Ebach, MD Clinical Assistant Professor Department of Pediatrics University of Iowa Iowa City, Iowa Steven T. Little Rock, Arkansas 72202 Rachel Rosen, MD, MPH Assistant Professor Department of Pediatrics Harvard Medical School.
Abdominal Pain
Vomiting
Feeding and Swallowing Disorders
Diarrhea
Constipation
Gastrointestinal Bleeding
Jaundice and Neonatal Cholestasis
Nutrition
CHAPTER 1
DEFINITION AND EPIDEMIOLOGY
Family History
Because pain fibers from abdominal organs communicate bilaterally with more than one adjacent spinal level, visceral pain is often felt in the midline as a poorly localized sensation. These fibers have small receptive fields and nociceptive signals through these fibers result in sharp, well-localized sensations.
Patterns of Pain
The location of abdominal pain is determined by the developmental origin of the affected internal organs (Table 1-2).
Early Life Events
PATHOGENESIS
At the level of the spinal cord there are inhibitory mechanisms (inhibitory interneurons of the gelatinous substance). Somatoparietal pain is the result of stimulation of the parietal peritoneum and is more intense and somewhat better localized than the visceral sensation.
Pain Perception
A good example of this is the pain associated with Crohn's disease of the small intestine. The most important component of the evaluation process is a careful history taken and a detailed physical examination.
Acute Abdominal Pain
In the absence of an obvious indication for surgery, patients with worrisome acute symptoms should be observed in the hospital or emergency department with serial abdominal examinations to clarify any diagnostic uncertainty.
CLINICAL PRESENTATIONS
General Approach to Pain
Common causes of acute abdominal pain have characteristic presentations and knowledge of these characteristics is essential for rapid diagnosis (Table 1–3). An acidotic breathing pattern is observed when presenting with the history of common causes of acute abdominal pain.
DIFFERENTIAL DIAGNOSIS
The pain on palpation at the place of maximum tenderness increases with abdominal wall pain when raising the head and contracting the rectus abdominis muscle, while with visceral pain it decreases. Re-examination of the patient during acute exacerbation of abdominal pain will often provide important clinical information.
Chronic or Recurrent Abdominal Pain
Patients experience dull, persistent pain in the right upper quadrant or epigastric pain radiating to the right scapula. Biliary colic pain usually resolves within six hours of onset, but that of acute cholecystitis is more persistent and is usually associated with low-grade fever, nausea, vomiting, tenderness in the right upper quadrant with wakefulness and a positive Murphy's sign - the patient stops inhaling if the inflamed gallbladder touches the palpating finger located under the right costal margin.
Chronic Abdominal Pain
A diagnosis of IBS is made when abdominal discomfort or pain occurring at least once a week for at least 2 months before diagnosis is associated with two or more of the following at least 25% of the time: (a) improvement with defecation; (b) onset associated with change in stool frequency; and (c) onset associated with a change in stool shape. A diagnosis of functional dyspepsia is made when symptoms of persistent or RAP centered in the upper abdomen occur at least once a week for at least 2 months prior to diagnosis.
DIAGNOSIS
An algorithmic approach for evaluating a patient with acute abdominal pain is shown in Figures 1–3 and 1–4. Abdominal pain and pharyngitis Pharyngeal swab for rapid investigation and/or culture for -hemolytic group A streptococcus Disease, dehydrated serum electrolytes, blood urea nitrogen, creatinine, glucose.
TREATMENT
The role of dietary modification in patients with chronic abdominal pain and FGIDs is not well validated. Suggested laboratory and imaging studies in patients with chronic abdominal pain based on clinical presentation.
PROGNOSIS AND CLINICAL COURSE
CHAPTER 2
DEFINITIONS AND EPIDEMIOLOGY
Stimulation of the vomiting center in the brainstem is the ultimate result of many possible initiating events. The vomiting center is a complex of nuclei of the central nervous system, including the nucleus tractus soliturus (NTS).
CLINICAL PRESENTATION
Stimulation of the emesis center initiates a programmed emetic response that causes the diaphragm to descend and the intercostal muscles to contract towards a closed glottis.
Acute Vomiting
Pregnancy Addison's disease Porphyria Drug abuse Diabetes mellitus Abbreviations: UTI = urinary tract infection; EoE = eosinophilic esophagitis. An unprepared barium enema showing the transition zone in an infant with Hirschsprung's disease is shown in Figure 19-6A.
Recurrent Vomiting
Investigations that may be needed include CBC, causes of acute, chronic and cyclic vomiting patterns. Hospitalization may be necessary if the patient requires intravenous fluids for dehydration, fails to urinate for.
DIFFERENTIAL DIAGNOSIS Gastroesophageal Refl ux versus
Other studies that should be ordered based on the clinical presentation are listed in Table 2-9. 12 hours, is found to have metabolic acidosis (anion gap⬎18 mEq/L), or is suspected of having metabolic or surgical problems.
Gastroparesis
Superior Mesenteric Artery (SMA) Syndrome
Motion Sickness
Although motion sickness improves in early adolescence, it may be a precursor to the development of subsequent migraine headaches.
Postoperative Vomiting
Chemotherapy-induced Vomiting
Cyclic Vomiting Syndrome
CVS is often misdiagnosed in emergency departments as acute viral gastroenteritis and food poisoning; however, patients with CVS are sicker both qualitatively (pallor and lethargy) and quantitatively (more likely to require IV rehydration). Approximately one-third of patients with CVS typically develop migraine headaches by age 9.5 years, and 50% are expected to develop migraine by age 15 years.17 Treatment in CVS is largely empiric and involves: (a) lifestyle changes, (b ) ) prophylactic antimigraine and/or anticonvulsant therapy, (c) failed antimigraine therapy (triptans) and (d) supportive and symptomatic treatment during episodes.
