pediatrics gastroenterology -...
TRANSCRIPT
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PEDIATRICSPEDIATRICSPEDIATRICSPEDIATRICS
GASTROENTEROLOGYGASTROENTEROLOGYGASTROENTEROLOGYGASTROENTEROLOGY
Atan Baas SinuhajiSub Division of Pediatrics Gastroentero-Hepatology
Department of ChildHealth
School of Medicine
University of North Sumatera
CONTENTS
1.GIS K1.GIS K--12 :=Introduction12 :=Introduction
=Vomiting=Vomiting
2.GIS K2.GIS K--17 :=Diarrhoea (1)17 :=Diarrhoea (1)
3.GIS K3.GIS K--21 :=Diarrhoea (2)21 :=Diarrhoea (2)
4.GIS K4.GIS K--27 :=Food Allergy27 :=Food Allergy
5.GIS K5.GIS K--33:=Necrotizing Enterocolitis 33:=Necrotizing Enterocolitis
=Abdominal distention=Abdominal distention
6.GIS K6.GIS K--34:=Tuberculous peritonitis34:=Tuberculous peritonitis
=Abdominal pain=Abdominal pain
=Disorder of ingestion=Disorder of ingestion
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7. GIS K-35:=Jaundice
8. GIS K8. GIS K--36:=Encephalopathy36:=Encephalopathy
=Gastrointestinal hemorrhage=Gastrointestinal hemorrhage
9. GIS K9. GIS K--37:=Constipation37:=Constipation
=Failure to thrive ( 1 )=Failure to thrive ( 1 )
10.GIS K10.GIS K--38:=Failure to thrive ( 2 )38:=Failure to thrive ( 2 )
11.GIS K11.GIS K--39=Body fluid balance39=Body fluid balance
PEDIATRICS PEDIATRICS PEDIATRICS PEDIATRICS
GASTROENTEROLOGYGASTROENTEROLOGYGASTROENTEROLOGYGASTROENTEROLOGY
SYSTEMATIC PROBLEM
BASEDFUNCTION
DIGESTIVE
SYSTEM
MAJOR SIGNS
&
SYMPTOMS
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DIGESTIVE SYSTEMDIGESTIVE SYSTEMDIGESTIVE SYSTEMDIGESTIVE SYSTEM
PERITONEUM
- ORAL CAVITY
- GI TRACT (ESOPHAGUS ANAL)
DIGESTIVE GLANDS
•SALIVARY GLANDS
•LIVER & BILE DUCT
•PANCREAS
DIGESTIVE TRACT
MAJOR SIGNS & SYMPTOMSMAJOR SIGNS & SYMPTOMSMAJOR SIGNS & SYMPTOMSMAJOR SIGNS & SYMPTOMS
1. DIARRHOEA
2. VOMITING
3. FAILURE TO THRIVE
4. JAUNDICE
5. ENCEPHALOPATHY
6. DISORDERS OF INGESTION
7. ABDOMINAL PAIN
8. ABDOMINAL DISTENSION
9. CONSTIPATION
10. GASTROINTESTINAL HEMORRHAGE
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FUNCTIONFUNCTIONFUNCTIONFUNCTION
1. EATING & DRINKING
2. DIGESTION & ABSORPTION
3. SECRETION
4. MOTILITY
5. ENDOCRINE
6. DEFENCE
7. EXCRETION
DIGESTION
BREAK DOWN
DIETARY FOOD
- PHYSIS
- CHEMICAL
- MECHANICAL
SMALLER PARTICLES
&
CAN BE ABSORBED
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DIGESTIONDIGESTIONDIGESTIONDIGESTION
INTRALUMINAL
-PANCREAS
-LIVER
-STOMACH
INTRACELLULAR
- PEPTIDASE
- LIPASE
MEMBRANE- SUCRASE- MALTASE- LACTASE- GLUCOAMYLASE
ABSORPTION
TRANSPORT OF WATER OR
DIGESTIVE PRODUCTS
LUMEN
MUCOSA
VESSELSBLOOD
LYMPH
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DIGESTION DIGESTION DIGESTION DIGESTION ---- ABSORPTIONABSORPTIONABSORPTIONABSORPTION
INTRALUMINAL DIGESTION
PARACELLULAR
INTERCELLULAR
SPACE
TRANSCELLULAR
MEMBR. DIGESTION
CELLULAR UPTAKE
INTRACELL. DIGESTION
BASOLAT. MEMBRANE
INTERCELLULAR SPACE
BASEMENT MEMBRANE
INTERSTITIAL SPACE
(LAMINA PROPIA)
VESSELS
- BLOOD
- LYMPH
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TRANSCELLULERTRANSCELLULER
Tight
Junction
Basolateral
Membrane
Intercelluler
space
E
n
t
e
r
o
c
y
t
e
Luminal
Membrane
Basal
MembraneLamina
propia
PARACELLULERPARACELLULER
Vessel
VOMITING
Atan Baas Sinuhaji
Department of ChildHealth
School of Medicine,University Of Sumatera Utara
Medan
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Vomiting
overt reflux
passage of gastric contents into
the mouth
Reflux
Movement of gastric contents retrogradeInto esophagus or more proximal
Food/Drink
Gases -Gastric acid
-Pancreatic juice
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REFLUX
OVERT OCCULT
INTO THE MOUTH
VOMITING
INTO THE
ESOPHAGUS
RESPIRATORY
TRACT
LARYNGITIS PNEUMONIAASPIRATION
REFLUX
GASTRIC PRESS. = ESOPH. PRESS.
