Gastrointestinal Disorders

32 Gastrointestinal Disorders



Nancy Barber Starr, Catherine G. Blosser, Margaret A. Brady, Catherine E. Burns, Ardys M. Dunn, Ann M. Petersen-Smith


The gastrointestinal (GI) system, also known as the digestive system, is essential for lifelong health. This system provides the nutrients that give the body’s cells the energy needed to function. Sustained operation and maintenance of this system are essential for normal growth and development and for the effective functioning of other organ systems.


The pediatric primary care provider plays an integral role in the care of children with GI dysfunction. A thorough understanding of the anatomy, physiology, and common disorders of the GI system is needed to appropriately assess and treat pediatric GI problems. This chapter focuses on pathologic GI disorders commonly seen in children. Other problems of the GI system, such as obesity, anorexia, bulimia, encopresis, and constipation, are discussed in Chapters 10, 12, and 19.



image Anatomy and Physiology


The GI system begins to develop during the third week of gestation. The primitive gut is initially formed and then divides into the foregut, midgut, and hindgut. The structures further develop in an intricate and complex fashion to become the digestive tract and accessory organs.


The GI tract extends from the mouth to the anus. It includes the organs of digestion and accessory organs, such as the liver, pancreas, and gallbladder. The system provides the following functions: ingestion of food, movement of food from the mouth toward the rectum, mechanical dissolution of food, chemical dissolution of food, absorption of nutrients, and expulsion of waste products. The mouth serves as the site for ingestion, chewing, and mixing of food with saliva. The tongue senses the texture and taste of foods, which initiates salivation and the release of gastric juices in the stomach. The esophagus transports food from the mouth to the stomach by peristalsis, the sequential contraction and relaxation of the musculature in the esophagus. The upper esophageal sphincter prevents air from being swallowed while breathing. The lower esophageal sphincter (LES) prevents food from being regurgitated from the stomach, which is important because intraabdominal pressure exceeds intrathoracic and atmospheric pressures. The stomach serves as a reservoir for ingested foods. It secretes digestive juices, mixes food with the gastric fluids, and propels the liquid material into the small intestine. The small intestine’s primary function is absorption of nutrients (carbohydrates, fats, proteins, minerals, and vitamins) into the systemic circulation. Absorption occurs through villi, which cover the mucosal folds and serve as the functional unit of the intestine. Each villus contains an artery, a vein, and a lymph vessel that transport nutrients from the intestine into the systemic circulation. The villi are covered with enterocytes, whose major role is the digestion of carbohydrates and proteins. Enterocytes secrete proteins and enzymes known as brush border enzymes, which assist in digestion.


Carbohydrates must be converted to monosaccharides before their absorption is possible. This process begins in the mouth, where the salivary enzyme amylase breaks down complex starches into disaccharides. The brush border enzymes in the small intestine convert disaccharides into monosaccharides (sucrose to glucose and fructose, lactose to glucose and galactose, and maltose to glucose). When this process is hindered, disaccharides remain osmotically active and can cause diarrhea.


Fat absorption, which occurs mainly in the jejunum, is accomplished through the addition of lipases secreted by the pancreas. Lipases break down fats into particles that are easily absorbed by the villi. Fats then rely on the lymphatic system for absorption.


Proteins are converted to amino acids by pancreatic enzymes. The resulting amino acids are further divided into smaller amino acid particles that are absorbed via the brush border into the systemic circulation. After appropriate absorption of nutrients, the small intestine is left with the initial fecal liquid. This liquid is then propelled by peristalsis into the large intestine. The large intestine removes water from the fecal liquid and allows for short-term storage. The fecal mass, which consists of waste products, bacteria, intestinal secretions, and shed cells, is pushed into the sigmoid colon.


