gi review and what’s new - d2rw76b9nsxu2w.cloudfront.net · gi review and what’s new 1 ... ibd...

8/2/2017

1

GI REVIEW AND WHAT’S NEW

1

SHEILA BELL, MS, RN, CPNP‐PC

Center for Gastrointestinal Motility and Functional Disorders

Division of Pediatric Gastroenterology and Nutrition

Boston Children’s Hospital

OUTLINE1. IBS – IRRITABLE BOWEL SYNDROME2. CHRONIC RECURRENT ABDOMINAL PAIN (AKA

AS FUNCTIONAL ABDOMINAL PAIN OR FAP)3. GASTROESOPHAGEAL REFLUX4. CONSTIPATON / FECAL SOILING (ENCOPRESIS)5. DIARRHEA6. CELIAC DISEASE7. IBD – CROHNS DISEASE/ULCERATIVE COLITIS8. APPENDITICITIS9. INTUSSEPTION

IBS DEFINITION

A. IBS is a functional gastrointestinal disorder MARKED by abdominal pain

OR discomfort, bloating and irregular bowel habits, such as diarrhea or constipation.

National Institutes of Health

NIDDK

2011

3

8/2/2017

2

B. Rome III diagnostic criterion for IBS in children ages 4 – 18. Both of the following must include:

1. Abdominal discomfort (as defined by an uncomfortable sensation not

described as pain) or pain associated with 2 or more of the following at

least 25% of the time:– Improvement with defecation

– Onset associated with a change in frequency of stool

– Onset associated with a change in form (appearance) of stool

2. No evidence of an inflammatory, anatomic, metabolic or neoplastic process that explains symptoms.

Criteria must be fulfilled at least once per week for at least 2 months prior to diagnosis.

WHAT ABOUT THE SUBTYPES?IBS – C IBS – MIXED

IBS – D IBS – UN-SUBTYPED

ANY MORE CONFUSION!!!!

4

IBS SYMPTOMS

• Abdominal pain/discomfort

• Bloating /distension

• Abdominal pain associated with defecation

• Frequency of bowel movements

• Consistency

• Size/Quantity

• Appetite in AM

• Nausea

DiLorenzo / Hyams

5

Alarm features in children and adolescents with abdominal pain and abnormal stool pattern

• Gastrointestinal bleeding

• Peri-rectal disease

• Fever

• Arthritis

• Persistent vomiting

• Persistent right upper or right lower quadrant pain

• Dysphagia

• Involuntary weight loss

• Nocturnal symptoms

• Family history of inflammatory bowel disease

• Pubertal delay

“ Based on a review of the literature, the accuracy of such alarm features is disappointing.”

IBS Task Force

American College of Gastroenterology, 2009

6

8/2/2017

3

FACTS (I)

• One of the most common symptoms seen by Gastroenterologists and primary care physicians

• World wide prevalence of 10 – 15 %

• 25 to 50% of people with symptoms seek medical care

• Female to male ration 2:1

• IBS consumes $ 20 billion in direct and indirect expenditures

Gastroenterology, 2006

Am. J. Gast, 2009

7

FACTS (II)

• Approximately 8% of middle school children and 17% of high school children have IBS like symptoms

• Rome III has NO diagnostic criteria for children younger than age 4

• 5% of middle and high school students have dyspeptic symptoms

Hyams

J. Ped 1996

J. Ped GN 2008

8

CONCLUSIONS• IBS is a complex common condition with multiple symptoms

presenting without a reliable Biomarker.

• Organic disorders can mimic IBS symptoms especially in the pediatric population

• Sound judgment and careful clinical observation is mandatory in assessing patients with IBS like symptoms

• Red flags and alarm signs should be explored in depth and validated in the pediatric patient with IBS like symptoms

• Doctoring and careful clinic assessment is the most important test in this population.

