Functional gastrointestinal disorders in chn of early age

GASTROINTESTINAL DISORDERS IN CHILDREN OF EARLY AGE

PRESENTED BY SAKPAKU PAUL KUDZOMEDICAL INSTITUTE,DNEPROPERTROVSK

OUTLINE OF PRESENTATION Introduction G1. Infant Regurgitation G2. Infant Ruminating Syndrome G3. Cyclic Vomiting Syndrome G4. Infant Colic G5. Functional Diarrhea G6. Infant Dyschezia G7. Functional Constipation H1. Aerophagia H2. Functional dyspepsia H3. Irritable bowel syndrome(IBS) Structural disorders

Introduction Infant and toddler FGIDs include a variable combination

of often age dependent, chronic or recurrent symptoms not explained by structural or biochemical abnormalities

Functional symptoms during childhood are sometimes accompaniments to normal development(e.g. infant regurgitation) or they may arise from maladaptive behavioral responses to external stimuli (e.g. in functional constipation, retention of feces is learned response to painful constipation)

Clinicians depend on the reports and interpretations of the parents, who know their child best and the observation of the clinician who is trained to differentiate between health and illness

G1. Infant Regurgitation Definition: Involuntary return of previously swallowed food or

secretions into or out of the mouth in neonates and toddlers

Regurgitation is distinguished from vomiting (a CNS reflex involving both autonomic and skeletal muscles in which gastric contents are forcefully expelled through the mouth because of coordinated movements of the small bowel, stomach, esophagus diaphragm

Gastroesophageal reflux refers to movement of gastric contents retrograde and out of the stomach

When gastroesophageal reflux causes or contribute to tissue damage or inflammation (e.g. esophagitis, obstructive apnea, reactive airway diseases, pulmonary aspiration, feeding and swallowing difficulties or failure to thrive), it is called gastroesophageal reflux disease

Diagnostic criteria(according to Rome III)

Must include both of the following in otherwise healthy infants 3 weeks to 12 months of age:

1. Regurgitation two or more times per day for 3 or more weeks

2. No retching, hematemesis, aspiration, apnea, failure to thrive, feeding or swallowing difficulties, or abnormal posturing

Milk allergy may be present with eczema or wheezing

Regurgitation persisting past the first year of life should be evaluated to exclude an anatomic abnormality such as malrotation or gastric outlet obstruction

Treatment/management Effective reassurance (regurgitation

occurs more than once a day in 67% of healthy 4 month old infants)

Thickened feedings and elimination of cow milk protein from diet

Prokinetic agents such as cisapride 0.2mg/kg/dose 4 times a day for 4-8 weeks, domberidone, metoclopramide, levosulphiride, benzamide, Prucalopride, Mosapride, itopride,

G2. Infant Ruminating Syndrome

Rare disorder characterized voluntary, habitual regurgitation of stomach contents into the mouth for self-stimulation

Infant ruminating syndrome results from deficit in the infant-caregiver relationship

Diagnostic criteria G2. Infant Rumination Syndrome Diagnostic criteria Must include all of the following for at least 3 months:

1. Repetitive contractions of the abdominal muscles, diaphragm, and tongue

2. Regurgitation of gastric content into the mouth, which is either expectorated or rechewed and reswallowed

3. Three or more of the following: a. Onset between 3 and 8 months b. Does not respond to management for gastroesophageal

reflux disease, or to anticholinergic drugs, hand restraints, formula changes, and gavage or gastrostomy feedings

c. Unaccompanied by signs of nausea or distress d. Does not occur during sleep and when the infant is

interacting with individuals in the environment

Treatment/Management Treatment includes: Helping the mother improve her ability

to recognize and respond to her infant’s physical and emotional needs.