Entry of feces into the rectum stimulates the defecation reflex. This reflex stretches the rectal wall, relaxes the internal anal sphincter, and thereby creates the need to defecate. If this urge is ignored, further fluid resorption occurs as the stool is retained, resulting in an increase in stool mass and dryness. Excessive stretching of the colon from the hard, dry stool bolus can lead to decreased peristalsis, further complicating the retention of stool.



image Pathophysiology


The GI tract can be affected by illness, injury, or other problems that prevent it from functioning normally. Dysfunction can be localized or systemic. Categories of dysfunction include the following: disorders of motility; infection; malabsorption syndromes; impairment of digestion, absorption, and nutrition; congenital malformations and genetic syndromes; metabolic disorders; behavioral problems; injuries and trauma; and food intolerances such as lactose and gluten intolerance.



image Assessment



History


The history assesses the following:



• Family history of any GI disease (e.g., gallbladder disease, ulcers, or allergy to any food product)


• Past medical history related to the GI system (e.g., illnesses, surgeries, anatomic problems, such as cleft lip or palate, esophageal atresia)


• Feeding habits and nutrition history or current diet (what, when, how often, what tolerated)


• Changes in appetite


• Presence of pain (onset, location, type, quality, aggravating and alleviating factors)


image Epigastric pain usually indicates pain from the liver, pancreas, biliary tree, stomach, and upper part of the small bowel (duodenum).

image Periumbilical pain is generated from the distal end of the small intestine, cecum, appendix, and ascending colon.

image Colonic visceral pain is lower abdominal pain that can be dull, diffuse, cramping, or burning.

image Suprapubic discomfort indicates distal intestine, urinary tract, and pelvic organ dysfunction.

image Referred pain is a diagnostic challenge. For example, because of convergent nerve pathways, inflammation of the diaphragm can generate pain that is perceived as shoulder or lower neck pain. When visceral pain is overwhelming, referred pain occurs.

image Acute continuous pain is more indicative of an acute process.

image Secondary autonomic nervous system stimulation associated with acute abdominal pain can produce symptoms of sweating, nausea, vomiting, pallor, and anxiety.

• Bowel habits (frequency, times per week, consistency, associated pain, the need for medications or enemas)


• Constipation and diarrhea (patient’s definition of each, how often they occur, treatment tried)


• Thirst level (increased or decreased)


• Food intolerance or allergy (what foods, symptoms, treatment)


• Heartburn, belching and flatulence, vomiting


• Other signs or symptoms (e.g., apnea or asthma that may be caused by gastroesophageal reflux [GER])



Physical Examination


When assessing a suspected GI problem, a head-to-toe physical examination is indicated.



• Plot growth parameters, including weight for height, to establish proportionality of the patient and exclude certain growth aberrations from the diagnosis.


• Determine body mass index (BMI). The BMI is one of the first indicators used to assess body fat and is a common method of tracking weight problems and obesity in children 2 years and older (see Chapter 10 for more details).


• Determine hydration status (skin turgor, mucous membranes, peripheral pulses, tears, capillary filling).


• Inspect the abdomen for visible peristalsis, rashes, lesions, asymmetry, masses, enlarged organs, and pulsations.


• Auscultate for frequency of bowel sounds (normal is 5 to 20 per minute).


• Percuss for density and to measure organs.


• Palpate both lightly and deeply.


• Assess peritoneal irritation:


image Have the patient walk standing straight up or cough.

image Have the patient stand on tiptoes and fall onto the heels or jump.

image Palpate for rebound tenderness and a positive Rovsing sign.

image Check for the obturator sign: A supine patient flexes the right thigh at the hip with the knee bent and internally rotates the hip. The sign is positive when it induces abdominal pain.

image Check for the psoas sign: The patient lies on the left side and extends and then flexes the right leg at the hip. A positive sign is one that induces abdominal pain.

• Perform a rectal examination when intraabdominal, pelvic, or perirectal disease is suspected (the newborn examination should always routinely assess for anal stenosis). Include external inspection and internal palpation for masses, stool, or irregularities. The index finger is typically used because of its increased sensitivity; however, in infants and young children, use the fifth finger. Insert a gloved, lubricated finger into the rectum. Place the other hand on the abdomen for a bimanual examination. Young pediatric patients should be supine with their feet held together and knees and hips flexed, putting their legs over their abdomen. Adolescent males can be lying on their side or standing with the hips flexed and the upper part of the body on the examination table. Adolescent females can be lying on their side or, if a concurrent pelvic examination is to be done, in the lithotomy position.


• Perform a gynecologic examination if a pathologic pelvic condition is suspected (see Chapter 35).