FUNCTION HIATAL
HERNIA
GASTRIC PRESS. > ESOPH. PRESS.
OBSTRUCTION PERISTALSIS
IN OUT Lower Esophageal
Sphincter (LES)RELAXATION
GastricOutlet
Obstruc.
Pyloric
Stenosis
AbdomInal Tumor
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LES RELAXATION
TRANSIENT CONTINOUS
“Gastroesophageal
reflux”Chalasia
HIATAL
HERNIA=
PARTIAL
THORACICSTOMACH
SLIDING HIATUSHERNIA
PARAESOPHAGEAL
HERNIA = ROLLING
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REFLUX
GASTRIC ACID
= ACID REFLUX
FOOD/DRINK GASES
ERUCTATION HICCUP
= SINGULTUS
= “CEKUKAN”
HEART BURN
= PYROSIS
= “SENDAWA”
Metaplasia
Epithel of
esophagus
Barret’s
esophagus
ULCUS
stricturebleeding
CONSEQUENCES OF REFLUX
1.- SINGULTUS- ERUCTATION
2. HEART BURN = “SENDAWA”3. ESOPHAGITIS & BARRET’S ESOPHAGUS4. CHRONIC PNEUMONIA ASPIRATION5. FAILURE TO THRIVE (FTT)6. LARYNGITIS7. RUMINATION8. SANDIFER’S SYNDROME9. FOOD REFUSAL
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VOMITING
RETURN OF FOOD/DRINK
FROM THE STOMACH TO THE MOUTH
TRUE
VOMITINGREGURGITATION
= SPITTING
= “MINTAR”
= “GUMOH”
PHYSIOLOGICPATHOLOGIC
COMPLICATION (GASTROESOPHAGEAL
DISEASE = GER Disease)
GER
Gastroesophageal reflux (GER)
Physiologic passage of gastric
content to esophagus
Transient LES relaxation
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Gastroesophageal reflux
- 50% of infant 0-3 months of age
- 25% of infant 3-6 months of age
- 5% of infant 10-12 months of age
Resolving in most by 12 months and
nearly all by 24 months
Gastro Gastro –– Esophageal Reflux DiseaseEsophageal Reflux Disease
(GERD) (GERD)
GER that causes symptoms or complications that GER that causes symptoms or complications that
effect quality of lifeeffect quality of life
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GERD GERD ≠ ≠ VOMITINGVOMITING
-- Not all vomiting are GERDNot all vomiting are GERD
-- Many GERD children do not vomitMany GERD children do not vomit
TRUE VOMITING
�� NAUSEANAUSEA
�� RETCHINGRETCHING
�� FORCEFUL GASTRIC CONTENTS/ FORCEFUL GASTRIC CONTENTS/
INTRA ABDOMINAL PRESSURE INTRA ABDOMINAL PRESSURE ↑↑↑↑
�� SYMPTOMS OF AUTONOMIC SYMPTOMS OF AUTONOMIC
NERVUS SYSTEM (+)NERVUS SYSTEM (+)
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REGURGITATION
�� THE YOUNG BABYTHE YOUNG BABY
�� NOT MATURE NOT MATURE L.E.S.L.E.S.