9

8/2/2017

4

Functional or Chronic Recurrent

Abdominal Pain

CRAP

Chronic Abdominal Pain in Pediatrics

Affects 13% of middle school and 17% of high school students

Interferes with daily living in 21% of students

Hyams, et al

J. Pediatrics 1996; 129: 220 - 226

Overview (I)

3 or more episodes of pain occurring over 3 month period or longer in children 4 to 16 yo with no other associated GI symptoms

Abdominal pain is common complaint & one of the primary reasons for referral to pediatric gastroenterology

Described as crampy, dull or aching pain that rarely radiates, lasts minutes to hours, may occur daily and extend over weeks, months or years

10 to 24% of children experience chronic or recurring abdominal pain

MUST rule out organic or treatable causes first (usually less than 10% of cases)

Young RJ, Philichi L, Clinical Handbook of Pedi GI, Quality Medical Publishing; St. Louis, Mo, 2014 1 ‐ 13

8/2/2017

5

Overview (II)

When asked to point to pain, child usually points around the umbilicus

Seldom occurs during sleep, may interfere with going to sleep or be present upon awakening. Often accompanied by complaint of headache or nausea

Quite unusual in child under 2 years of age, often presents around 4‐5 yo, peaks at 8‐10 yo and persists into adolescence.

Psychologic impact – often “super achievers”, tolerate failure poorly, stress or emotions may cause pain, disrupts child's normal activities, results in poor school attendance and even avoidance of fun activities.

Young RJ, Philichi L, Clinical Handbook of Pedi GI, Quality Medical Publishing; St. Louis, Mo, 2014 1 ‐ 13

History & Diagnosis

• HPI & ROS

*Location, character, duration and intensity of pain

*Time of day or night pain occurs

*Appetite, diet, N&V, food intolerance

stool frequency, consistency, flatulence

*Growth and energy level

*Medication and nutritional interventions tried

*Travel history

• Family History

*IBS*Celiac Disease

*IBD (particularly Crohn’s Disease)

*Inherited disorders

*Migraine headache

• Psychosocial History

*Interference with school, play and peers*Family dynamics, environment and socioeconomic factors

*Hobbies

*Spiritual or cultural factors

*Sexual activity/abuse

*Substance abuse

*Psychiatric history

• Diagnostic TestingReserved for those with atypical S & S

Labs – (CBC, ESR, CRP, Chemistries, IgA, TTGA IgA, UA, UC, Stool, HCG)

Imaging ‐ (ABD/pelvic US, UGI w/SBFT, ABD CT)

EGD, Colonoscopy, ERCP

LHBT, Urea breath test

8/2/2017

6

Relevance….•Common•Functional and developmental impairment attendance and/or performance

•Individual and family suffering•Risk of costly and potentially dangerous physical investigations and treatments

•Excess health and mental health use•Commonly associated with psychiatric disorder in pediatric medical settings

•Possible heightened risk of functional somatic symptoms in adulthood•Possible heightened risk of psychiatric disorder in adulthood

Campo , 1999

Treatment/Therapy

• Clearly define problem for child & family. They should understand that pain is real but that measures need to be taken to lessen it’s impact.

• Counseling sometimes helping to teach coping

• Dietary interventions not consistently helpful. Diet high in insoluble fiber may help. (Enough grams of fiber to equal child’s age plus 5 everyday)

• Trial of acid blockade or antispasmodic medication may be tried. Antidepressants (tricyclic or SSRI’s sometimes considered) Medication is generally discouraged. Avoid pain meds.

• Parents need to encourage normal activities. Avoiding activities during pain episodes only allows child to focus on pain more. Diversion activities including staying in school may actually lessen the severity of pain.

• Increasing parents and child’s knowledge of the condition through education may increase their confidence to manage episodes independently and reduce health care visits.

Hypnotherapy Effective for Functional Abdominal Pain and IBS in Children

• 53 patients (31 F, 21 M) ages 8 to 18 years - All + 12 mo hx of IBS or FAP

• Failed to respond to PPI, laxatives or psychotherapy

Therapy: 1. Hypnotherapy (65/50 min x 3 mo)

2. Supportive therapy (6/30 min x 3 mo)

3. End point: pain intensity and frequency

Results: - Lower score in Hypnotherapy group

(14.1 to 8.0) (13.5 to 1.3)