Common Diagnostic Studies


Laboratory tests are performed as indicated:



• Urinalysis (UA) and urine culture


• Complete blood count (CBC) with differential


• Serum chemistry screen, liver profile, lipid profile, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), thyroid function


• Stool examination for ova and parasites (O&P), culture, blood, white blood cells (WBCs), pH, reducing substances


• Fecal fat collection for 72 hours to rule out fat malabsorption


• Pregnancy test


• Urine tests for gonorrhea or chlamydia, Papanicolaou (Pap) smear and vaginal cultures and/or smears if pelvic or gynecologic pathologic condition is suspected


Imaging of the abdomen may include the following (Clayton, 2010):



• Radiography


image Abdominal x-ray, as the preliminary study; available, less expensive, with lower radiation

image Upper and lower GI series with fluoroscopy demonstrate anatomy and function

image Air contrast enema (diagnose and treat intussusceptions)

image Bone age (to assess suspected growth abnormalities)

image Chest radiographs (to rule out pneumonia)

• Ultrasound (US)—no ionizing radiation, noninvasive, relatively inexpensive (especially for pyloric stenosis, intussusceptions, appendicitis, cholelithiasis, trauma)


• Computed tomography (CT) scan—used only after other imaging studies; quick, but invasive, increased radiation, possible sedation (helpful in nephrolithiasis, appendicitis [the gold standard], intraabdominal masses, pancreatitis)


• Magnetic resonance imaging (MRI)—noninvasive and no ionizing radiation; more costly, sedation may be required (useful in a wide range of disorders)


• Nuclear medicine (scintigraphy)—provide functional and quantifiable data (especially with biliary disease, GER, and Meckel diverticulum)


Specialized tests may also be considered:



• Barium swallow


• Duodenal aspirate to identify existing infection


• Esophageal pH probe to establish gastroesophageal reflux disease (GERD), with a pH of less than 4 representing a reflux episode


• Capsule endoscopy


• Breath hydrogen test if lactose intolerance is suspected


• Sweat chloride test if cystic fibrosis (CF) is suspected (see Chapter 31)



image Management Strategies



Medications


Many common medications are used to treat various GI disorders:



• Antibiotics, antifungals, or anthelmintics for bacterial, fungal, or parasitic infections


• Antiemetics for nausea or vomiting


• Antidiarrheals occasionally for persistent diarrhea or diarrhea associated with chronic disease, but never for acute diarrheal diseases because toxins need to be excreted from the body


• Stool softeners, laxatives, and cathartics for acute treatment and long-term management of constipation and encopresis (see Chapter 12)


• Medications that alter GI motility or tone to treat GERD


• Oral steroids, parenteral steroids, and other immunosuppressants in the treatment of inflammatory bowel disease


• Pain medication and antispasmodics in selected acute and chronic GI conditions


• Medications that alter gastric acidity to treat GERD and ulcer disease


• Iron supplementation as supportive therapy for chronic disease



Probiotics and Prebiotics


Probiotics are foods or dietary supplements with viable microorganisms that alter the microflora of the host, stimulating favorable growth and/or activity of bacteria. Prebiotics are supplements or foods with nondigestible ingredients that benefit the host by stimulating favorable growth and/or activity of probiotic bacteria. Probiotics have been studied more extensively than prebiotics, with modest effectiveness shown in the prevention of acute infectious diarrhea as well as the treatment of acute viral gastroenteritis and in the prevention of antibiotic-associated diarrhea. There is also some evidence of effectiveness in preventing necrotizing enterocolitis in low birthweight infants, and in treating Helicobacter pylori gastritis, irritable bowel syndrome, chronic ulcerative colitis, and colic. Prebiotics may be of some benefit in preventing infection in healthy infants. Though these products seem to be safe in healthy infants and children, there is some concern about the safety of administering them to high-risk children including immunocompromised, ill preterm infants, and/or children with indwelling medical devices (Thomas et al, 2010; Weng and Walker, 2006). See Chapter 42 for further information about using probiotics.



