2.

01B
November 06, 2017
GASTROINTESTINAL DISORDERS IN CHILDREN PART IB
Dra. Ruby Ann Punongbayan
Department of Pediatrics

Disease Characteristics Clinical Features Diagnosis Treatment

Achalasia  Loss of LES  Primary esophageal  Barium fluoroscopy  Pneumatic dilatation
relaxation and motor disorder of o smooth tapering of (success rate: 70-80%)
esophageal unknown etiology the lower  Surgical myotomy (Heller
peristalsis(selective presenting with esophagus leading procedure; success rate:
loss of dysphagia for solid to the closed LES 85-95%)
postganglionic and liquids and resembles a
inhibitory neurons “bird’s beak”
that normally lead to  Manometry
sphincter o confirms the
relaxation) diagnosis
 Uncommon before (incomplete
school age; usually relaxation of a high
18 y/o and above pressure LES
during swallowing)
Gastroesopha  Most common  Recurrent aspiration  Esophageal pH  Conservative therapy and
geal reflux esophageal pneumonia, right probe/monitoring: lifestyle modification
disease disorder in main stem bronchus – o definitive test  Dietary measures:
(GERD) children of all ages wider and shorter –is o document acidic o thicken the formula: 1
 Frequent or clinically seen in x-ray reflux episodes tablespoon rice cereal
persistent episodes as consolidation per ounce of milk to
of retrograde (white, opacified) in  Endoscopy: decrease the frequency
movement of the RIGHT UPPER o shows erosive of overt regurgitation
gastric contents LOBE esophagitis and and the height of reflux
across the lower  Infants: complications such o avoid acidic or reflux-
esophageal o postprandial as strictures or inducing foods (mint,
sphincter (LES) into regurgitation Barrett esophagus tomatoes, chocolates),
the esophagus and o signs of o also used juices, alcohol,
thus produce esophagitis therapeutically to caffeinated and
esophagitis or (irritability, dilate reflux- carbonated drinks
esophageal arching, choking, induced strictures  Awake: prone or upright
symptoms, or in gagging, feeding carried position
those who have aversion)  Antacids, H2RA, PPis,
respiratory sequelae o failure to prokinetic agents
 Infant reflux thrive(underwei o Esomeprazole 10mg
becomes evident in ght, feeding for 1-11 years old; 20-
the 1st few months aversion: 40mg for >12 years old
of life, peaks at ∼4 psychologically, (currently
mo, and resolves in the infant has recommended for
up to 88% by 12 mo associated pedia patients,
and nearly all by 24 feeding to availbale in granules so
mo. regurgitation easier ipainom)
after) o Omeprazole: 0.7-3.3
 Older Children: mg/kg/day
o regurgitation  Medical treatment usually
(preschool for 4-6 weeks. If no
years) , improvement pa rin, patient
abdominal and is referred to have
chest pain (later surgery:Fundoplication
childhood and
adolescence)
o occasional neck
contortions
(arching, turning
of head)
designated as
Sandifer
syndrome
o respiratory
manifestations
related to
asthma or

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 Lecture Title

sinusitis

Foreign body  Coins and small  Choking, gagging or  Chest radiograph,  Asymptomatic blunt objects
in the toys: most coughing followed by chest and abdomen (AP may be observed up to 24
esophagus frequently ingested; excessive salivation, and Lateral View), of a hours in anticipation of
80% are between dysphagia, food coin lodged in the passage into the stomach
6mos to 3 y/o. refusal, emesis, or esophagus:  Indications for Endoscopy:
 Most lodge at the pain in the throat or o AP View→ Flat o Sharp objects, disc
level of the (a) sternal notch surface button batteries or
cricopharyngeus  Stridor – block in the o Lateral View → foreign bodies with
(UES), (b) the aortic upper airway, Edge of the coin respiratory symptoms
arch, or (c) superior inspiratory problem o The reverse is true o Symptomatic + Failure
to the diaphragm at  Wheezing – block in for coins lodged in to visualize the object
the LES (3 strictures the lower airway, the trachea; here,  Glucagon (0.05 mg/kg IV)
of esophagus) expiratory problem the edge is seen may be useful in facilitating
 Perforation of anteroposteriorly passage of distal esophageal
oropharynx or and the flat side is food boluses by decreasing
proximal esophagus seen laterally the LES pressure (meat
- cervical swelling, impactions) – but according
erythema, to doc, no medication daw!
subcutaneous  Button batteries in
crepitations particular must be
expediently removed,
because they may induce
mucosal injury with as little
as 1 hr of contact time and
involve all esophageal
layers within 4 hrs.

