Pediatric_Gastroenterology_2024.pptx

Pediatric Gastroenterology Scott Cyrus, DO, FACOP Chair Department of Clinical Medicine Professor and Chief Division of Pediatrics Burrell College of Osteopathic Medicine August 14, 2024 @ 10:00 – 11:00 am [email protected] GOALS 1. To have the BCOM medical students understand pedia...

Pediatric Gastroenterology Scott Cyrus, DO, FACOP Chair Department of Clinical Medicine Professor and Chief Division of Pediatrics Burrell College of Osteopathic Medicine August 14, 2024 @ 10:00 – 11:00 am [email protected] GOALS 1. To have the BCOM medical students understand pediatric gastrointestinal disorders 2. To have the BCOM students differentiate the characteristics of the different pediatric gastrointestinal disorders 3. To have the BCOM students recognize in the clinical setting the presentations of pediatric gastrointestinal disorders  OBJECTIVES At the conclusion of the lecture, YOU will be able to: 1. Differentiate the characteristics of pediatric gastrointestinal disorders and create a differential diagnosis for abdominal pain 2. Describe common characteristics of pediatric gastrointestinal disorders involving diarrhea, vomiting, reflux, and constipation 3. Compare and contrast the pediatric gastrointestinal disorders requiring immediate intervention and monitoring versus reassurance. 4. Differentiate the signs and symptoms of liver  Gastroesophageal Reflux and Neonatal and Child Stomach The stomach lying horizontally, is round until approximately 2 years of age. In horizontally lying of baby the gastric fundus is lower than the antral part of the stomach. The lower esophageal sphincter has a poor development of mucous membrane and muscular layer, its tone is decreased or relaxed  Gastroesophageal Reflux and Neonatal and Child Stomach Pyloric sphincter is developed well. The fundus of the stomach is under the left dome of the diaphragm. Gastroesophageal reflux and regurgitation is frequent in infants Sandifer syndrome involves spasmodic torsional dystonia with arching of the back and rigid opisthotonic posturing, mainly involving the neck, back, and upper extremities, associated with symptomatic gastroesophageal reflux  Neonatal Liver and Jaundice The liver, from a gastrointestinal standpoint, is an exocrine gland that produces bile to digest fats The liver remains functionally immature until approximately 1 year of age During uterine life, the predominate hemoglobin is HbF required to carry oxygen since the oxygen tension available to the fetus is decreased After delivery, the newborn no longer requires hemoglobin F, and the excess cells are destroyed by the reticuloendothelial system and not replaced  Neonatal Liver and Jaundice When the erythrocytes are broken down, the end products of metabolism are formed, and hemoglobin becomes a protein, consisting of globin, heme, and bilirubin Unconjugated (indirect) bilirubin is formed in the liver and spleen from these byproducts and then binds to albumin in the plasma Since newborn albumin has limited binding capacity, a significant amount of unconjugated bilirubin accumulates, and plasma concentrations may become elevated It results in visible jaundice  Neonatal Liver and Jaundice Bilirubin rises in the newborn and peaks at 3-5 days of age. Dependent on gestational age and neurotoxicity risk factors (Iso-immune disease, sepsis decreased albumin) Bilirubin that rises to 25 to 30 or greater can cause kernicterus. Bili is measured at 24 hours of age to determine its severity and predictability to get greater than safe levels. Photo Therapy is the appropriate initial treatment Exchange transfusion is necessary only in severe cases. Colic Colic is a bit of a mystery The term applies to any healthy, well-fed infant who cries more than 3 hours a day, more than 3 days a week, for more than 3 weeks Colic is likely to start around age 2 weeks if your infant is full-term (or later if premature). It almost always goes away on its own by 3 or 4 months. Your baby's sex and birth order, and whether you breast- or bottle- feed, don’t affect it. Kids who had colic as babies are no different from those who didn’t. Colic Possible etiology A growing digestive system with muscles that often spasm Gas Hormones that cause stomach pain or a fussy mood Oversensitivity or overstimulation by