Nutrition and activity


A nutritional plan that meets the recommended daily needs should be encouraged to promote normal GI function, growth, and development. Intake of fluids to ensure hydration is equally important. Dysfunction of the GI tract can be either short term or long term and can require alterations in dietary intake. Consultation with a registered dietitian is important in designing an adequate nutritional plan for a child with a long-term GI problem (see Chapter 10 for more detail).


Age-appropriate activity should be encouraged on a regular basis to help maintain normal GI function. Some GI maladies require short-term rest, but generally the system functions better when activity is regular and consistent.



Counseling and Education


It is important to spend time assessing and planning for the unique needs of a child with GI dysfunction. Helping the family understand the disease or disorder and its course, prognosis, and management is essential to normalize life for the child.



image Upper Gastrointestinal Tract Disorders



Dysphagia



Description


Dysphagia, or difficulty swallowing, may be caused by a variety of disorders. Younger children may be unable to swallow, and older children can have awareness that something is wrong with their swallowing ability or may complain of something being stuck in their throat (globus). The physiology of swallowing is complex with oral, pharyngeal, and esophageal phases. The oral phase refers to ingestion, mastication, and the propulsion of food to the back of the mouth as a bolus. The pharyngeal phase includes the swallowing and transfer of food from the pharynx to the esophagus. Airway closure is critical during the pharyngeal phase, and the child needs to have intact motor and sensory pharyngeal protective mechanisms to prevent aspiration. The esophageal phase allows food to pass into the stomach.



Epidemiology


Dysphagia may occur as a result of a structural defect, neurologic or motor disorders, or mucosal injury. Structural defects make it more difficult to swallow solids than liquids. Common structural defects include esophageal narrowing (stricture, web, or tumor) or extrinsic obstruction (vascular ring). Nonstructural causes arise from motility disorders of the oropharynx or esophagus and are uncommon in children. Prematurity and neurologic impairment from disorders such as cerebral palsy or muscular dystrophy can be causes of dysphagia. Mucosal injury most commonly occurs from GERD or gastritis, but can also be due to caustic ingestion or medication. The number of children with swallowing difficulties has escalated because the advances in technology have increased the survival of children with special health care needs.



Clinical Findings



History




• Progressive dysfunction


• Persistent drooling or cough


• Discomfort with swallowing or a sense of food getting stuck


• Picky eating (e.g., a child who prefers liquids to solids) or food refusal


• Heartburn, halitosis, chest pain



Physical Examination




• Observe the infant or child feeding, paying special attention to the adequacy of the child’s oral motor skills and safety of swallowing.


• Perform a complete physical examination, paying particular attention to mouth, throat, and neck.



Diagnostic Studies


Diagnostic tests may include:



• Lateral neck films


• Barium swallow (usually the initial procedure because it is especially effective in detecting esophageal narrowing)


• Fiberoptic endoscopy evaluation of swallowing


• Videofluoroscopy swallowing study


• Manometry (gold standard for diagnosing motor disorders)


• MRI (for structural abnormalities)


• Electromyography



Differential Diagnosis


Obstructive and compressive lesions usually cause trouble only with solids. Physiologic dysfunction is usually associated with systemic disease, and the patient has trouble with both liquids and solids. A dysfunctional feeding relationship between child and feeder can manifest as dysphagia.



Management


Difficulty with swallowing requires evaluating associated cognitive, developmental, and behavioral issues. A multidisciplinary approach is recommended to provide a comprehensive, cost-effective evaluation and consistent care for the child and family. Health professionals from otolaryngology, gastroenterology, nutrition, occupational therapy, psychology, and speech-language pathology may be involved.



Vomiting and Dehydration



Description


Vomiting is the forceful emptying of gastric contents coordinated by the medullary vomiting center and/or the chemoreceptor trigger zone of the brain. It is differentiated from regurgitation, which is a passive reflux of gastric contents. It can be caused by GI or extraintestinal disorders that are either acute or chronic. Vomiting can be classified as projectile (often arising from the central nervous system [CNS]) or nonprojectile (often seen in GER), and bilious, bloody, nonbilious, or nonbloody.


The age of the child helps to formulate an appropriate list of potential diagnoses (Chandran and Chitkara, 2008).