After one year - <14 years old did better

CLINICAL REMISSION observed in 59% of hypnotherapy group

Vlieger, Benninga

Gastroenterology 2007; 133 (5) 1430-6

8/2/2017

7

Organic Abdominal Pain Red Flags

Weight Loss

Abdominal Distension

Localized/Nocturnal Pain

Rectal Bleeding

Family History of IBD

8/2/2017

8

Signs & Symptoms of GER

• INFANTRegurgitation

Persistent vomiting

Poor weight gain or weight loss

Irritability

Feeding refusal

• CHILD or ADOLESCENT Regurgitation

Persistent vomiting

Poor weight gain or weight loss

Dysphagia, odynophagia

Abdominal pain/substernal pain/heartburn

Persistent throat clearing or cough

Bad breath

Hoarseness, Sore Throat

Diagnostic Testing

• Upper GI Series

look at anatomy, reflux, gastric emptying

• pH probe monitoring for acid reflux or impedance for non‐acid reflux

• Endoscopy with biopsies

• Gastric emptying scan

• Occasionally modified barium swallow, blood work, further testing

8/2/2017

9

GERD & Reactive Airway Disease

25

• Etiological role for GER in reactive airway disease has not been demonstrated

• Association of asthma and reflux measured by IEpH/MII has been reported

• So far old diagnostic methods have been partially helpful: – Restech to measure pharyngeal reflux

– Lipid laden macrophages and Colombo score

– Bronchoscopy

– Scintigraphy

– Pepsin/Bile measurementsRosen, Pediatrics; 2008 Borrelli; JPGN, 2011

Complications of Gerd

GERD

EsophagitisPulmonary

Complications NCCP

Ulcer

Stricture

Bleeding Barrett’s Esophagus

Adenocarcinoma

8/2/2017

10

8/2/2017

11

Eosinophilic Esophagitis

Disorder characterized by a severe, isolated eosinophilic infiltration of the esophagus with symptoms similar to GER or Dysphagia

6% of patients presenting with GER

Unresponsive to acid suppression

8/2/2017

12

Eosinophilic Esophagitis Con’t

No Malignant consequences

Endoscopic Findings: White Plaques, Furrows & Trachealization (Feline esophagus)

Therapy: elemental diet, dietary elimination, topical and systemic steroids, montelukast esophageal dilatation

Liacuras, J. Med Gast Nut, 2003: 37:523, 528

Eosinophilic Esophagitis (Feline Esophagus)

Treatment

LIFESTYLE

• Infant Avoid overfeeding

Thicken formula with rice cereal (1‐3 tsp.per oz)

Hypoallergenic formula

Increase caloric density of formula or tube feeding

Keep upright 30 minutes after feeds

• Child or AdolescentAvoid caffeine, chocolate, fatty foods, carbonated beverages

Avoid eating 2‐3 hours before bedtime

Small frequent meals

Left‐sided positioning & elevation of HOB

Obesity, tobacco smoke, alcohol intake are associated with reflux

MEDICAL THERAPY

• Histamine‐2 receptor antagonists

Cimetidine (Tagamet, Tagamet HB)

Famotidine (Pepcid AC, Pepcid Oral, Suspension) Nizatidine capsules (Axid AR, Axid Capsules, Nizatadine Capsules) Ranitidine (Zantac, Zantac 75, Effervesent, Syrup)

• Proton Pump Inhibitors

Esomeprazole (Nexium)

Lansoprazole (Prevacid) Omeprazole OTC (Prilosec OTC) Omeprazole capsules (Prilosec) Pantoprazole (Protonix) Rabeprazole (Aciphex)

• Prokinetic Agents

8/2/2017

13

Pharmacologic Treatment (I)

37

• Antacids:1. Alginate and Bicarbonate (Gaviscon)

2. Aluminum OH/Magnesium OH + Simethicone (Mylanta)

3. Calcium Carbonate (Maalox, Tums)

• Anti‐Bile1. Sucralfate

2. Cholestyramine

Pharmacologic Treatment (II)

38

H2RA

1. Cimetidine (5 – 10 mg/kg/dose) QID

2. Ranitidine (3 – 5 mg/kg/dose) BID

3. Famotidine (0.5mg/kg/dose) BID

4. Famotidine + Ca Carbonate + Mg OH (Pepcid Complete)

No need to activate Proton Pump

39

Pharmacologic Treatment (III)• Proton Pump Inhibitors

– Omeprazole (0.7 – 3.3 mg/kg/day)