COMPLICATIONS
CVS is currently defined by meeting consensus diagnostic criteria as outlined in Table 2-10.16 The key to the diagnosis of CVS is recognition of the repeated episodes of vomiting, particularly episodes starting in the early morning and with negative radiographic, laboratory, and endoscopic assessments. Patients and families are often very relieved when the doctor identifies CVS as a diagnosis and can reassure them that it is not a life-threatening disease.
TREATMENT Acute Vomiting
Chronic Vomiting
If the cause is not identified, it is appropriate to refer the patient to a pediatric gastroenterologist for further evaluation. Prokinetics such as oral erythromycin 2 mg/kg every 8 hours for 2 weeks are used in patients with gastroparesis.
Cyclic Vomiting
If symptoms persist, referral to a pediatric gastroenterologist for further intervention includes botox injection into the pylorus or nasojejunal tube.
ACKNOWLEDGMENT
CHAPTER 3
Pediatric eating disorders can be defined as problems with developmentally appropriate food intake. Pediatric eating disorders may be associated with medical conditions (often gastrointestinal), malnutrition or failure to gain weight, developmental delays that affect skill acquisition, and interpersonal disorders.
Failure to Gain Weight
Failure to acknowledge and move beyond the family's initial perceptions will result in an inability to build the confidence required to guide the family through the management of an eating disorder. The former can include almost any pediatric disorder; the latter can include failure to gain weight, gastroesophageal reflux disease (GERD), and dysphagia.
Gastroesophageal Refl ux
The family of a child who has previously had a comprehensive multidisciplinary evaluation that was negative may still believe that a medical etiology has been overlooked. These medical records must be reviewed prior to the clinic visit, sometimes with a limited telephone conversation with the family.
Dysphagia (Swallowing Problem)
These limits should be individualized and should take into account body position, food texture, onset of fatigue, rate of food delivery, and duration of the meal, as guided by a speech-language pathologist. Surveillance of pulmonary disease, even in the asymptomatic child at risk, can be performed intermittently by computed tomography examination.
Behavioral Factors
Medical Subspecialty Consultation
Dysphagia and Skill Development
Weight Gain and Nutrition
Stimulus control procedures systematically expose the child to new and unpreferred foods and prevent the occurrence of unwanted behavior (eg, preventing a child from running away from the table). With repeated exposures the child learns that the food is safe resulting in extinction of the response.
Components of Behavioral Management
When differential reinforcement techniques are applied and consistently applied after observing the desired behavior, the child quickly learns how to behave, reinforcing the child's appropriate mealtime behavior. Design is a useful behavioral tool for the outpatient setting because families can gradually achieve a larger goal over time without undue stress on the child or family system.
SUMMARY
CHAPTER 4
Extraintestinal manifestations such as skin rash or joint pain that may be associated with celiac disease or inflammatory bowel disease should be inquired about. Digital clubbing can be a sign of chronic disease such as Crohn's disease, celiac disease or cystic fibrosis.
Acute Diarrhea
It is transmitted through contaminated food, especially pork products such as chitterlings (pig intestines).8 It mimics appendicitis in approximately 40% of patients. It can be associated with immunodeficiency disorders such as immune dysregulation, polyendocrinopathy, enteropathy and X-linked (IPEX).
Chronic Diarrheal Disorders
Celiac disease should be considered in any child with diarrhea and weight loss, but especially in the preschool age. It is estimated that 10-15% of children have IBS.18 Tables 4-6 show symptoms, physical examination findings, and laboratory results where consultation with a pediatric gastroenterologist may be considered in the child with chronic diarrhea.
DIAGNOSIS Acute Diarrhea
Low serum albumin suggests a protein-losing enteropathy, which may be associated with inflammatory diarrhea. Abdominal computed tomography may also show signs of thickening of the bowel wall, suggesting inflammatory bowel disease.
Chronic Diarrhea
A complete blood count can reveal anemia, which is common in inflammatory bowel disease or celiac disease. Upper endoscopy and colonoscopy with biopsies are used to investigate patients who are suspected of having inflammatory bowel disease.
TREATMENT Acute Diarrhea
The use of probiotics to prevent diarrhea acquired in day care centers or hospitals has less strong evidence support, but may be useful in preventing antibiotic-associated diarrhea.25. Increasing dietary fat to 35–50% of their calories can help slow motility and reduce diarrhea.30.
INTRODUCTION
DEFINITION
EPIDEMIOLOGY
CHAPTER 5
Normally, the penetration of feces into the rectum leads to relaxation of the internal anal sphincter. Older children/youth (>4 years) Must include 2 months of two or more of the following.
Examination
Two other functional disorders should be considered in the differential diagnosis of functional constipation. A plain abdominal radiograph is recommended in practice guidelines by the NASPGHAN committee when constipation is suspected.1 This may be obtained in case of an unreliable history or examination such as in an obese child.
Education
It must be emphasized that incontinence is an involuntary process due to fecal retention and that the child has no direct control over it. It must be emphasized to the family that the problem is often chronic and relapses may occur, requiring long-term treatment for months to years.
Disimpaction
Knowing this usually alleviates some of the conflict that usually exists between the child and his parents. Ongoing education and constant physician support during regular follow-up visits are necessary to keep the patient and family involved in their treatment plan.
Maintenance Therapy
Laxative Therapy
Osmotic Laxatives
It has been effectively used for long-term maintenance therapy in children.1 Higher doses of lactulose for 3-7 days can be used for successful bowel movement. It is a non-toxic, highly soluble compound that is minimally absorbed in the gastrointestinal tract and, unlike lactulose, is not fermented by intestinal bacteria.
Lubricant Laxatives
Because it is not absorbed by the small intestine, it acts as an osmotic agent. It is available as a virtually tasteless and odorless powder that can be dissolved in a variety of beverages.