light, noise, etc. A moody baby A still-developing nervous system  Colic Infants could be irritable because of: An infection Acid reflux or stomach problems Pressure or inflammation of the brain and nervous system Eye trouble, like a scratch or increased pressure Irregular heartbeat Injury to bones, muscles, or fingers Treatment: Restrictive diet, change formula, gas drops, prescription  Abdominal Pain Abdominal pain is a common pediatric problem in 2-4 % of the office visits Chronic abdominal pain is defined as at least three bouts of pain severe enough to affect activities over a period of at least 3 months Functional abdominal pain is now classified as a pain-related fu Categorized as: Functional dyspepsia (discomfort in the upper abdomen) Irritable bowel syndrome or IBS (pain associated with changes in bowel habits, either diarrhea, constipation, or both) Abdominal migraine (paroxysmal abdominal pain associated with anorexia, nausea, and/or vomiting) Functional abdominal pain syndrome (functional pain without the features of dyspepsia, irritable bowel syndrome, or abdominal  The persistent or recurrent pain or discomfort localized to the upper abdomen Symptoms commonly occur after eating Functional Many children miss school because of the pain, nausea, and occasional vomiting Abdomina attributed to functional dyspepsia Prevalence between 5% and 16% in the l Pain United States Functional Unlike adults, the differential diagnosis is less extensive Dyspepsia Cancer of the stomach and esophagus is almost nonexistent Gastric and duodenal ulcers are much less common Helicobacter pylori infection in children in the US is an uncommon cause  The etiologies of FD is unknown but thought to be dysmotility Functional Abnormal antral contractility was associated with postprandial nausea Abdomina Adolescents with FD demonstrated delayed gastric emptying and decreased gastric l Pain volume accommodation after feeding Psychological factors may play a role in Functional symptom expression Dyspepsia Patients report higher anxiety and stress Treatment: Improve/Increase gut motility (Erythromycin)  Red flags: Should make you Suspicious of other Causes for the Pain Nocturnal symptoms that awaken the patient Functional Involuntary weight loss Abdomina Deceleration in linear growth Blood in the stool l Pain Fever Functional Urinary complaints Pain away from the umbilicus Dyspepsia (especially right lower/upper quadrant) Family history of inflammatory bowel disease Organomegaly  Peptic Ulcer Disease (PUD) Main pathogenic mechanism: A reduction of the protective effect of prostaglandins on gastric mucosa A common cause is Helicobacter pylori (HP) infection Use of nonsteroidal anti-inflammatory agents (NSAIDs) Aspirin and ibuprofen Steroids and antineoplastic and immunosuppressive drugs Stressful events shock, sepsis, burnings, major trauma, intracranial hypertension, surgical  Peptic Ulcer Disease Lesions generally appear 3–6 days after the event and the main related symptoms are bleeding and abdominal pain Most of the time, multiple lesions involving any part of the stomach are observed Stress and spicy foods do NOT cause ulcers; may exacerbate https://steptohealth.com/natural-treatment-stomach-ulcers/ existing ones  Peptic Ulcer Disease Cushing ulcers: Associated with a brain tumor or injury; they are typically single, deep ulcers located in the duodenum or stomach that are prone to perforation Obesity has been shown to have an association with PUD Neoplastic ulcers are related to the development of lymphomas Hypersecretory states that may uncommonly cause PUD Gastrinoma (Zollinger-Ellison syndrome) Multiple endocrine neoplasia type I (MEN-I) Leukemias, cystic fibrosis, short bowel syndrome, and hyperparathyroidism  Peptic Ulcer Disease The most significant symptoms involve dull stomachache or pain, intermittent abdominal discomfort (typically occurring several hours after a meal or in an empty stomach, often being relieved by eating), gas and bloating, nausea and, less commonly, vomiting Gastric and duodenal ulcers cannot be differentiated based on history alone Epigastric pain is the most common symptom of both gastric and duodenal ulcers and is characterized by a gnawing or burning sensation occurring shortly after meals with gastric ulcer and 2-3 hours afterward with duodenal