Caustic  Usually in <5y/o  Presentation:  In Chest Radiograph:  Esophagogastroduodenosc

ingestions (>50% of cases) vomiting, drooling, o Esophageal opy
 Acidic agents (20% refusal to drink, oral perforation→Air o For all symptomatic
of cases) burns, dysphagia, in the mediastinum patients; rapidly
o Bitter, less may abdominal pain, o Gastric identifies tissue
be ingested dyspnea, perforation→Free damage
o Coagulation hematemesis, stridor airunder the o Within 72 hours in
necrosis  Ingestion results in: diaphragm patients with features
o More o Esophagitis (immediate predictive of severe
superficial o Necrosis surgical mucosal injury in the
penetration o Perforation intervention) absence of signs of
o Low viscosity o Stricture perforation
and SG result formation  Dilution by water/milk –
in rapid transit  Circumferential recommended
to the stomach ulcers, white plaques,  Surgical resection - SI or
– gastric injury sloughing of mucosa colon interposition
 Alkali agents (70% (some are seen after
of cases) few hours pa)→  Neutralization, induced
o Tasteless, more increased risk of emesis and gastric lavage –
is ingested strictures CONTRAINDICATED
o Deep  Activated Charcoal - Not
liquefaction Absence of oropharyngeal used because it is for metal
necrosis lesions does not exclude the toxicity not for liquid
o Deep possibility of significant
penetration of esophagogastric injury
bowel mucosa which may lead to
o Perforation perforation or stricture
injury of the
esophagus

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 Lecture Title

Disease Characteristics Clinical Features Diagnosis Treatment

Intestinal obstruction  Accumulation of food,  N/V, abdominal  Abdominal xray: Poor  Fluid resuscitation
gas, intestinal secretions distention and gas distribution or  Nasogastric decompression
proximal to the point of obstipation gasless and cultures
obstruction bowel  Smooth bowel walls like  Antibiotics
distention decreased sausages/hose  Surgery for strangulation
intestinal absorption  Preferential dilatation of  Conservative measures for
inc. F&E secretion  the bowel proximal to adhesions or strictures
isotonic IV depletion the obstruction
inc. contractions then  Many dilated air fluid
hypoactive bowel sounds levels in a given loop at
different heights (candy
canes)
 Dilated loops in
“stepladder” fashion;
more orderly
Ground-glass appearance
in the RLQ with trapped
air bubbles seen in
meconium ileus. Ileus –
“Bag of popcorn”
Pyloric Stenosis  Most common cause of  Mass palpated from the Ultrasound: Confirmatory  Pre-operative treatment is
nonbilious vomiting left side located above test focused on correcting the fluid,
and to the right of the  Pyloric thickness 3- acid-base and electrolyte
umbilicus in the mid 4mm losses.
epigastrium beneath the  Pyloric length 15-  Surgery via RAMSTEDT
liver edge 19mm PYLOROMYOTOMY
 Pyloric diameter 10-  Incisions are made on the
14mm hypertrophied muscles of the
 Sensitivity 95% pylorus. This is done until the
Barium: mucosa bulges out and allows
 String sign: Elongated passage of food into
pyloric channel duodenum
 Shoulder sign: bulging
of pyloric muscle into
antrum
 Double Track sign:
barium streaks in the
narrowed channel