– Lansoprazole (0.8 – 1.1 mg/kg/day)

– Esomeprazole (0.7 – 1.5 mg/kg/day)

– Dexlansoprazole 30 – 60 mg/day

– Rabeprazole (0.5 – 1 mg/kg/day)

Maximal acid suppression can take 72 hours

Activated by food

Inactivated by acid

8/2/2017

14

40

Pharmacologic Treatment (IV)

Pro Motility Agents• Metoclopramide (0.1 – 0.3 mg/kg/dose) QID

• Erythromycin (5mg/kg/dose)

• Azithromycin

• Augmentin

• Domperidone

• 5HT4 Agonists Cisapride, Mosapride

Agonists of GABA receptor (TLESR) Blockers

• Lesogaberan

• Baclofen (0.5 mg/kg/day)

SUMMARY Despite recent advances in diagnosis and therapy of

GERD in children, this entity continues to be a chronic disease that requires careful medical monitoring and well thought therapeutic interventions.

Very seldom GERD is a curable condition and long term control is the ultimate outcome objective.

GERD plays a significant role in the frequency of carcinoma of the esophagus, therefore intervention in the pediatric age is desirable.

42

8/2/2017

15

Constipation/Encopresis

Overview and Definition (I)

ENCOPRESIS

• The underlying cause of encopresis is most often functional constipation.

• Child develops stool mass with incomplete emptying and stool leaks around impaction which results in encopresis.

• Defined as recurring passage of stool into inappropriate places, primarily loose stool in the underwear by a child older than 4 years developmentally without any other organic cause.

Young RJ, Philichi L, Clinical Handbook of Pedi GI, Quality Medical Publishing; St. Louis, Mo, 2014 40‐52

Overview and Definition (II)

CONSTIPATION• Defined as decrease in the frequency of bowel movements or difficulty

defecating for 2 or more weeks with distress to the child

• Constipation is usually functional and not related to an abnormality

• Can be from stress, illness, lack of exercise, change in diet, child who won’t stop to defecate

• Stools are hard and painful to pass leading to functional fecal retention

• Constipation may be a symptom of a disorder such as hypothyroidism, Hirschsprung’s disease, spinal cord dysfunction, colonic neuropathy, Celiac disease, CF or medication


8/2/2017

16

Constipation in Children

• 1 in 10 children seeks medical attention for constipation

• 3 % of pediatric outpatient visits

• 10 to 20 % of pediatric GI visits

• 12 to 19 % prevalence in USA

• 156 % increase in treating constipation during an 8 year period

Definition of Refractory Constipation

TYPE OF CONSTIPATION THAT IS UNRESPONSIVE TO DIETARY MANIPULATIONS AND LAXATIVE INTERVENTION WITH A PROFOUND IMPACT ON THE CHILD’S QUALITY OF LIFE.

CHILDHOOD CONSTIPATION: LONGITUDINALFOLLOW UP BEYOND PUBERTY

• 418 PATIENTS > OLDER 5 YEARS AT INTAKE

• 95 % FOLLOW UP FOR 5 YEARS (RANGE 1 – 8 YEARS)

• SUCCESSFUL Rx: 60 % AT 1 YEAR, 80 % AT 8 YEARS

• 50 % RELAPSE (BOYS > GIRLS)

• 16 YEARS AND OLDER / 30 % CONSTIPATION

NOT TRUE THAT CHILDHOOD CONSTIPATION GRADUALLY DISAPPEARS.

VAN GINKEL, et al.

Gastroenterology

2003:12: 357- 363

8/2/2017

17

Refractory Constipation AlgorithmRefractory Constipation

Medical Rx Failure

ACECure

Failure

Diversion

Reanastomosis

Surgical Resection

SubtotalColectomy

TotalColectomy

+Ileo‐rectalanastomosis

+Colo‐rectalanastomosisA. Flores

History• HPI & ROS

When did condition develop

Urinary Problems

Bowel Pattern – frequency, size, consistency, amount

Pain or bleeding with defecation

Fecal soiling/incontinence

Withholding behaviors

Social precipitating event

Abdominal pain

Diet

Weight loss

Vomiting

Medications

Toilet training history

Neurologic problems

• Medical History

Passage of meconium

Growth and development

Illness, surgery, hospitalization

• Family History

GI problems including constipation

Metabolic, Thyroid, Celiac Disease, CF

Other significant illness

• Psychosocial History

Family composition

Peer interaction

School/Public toilet use

Child’s temperament

Abuse

Diagnosis

• Careful physical exam

• Red Flags: abnormal neuro, anal stenosis, blood, FTT, Fever, tight empty rectum, vomiting, abdominal pain, pilonidal dimple