• Newborn or young infant—infectious process, congenital gastrointestinal anomaly, CNS abnormality, or inborn errors of metabolism


• Infants and young children—gastroenteritis, GERD, milk/soy protein allergies, pyloric stenosis or obstructive lesion, inborn errors of metabolism, intussusception, child abuse, intracranial mass lesion


• Older children and adolescents—gastroenteritis, systemic illness, CNS (cyclic vomiting syndrome [CVS], abdominal migraine, meningitis, brain tumor), intussusception, rumination, superior mesenteric artery syndrome, pregnancy


Dehydration is the loss of water and extracellular fluid. Volume depletion or hypovolemia (loss of extracellular fluid) and dehydration are used interchangeably. Dehydration is classified by the Centers for Disease Control and Prevention (CDC) (2008) as minimal to none (<3%), mild to moderate (3% to 9%), or severe (>9%). It can also be differentiated between infants and older children respectively as mild (5% and 3%), moderate (10% and 6%), or severe (15% and 9%) (Mahajan, 2009).



Epidemiology



Vomiting


Vomiting is one of the most common symptoms in childhood. Nonbilious vomit is generally caused by infection, inflammation, and metabolic, neurologic, or psychological problems. An obstructive lesion generally causes bilious vomiting. Bloody vomit accompanies active bleeding in the upper GI tract (gastritis, peptic ulcer disease).


Following is a list of potential causes of vomiting by site of origin:



• Oropharynx: Cleft palate and laryngopharyngeal cleft


• Upper GI: Congenital stricture, foreign body, gastritis and/or esophagitis, gastric web, pyloric stenosis, tracheoesophageal fistula, vascular ring, peptic ulcer disease (PUD)


• Small intestine: Annular pancreas, choledochal cyst, intestinal atresias and stenosis, intestinal malrotation with volvulus, intestinal pseudo-obstruction


• Colon: Hirschsprung disease, intussusception, meconium ileus, necrotizing enterocolitis, fecal impaction


• Hepatobiliary or pancreatic dysfunction


• Infections: Bacterial enteritis, otitis media, sepsis, urinary tract infection (UTI), viral gastroenteritis (VGE), hepatitis


• Neurologic: Congenital anatomic malformation, gray and white matter degenerative disorders, hydrocephalus, kernicterus, brain tumors, migraine headache, head trauma


• Other: Cow’s-milk protein allergy (CMP intolerance), inborn errors of metabolism, maternal drug exposure and/or withdrawal, toxic ingestions, appendicitis, cyclic vomiting, pneumonia, drug or alcohol ingestion, eating disorders, pregnancy



Dehydration


Dehydration is overwhelmingly the result of an infectious process, primarily viral, that often causes diarrhea. Children are at increased risk due to their higher surface area–to–volume ratios, higher rate of insensible loss, and in younger children the inability to communicate or actively replenish losses. Depending on the cause of dehydration, water and salts (primarily sodium chloride) may be lost in physiologic proportion or disparately, producing one of three types of dehydration: isonatremic (isotonic), hypernatremic (hypertonic), and hyponatremic (hypotonic). When dehydration is caused by simple diarrhea, homeostatic mechanisms can usually maintain sodium concentrations in the serum, resulting in isonatremia. When vomiting occurs with diarrhea and water intake is less, there is greater water loss than salt loss, potentially resulting in hypernatremic dehydration. When there is massive stool loss of water and salt and only water is ingested, there is a large salt loss, potentially resulting in hyponatremia.



Clinical Findings



History


The vomiting history should assess the following:



• History of illnesses, surgeries, or hospitalizations


• Medications currently being taken (including over-the-counter, herbal, cultural, and homeopathic remedies)


• Recent exposure to illness, injury, or stress; recent travel (including camping); swimming activities


• Possibility of poisoning


• Family history of GI disease or fetal or neonatal deaths (metabolic syndrome, congenital anomaly)


• Onset and duration of vomiting, quality and quantity, presence of blood or bile, odor, precipitating event


• Relationship of vomiting to meals, time of day, or activities


• Vomiting early in the morning


• Presence of associated symptoms: Diarrhea, fever, ear pain, UTI symptoms, vision changes, cough, headache, seizures, high-pitched cry, polydipsia, polyuria, polyphagia, anorexia


The dehydration history should assess the following:



• Mental status and thirst


• Parental concern regarding decreased tearing or urination, or depressed fontanelle in infants



Physical Examination




• Growth parameters and vital signs


• Neurologic examination: Nuchal rigidity, decreased level of consciousness, and behavioral changes, which can include irritability or lethargy. Sensorium remains intact until there is greater than 6% of weight loss as a result of dehydration. Hypotension is a late manifestation of dehydration.