Stimulant Laxatives
Because PEG can be mixed into a beverage of the patient's choice and is virtually undetectable, long-term daily compliance is reported to be as high as 90% of parents. PEG is as effective as lactulose and milk of magnesia, but adherence to therapy is better.13 It is generally well tolerated and has no major side effects.15 Minor side effects include transient dose-dependent diarrhea (10%) and bloating (6%).
Newer Laxative
Because lactulose is fermented by gut bacteria to produce fatty acids, hydrogen, and carbon dioxide, children who take it may experience gas, bloating, nausea, and abdominal cramps. PEG therapy is also successfully and safely used in constipated children under 2 years of age. 16.
Which Laxative to Use?
Functional constipation with faecal incontinence is associated with significant physical morbidity and psychosocial stress in children. Increased prevalence of obesity in children with functional constipation assessed in an academic medical center.
Behavioral Modifi cation
A physician should plan a systematic therapeutic approach, including patient education, appropriate use of laxatives, and behavioral therapy for children with functional constipation. A randomized, prospective comparative study of polyethylene glycol without electrolytes and milk of magnesia for children with constipation and fecal incontinence.
PROGNOSIS
Efficacy and optimal dose of daily polyethylene glycol 3350 for the treatment of constipation and encopresis in children. Polyethylene glycol 3350 without electrolytes for the treatment of functional constipation in infants and toddlers.
DEFINITIONS
The key to addressing a patient with GI bleeding is a rapid assessment of the severity of the bleeding and the child's hemodynamic status. Given the nature of the content, this chapter will focus on differential diagnosis, diagnostic approach, and treatment based on clinical presentation: hematemesis or coffee-ground emesis, hematochezia, and melena.
KEY INITIAL STEPS IN THE EVALUATION OF GI BLEEDING
Regardless of the source, visible blood from the gastrointestinal tract tends to be a very concerning problem for patients and their families who bring them quickly to medical care. Fortunately, serious GI bleeding is uncommon in the pediatric age group and the problem often resolves without specific intervention.
Determine the Severity of the Bleeding
CHAPTER 6
In stable and/or asymptomatic patients, a thorough history is probably the most important part of the evaluation. The severity of bleeding is often reflected in the clinical presentation and hemodynamic status of the patient.
Determine if it is Blood
In a clinically stable patient, minimal amounts of red blood or coffee grounds usually indicate slow bleeding (although heavy bleeding may occur with coffee-ground vomitus). Blood clots or red blood mixed in the vomit may indicate larger amounts of bleeding.
Determine if Blood Originated from the GI Tract
Large amounts of bright red blood in the stool or pure blood are usually high volume hemorrhages. Vaginal bleeding may be normal in the first week of life and is sometimes mistaken for LGI bleeding.
Determine if it is the Child’s Blood
Upper GI Bleeding
If there is severe UGI bleeding and/or rapid intestinal transit (e.g. in infants, short intestine), hematochezia may be observed. Finally, severe hemorrhage may occur with hypovolemic shock before hematemesis or passing of a bloody stool.
Lower GI Bleeding
This may include bleeding from the intestinal tract and rarely from the biliary system (hemobilia) or pancreatic ductal system (hemosuccus pancreaticus).
DIFFERENTIAL DIAGNOSIS BASED ON PRESENTATION
APPROACH TO DIAGNOSIS AND MANAGEMENT
Hematemesis or Coffee Ground Emesis
Causes of severe UGI bleeding most commonly include: Esophageal hematochezia or Melena depending on age and presentation (Always consider sources of UGI). Rare Causes of Hematochezia or Melena See rare causes of UGI bleeding in Table 6-6 Perianal group A beta-hemolytic streptococcus Hemorrhoids: internal or external.
Hematochezia or Melena
Anal fissures Anal fissures are usually in the midline, caused by traumatic passage of a large, hard stool. 2% of the population.11 It is the remnant of the omphalomesenteric duct (which connects the yolk sac and intestine during embryogenesis) located in the distal ileum (see Figure 6–6).
DIAGNOSTIC TESTS OF INTEREST
Although most risk factors are associated with prematurity (low birth weight, sepsis, and hypoxia), necrotizing enterocolitis also occurs in full-term infants. Certain diseases are associated with recurrent episodes of intussusception (eg, celiac disease, cystic fibrosis, and Ehlers-Danlos syndrome).
Radiography
Most are ileocolic and idiopathic or associated with lymphoid hyperplasia of the ileum (often following a viral illness). Only 20% of cases occur after the age of 2 years, but these more often have an identifiable cause.
Ultrasonography
Abdominal films may show air in the intestinal wall (pneumatosis intestinalis) and dilated intestinal loops. Air or contrast enema can diagnose and be therapeutic in up to 80% of cases.
Endoscopy and Colonoscopy
Nuclear Medicine Scans
Angiography
Medical Therapy for Minor Upper GI Bleeding
Medical Therapy for Active GI Bleeding
Endoscopic Therapy for Active GI Bleeding
Management of Variceal Bleeding
CHAPTER 7
Depending on the etiology and pathogenesis, this can lead to unconjugated or conjugated hyperbilirubinemia. This can be observed with breast milk jaundice, inadequate breastfeeding and reduced intestinal motility or intestinal obstruction.
History
The maternal and perinatal history should be reviewed, looking for signs of maternal illness during pregnancy or delivery (fever, rash and respiratory symptoms), traumatic birth and birth asphyxia. Relevant family history should be obtained, including that of jaundice, liver disease, anemia, hemolysis, metabolic disorders, or splenectomy.
Physical Examination
Causes of Unconjugated Hyperbilirubinemia
These disorders result in severe and chronic unconjugated hyperbilirubinemia with onset in the first days of life for type I and later for type II. In most breastfed babies, breast milk jaundice remains a harmless and physiological phenomenon.