ulcer Alarm symptoms supporting the suspect of GI bleeding or ulcer perforation involve sudden, sharp abdominal pain, black or bloody stools, and bloody or coffee-like vomits  Helicobacter Pylori ( H pylori) H pylori colonizes the stomach, induces inflammatory cytokines, and causes gastric inflammation H pylori has been associated with iron- deficiency anemia Most children infected with H pylori are asymptomatic Antral gastritis is the most common manifestation in children Duodenal and gastric ulcers may be associated with H pylori gastritis but are uncommon in children In developed countries, less than 10% of children younger than 12 years are infected  Esophagi tis Esophagitis (inflammation of the squamous esophageal epithelium) https://www.webmd.com/digestive-disorders/esophagitis-2 (*Most Common) Results from various causes: GERD: acid and nonacid * Infection* Corrosive ingestions * Food allergies Esophagi In infants, may be difficult tis to differentiate from colic Treatment often includes therapy for excessive gas Changing of formulas, especially because parents may note pain and crying, pulling up of legs, and abdominal distention Over the long term, all types of esophagitis can be complicated by the development of strictures  Esophagitis Diagnostic Test: An upper gastrointestinal (UGI) study should be considered in all patients with persistent emesis and in whom esophagitis is suspected Esophagogastroduodenoscopy (EGD) is performed to allow more definitive visualization of the esophageal mucosa Biopsy samples are always obtained to look for histologic confirmation Treatments: Antacids, Proton Pump Inhibitors, H2 blockers  Eosinophilic Esophagitis (EE) 75% of individuals are white males Incidence approximately 1 in 10,000 people Etiology is unknown, but it appears to be related to food allergies More common in patients with other allergic diseases, such as asthma In young children, mimics gastroesophageal reflux disease (GERD) Feeding disorders Poor weight gain  Eosinophilic Esophagitis (EE) An inflammatory condition in which the wall of the esophagus becomes filled with large numbers of white blood cells (eosinophils) The condition inflames the esophagus Symptoms: Difficulty swallowing Pain Nausea Regurgitation Vomiting Can cause the esophagus to narrow over time Food can become stuck, or impacted Eosinophilic Esophagitis (EE) Most common treatments are dietary therapy and topical steroids (budesonide) Proton Pump inhibitors Dietary Therapy include Elimination Diet; milk, soy, wheat, eggs, nuts, and fish (65–75% effective) Allergy testing (skin prick or patch testing) A strict elemental diet, in which all foods are eliminated, and patients are given a formula  Esophageal Achalasia A motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation Rare in children The most common symptoms: Vomiting Dysphagia Regurgitation Weight loss Definitive diagnosis is made with barium swallow study and esophageal manometry  Gastroenteritis Often considered a benign disease Remains a leading cause of pediatric morbidity and mortality around the world 520,000 deaths annually in children younger than 5 years Viruses remain by far the most common cause Several bacterial species also play an important role Two primary mechanisms: Damage to the villous brush border of the intestine, causing malabsorption of intestinal contents and leading to osmotic diarrhea Release of toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen, leading to secretory diarrhea  Diarrhea Vomiting Gastroenteri Increase or decrease in urinary frequency tis Abdominal pain Symptoms Presence of fever, chills, myalgias, rash, rhinorrhea, sore throat, cough; Including weight loss and increased Changes in appearance malaise, lethargy, or irritability, as well as changes in the amount and and behavior frequency of feeding and the child’s level of thirst History of recent antibiotic use - Increases the likelihood of Clostridium difficile (C. diff)  History of travel to endemic areas: parasitic diseases (Giardia and Cryptosporidium) or cholera Daycare: Rotavirus or norovirus Gastroenterit is Campylobacter, Salmonella, Shigella, and enterohemorrhagic Escherichia coli (EHEC) species Symptomatic Treatment Usually  Increasing in number of cases, 1.3 cases to every 1000 adult cases 10% < 6 months, 21% 0.5 to 10 years, and 69% in 11 to 21 Cholecyst years old Subdivided into 2 subtypes: Acute and Chronic (though closely related) itis Acalculous cholecystitis (cholecystitis without stones) is not unusual Intermittent abdominal pain, possible scapular radiation pain Infants: Irritability jaundice, and acholic stools.  