Infant rumination may be exacerbated by the noxious stress of the workup that accompanies “diagnosis by exclusion.” After rumination subsides, it usually does not recur, even in families whose mental health remains poor

G3. Cyclic Vomiting Syndrome

Cyclic vomiting syndrome (CVS) consists of re-current, stereotypic episodes of intense nausea and vomiting lasting hours to days that are separated by symptom-free intervals lasting weeks to months

Diagnostic criteria Must include both of the following: 1. Two or more periods of intense

nausea and unremitting vomiting or retching lasting hours to days

2. Return to usual state of health lasting weeks to months

Treatment/management daily treatment with amitriptyline, pizotifen,

cyproheptadine, phenobarbital, or propranolol may reduce fre-quency or eliminate episodes.

Foods, emotional factors, or physical stressors that trigger episodes may be identified and avoided.

Once an episode starts, patients should be sedated until the episode ends

Symptoms may be interrupted by titrating intravenous lorazepam or another long-acting benzodiazepine until the patient enters restful sleep.

Intravenous fluids, electrolytes, and H2-histamine receptor antagonists are administered until the episode is over

Treatment and prevention I. Between attacks: Elimination of trigger factors. Sedatives, neuroleptic drugs:

amitriptyline, sanomigran(pizotifen), phenobarbital, or propranolol may reduce frequency or eliminate episodes

II. During the prodome CVS:

Oral: Antiemetic medications (ondansetron) Sedative, anxiolytic and antiemetic

drugs (longacting benzodiazepine) Acidinhibiting drug agent to protect

esophageal mucosa and dental enamelDeep sleep several hours may prevent

the episode

III. Once an episode starts Intravenous: Sedation of patient till episode ends

(diazepam or lorazepam) Fluids, electrolytes H2-histamine receptor antagonists

G4. Infant Colic The term ‘colic’ implies abdominal pain

caused by obstruction to flow from the kidney, gallbladder or intestines.

In contrast, “infant colic” is a behavioral syndrome of early infancy involving long crying bouts and hard-to-soothe behavior. Infant colic is defined as “paroxysms of irritability, fussing or crying lasting >3 hours per day and occurring >3 days each week.

Diagnostic criteria Must include all of the following in

infants from birth to 4 months of age: 1. Paroxysms of irritability, fussing or

crying that starts and stops without obvious cause

2. Episodes lasting 3 or more hours/day and occurring at least 3 days/wk for at least 1 week

3. No failure to thrive

Treatment/management Nonanalgesic, nonnutritive soothing

maneuvers, such as rhythmic rocking and patting 2–3 times per second in a quiet environment, may quiet the baby who may nevertheless resume crying as soon as he or she is put down

G5. Functional Diarrhea Functional diarrhea is defined by daily

painless, recurrent passage of 3 or more large, unformed stools for 4 or more weeks with onset in infancy or preschool years.

There is no evidence for failure to thrive if the diet has adequate calories.

The child seems unperturbed by the loose stools, and

The symptom resolves spontaneously by school age

Diagnostic criteria Must include all of the following: 1. Daily painless, recurrent passage of

three or more large, unformed stools 2. Symptoms that last more than 4 weeks 3. Onset of symptoms that begins

between 6 and 36 months of age. 4.Passage of stools that occurs during waking hours.

5.There is no failure-to-thrive if caloric intake is adequate

The clinician queries about recent enteric infections, laxatives, antibiotics, or diet changes. Stools often contain mucus and/or visible undigested food

Treatment/management It is IMPORTANT to avoid restrictive

diets that may cause calorie deprivation.

Children recover spontaneously, and usually no treatment other than effective reassurance for the parents is necessary.

G6. Infant Dyschezia At least 10 minutes of straining and

crying before successful passing of stool

The symptom is caused by failure to relax the pelvic floor during the defecation effort and generally resolves spontaneously

Diagnostic criteria Must include both of the following in an

infant less than 6 months of age 1. At least 10 minutes of straining

and crying before successful passage of soft stools

2. No other health problems

Treatment/management Effective reassurance

To encourage the infant’s defecation learning, the parents are advised to avoid rectal stimulation, which produces artificial sensory experiences that may be noxious or that may condition the child to wait for stimulation before defecating.

Laxatives are unnecessary.