• Labs: thyroid, calcium, celiac, lead, sweat test

• KUB, BE, transit study, MRI of LS spine

• Rectal manometry, colonic motility

8/2/2017

18

Treatment/Therapy (I)

• Diet

Whole grains, fruits, vegetables

Sorbitol containing liquids (prune, pear)

?? Milk elimination

• Behavior Modification

Toileting 5‐10 min after meal/gastrocolic

Suspend toilet training until resolved

Motivation: rewards, calendar, diary

Psychological support/praise

• Biofeedback

• Medical

Disimpaction: enemas, suppositories

Maintenance: laxatives, lubricants, stimulants

Treatment/Therapy

• Surgery (very small percentage)

Bowel irrigation via ACE (appendix, cecum, colon)

Ileostomy/Colostomy

• Education ‐ CRITICAL

Relapses are common

Do not stop meds suddenly – wean slowly

Fecal soiling usually occurs without child’s knowledge

Provide positive reinforcement

Can take 6 to 12 months or longer for condition to resolve

Allow unhurried use of toilet

Diarrhea

8/2/2017

19

Overview

• Diarrhea is an increase in frequency, volume and liquidity of stool

• Acute diarrhea is of < 3 weeks duration, self‐limiting, and most often infectious from viral, bacterial or parasitic agents

• Chronic diarrhea has duration of > 4 weeks, cause may be (1) viral, bacterial or parasitic agents (2) carbohydrate intolerance (3) milk soy allergy (4) IBD, IBS, short‐gut (5) rare congenital disorders (6) Immunodeficiency states (HIV, SCID)


Definition

• Diarrhea compromises 4 types

Secretory – large volumes of watery diarrhea caused by viruses, protozoas, excessive gastric secretions or congenital digestion problems

Osmotic – caused by poorly absorbed solutes or malabsorption of lactose or sucrose in enzyme deficient states

Inflammatory – exudative diarrhea with blood and mucous from IBD, bacterial invasion, vascular changes

Abnormal intestinal motility – increased bowel contractions that propel fluid thru intestine before absorption (antibiotics, inflammation, obstruction, neuropathy)


History

HPI & ROS

Age of onset

Character of stool – bloody, bulky, watery, steatorrhea

Associated symptoms – vomiting, abdominal pain, fever, arthralgia, weight loss, movement of fluid in and out GI tract

Travel

Infectious contacts

Diet – amount of fluid intake, dietary extremes

Medications

Medical History

Recent use of antibiotics

History of abdominal or intestinal surgery

Recent hospitalization

Family History

Celiac disease

Inflammatory bowel disease

Food allergies

Lactose intolerance

Psychosocial History

Travel to endemic areas

Ill family members

Source of water in the home

8/2/2017

20

Diagnosis

CBC, ESR, CRP, Albumin, Iron, TIBC

Stool (choose tests based on history)

O &P, Occult blood, culture (S, S, C), Yersinia,

C. Diff toxin A & B, Rotavirus, Norwalk agent, Adenovirus, Cryptosporidium, Giardia, E. coli, Staph aureus, reducing substances, fecal fat

Lactose hydrogen breath test

UGI with SBFT

Consider EGD and Colonoscopy

Treatment/Therapy (I)

• All treatment based on suspected cause

• Chronic nonspecific diarrhea Reassurance, high fiber diet, higher fat diet, avoid fluids with fructose and sorbitol

• Antibiotic/Antiparasitic agents

• Inflammatory Bowel Disease

5‐ASA (oral or rectal), Steroids, Immunomodulators, Immunosuppressive therapy, biologics

• Adsorbents and/or antimotility agents as appropriate

Treatment/Therapy (II)

• Education

Signs and symptoms of dehydration

Clear liquids during acute phase only

Maintain balanced diet or normal feedings (may temporarily decrease lactose)