Cholecystitis 3 types of stones: Cholesterol, Pigment and Brown Cholesterol gallstones are radiolucent, Composed of cholesterol (>50%), calcium salts, and glycoproteins Pigment stones are radiopaque, black, and associated with hemolytic disease Brown stones are orange, soft, greasy, and form in the ductal system Most common complication, Pancreatitis Abdominal ultrasonography is the diagnostic tool of choice Cholecystectomy is the standard of care for cholecystitis  Pancreatitis Multiple types; Acute, Acute recurrent (two or more acute episodes), Acute Hemorrhagic, Chronic, and Pseudocysts Acute affects 1 in 10,000 children, Chronic 2 in 100,000 children per year Main risk factor; inherited genetic variants, obstructed ducts Cystic Fibrosis is the Most Common inherited genetic cause Shwachman Diamond Syndrome 2nd MC with pancreatic insufficiency  Pancreatitis Characterized by inflammation of the pancreas, clinical signs of epigastric abdominal pain, vomiting, and elevated serum digestive enzymes Imaging Studies: US, CT, and MR cholangiopancreatography Laboratory studies: Complete Metabolic Profile (CMP) Lipid Panel, Amylase, Lipase*, CBC, Calcium Treatment: Pain management, pancreatic enzymes, bowel rest, insulin, IV fluids Mild forms can be treated at home  Toddler’s Diarrhea AKA as chronic nonspecific diarrhea of childhood Affects children from 6 months to 5 years of age They will have 3-10 loose stools per day These stools typically occur during the day when the child is awake and sometimes immediately after eating Stool is frequently watery or loose and may have food particles present The stools should not contain blood Despite the diarrhea, the child continues to grow and gain weight appropriately The child is active and has a normal appetite Abdominal pain is atypical Toddler’s diarrhea is not considered a disease  Toddler’s Diarrhea The etiology is thought to be high carbohydrate diet, sweetened drinks Treatment: Avoid drinks with sorbitol or fructose. Your child should not receive more than 4-6 ounces a day. Avoid other sweetened clear liquids. Give your child the recommended amount of milk for age, and water as requested. Fiber supplements can sometimes add bulk to the stool. Increased dietary fat can decrease diarrhea. For example, switching to whole milk may be the only dietary change necessary. Other changes in the diet are usually unnecessary and can interfere with growth. Medications are only rarely recommended and should be only used under a physician’s guidance.  Inflammatory bowel disease (IBD) includes Crohn's disease and ulcerative colitis An inflammatory disease affecting approximately 1.6 million Americans, Irritable including as many as 80,000 children Bowel Most cases are diagnosed before the age of 35 Syndrom IBD is one of the most significant chronic diseases affecting children e and adolescents. Bleeding is less common in individuals with Crohn’s disease than in persons with ulcerative colitis, but both may have bloody diarrhea as part of the clinical scenario  Ulcerative Colitis versus Crohn’s Disease Ulcerative colitis (UC) is a disease characterized by remitting and relapsing inflammation of the large intestine UC, Crohn’s disease (CD), and indeterminate colitis account for the disorders that represent inflammatory bowel diseases (IBDs) Many patterns of presentation are possible within the pediatric age group The hallmark symptoms of UC include abdominal cramping, diarrhea, and bloody stools, but physical symptoms vary with the extent, duration, and severity of the disease. UC affects the rectum, with contiguous involvement that can include the entire large intestine. The disease phenotype can be characterized according to the Paris Classification, which divides the disease into isolated proctitis, left-sided colitis, extended colitis, and pancolitis. Extra-intestinal manifestations of UC, such as joint pain, ophthalmic conditions, and hepatobiliary disease may occur in some patients. In the United States, 2 of every 