G7. Functional Constipation Constipation represents the chief

complains in pediatric outpatient visits. Children with functional constipation

develop symptoms during the first year of life

Fecal incontinence (involuntary passage of colon contents) may occur in infants and toddlers who accumulate a rectal fecal mass

Diagnostic criteria Must include one month of at least two of the following in

infants up to 4 years of age: 1. Two or fewer defecations per week 2. At least one episode/week of incontinence after the

acquisition of toileting skills 3. History of excessive stool retention 4. History of painful or hard bowel movements 5. Presence of a large fecal mass in the rectum 6. History of large diameter stools which may obstruct

the toilet Accompanying symptoms may include irritability, decreased

appetite, and/or early satiety. The accompanying symptoms disappear immediately following passage of a large stool.

Onset frequently occurs during 1 of 3 periods:

(1) in infants with hard stools, often corresponding with the change from breast milk to commercial formula or introduction of solids;

(2) in toddlers acquiring toilet skills, as they attempt to control bowel movements and find defecation painful; and

(3) as school starts and children avoid defecation throughout the school day

Treatment/management The first step in treatment is family

education during the initial visit

Referred to the pediatric gastrointestinal specialist

H1. Aerophagia Aerophagia  is a condition of

excessive air swallowing, which goes to the stomach. 

Aerophagia may also refer to an unusual condition where the primary symptom is excessive flatus, belching is not present, and the actual mechanism by which air enters the gut is obscure.

Diagnostic criteria Must include at least two of the

following 1. Air swallowing 2. Abdominal distention due to

intraluminal air 3. Repetitive belching and/or increased

flatus * Criteria fulfilled at least once per

week for at least months prior to diagnosis

H2. Functional Dyspepsia Dyspepsia: Indigestion

Diagnostic criteria Must include all of the following: 1. Persistent or recurrent pain or discomfort

centered in the upper abdomen (above the umbilicus)

2. Not relieved by defecation or associated with the onset of a change in stool frequency or stool form (i.e., not irritable bowel syndrome.

3.No evidence of an inflammatory, anatomic, metabolic or neoplastic process that explains the subject’s symptoms

* Criteria fulfilled at least once per week for at least 2 months prior to diagnosis

H3. Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine (colon). Irritable bowel syndrome commonly causes cramping, abdominal pain, bloating, gas, diarrhea and constipation. IBS is a chronic condition that you will need to manage long term.

Diagnostic criteria Must include both of the following: 1. Abdominal discomfort(an uncomfortable sensation not

described as pain) or pain associated with two or more of the following at least 25% of the time:

a. Improvement with defecation b. Onset associated with a change in frequency of stool c. Onset associated with a change in form (appearance)

of stool 2. No evidence of an inflammatory, anatomic, metabolic, or

neoplastic process that explains the subject’s symptoms * Criteria fulfilled at least once per week for at least 2

months prior to diagnosis .

Structural esophageal disorders

Esophageal atresia

There are five types of esophageal atresia:

Type A. Isolated esophageal atresia(8%); The upper and lower segments of the esophagus end in pouches, like dead-end streets that don't connect. ...

Type B. Proximal fistula with distal atresia(1%); The lower segment ends in a blind pouch. ...

Type C. Proximal atresia with distal fistula(85%); The upper segment ends in a blind pouch. ...

Type D. Double fistula with intervening atresia(1%); TEF is present on both upper and lower segments.

Type E. Isolated fistula(4%); Both upper and lower segment are connected to tracheal fistula by a tube

Types of atresia

Types of atresia

Anatomical disorders of stomach Diagrams with the most common, anatomical variances of the stomach: typical shape of the

stomach (a), malrotation (b), sliding hiatal hernia (c), paraesophageal hiatal hernia (d), mixed-form hiatal hernia (e), upside-down hernia (f), congenital short esophagus (g), cascade (h), lack of the whole organ (i), lack of the fundus (j), short body (k), advanced enlargement (l), congenital gastroduodenal (m) and gastroileal (n) fistula

Esophageal achalasia

Cleft and lip palate

Diagnosis Barium enema Endoscopy Colonoscopy Gastroenterography

Treatment Surgery Thoracotomy: Extra-pleural Trans-pleural