Causes of Conjugated Hyperbilirubinemia
Obstruction of bile ducts by inspired secretions is thought to play a major role in pathogenesis. Defects in transporters in the bile canalicular membrane of hepatocytes have been described as causes of cholestasis.
Blood and Urine Testing
Further confi rmation can be determined by documenting decreased fumarylacetoacetate hydrolase activity in red blood cells or fibroblasts.20. The diagnosis of alpha 1-antitrypsin deficiency is suggested by a low serum level of alpha 1-antitrypsin.
Radiologic Testing
Histological Assessment
If the diagnosis of biliary atresia is confirmed, portoenterostomy is the only therapeutic intervention, apart from liver transplantation. Accelerated immunization programs are sometimes implemented, especially for live virus vaccines if future liver transplantation is anticipated.
CONCLUSIONS
CHAPTER 8
NUTRITIONAL NEEDS AND REQUIREMENTS
NUTRITION IN HEALTH
The average daily level of intake of a nutrient that, based on scientific evidence, is estimated to meet the requirements of half of healthy individuals of a given gender and in a given age group Recommended Diets. The average daily level of nutrient intake that meets the nutrient requirements of nearly all healthy individuals of a given sex and in a given age group.
Infant Requirements (0–6 and 7–12 months)
This means that no reference values apply for non-breastfed infants (Tables 8–2 and 8–3). The AIs, based solely on estimates of nutrients in breast milk, may result in marked deficiencies of certain nutrients if these nutrients are fed at AI levels to non-breastfed infants.
Toddler Requirements (1–3 years)
Additionally, this approach assumes that the mother is not nutrient deficient, that all birth events were optimal (umbilical cord clamping, etc.), and that breast milk has at least an average amount of nutrients. If any of these assumptions are incorrect and the baby is not receiving supplements, nutrient deficiencies can occur.
School Age Requirements (4–8 years)
Human milk is a matrix of interacting factors and each factor may be more or less bioavailable in this matrix compared to the bioavailability of the factor when not in the human milk matrix. Physical evidence of a single nutrient deficiency is not commonly found in the developed world.
Anthropometrics
Pre-teen Requirements (9–13 years)
Teenager Requirements (14–18 years)
Nutritional Assessment
The resulting curves show that the WHO babies were heavier than the CDC babies for the first few months, but in the second half of the first year the trend reversed. Similarly, the WHO infants grew faster for a few months, but by one year of age the linear difference disappeared.
Growth Charts
To do this, baby-mother pairs were selected to be followed from several sites around the world. Interestingly, despite ethnic, cultural and geographic differences, WHO infants showed very similar growth.2.
NUTRITION SUPPORT
Defi nition
Pathogenesis and Clinical Presentation
Laboratory Tests
Observation of Feeding Behavior
Dietary Supplements
Treatment
If these assessments indicate inadequate intake for the child's needs and the absence of fat malabsorption, food sources of nutrients can be used as an initial step in NS. This ensures that the child receives all the nutrients necessary for growth in a small volume and the ratio of nutrients is the same as in the original formula.
ENTERAL NUTRITION
Formulas can be further modified by adding modular components such as fat, carbohydrates and proteins. Gastrostomy tube (G-tube, PEG) No device in the face, minimally invasive placement procedure, the tube can be used immediately after placement.
PARENTERAL NUTRITION
If PN is required for less than 7 days and the child is not malnourished, peripheral support can be used. Some of the complications, such as air embolism, lipid thrombus, catheter perforation of the heart, etc., can be life-threatening.
NUTRITION NEEDS IN DISEASE
The dietitian and pharmacist of the NS team can help you decide which products to choose. Therefore, it is important that the NS team, including physicians, dieticians and pharmacists who are trained and experienced in NS, supervise the patient receiving PN.
Malabsorption and Nutrition
The purpose of NS is to replenish malnourished children, sustain children through metabolic stress (burns, trauma, and surgeries), provide supplemental nutrition required by a chronic illness (liver, inflammatory bowel disease, cystic fibrosis, and cancer), and ensures normal growth.
Nutrition in Liver Disease
The amount and type of protein that should be consumed in liver disease has been controversial, especially in end-stage liver disease. In older children and adolescents, receiving the RDA of protein will maintain nitrogen balance and not adversely affect underlying liver disease.
Pancreas and Nutrition
EFA deficiency is well described in cystic fibrosis and is associated with symptoms including scaly dermatitis, alopecia, thrombocytopenia, hemolytic anemia, and growth retardation due to long-chain omega-3 and omega-6 polyunsaturated fatty acids. series cannot be synthesized by humans and must be ingested through diet. Fatty acids from the omega-3 series are found as components of cell membranes and exhibit profound anti-inflammatory effects.
Small Bowel and Nutrition
Imaging in Pediatric Gastroenterology
Endoscopy
Esophageal pH and Impedance Monitoring
Free air can be detected at the highest part of the peritoneal cavity, below the diaphragm on an upright frontal projection, along the nondependant flank on a frontal decubitus projection (Figure 9–1), or along the anterior abdominal wall. on cross table lateral projection. Other structures seen in this situation include the falciform ligament of the liver and sometimes the umbilical arterial ligaments.
IMAGING TECHNIQUES
This is most easily achieved in many patients by obtaining upright frontal films. It can be seen as a bubbly translucency along the bowel or a curved/annular translucency.4 Intramural gas eventually finds its way to the portal veins via the mesenteric veins (Figure 9-3).
Introduction
Radiographs using a horizontal beam technique are essential to detect a small amount of free air (pneumoperitoneum). Air bubbles carried by the mesenteric veins circulating in portal veins can be demonstrated even before visualization of portal venous gas on radiographs.