• Abdominal examination: Inspect for distention, abdominal scars from previous surgery (may be associated with obstruction and/or adhesions), or visible peristaltic waves. Auscultate bowel sounds (i.e., increased with gastroenteritis, decreased with obstruction, absent with ileus or peritonitis). Palpate the abdomen for pain and/or rebound tenderness. Assess abdominal organs (liver and spleen size, masses). Perform a rectal examination as indicated.


• Respiratory examination: Tachypnea, decreased oxygen saturation, stridor


• Assessment of dehydration (Table 32-1)


image One of the most useful clinical signs of hydration is capillary refill time (CRT). Normal CRT is less than 2 seconds. CRT, skin turgor, and tachypnea, considered together, are most helpful in determining dehydration (Steiner et al, 2004).

image A clinical dehydration scale (CDS) is a predictive tool regarding length of stay and need for intravenous fluids (Goldman et al, 2008). The four parameters used for assessment are general appearance, eyes (sunken or not), moistness of mucous membranes, and presence of tears.

image Mahajan (2009) provides five points to assess the level of dehydration: volume deficit with history and physical, osmolar disturbance (serum sodium and osmolality), acid-base disturbance (blood pH, Pco2, serum bicarbonate), potassium, and renal function (blood urea nitrogen [BUN]), creatinine, urine specific gravity.


TABLE 32-1 Assessment of Dehydration

image


Diagnostic Studies


Diagnostic studies are performed as indicated by the probable diagnosis:



• Complete blood count (CBC) with differential, blood culture


• Electrolytes, including BUN and creatinine, glucose, and liver function tests


image Serum bicarbonate less than 17 mEq/L (differentiates mild from moderate/severe hypovolemia) (Mahajan, 2009)

image Serum sodium less than 130 (hyponatremic) or more than 150 (hypernatremic)

• CRP and ESR


• Serum lactate, organic acids, ammonia for metabolic disorders (may only be abnormal during episodes of vomiting)


• UA and urine culture


• Toxicology screen


• Stool for culture and occult blood, leukocytes, parasites, fat, pH, reducing substances


• Rapid strep test and/or throat culture


• Pregnancy test


• Abdominal radiographs (suspected obstruction or foreign body ingestion, organomegaly, or a palpable mass)


• Chest radiograph (suspected pneumonia)


• US (abscesses, masses, stenoses, cysts, appendicitis, pyloric stenosis)


• Barium swallow or enema (malrotation, pyloric stenosis, GER, masses)


• Endoscopy (obstruction, hemorrhage, infection; collect biopsies)


• Esophageal pH probe analysis, scintiscan


• CT scan or MRI to diagnose masses, inflammation, herniations, perforations, and obstructions


• Electroencephalogram (EEG)



Differential Diagnosis


See Table 32-2.


TABLE 32-2 Differential Diagnosis of Vomiting in Infants and Children

































































Infant Child Adolescent
Common Conditions
Gastroenteritis Gastroenteritis Gastroenteritis
GERD GERD GERD
Overfeeding Gastritis Gastritis
Anatomic obstruction: pyloric stenosis, malrotation with intermittent volvulus, intestinal duplication, Hirschsprung disease, antral/duodenal web, foreign body, or incarcerated hernia Toxic ingestion: lead, iron, or vitamins A and D Toxic ingestion
Systemic infection: UTI, pneumonia, hepatitis Systemic infection: UTI or pyelonephritis; pneumonia; hepatitis Systemic infection
Pertussis syndrome Pertussis syndrome Pertussis syndrome
Otitis media Otitis media, sinusitis Sinusitis
  Appendicitis, small bowel obstructionMigraineMedication: ipecac, digoxin, theophylline, etc. Appendicitis, small bowel obstruction, IBD
  Migraine
  Medication: ipecac abuse/bulimia
    Pregnancy, PID
Rare Conditions


