Gastroenterolgy Presentations:

1.Vomiting:
Is the forceful ejection of gastric contents. Often benign and due to feeding disorders or mild GORD or gastroenteritis. Causes of vomiting in children red flags Associated clinical features Differential diagnoses Bile-stained vomit Haematemesis Projectile vomiting, in first few weeks of life Vomiting at the end of paroxysmal coughing Abdominal distension Hepatosplenomegaly Blood in the stool Severe dehydration, shock Intestinal obstruction Oesophagitis, peptic ulceration, oral/nasal bleeding Pyloric stenosis Whooping cough (pertussis) Intestinal obstruction, including strangulated inguinal hernia Chronic liver disease Intussusception, gastroenteritis salmonella or campylobacter Severe gastroenteritis, systemic infection (urinary tract infection, meningitis), diabetic ketoacidosis Raised intracranial pressure Gasto-oesophageal reflux, coeliac disease and other chronic gastrointestinal conditions

Bulging fontanelle or seizures Failure to thrive

Gastro-oesophageal reflux Occurs in otherwise normal infants, but risk is increased if neuromuscular problems or surgery to the oesophagus or diaphragm Investigations: (24hr pH monitoring, endoscopy) are performed if diagnosis is unclear or complications occur such as failure to thrive, oesophagitis and pulmonary aspiration. Management: Treated if troublesome with upright positioning, thickening, medication and sometimes fundoplication. Pyloric stenosis More common in Clinical features: forcefulness over feed

boys

and those with

maternal family history and

Vomiting, which increases in frequency time, ultimately becoming projectile

Signs: visible gastric peristalsis, palpable abdominal mass on test and possible dehydration Associated with hyponatraemia, hypokalaemia and hypochloraemic alkalosis

feed

Investigations: Diagnosis

may be

confirmed

by ultrasound

Management: Treated by surgery- pyloromyotomy after rehydration (0.45% saline and 5% dextrose with potassium supplements) and correction of electrolyte imbalance

2. Abdominal Pain
Causes of acute abdominal pain

Intra-abdominal Medical Surgical

Extra-abdominal

Acute appendicitis, Intestinal obstruction including intussusception, Inguinal hernia, Peritonitis, Inflamed Meckel diverticulum, Pancreatitis, Trauma

Non-specific abdominal pain, Gastroenteritis, Urinary tract: urinary tract infection acute pyelonephritis hydronephrosis renal calculus HenochSchnlein purpura, Diabetic ketoacidosis, Sickle cell disease, Hepatitis, Inflammatory bowel disease, Constipation, Recurrent abdominal pain of childhood, Gynaecological in pubertal females, Psychological, Lead poisoning, Acute porphyria (rare), Unknown

Upper respiratory tract infection, Lower lobe pneumonia,Torsion of the testis, Hip and spine problems.

Acute Appendicitis Commonest cause of abdominal pain in childhood. Occurs at any age, but uncommon in children <3. Clinical features: Symptoms Anorexia, Vomiting, Abdominal pain, initially central and colicky (appendicular midgut colic), localising to the RIF (from localised peritoneal inflammation) Signs: Flushed face, fever 37.238C, Abdominal pain worse on movement, Persistent tenderness with guarding in the RIF (McBurneys point). Management: Surgical Intussusception Invagination of proximal bowel into a distal segment. Occurs 3 months and 2 years Clinical features: paroxysmal colicky pain (sausage shaped) redcurrant jelly stool with pallor, abdominal

between

mass

Management: Reduction is attempted by rectal air insufflation unless peritonitis is present Surgery is required if reduction with air is unsuccessful or for peritonitis. Shock is an important complication and requires urgent treatment

Coeliac disease A gluten-sensitive enteropathy

Clinical features: Classical presentation is at 824 months with abnormal stools, failure to thrive, abdominal distension, muscle wasting and irritability Can have short stature, anaemia. Diagnosis: positive serology (IgA tissue transglutaminase and endomysial antibodies), flat mucosa on jejunal biopsy and resolution of symptoms and catch-up growth upon gluten withdrawal Management: gluten-free diet for life

Crohns disease A transmural, focal, subacute or chronic inflammatory disease, most affecting the distal ileum and proximal colon. commonly

Clinical features: General ill health: fever, lethargy, weight loss, growth failure, puberty delayed, Classical presentation (25%), abdominal pain, diarrhoea, weight loss Raised ESR/CRP Diagnosis: based on biopsy

Management: Remission is induced with nutritional therapy, when the normal diet is replaced by whole protein modular feeds (polymeric diet) for 68 weeks. This is effective in 75% of cases. Systemic steroids are required if ineffective. Immunosuppressant medi-cation (azathioprine, mercaptopurine or methotrexate), anti-TNF Ulcerative colitis Recurrent, inflammatory and ulcerating disease involving the the colon. 90% of children have a pancolitis. Clinical features: presents with rectal bleeding, pain. Weight loss and growth failure mucosa of

diarrhoea and colicky

Management: In mild disease, aminosalicylates used for maintenance Extensive disease requires steroids for acute exacerbations and immunosuppresants azathioprine Colectomy with an ileostomy or ileorectal pouch is undertaken for severe disease References Rapid peads Illustrated colour text of paediatrics