Radiographs
CHAPTER 9
Portal venous gas is demonstrated as branching air density in the right lobe of the liver. A diagnosis of acute appendicitis can be made in these patients when they present with appropriate clinical and laboratory findings.
Upper Gastrointestinal Series
A typical appendicitis is seen in the lower right quadrant as a round, laminated calcification. Torsion of the ovary containing dermoid or teratoma should be suspected when formed teeth or small skeletal structures are seen in the pelvis of a woman with acute abdominal pain.
Small Bowel Follow-through
Contrast Enema
Sectional Imaging
Chemical shift imaging (in-phase and reversed-phase imaging) is another technique used primarily for liver and kidney imaging. In phase imaging, the signal from both water and fat protons contributes to the tissue signal intensity.
Nuclear Medicine
Gadolinium (Gd) is the most commonly used MRI contrast media that has increased the signal intensity of water molecules on T1-weighted images. This technique is used to detect focal or diffuse fatty liver infiltration, fatty liver tumors and adrenal adenomas.
IMAGING FEATURES OF PEDIATRIC GASTROINTESTINAL DISORDERS
Acute Abdominal Emergencies
US of the hepatic hilus (a and b) shows triangular hyperechogenicity (white arrow) connecting the area of fibrosis and the vestigial gallbladder (black arrow). Oblique upper GI view (c) shows an elongated narrow pyloric duct (arrows) and characteristic deformation of the gastric antrum.
Congenital Malformations
They are usually echogenic, mobile, and produce a distinct acoustic shadow (Figure 9–12). Choledocholithiasis usually results from the migration of stones from the gallbladder into the common bile duct. US can demonstrate stones in the common bile duct, but sometimes this is difficult due to interstitial gas in the duodenum.
Infections
The T1-weighted fat-suppressed image is a particularly useful sequence in which the pancreas appears with high signal intensity in contrast to the lower signal intensity of the duodenum. On US, it appears as an anechoic fluid-filled mass with the typical double-wall sign with the echogenic inner layer representing the mucosa-submucosa and the hypoechoic outer layer representing the muscularis.
Tumors
Other findings are enlarged feeding arteries and draining veins and a small aorta distal to the origin of the celiac artery. The most common causes of metastases to the liver in children are Wilm's tumor, neuroblastoma, lymphoma and leukemia.
Infl ammatory Bowel Disease
As a medical procedure, endoscopy has been performed since the early nineteenth century and originally involved the use of alcohol or turpentine lamps as light sources for rigid instruments.1 The birth of modern endoscopy can be dated to the 1960s with the development of flexible fiberoptic instruments. In the 1970s, the diameter of endoscopes became small enough to allow the examination of children.2 Before the use of endoscopy, diseases of the gastrointestinal tract were diagnosed mostly by fluoroscopic contrast studies.
THE ENDOSCOPY UNIT
CHAPTER 10
In the 1980s, endoscopes were specifically designed for use in children, confirming the importance of endoscopy in the field of pediatric gastroenterology. If patients are critically ill or unstable, at significant risk of dehydration, or at risk of hypoglycemia, it may be appropriate to perform bowel preparation in the hospital, where intravenous fluids can be administered concurrently.
Sedation
The clear diet consists of soup, clear fruit juices (no pulp or sediment), ice cream sundaes, and flavored gelatin desserts (no added fruit). All bowel cleansing approaches carry some risk of electrolyte imbalance and dehydration and should be used with caution in sick patients.
PREPARING CHILDREN FOR ENDOSCOPY
In general, it is best if children can avoid eating red-colored liquids, popsicles, and gelatin, as these tend to temporarily stain the mucosa red and make it difficult for the endoscopist to identify the true erythema or hemorrhage. The inability of patients to tolerate the bowel preparation, due to the inability to follow the instructions or due to the inability to tolerate the preparation, can also be regarded as an indication for admission for a bowel cleansing.
PREPARING FOR COLONOSCOPY
This approach is again used in children who would be classified as ASA I or II, and are stable and otherwise healthy. Very small infants, very sick children, and those with significant comorbidities, including cardiac or respiratory diagnoses, are best served with general anesthesia in the operating room.
Prophylactic Use of Antibiotics Prior to Endoscopy
A growing practice trend among pediatric endoscopists is the use of anesthetic support to perform endoscopy in children outside of the main operating room, often in a separate ambulatory endoscopy suite, using propofol.
UPPER GASTROINTESTINAL ENDOSCOPY
Instruments
Contraindications for Upper Endoscopy
Indications for Upper Endoscopy
Upper Endoscopy Examination Basics
Colonoscopes also have an auxiliary water jet that allows stool, mucus and debris to be flushed away in the colon with the push of a button on the scope, or on a foot switch unit when an optional flush pump is connected. The Olympus colonoscopes also have a variable stiffness switch that increases the stiffness of the insertion tube and can be useful in difficult looping colons.
Indications for Colonoscopy
In comparison, colonoscopes offer greater scope in all four directions with 180° up and down and 160° left and right deflection.
COLONOSCOPY
In the middle of the haustra, the wall is thrown into crescent-shaped folds, the plicae semilunares, which protrude into the lumen of the colon. The cecum is characterized by the star-like formation formed by the convergence of the three teniae coli.
Contraindications for Colonoscopy
Colonoscopy Examination Basics
DIAGNOSTIC TECHNIQUES IN UPPER ENDOSCOPY AND
POST-PROCEDURE CARE
THERAPEUTICS PROCEDURE IN ENDOSCOPY
Percutaneous Endoscopic Gastrostomy (PEG)
The guidewire is grasped using a snare or forceps and pulled out through the mouth as the endoscope is withdrawn. –E) The gastrostomy tube is connected with a wire and pulled back into the stomach and out through the needle tract.