Volvulus  Twisting of loops of  Triad (SIR)  Abdominal Xray: bird’s  Derotation and
intestine around its o Sudden onset of beak sign, inverted u decompression by barium
mesenteric attachment severe epigastric sign, coffee bean sign enema or with rectal tube,
which usually occurs at pain sigmoidoscope or
the sigmoid colon and o Inability to pass colonoscope if no signs of
cecum tube to stomach bowel ischemia or
o Intractable perforation
Retching with  Laparoscopic derotation or
emesis laparotomy +/- bowel
resection

Duodenal Atresia  Lumen fails to recanalize  Bilious Vomiting with  Double bubble sign on  NGT/OGT decompression
during 4th-5th week of or without abdominal plain abdominal X-ray with IV fluid replacement
gestation distention usually noted due to gas-filled  Surgery via
 Obstruction is distal to on 1st day of life stomach and proximal Duodenoduodenostomy
Ampulla of Vater  Polyhydramnios in duodenum with gastrostomy tube
50% due to failure of 
absorption of amniotic
fluid in distal intestine
 Jaundice in 1/3 of
patients

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 Lecture Title

Disease Characteristics Clinical Features Diagnosis Treatment

Malrotation -Incomplete rotation of the -ultrasound or contrast x- Surgery
intestine during fetal ray: corkscrew sign
development which is -Upper GI series: GOLD
completed by 3 months of STANDARD (shows
gestation malposition of ligament of
- Most common type Treitz)
involves failure of the
cecum to move into the
RLQ
Meckel Diverticulum -Remnant of the -Typical diverticulum is a 3- -Meckel radionuclide scan -surgical excision if
omphalomesenteric duct 6cm outpouching of the (sensitivity of 85% and symptomatic
which connects the yolk sac ileum along the specificity of 95%) (diverticulectomy either by
to the gut in the embryo and antimesenteric border 50- laparoscopy or open
provides nutrition 75cm from the ileocecal procedure)
- Accounts for 50% of all valve
lower GI bleeding in <2 year- -Symptoms usually arise
old children within the first 2 years of
life
-intermittent painless
rectal bleeding and brick-
colored stool
Hirschsprung Disease -Congenital aganglionic -Decreased motility in the -Rectal suction biopsy: -temporary colostomy (until
megacolon affected bowel segment GOLD STANDARD infant is 6-12 months of age)
-Most common cause of -Lack of propagation of -Abdominal x-ray:  then do definitive
lower intestinal obstruction peristaltic waves into the Transition zone between procedure (Swenson,
in neonates aganglionic colon normal dilated proximal Duhamel, Boley endorectal
-Absence of Meissner and -Abnormal or absent colon and a smaller-caliber pull-through via
Auerbach plexus and relaxation of this segment obstructed distal colon due laparoscopy)
hypertrophied bundles with and of the internal anal to nonrelaxation of the
high concentration of sphincter aganglionic bowel
acetylcholinesterase -Empty rectal vault upon
between the muscular and DRE with normal anal tone
submucosa layers -delayed passage of
meconium
-history of chronic
constipation
-Pellet-like or ribbon-like
stool
-Currarino triad (older
patients):
o Anorectal
malformation
o Sacral bone anomalies
o Presacral masses

Intussusception -Occurs when a portion of -Severe paroxysmal Plain abdominal x-ray: (+) -Acute intussusception
the alimentary tract is colicky pain that recurs at density should be reduced:
telescoped into an frequent intervals with Barium enema: coiled Hydrostatic reduction vs.
adjacent segment straining efforts spring sign “air” enema
-Most common cause of -Legs and knees are flexed Ultrasound: tubular mass, -Resection with end-to-end
intestinal obstruction with loud crying (doubling doughnut or target sign anastomosis: if manual
between 3 months-6 years up) operative reduction fails
old -currant jelly stool
-Most often ileocolic and - Palpation of abdomen:
ileoileocolic slightly tender sausage-
shaped mass in the RUQ
which may increase in size
and firmness during a
paroxysm of pain
-Child looks well in between
the paroxysms of pain

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 2.01B
November 06, 2017
GASTROINTESTINAL DISORDERS IN CHILDREN PART IB
Dra. Ruby Ann Punongbayan
Department of Pediatrics

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