• Other gastrointestinal disorders: achalasia, gastroparesis, peptic ulcer, food allergy or pancreatitis



• Neurologic: hydrocephalus, subdural hematoma, intracranial hemorrhage or mass, infant migraine, Chiari malformation, or meningitis



• Metabolic/endocrine: galactosemia, hereditary fructose intolerance, urea cycle defects, or amino and organic acidemias, congenital adrenal hyperplasia



• Renal: obstructive uropathy or renal insufficiency



• Cardiac: congestive heart failure or vascular ring



• Others: pediatric falsification disorder (Munchausen syndrome by proxy), child neglect or abuse, cyclic vomiting syndrome, or autonomic dysfunction


GERD, Gastroesophageal reflux disease; IBD, inflammatory bowel disease; PID, pelvic inflammatory disease; UTI, urinary tract infection.


Adapted from Blanchard S, Czinn S: Peptic ulcer disease in children. In Kliegman RM, Behrman RE, Jenson HB et al: Nelson textbook of pediatrics, ed 18, Philadelphia, 2007, Saunders, pp 1572-1574; Vandenplas Y, Rudolph C, Di Lorenzo C, et al: Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), J Pediatr Gastroenterol Nutr 49(4):498-547, 2009. Used with permission of Lippincott Williams & Wilkins.



Management



Vomiting




• Identify and alleviate the cause as soon as possible.


• Antiemetics, though not recommended in acute gastroenteritis, or when cause is unknown, may at times be warranted. Newer medications such as 5-HT3 receptor antagonists (ondansetron or granisetron) do not have adverse effects on the CNS and may be indicated in older children (Chandran and Chitkara, 2008; Ulshen, 2009).


• Refer to specialist for persistent vomiting, recurrent vomiting, or vomiting associated with significant underlying process.



Dehydration




• Determine the degree of dehydration.


image If minimal, mild, or moderate, oral rehydration solution (ORS) with 70 to 90 mEq/L sodium, 25 g/L glucose, 20 mEq/L potassium, 30 mEq/L base (in the form of citrate, acetate, or lactate) with a defined osmolarity of 240 to 300 mOsm/L is recommended.

image If severe, immediate and aggressive intervention is needed (e.g., intravenous [IV] fluids).

image Pediatric subcutaneous rehydration using recombinant human hyaluronidase is an alternate method, effective when used in children with mild to moderate dehydration who require parenteral therapy (Allen et al, 2009).

• Initial rehydration, maintenance of fluids, and replacement of ongoing losses are stages of treatment (Table 32-3). Physiologically sodium and glucose are coupled in transport across the intestinal brush border into systemic circulation to maximize rehydration. Administration of fluid should be in frequent, small (5 mL or less) amounts. Larger amounts may be given as tolerated. Plain water, juices, soda, milk, and sports drinks should be avoided because these liquids are hyperosmolar and do not provide appropriate replacement of sugars and electrolytes. A pediatric emergency department using ORS in children with moderate dehydration showed not only successful rehydration, but also a decreased length of stay, less staff use, and more satisfied parents (Bell, 2010). Palatability of ORS does not affect the quantity consumed (Freedman et al, 2010). Homemade solutions can be used when premade ORS is not available (see http://rehydrate.org). Refeeding should resume as quickly as possible because the gut needs nutrition to facilitate mucosal repair following injury.


• Antiemetics. A single dose of an oral disintegrating tablet of ondansetron (2 mg for children 8 to 15 kg, 4 mg for children 15 to 30 kg, and 8 mg for more than 30 kg) reduces vomiting, decreases the chance of dehydration, and increases the success of oral hydration (Amir, 2007; Freedman et al, 2006; Roslund et al, 2006).


• Monitor urine output.


• Treat fever.


• Refer if the child has a toxic appearance, severe dehydration, projectile vomiting, abnormal examination, vomiting for greater than 12 hours, or vomiting of blood, bile, or fecal matter, or significantly decreased urine output.



TABLE 32-3 Treatment Based on Degree of Dehydration

image


Complications


Dehydration, fluid and electrolyte imbalance, aspiration pneumonia, hemorrhage, or a tear of the esophagus are possible.