Management of GI Bleeding
Endoscopic dilation can be performed with balloon dilation through the scope (TTS) or with Savary-Gillard dilators. TTS balloon dilatation allows direct visualization of the passage of the balloon through the stricture.
Stricture Dilation
The Savary dilator is advanced over a guidewire that is placed endoscopically through the stricture, and the procedure is usually performed under fluoroscopic guidance. Some clamps can be opened and closed multiple times, while others are rotatable to facilitate accurate placement (Figure 10–7c).
Polypectomy
These agents and others can be injected directly into the varices to treat variceal hemorrhage. Complications of sclerotherapy include stricture formation, tissue ulceration, bleeding, perforation, infection, and string formation.
ADVANCED PROCEDURES Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Endoscopic Ultrasound
Small Bowel Imaging
Gastroesophageal reflux disease (GERD) is distinguished by reflux into the esophagus that leads to well-defined symptoms or medical problems (see Chapter 12). In the present chapter, we will review the current techniques used for the dynamic detection of reflux episodes.
CATHETER-BASED ESOPHAGEAL pH MONITORING
The first test used was esophageal pH monitoring, in which an electrode designed to detect changes in pH is used to assess the frequency and duration of acid reflux in the distal esophagus. In addition, we have seen the development of the technical ability to measure both acid and non-acid reflux with multichannel intraluminal impedance (MII).
Equipment
Gastroesophageal reflux (GER), defined as the passage of stomach contents into the esophagus, occurs daily as a normal process in infants, children, and adults. When children present with atypical problems or extraesophageal symptoms, testing may be required to document the presence or absence of pathologic reflux or an association between reflux events and specific symptoms.1.
Electrode Placement
CHAPTER 11
Correct placement of the pH electrode relative to the lower esophageal sphincter (LES) is very important for accurate data. As a result, there are other methods for locating the pH electrode in children, including calculating the length of the esophagus according to Strobel's formula4 and fluoroscopy.
Recording Conditions
Similarly, as pH electrodes are placed higher and higher in the esophagus above the LES, there is a linear decrease in acid exposure time, ultimately reducing the sensitivity of the test. In adult studies, the pH electrode is typically inserted through the nose and placed 5 cm above the upper margin of the LES.2 Ideally, localization of the LES is best achieved with stationary esophageal manometry before placement of the catheter.
Defi nitions and Criteria
Because of the two nasal intubations required, this additional procedure is difficult in children, but manometry has not become standard procedure prior to pH probe placement in children. Because of concerns about the accuracy of applying Strobel's formula to children over 1 m tall, the working group of the European Society of Pediatric Gastroenterology and Nutrition recommended the use of X-ray or fluoroscopy to confirm the placement of the pH electrode so that the sensor or tip lies above the third vertebral body above the diaphragm throughout the respiratory cycle.3 In the absence of manometry, radiographic verification of catheter placement is generally necessary and catheter placement can be adjusted accordingly.
Normal Ranges
Diagnostic Accuracy
Reproducibility
Symptom Correlation
These various issues have made it ultimately elusive to establish normative values for proximal reflux. However, at the present time, the clinical advantage of dual-test pH monitoring in children has not yet been clearly established; more research is needed before these new methodologies become part of the routine evaluation of children with extraesophageal manifestations of reflux.
Limitations of Catheter-based pH Monitoring
There is also no agreement on the definition of a proximal reflux event; conventionally, this has been defined as a drop in pH below 4, based on the pH threshold for distal esophageal reflux. Studies using dual-probe pH monitoring in children and adults have had mixed results in terms of sensitivity and specificity for extraesophageal manifestations of reflux as well as intra-subject reproducibility.18 Newer diagnostic modalities, such as oropharyngeal or nasopharyngeal pH -monitoring, and the non-invasive measurement of exhaled breath condensates for the detection of aspiration of gastric contents is currently being investigated.
WIRELESS pH MONITORING
However, recent data have suggested that non-acidic or weakly acidic reflux with a pH between 4 and 7 may also play a clinically important role in aerodigestive disease,16,19 and there have been proposals to revise the pH criteria for proximal reflux. Given the size of the capsule, it is not recommended for use in young and small children, so caution should be exercised if considering placement in a 4-year-old child.
MULTICHANNEL INTRALUMINAL IMPEDANCE
The pH measurement shows that the pH drops below 4 at the same time as the impedance-detected episode, indicating acid reflux. Because MII-pH detects both acid and non-acid reflux, it is possible and often ideal to examine patients while taking acid-suppressing medications to assess therapeutic efficacy.
Defi nitions
Unlike with pH data, there have not been studies to show the optimal length for MII pH recording, so currently standards for pH monitoring have been adopted. Adult studies have shown that acid suppression therapy with proton pump inhibitors does not reduce the total number of reflux events, but rather converts them from acid to non-acid events.31 Because the total number of events is unchanged, it is still possible to make correlations with symptoms and both acid and non-acid -acid events, although some literature suggests that symptom correlation may be higher if studies are performed while acid suppression therapy is off.32.
Sensitivity
The pH probe alone performed significantly worse than the MII-pH in detecting weakly acidic and non-acidic reflux events. Sensitivity decreased to 53% when a pH drop of 1.5 was used to define a reflux episode compared to the gold standard MII-pH.37.
Interpretation
The pH probe had a sensitivity of 28% for detecting non-acidic or weakly acidic reflux as demonstrated by MII-pH; conversely, 83% of weakly acidic events detected by the pH probe were not detected by MII-pH.36 Aanen et al. In our own studies, we found that the sensitivity of MII-pH in pediatric patients not receiving acid suppressive therapy was 76- 13%, compared to the pH probe whose sensitivity was 80-18%.