100,000 children (ages 10-19 y) are affected, and 20-25% of all cases UC occur in persons aged 20 years or  Ulcerative Colitis verses Crohn’s Disease Crohn's disease Ulcerative colitis Crohn's disease is characterized Ulcerative colitis is by a chronic inflammatory characterized by continuous process that may affect any part segments of inflammation in of the GI tract, from the mouth the large intestine (colon) and to the anus, extending through the rectum. Only the one or more layers of the intestinal wall. It may appear in innermost layer of the “patches”, affecting one area of intestinal wall is affected. the GI tract and not the next. Ulcerative Colitis verses Crohn’s Disease http://www.chop.edu/conditions-diseases/inflammatory-bowel- disease  IBS Treatments The main goals of medical treatment are to relieve symptoms, prevent flares, and achieve mucosal healing (healing of the intestine) and remission Adalimumab (Humira) The ultimate aim is Adalimumab-adbm ( Cyltezo) for a child to lead a Adalimumab-atto ( normal life as Amjevita) possible Certolizumab (Cimzia) Infliximab (Remicade) Treatment with Infliximab-abda (Renflexis) Infliximab-dyyb (Inflectra) medication is one Natalizumab (Tysabri) therapeutic option Risankizumab (Skyrizi) Medications; Steroids  IBS Treatments Nutritional therapy, often when used with medical treatment, is another important therapy that can include a variety of options. Surgery may be a therapeutic option These chronic diseases can be treated, but are not yet curable  Motility Disorders Pediatric gastrointestinal motility disorders are common Relative benign conditions (constipation) to more serious disorders (esophageal achalasia, Hirschsprung disease, and intestinal pseudo- obstruction) Primary diseases such as congenital pseudo- obstruction or Hirschsprung disease occur more often in children Diagnostic studies: Radiography: plain films, Barium enema, upper gastrointestinal series with small- bowel follow-through  Constipation Fecal Impaction and Soiling Common childhood problem with both somatic and psychological effects Likely multifactorial, and seldom due to organic pathology Primary Encopresis: Continuous soiling throughout their lives, without being initially toilet trained Secondary Encopresis: Soiling after they have been successfully toilet-trained Children benefit from prompt and thorough management of this disorder  Constipation Goals of treatment To produce soft, painless stools and to prevent re- accumulation of feces. Education, behavioral modification, daily maintenance of stool softeners, and dietary modification are all important components of therapy Fecal dis-impaction may be necessary at the outset of treatment X-rays and investigations are rarely necessary Polyethylene glycol 3350 and electrolytes. Gastroenterologist referral should be made in refractory cases or when there is a suspicion of organic pathology Polyethylene glycol is a safe, effective, and well- tolerated long-term treatment for constipation Rarely, children need to be admitted and use  Celiac Disease Celiac disease may develop any time after wheat or other gluten-containing foods are introduced into the diet Typical celiac disease appears at 9-24 months of age It is unknown why some children become ill early in life and others fall ill only after years of exposure There is wide variation in the severity of symptoms – many children will experience symptoms within minutes to hours after consuming gluten, which may only last a few hours. In others, symptoms may last several days or up to two weeks  Celiac Disease There is wide variation in the severity of symptoms – many children will experience symptoms within minutes to hours after consuming gluten, which may only last a few hours. In others, symptoms may last several days or up to two weeks Many children have mild symptoms that are easy to miss, such as having excessive gas, abdominal pain, or constipation Other children have more severe symptoms that can result in an earlier diagnosis, including failure to thrive, weight loss, and vomiting Typically responds well to treatment with the gluten-free diet. Most children feel significantly better after two weeks on the diet and attain normal height, weight, and bone health.  