Kids and guts- common pediatric GI complaints TTAnderson MD 8/10/2016 Family and Community Medicine

What will we accomplish today? Outline differential diagnoses for some common GI complaints in pediatric patients “Think outside the box” Discuss evaluation approaches esp radiology and labs Review evidence-based management of acute gastroenteritis

Vomiting- what is your differential? Take a minute to write down your differential Think about “red flags” with vomiting Now, a few vignettes

Think outside the box Think outside the box Source: http://search.rainbowresource.com/the-human-body downloaded 6/11/2013

Reminder of the importance of History of Present Illness 7 cardinal features (OPQQRST) Onset and chronology (time of onset, intervals between recurrences, duration, periodicity and frequency, course) Position and radiation Quality Quantification Related symptoms (think ROS, positives/negatives) Setting Transforming factors (Ch 4, The Patient History Evidence-Based Approach to Differential Diagnosis, 3rd ed Remember “semantic qualifiers” – e.g. acute vs chronic and “key case features”-e.g. weight loss

Vomiting: It’s not just the guts Vomiting: It’s not just the guts! GER GERD Infectious gastroenteritis Anatomic obstruction Remember to think outside the box Increased ICP UTI DKA Eating disorder

Approach to the infant with recurrent regurgitation and vomiting. Warning signs: Bilious vomiting GI tract bleeding  Hematemesis  Hematochezia Consistently forceful vomiting Fever Lethargy Hepatosplenomegaly Bulging fontanelle Macro/microcephaly Seizures Abdominal tenderness or distension Documented or suspected genetic/metabolic syndrome Associated chronic disease Approach to the infant with recurrent regurgitation and vomiting. Lightdale J R et al. Pediatrics 2013;131:e1684-e1695 ©2013 by American Academy of Pediatrics

Approach to the infant with recurrent regurgitation and weight loss. Warning signs: Bilious vomiting GI tract bleeding  Hematemesis  Hematochezia Consistently forceful vomiting Fever Lethargy Hepatosplenomegaly Bulging fontanelle Macro/microcephaly Seizures Abdominal tenderness or distension Documented or suspected genetic/metabolic syndrome Associated chronic disease Approach to the infant with recurrent regurgitation and weight loss. Lightdale J R et al. Pediatrics 2013;131:e1684-e1695 ©2013 by American Academy of Pediatrics

Diarrhea What do families mean when they say “diarrhea”? Important to ask. Diarrhea is an increase in the number of stools per day and/or more loose or liquid stools. When diarrhea lasts for more than four weeks, it is called “chronic”. What is your differential diagnosis for diarrhea? “Red flags”? Why would you send stool studies and which ones?

Constipation What is it? stools may be infrequent (though breast fed babies may stool as little as once a week) hard/painful, large-diameter history of excessive stool retention (it hurts to poop so hold it and don’t poop and then the stool gets harder) and overflow NASPHAGAN guideline- functional/uncomplicated constipation- imaging rarely needed dietary manipulations including sorbitol (juice) +/- evidence for fiber and fluids… oral meds polyethelene glycol, lactulose

Warning signs constipation (NASPHAGAN) Alarm signs and symptoms in constipation Constipation starting extremely early in life (<1 mo) Passage of meconium >48 h Family history of HD Ribbon stools Blood in the stools in the absence of anal fissures Failure to thrive Fever Bilious vomiting Abnormal thyroid gland Severe abdominal distension Perianal fistula Abnormal position of anus Absent anal or cremasteric reflex Decreased lower extremity strength/tone/reflex Tuft of hair on spine Sacral dimple Gluteal cleft deviation Extreme fear during anal inspection Anal scars HD¼Hirschsprung disease.

A segue to management of gastroenteritis

Oral Rehydration Therapy  "The discovery that sodium transport and glucose transport  are coupled in the small intestine so that glucose accelerates absorption of solute and water (is) potentially  the most important medical advance this century." British Scientific Journal - 5th August, 1978   

Na-Glu co- transport

“PO challenge” DON’T expect kids to stop vomiting DO give families the tools to correct/prevent dehydration Give total target (x cc in one hour) teach to give small volumes with spoon, syringe or cup teach assessment of dehydration

Refeed early with age-appropriate diets

IF ORAL REHYDRATION WORKS IN DEVELOPING COUNTRIES WHY NOT IN THE U.S.? The "Simple Solution" Preparing a Salt and Sugar Solution at Home Mix an oral rehydration solution using  one of the following recipes; depending on ingredients and container availability: Recipe  1 Making a 1 (one) litre solution using Salt, Sugar and Water Ingredients: 1/2 level teaspoon of salt Six level teaspoons of sugar one litre of clean drinking or boiled water and then cooled 5 cupfuls (each cup about 200 ml.) Preparation Method: Stir the mixture till the salt and sugar dissolve.

Should you think of anti-emetics? Recent data : ondansetron as an adjunct to oral rehydration may decrease the need for IV fluids Cochrane systematic review, 2012: Carter B, Fedorowicz Z. BMJ Open 2012;2:e000622. doi:10.1136/bmjopen-2011-000622 Not “approved” for acute gastroenteritis Dosing starts at 6 mo/8 kg Usually single dose Side effects prolonged QT, diarrhea Personal perspective from TTA: reinforces idea that medicine is needed for a common problem…

Resources Management of acute gastroenteritis https://www.guideline.gov/summaries/summary/35123/evidencebased-care-guideline-for-prevention-and-management-of-acute-gastroenteritis-age-in-children-aged-2-months-to-18-years Recipe for home-made ORS http://rehydrate.org/http://rehydrate.org/solutions/homemade.htm GERD Gastroesophageal reflux: management guidance for the pediatrician. Lightdale JR, Gremse http://pediatrics.aappublications.org/content/131/5/e1684.long Functional constipation http://www.naspghan.org/files/documents/pdfs/cme/jpgn/Evaluation_and_Treatment_of_Functional.24.pdf Patient handouts from NASPGHAN http://www.gikids.org/content/33/en/digestive-topics

Excellent patient handout from the National ORT project- may duplicate for your use