Normal Values
Symptom Association
Cough occurs as simultaneous high-pressure surges in the esophagus (Figure 11–10), allowing accurate correlation between reflux and cough without the possibility of recording error. The utility of this technology is currently limited by the need to place two catheters at the same time, which is an important consideration in the pediatric population.
Proximal Refl ux
In a study by Sifrim et al., there was an average delay of 28 seconds between the time when a patient coughed and when they actually recorded a cough on the symptom log.53 Furthermore, patients only recorded an average of 38% of hoods on. on the log.53 To address this limitation, impedance sensors can be paired with pressure sensors, the latter of which measure esophageal pressure spikes that occur when a patient coughs.
Role of Assessing Therapy
Clinical Indications
Traditional catheter-assisted pH measurement, however, has several limitations, including issues of sensitivity and specificity for the diagnosis of GERD in the absence of erosions, as well as for extraesophageal manifestations, intranasal catheter portability, and the inability to record nonacid reflux events. Wireless pH monitoring has proven to be a safe and effective way to study children.
ACKNOWLEDGMENTS
- Gastroesophageal Refl ux Disease
- Gastritis and Peptic Ulcer Disease
- Abdominal Wall Defects
- Atresias, Webs, and Duplications
- Infl ammatory Bowel Disease
- Food Allergy and Intolerance
- Celiac Disease
- Disorders of Gastrointestinal Motility
- Short Bowel Syndrome
- Surgical Emergencies
- Polyps and Tumors of the Intestines
- CHAPTER 12
Esophageal pH monitoring and impedance measurement: a comparison of two diagnostic tests for gastroesophageal reflux. Gastroesophageal reflux and respiratory symptoms in infants: status of the intraluminal impedance technique.
Genetic Factors
A minor proportion of reflux episodes occur when the LES does not increase pressure during a sudden increase in intra-abdominal pressure or when the resting LES pressure is chronically reduced. In hiatal hernia, the anti-reflux barriers of the LES (including the crural support, the intra-abdominal segment and the angle of His) are compromised, and transient LES relaxations also occur with greater frequency.
GERD in Adults versus Children
Aerodigestive reflexes (oral, pharyngeal and esophageal coordinated functions) are fully developed in most children before birth, by an estimated 38 weeks of gestational age. Hiatal hernias are prevalent in adults and children with severe reflux complications, and the size of the hernia is a major factor in the severity of GERD.
Altered Motor Function
Vomiting
Other Risk Factors for GERD in Children
Recently, a study of infants with colic found abnormal pH test results only in those with excessive regurgitation or feeding difficulties.36 Taken together, the association between crying, night awakenings, and GER remains based on a “diagnostic” test. unclear.
Anatomic Lesions
CLINICAL FEATURES IN INFANTS
Crying and Sleep Disturbances
Additionally, rumination is associated with an absence of nocturnal symptoms, does not occur when lying down, does not respond to prokinetics or acid suppression, and has a female predominance.27,28 Infant rumination syndrome is a rare disorder characterized by by voluntary, frequent regurgitation of stomach contents into the mouth for self-stimulation, and may be a sign of social deprivation or severe psychosocial dysfunction in the family.29 The Rome III criteria26,29 for rumination syndrome require GERD to be eliminated from the differential diagnosis.
EXTRAESOPHAGEAL
MANIFESTATIONS OF GERD
Asthma
CLINICAL FEATURES IN OLDER CHILDREN
Apnea
The sensitivity, specificity, and positive predictive value of the upper GI series ranged from 29% to 86%, 21% to 83%, and 80% to 82%, respectively, when compared with esophageal pH monitoring.94-96 Short duration of the upper GI series produces false-negative results, while the frequent occurrence of non-pathological reflux during examination produces false-positive results. Therefore, routine performance of upper GI series to diagnose GER and GERD is not justified.97.
Scintigraphy
The PPI Test: Empiric Trial of Acid Suppression
Barium Contrast Radiography
Therefore, routine performance of upper GI series for the diagnosis of GER and GERD is not warranted.97. record that esophageal pH 4.0)23. In children with esophagitis, normal esophageal pH monitoring suggests a diagnosis other than GERD.122,123.
Multichannel Intraluminal Esophageal Impedance
Recently, the value of esophageal pH-metry in the diagnosis and management of pediatric GERD has been questioned due to its lack of applicability. most widely used electrodes are slow. Esophageal pH monitoring may correlate poorly with symptom severity and with response to therapy in pediatric patients.70 In infants with suspected GERD, an abnormal pH study (RI 10%) was associated only with pneumonia, apnea with restlessness, smaller stools. than once daily and constipation.70 An abnormal RI is seen more frequently in adults with erosive esophagitis than in normal subjects or in those with non-erosive reflux disease, but there is considerable overlap between the groups.119 In pediatric patients, the calculated area below pH 4, The 0 curve has been associated with erosive esophagitis (Gold et al., unpublished data).
Esophageal pH Monitoring
However, it is important to note that the presence of endoscopically normal esophageal mucosa does not exclude a diagnosis of non-erosive reflux disease or esophagitis of other etiologies.158,159 For improved performance, MII and pH electrodes. The combined measurement of pH and impedance (pH/MII) provides additional information on whether a refluxed material is acidic, weakly acidic or non-acidic.
Invasive Diagnostic Approaches to GERD and Extraesophageal GERD
Histologic findings of eosinophilia, papillary elongation (rete pegs), basal cell hyperplasia, and dilated intercellular spaces (DIS or spongiosis) are neither sensitive nor specific for reflux esophagitis. Recent studies have shown considerable overlap between the histology of reflux esophagitis and EoE. Many histological parameters are affected by drugs used to treat esophagitis or other disorders.