�� NAUSEA (NAUSEA (--))
�� NOT FORCEFULNOT FORCEFUL
�� SYMPTOMS OF ANS (SYMPTOMS OF ANS (--))
RUMINATION
- RETURN OF FOODS INTO THE MOUTH
- FOODS RECHEWED
- FOODS REINGESTED
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NAUSEA
- UNPLEASANT SENSATION & OFTEN
CULMINATING IN VOMITING
- CONTRACTION OF PYLORIC
ANTRAL
- SYMPTOMS OF ANS (+)
VOMITING IN INCREASE INTRACRANIAL PRESSURE
- PROJECTILE
- NAUSEA (-)
- RETCHING (-)
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DIAGNOSIS GER
1. History
2. Body weight ���� poor weight gain ?
3. Diagnostic Test
- Upper GI series ���� rule out anatomical
abnormalities
- pH probe (12-24 hours) ���� Acid reflux����Gold
Standard
- Scintigraphy
- Endoscopy ���� complication
TREATMENT GER
1. Conservative therapy
2. Pharmacotherapy
3. Surgery ���� Nissen Fundoplication
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Conservative Therapy
1. Prone position and upright position :
- The infant is awake and observed
SIDS
2. Small frequent feeding
3. Thickening of formula
Pharmacotherapy
1. Acid Neutralization : Antacids
2. Antisecretory ( Cimetidine, Ranitidine,
Omeprazole, etc)
3. Prokinetic
- Metoclopramide ���� Extrapyramidal
Symptoms
- Bethanechole ���� Bronchospasme
- Cisapride : 0,2 mg/kg/dose 3 or 4 x daily
Arrythmia
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VOMITING
SURVIVAL VALUE
DEFENSE- UNDERLYING
- COMPLICATION
THREATENINGTOXIC
COMPLICATION OF TRUE VOMITING
1. Body Fluids Imbalance- dehydration- hyponatremia
- hypokalemia- hypochloremia- hypocalcemia ==> tetany
- metabolic alkalosis2. Mallory Weiss Syndrome
3. Pneumonia aspiration4. Intake - hypoglicemia
- starvation- Failure To Thrive- Metabolic acidosis
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VOMITING
Na+
WaterCl-H+ K+
Hyponatremia
Met. Alk.
dehydration Hypo-
chloremia
Hypokalemia
hypovolemia
RBF
Renin
Aldosteron ↑↑↑↑
Retention of Na+ & Water
Loss of K+Loss of H+
hypocalcemia
VOMITING
DIGESTIVE TRACTOUTSIDE
Surgery Medical
- obstruction
- inflammation- perforation
- gastritis
- peptic ulcer- Gastroenteritis
- psychogenic- neurogenic:
int.cran. press.↑↑↑↑
- systemic:sepsis- hemodynamic
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MANAGEMENT
1. STABILIZATION OF
GENERAL CONDITIONBody Fluids Imbalance
2. PROTECTION AGAINST ASPIRATION
3. CAUSAL
4. CALORI/ PROTEIN
5. COMPLICATIONS
6. ANTIEMETIC DRUGS
ABDOMINAL EMERGENCY
PNEUMONIA ASP.
CEREBRAL EDEMA
NO RECOMMENDED
ANTI EMETIC
1. DOPAMINE receptor antagonist
- metoclopramide
- domperidone2. Cannabinoid (dronabinol)
3. Anticholinergic (Scopolamine)
4. 5HT3 receptor antagonist
- ondansetron
5. Phenothiazine dan anti histamin
- phenergan, benadryl
- largactil
6. Corticosteroid
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BOWEL
OBSTRUCTI0N
COMPLETE
PYLORIC STENOSIS
INCOMPLETE
INVAGINATION
INVAGINATION = INTUSSUSCEPTION
PROXIMAL BOWEL
(INTUSSUSCEPTUM)
DISTAL BOWEL
(INTUSSUSCIPIENS)
SPONTANEUS
REDUCTION
CONTINUING
3 months - 3 years
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TYPE OF INVAGINATION
- ILEOCOLIC > > >- ILEOILEIC- CECOCOLIC- COLICOCOLIC- ILEOILEOCOLIC
SIGNS & SYMPTOMS- SUDDEN ONSET- PAROXYSMAL PAIN- VOMITING- BLEEDING PERANUM- TUMOR- SIGNE de DANCE- ABDOMINAL DISTENTION - DEFECATION & FLATUS (-)
- WATER & ELECTROLYTES
- HYDROSTATIC
- OPERATIVE
Th / :
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DIAGNOSTIC
CLINIC
RADIOLOGIC
PLAIN OF ABDOMINAL PHOTO
SIGN OF OBSTRUCTION
BARIUM ENEMA- CUPPING- COIL SPRING