Hematochezia Gastrointestinal (GI) bleeding in infants and children occurs frequently Neonates Anal fissures are the most common cause of GI bleeding in infants Typically, bright red blood streaks the stool or causes spots of blood in the diaper Tear at the mucocutaneous line, most commonly located dorsally (six o’clock position) and in the midline  Hematemesis Neonates: Most Common cause: Vomited swallowed maternal blood (Apt, alkali denaturation test) Other common causes: Milk Protein Allergies Bacterial enteritis Intussusception Lymphonodular hyperplasia Milk or soy enterocolitis Allergic colitis  Hematemesis Children aged 1 month to 1 year Peptic esophagitis caused by gastroesophageal reflux (GER) is a common cause of bleeding Children aged 1-2 years Peptic ulcer disease Children older than age 2 years Esophageal varices can result from portal hypertension The increased resistance to blood flow through the portal system is due to prehepatic, intrahepatic, and suprahepatic obstruction The most common causes of portal hypertension in children include portal vein thrombosis (prehepatic) and biliary atresia (intrahepatic)  Hematochezia Children older than 2 years through teenage common cause Juvenile polyps Inflammatory bowel disease (IBD) Crohn disease Ulcerative colitis Infectious diarrhea: Escherichia coli and species of Shigella. Antibiotic-associated colitis and Clostridium difficile colitis  Hemateme sis Children older than age 12 years Duodenal ulcers, esophagitis, gastritis, and Mallory-Weiss tears https://ufhealth.org/mallory-weiss-tear  CVS starts to occur between the ages of 3 and 7 years Characterized by recurrent, severe, stereotypical spells of vomiting between which the patient Cyclic returns to normal or baseline (eg, if disabled) Vomiting health Syndrome First described more than a century ago (CVS) A disorder of unknown etiology and pathophysiology and is currently classified as a functional vomiting disorder Recent research efforts have identified the pathophysiologic roles of autonomic dysfunction, stress, and mitochondrial genetics  3 essential diagnostic questions to make a tentative diagnosis: Cyclic Has the child had 5 episodes of vomiting or Vomiting at least 3 episodes over 6-months? Syndrom Does the child return to normal (or to baseline) e (CVS) health in between episodes? https://pedclerk.bsd.uchicago.edu/page/abdominal-migraine-and-cyclic- vomiting-syndrome Are the episodes similar in time of onset, duration, and associated symptoms?  Cyclic Vomiting Syndrome (CVS) 4 phases 1. Symptom-free interval phase: The child is normal between bouts 2. Prodromal phase: Usually has nausea and abdominal pain that can last a few minutes to a few hours. Can skip this phase and treatment may halt this phase. 3. Vomiting phase: Repeated bouts of paroxysmal vomiting are associated with nausea, exertion, fatigue, and drowsiness. 4. Recovery phase: Subsiding the nausea and vomiting, which may take a couple of days, the child returns to normal. The lethargy and energy https://pedclerk.bsd.uchicago.edu/page/ levels may take longer to resolve. abdominal-migraine-and-cyclic-vomiting-syndrome  Cyclic Vomiting Syndrome(CVS) Pallor Lethargy Anorexia Nausea Retching Abdominal pain Approximately 80% of patients have a family member with migraine Up to 80% of children and up to 25% of adults have Migraine headaches The pace of vomiting at its peak is uniquely severe at once every 10 minutes, on average  Cyclical Vomiting Syndrome (CVS) Results of an upper gastrointestinal (UGI) x-ray to exclude malrotation and basic metabolic screening labs (electrolytes, glucose, blood urea nitrogen, creatinine) are normal, one can initiate empiric therapy Treatment: Anti-emetics, Anti- anxiety, Anti-depressant medications  Pica An eating disorder that involves eating items that are not typically thought of as food and that do not contain significant nutritional value, such as hair, dirt, and paint chips A period of at least one month The ingestion of the substance(s) is not a part of http://www.coastweek.com/3836-Zambia-approves-new-legislation-regulating- traditional-medicines.htm culturally supported or socially normative practice  Pica Typical substances may include paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal, ash, clay, starch, or ice The eating of these substances must be developmentally inappropriate In Children