MANAGEMENT
Currently, the primary role of esophageal histology is to rule out other conditions in the differential diagnosis, such as EoE, Crohn's disease, Barrett esophagus, infection, and others. In vitro studies have shown a decrease in the absorption of minerals and micronutrients from infant formulas that are commercially infant formulas, which may benefit infants with weight.
LIFESTYLE CHANGES
Excessive caloric intake is a potential problem with long-term use of foods thickened with rice grains or corn starch.183 Thickening a 20 kcal/oz infant formula with one tablespoon of rice grains per ounce increases the caloric density to 34 kcal/ounce. oz. These formulas reduce the frequency of overt belching and vomiting compared to unthickened formulas or formulas thickened with rice grains.
Feeding Changes in Infants
A largely untested potential advantage of AR formulas is that because they thicken in the stomach, they do not require a large-bore nipple hole and do not substantially increase suction. Esophageal pH and combined pH/MII monitoring show that reflux is quantitatively similar in the left-down and prone positions.
Lifestyle Changes in Children and Adolescents
Prone positioning may be beneficial in children over 1 year of age with GERD or GERD, in whom the risk of SIDS is negligible. The measured reflux in these two positions is less than in the right side down and in the supine position. Additional MII studies in preterm infants showed that postprandial reflux was greater in the right side down than in the left side down. .202 The impedance data led to the recommendation to place infants right side down for the first hour after feeding to promote gastric emptying, and then switch to left side down to reduce GER.
Tube Feedings
From a practical point of view, it is important that parents and doctors realize that side-lying position can change unnoticed to prone position during sleep. Most importantly, it is not recommended to use a pillow together to keep a child in the side position.203
Positioning Therapy for Infants
Although this is much less common than it was in the pre-acid-suppressing era, all acid-buffering agents should be used with extreme caution in infants and young children. In adults, sucralfate (1 g orally QID) reduced symptoms and accelerated healing of nonerosive esophagitis.220 The only randomized controlled trial in children demonstrates that sucralfate was as effective as cimetidine in the treatment of esophagitis.221 Available data are less than adequate for guidelines that are evidence-based and make recommendations about the safety or efficacy of sucralfate in the treatment of GERD in infants and children, particularly regarding the risk of aluminum toxicity with long-term use.
Histamine-2 Receptor Antagonists (H 2 RAs)
In one clinical trial, a commercial liquid preparation containing only sodium/magnesium alginate significantly reduced the mean frequency and severity of vomiting in infants compared to placebo.217,218 Another placebo-controlled study of this preparation in infants showed that although symptoms improved with therapy the only objective change on the combined pH/MII evaluation was a marginal decrease in the degree of esophageal reflux.219 Alginate is also available in tablet form and is useful for treating symptoms on demand. None of the surface agents are recommended as the sole treatment for severe symptoms or erosive esophagitis.
PHARMACOLOGICAL INTERVENTION
In older studies of alginic acid therapy in pediatric patients with GERD, the liquid preparations used also contained buffering agents, making it difficult to isolate the effect of the surface protectant itself.216 Efficacy in these studies varied widely. In addition, long-term or long-term use of the surface agents, even as adjunctive therapy for GERD-related symptoms and esophageal disorders, is not recommended.
Buffering Agents
To date, no PPI has been approved for use in infants aged 1 year in either North America or Europe. Gastric pH begins to rise within 30 minutes of administration and the effect lasts for 6 hours.223 In an infant study, ranitidine (2 mg/kg per dose orally) reduced the time gastric pH was below 4.0 by 44 % when given twice daily and by 90% when given three times daily.224 Tachyphylaxis to intravenous ranitidine has been observed after 6 weeks, and tolerance to oral H2RAs in adults is well known.225-227 A a number of placebo-controlled, randomized adult trials have been demonstrated. that cimetidine, ranitidine and famotidine are all superior to placebo in relieving symptoms and healing the esophageal mucosa.228-230 However, the efficacy of H2RAs in achieving mucosal healing is much greater in mild esophagitis than in severe esophagitis and31infantitis2. children with erosive esophagitis, significant improvement in clinical and histopathological scores was demonstrated in the cimetidine-treated group compared to the placebo group.232 Recently, a randomized controlled trial of 24 children with mild to moderate esophagitis showed that nizatidine (10 mg/kg/ . day ) was more effective than placebo in esophagitis healing and symptom relief.233 No randomized controlled trials in children demonstrate the effectiveness of ranitidine or famotidine in the treatment of esophagitis; However, clinical practice guidelines suggest that these agents are as effective as cimetidine and nizatidine.2 Extrapolating the results of a large number of adult studies to older children and adolescents suggests that H2RAs can be used in these patients for the treatment of GERD symptoms and for esophagitis healing, although H2RAs are less effective than PPIs for both symptom relief and esophagitis healing.
Proton Pump Inhibitors
In the retrospective case review, 18 cases of biopsy-proven PPI-induced acute interstitial nephritis causing acute renal failure were reported, and the authors suggest that this entity may not be recognized as "unclassified acute renal failure".265 Despite the small size of the studies. , and the lack of This result may be due to the lack of city-specific symptoms. However, this may also be due to the quality of case selection, PPI dose, study duration, and outcome variables.
Prokinetic Therapy
Children with developmental delay were even more likely to be hospitalized in the year after antireflux surgery than before surgery.313 In a recent pediatric study, Nissen fundoplication did not reduce the number of hospital admissions for pneumonia, respiratory distress/apnea, or failure. to thrive even in those with underlying NI.314. Complications after antireflux surgery can result from changes in gastric volume and from changes in current gastric volume, although the “class of agents” is wide ranging.
Anti-refl ux Surgery
Chronic cough due to gastroesophageal reflux disease: evidence-based clinical practice guidelines from the ACCP. Is acid gastroesophageal reflux in children with ALTE etiopathogenetic factor of life-threatening symptoms.