When to call health care provider

Importance of good hand washing/use of ethyl alcohol based hand sanitizer

8/2/2017

21

CELIAC DISEASE

OVERVIEW• Celiac Disease (CD) also called gluten intolerance, gluten

sensitive enteropathy, nontropical sprue or celiac sprue is lifelong sensitivity to gluten that can damage small intestine

• Gluten is storage protein found in wheat, rye, barley

• Variety of clinical GI and non- GI manifestations beginning in childhood or adult life

• Maybe completely asymptomatic

• Prevalence of CD in U.S. children is estimated to be 1:100

PATHOPHYSIOLOGY

• CD caused by immune response to gluten

• Both exposure to gluten and presence of human leukocyte antigen (HLA) DQ2/DQ8 genes are necessary

• Unknown environmental factors, stress and other unidentified genes also critical

8/2/2017

22

GI MANIFESTATIONS

Chronic or recurrent diarrhea

Abdominal distension

Anorexia

Failure to thrive or weight loss

Abdominal pain or irritability

Vomiting

Constipation64

Old paradigm - CD is a disease of small intestine

Celiac disease• villous atrophy

• malnutrition

London, year 1938

65

OVERVIEW• Celiac Disease (CD) also called gluten intolerance, gluten

sensitive enteropathy, nontropical sprue or celiac sprue is lifelong sensitivity to gluten that can damage small intestine

• Gluten is storage protein found in wheat, rye, barley

• Variety of clinical GI and non- GI manifestations beginning in childhood or adult life

• Maybe completely asymptomatic

• Prevalence of CD in U.S. children is estimated to be 1:100

8/2/2017

23

PATHOPHYSIOLOGY

• CD caused by immune response to gluten

• Both exposure to gluten and presence of human leukocyte antigen (HLA) DQ2/DQ8 genes are necessary

• Unknown environmental factors, stress and other unidentified genes also critical

New paradigm: multi-organ autoimmune disease

Celiac disease• villous athrophy

• malnutrition

• malignanciesBone

• osteoporosis, fractures

• arthritis

• dental anomalies

Hepatitis

Cholangitis

Skin & mucosa

• dermatitis herpetiformis

• aphtous stomatitis

• hair loss

Reproductive

• miscarriage, infertility

• delayed puberty

Central nervous system

• ataxia, seizures

• depression

Carditis, cardiomyopathy

Anemia

68

Non-GI Manifestations

o Dermatitis herpetiformis

o Dental enamel hypoplasia

o Aphtous stomatitis

o Osteopenia/osteoporosis

o Epilepsy w/occipital calcifications

o Short stature

o Delayed puberty

o Resistant iron deficiency anemia

o Hepatitis

o Arthritis

o Infertility

o Fatigue

69

8/2/2017

24

Dermatitis Herpetiformis

• Erythematous macule > urticarial papule > tense vesicles

• Severe pruritus

• Symmetric distribution

• 90% no GI symptoms

• 75% villous atrophy

• Gluten sensitive

By permission of Dr. A. Fasano70

Involve the secondary dentition

Dental Enamel Defects

By permission of Dr. C. Catassi71

Aphtous Stomatitis

By permission of Dr. C. Mulder72

8/2/2017

25

Osteopenia/OsteoporosisLow bone mineral density by DEXA in a child with untreated CD

By permission of Dr. S. Mora 73

Occipital Calcification & Epilepsy

By permission of Drs. C. Catassi and G, Holmes74

Medical/Family History

Associated Conditions• Autoimmune thyroiditis

• Type I diabetes

• IgA deficiency

• Trisomy 21

• Turner’s syndrome

• William’s syndrome

Increase risk of developing CD by 3% to 12 %

Family History

• Having relatives with CD increase risk

1:22 in first degree relative

1:39 in second degree relative

• Relatives with autoimmune disease

75

8/2/2017

26

Diagnostic Testing • Serologic Tests:

Total serum IgA, Human TTG IgA, Endomysial IgA, may also obtain Antigliadin IgG or IgA (AGA) in young children or those deficient in IgA

• Intestinal biopsy if serology positive:

EGD and small bowel biopsy of distal duodenum or proximal jejunum

Visually may be normal or scalloping, notching or aphthous ulcers

• Pathology:

Number of intraepithelial lymphocytes

Degree of crypt hyperplasia and villous atrophy

76

Genetic Testing

• High negative predictive value

• Does not diagnosis Celiac Disease

• HLA DQ2/DQ8

Essential for development of disease

Genetic markers can identify individuals as high or low risk for developing CD

77

Treatment and Follow-up

• Gluten-free diet for life

• Nutrition education for child and family

• Refractory sprue may require immune suppressants

• Periodic assessment of growth & symptoms, repeat TTG after 3 to 6 months then yearly, good measure of compliance

• Repeat EGD 18 -24 months after Dx to ensure mucosal healing

78

8/2/2017

27

Inflammatory Bowel Disease

CROHN’S DISEASEVERSUS

ULCERATIVE COLITIS

79

OVERVIEW

• Affects all age groups – diagnosis usually in second decade (over age 10 years)

• Affects males and females equally

• More common in Caucasian than non-Caucasian

• More common in industrialized nations

• Classified as auto-immune disease

80

81

8/2/2017

28

High

Medium

Low

Global Prevalence of IBD

82

PATHOPHYSIOLOGY

Crohn’s Disease• Can affect GI tract from mouth to

anus

• Small bowel (terminal ileum) involved in 90% of cases

• 50 % may have both ileal and colonic involvement

• Perianal involvement including skin tags, anal fissures, fistulas and abscesses in 40 % of cases (may precede intestinal symptoms)

• Symptoms depend on location and extent of inflammation

Ulcerative Colitis• Chronic relapsing inflammatory

disease of colonic and rectal mucosa

• May involve entire colon and rectum but with varying degrees in ulceration, edema, hemorrhage

• Inflammation generally limited to mucosal layer of bowel wall but may extend deeper with more severe colitis

• Due to similar features may be difficult to differentiate from Crohn’s Disease

83

Presenting Symptoms

GI Manifestations• Diarrhea/cramping

• Weight loss/growth retardation

• Abdominal pain

• Rectal bleeding

• Early satiety

• Nausea/anorexia

Extraintestinal • Fever

• Mouth Sores

• Joint pain/swelling

• Rashes

• Eye issues

• Perianal complaints

• Liver Disease

84

8/2/2017

29

Etiologic Interplay

Nature Nurture

IBD

Genes Environment

85

Diagnostic Testing

• Lab Work:CBC with differential, Chem 20, ESR, CRP, Serology 7

• Imaging Studies:UGI with SBFT, Ultrasound, Abdominal/pelvic CT, MRI

• Endoscopic Procedures:

Upper Endoscopy with biopsies, Colonoscopy with biopsies, Flex sigmoidoscopy, Capsule Endoscopy

86

Medical Management• 5-Aminosalycilates

• Rectal preparations of mesalamine

• Steroids

• Immunomodulators

• Antibiotics

• Proton Pump Inhibitors

• Biologic Agents

• Vitamins and Minerals

• Probiotics

87

8/2/2017

30

Surgical ManagementCrohn’s Disease

• Resection

• Ileostomy or Colostomy

• Incision and Drainage

Ulcerative Colitis• Colectomy

• Endorectal Pull through

• IPAA (ileal pouch-anal anastomosis )

88

LIFESTYLE

• Well balanced diet

• Avoid nuts, seeds, popcorn, lactose

• Nutritional supplements

• Polymeric enteral diet (orally or overnight with NG tube)

• Coping skills

• Stress management

89

Follow-up• Monitor growth and development• Encourage normal function including school and

age appropriate activities• Monitor labs, assess for medication side effects,

repeat imaging and endoscopic evaluations• Monitor for disease complications (bone density,

non-compliance with meds & diet)• Monitor for recurrence/flares• Education and support

90

8/2/2017

31

Ball JW, Bindler RC, Child Health Nursing, 3rd Edition. Pearson publishing, 2013 Chapter 30



8/2/2017

32




8/2/2017

33




8/2/2017

34

THANK YOU

• QUESTIONS ??

• COMMENTS !!

100

gi review and what’s new - d2rw76b9nsxu2w.cloudfront.net · gi review and what’s new 1 ... ibd...

Documents