis, yersinia

enterocolitica, Camphylobacter jejuni, tuberculosis, allergic enteropathies, vasculitis, neoplasms,

Inflammatory bowel disease (IBD)-differences

• Ulcerative colitis-

• * ulcerations limited to mucosal layer

• * large intestine+ rectum * pseudopolyps * x-ray continuous- diffuse * no granulomas * no strictures * no fistulas

• Crohn’s disease-

• * ulcerations patchy, transmural, noncaseating granulomas * any part (ileum 85%)+ rectum * pseudopolyps + strictures * x-ray segmental- patchy * granulomas * frequent strictures * fistulas

Ulcerative colitis- endoscopy imagesNormal mucosa of ileum (left), granular appearance- active (right)

Ulcerative colitis- endoscopy imagesRedness and swelling of ileum mucosa

Ulcerative colitis- endoscopy imagesLeft- mucosal inflammation-redness, ease of bleeding, right -pseudopolips

Crohn disease- (left) pseudopolips, (right) mucosal inflammation, edema, swelling, bleeding, granular appearance

Crohn disease-pseudopolips, fibrosis

IBD- Management

• Oral nutritional support to correct deficits of macronutrients and micronutrients, deliver 125% of calories for height age, multivitamin and mineral supplements,

• Naso- gastric nocturnal feeding• High-calorie intravenous nutrition through a central venous

line • Consider elemental diet

IBD- Management

• Avoid overtreatment !!!• Anti-inflammatory/ immunomodulatory medication: 5

amino- salicylates (sulfasalazine, mesalamine, aminosalicylic acid), metronidazole, ciprofloxacin, fish oil,

• Prednisone (oral, intravenous, enema)• Steroid complications: Cushing, growth retardation, aseptic

necrosis of bones, diabetes t.II, osteoporosis, cataract formation,

IBD- Management

• Immunosuppressive: Azathioprine, 6-mercaptopurine, Cyclosporin A, -globulin, • Immunoregulation treatment: Remicade• Surgical resection: surveilance surgery, sub- or total

colectomy• Complication after surgery: recurrences > 90%, „short gut”

syndrome