Patient Education


Providing written information to the parent about care that is needed during all stages of oral rehydration therapy is helpful. Also include information about signs that indicate the child is worse or not responding to treatment in the expected time frame.



Cyclic Vomiting Syndrome



Description


CVS is characterized by recurrent, discrete, self-limited episodes of vomiting between which are completely symptom-free periods. CVS is often associated with abdominal migraines (discussed on p 765). During episodes there is intense nausea and unremitting vomiting (a median of six times per hour at peak) often with bilious emesis (83%) and severe abdominal pain (80%) (Li et al, 2008). Accompanying symptoms include pallor, listlessness, anorexia, nausea, retching, abdominal pain, headache, and photophobia. The periods of vomiting may last hours or even days; the symptom-free periods may last for weeks or even years. Consensus criteria for CVS have been established for diagnosis (see www.naspghan.org).



Epidemiology


Although the typical child with CVS is healthy up to 90% of the time, there are substantial morbidity and medical costs when episodes occur because of missed days of school (average 24 per child), high rate of IV rehydration, the cost of laboratory and imaging studies, endoscopic procedures, emergency department visits, and missed work by a parent (Li et al, 2008).


The etiology of CVS is unknown, but there is a link with migraines. Cyclic vomiting may occur any time between infancy and young adulthood, most commonly diagnosed between 3 and 7 years old. Girls are affected more often than boys (60:40), as are Caucasian, elementary school–age children. Affected individuals tend to have mothers and maternal grandmothers who have a higher incidence of migraine headaches, depression, anxiety, irritable bowel syndrome (IBS), and hypothyroidism (Boles et al, 2005; Li et al, 2008). CVS is often a precursor of later classic migraines.



Clinical Findings



History




• Red flags have been identified (Box 32-1)


• Family history positive for migraine headache is common


• A prodromal period (some combination of pallor, anorexia, nausea, abdominal pain, or lethargy) and/or a recovery period (from ill to playing again) that is brief


• Episodes that begin and end abruptly


• Episodes more likely to occur early in the morning (3:00 to 4:00 am) or on awakening


• An identifiable trigger is commonly seen in children—physical stress (infection, lack of sleep, menstrual periods) or psychological stress (birthdays, holidays, school-related), or food products (e.g., chocolate, cheese, monosodium glutamate)


• Intense nausea not relieved by vomiting


• Headache, motion sickness, photophobia, phonophobia, or vertigo may occur



BOX 32-1 Red Flags of Cyclic Vomiting Syndrome




• Abdominal signs (e.g., bilious vomiting, abdominal tenderness, and/or severe abdominal pain, hematemesis)


• Triggering events (e.g., fasting, high-protein meal, or intercurrent illness)


• Abnormal neurologic examination (e.g., severely altered mental status, abnormal eye movements, papilledema, motor asymmetry, and/or gait abnormality [ataxia])


• Progressively worsening episodes or conversion to a continuous or chronic pattern



Physical Examination


Physical examination is normal, although children with CVS appear substantially more ill than children with viral gastroenteritis. If any red flags are present, further workup is indicated.



Diagnostic Studies


Screening labs during a vomiting episode help exclude other diagnoses:



• Electrolytes including HCO3


• Upper GI radiographs (to exclude malrotation)


• Abdominal US in refractory cases (rule out transient hydronephrosis)


• If hyponatremic or hypoglycemic, rule out Addison disease and fatty acid oxidation



Differential Diagnosis


CVS is a diagnosis of exclusion. Severe GI symptoms can indicate hydronephrosis, cholelithiasis, pancreatic disease, or ureteropelvic junction. CVS precipitated by concurrent illness, fasting, or high-protein meals can indicate a metabolic disorder. An abnormal neurologic examination is suggestive of increased intracranial pressure. Approximately 10% of children with CVS-like history have a specific underlying disorder. Although uncommon, Munchausen by proxy syndrome has been known to mimic CVS in a child given ipecac (Li et al, 2008).

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Jul 24, 2016 | Posted by in PEDIATRICS | Comments Off on Gastrointestinal Disorders

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