Hafiz Usman Warraich Roll#C GI Disorders in Children Dr Shreedhar Paudel 24/03/2009

Approach to a Child With Abdominal Pain Acute abdominal pain Causes Surgical causes (children of ≤ 2 yrs age) -Malrotation -Intussusception -Necrotising enterocolitis -Incarcerated inguinal hernia -Volvulus -Appendicitis

Causes of Ac Abd Pain… Medical causes (≤ 2 yrs age) – Gastroenteritis – UTI – Basal pneumonia – Hepatitis – Spontaneous bacterial peritonitis

Causes of Ac Abd Pain… Surgical causes(children of ≥ 2 yrs age) – Appendicitis – Intestinal obstruction – Meckel’s diverticulum – Peritonitis – Cholecystitis – Incarcerated inguinal hernia – Trauma

Causes of Ac Abd Pain… Medical causes(children of ≥ 2 yrs age) – Worm infestation – Gastroenteritis – Hepatitis and liver abscess – UTI – Primary peritonitis – Pancreatitis – HSP – Ischemic bowel disease – Mesenteric lymphadenitis – Lead poisoning

Chronic & Recurrent Abdominal Pain Recurrent or persistent bouts of abdominal pain that occurs over a minimum of 3 months. Types:- Organic abdominal pain - Non organic abdominal pain

Organic abdominal painNon organic abdominal pain Organ dysfunctionMental dysfunction Localized pain-spasmodic/ fixed Aka functional abdominal pain Referred painNo localized pain Pain awakens the child from sleep Often recurrent Sudden onset and severe pain Not a/w signs and symptoms, dull ache in periumbilical region

Organic abd painNon organic abd pain High grade feverSite of pain: child usually places the entire hand over the umbilicus DysuriaNo radiation of pain JaundiceDays and weeks of pain free intervals Anorexia and loss of weight Pain is usually brief Special physical findingsNo findings

Treatment of functional abdominal pain Organic causes should be excluded Assurance of parents: absence of major illness Child psychologists for management Pain may be relieved by anticholinergic agents

Causes of chronic and recurrent abdominal pain Children < 2yrs : -Colic- uncontrollable crying in a baby that has no known cause. - Malabsorption -Milk allergy -Rotational defects -Hirschprung disease -Esophagitis

Causes of chronic and recurrent abdominal pain Children > 2years: -functional pain -constipation -giardiasis -intra-abdominal abscess -lead poisoning -pancreatitis -urolithiasis -intestinal parsites

Case 1 11 yrs old child with h/o abdominal pain for 2 mo—no associated symptoms --pain not localised What is the diagnosis?

Case 2 4 yrs male child, with --abdominal pain-4 days --nausea, vomiting, headache --Fever --Urine-dark --no diarrhoea --continuous pain What is the diagnosis?

Case 2 contd…. Site of pain– Rt upper quadrant Cough ???– to r/o basal pneumonia Not functional pain coz fever present D/D --Hepatitis—subclinical infective hepatitis—call after 3-4 days yellow sclera will be obvious. --Liver abscess

Case 3 18/12 yrs female child, --winter month --excessive crying and vomiting—severe abdominal pain suspected --mild fever 2 days back with running nose --stool 2-3 times a day with blood What are D/Ds?

Intussusception-- important surgical condition missed with acute bacterial desentery.

Gastro-oesophageal reflux Common—neonates and early infancy 1 st week of life incidence—85% Declines to 6% by 2 months Manifested as recurrent history of vomiting  Management --not required unless child looses weight and develops recurrent aspiration pneumonia --keep child upright after each feeding

Congenital Pyloric Stenosis Manifests in neonatal period More common in 1 st born males Projectile vomiting—2 nd week after birth Mass—firm and round palpable in the epigastrium with visible peristalsis L→R (as condition progresses) If not treated early—dehydration with electrolyte imbalance

Congenital Pyloric Stenosis

Congenital Pyloric Stenosis contd… Treatment: --Rammstedt’s operation- choice --feeding after few hours of operation --electrolyte, dehydration and alkalosis must be corrected before the operation

Intussusception A portion of the alimentary tract is telescoped into a segment just caudal to it. Frequently misdiagnosed as desentry in infancy and early childhood Usually healthy children Cases may coincide with outbreaks of adenoviral infections

Intussusception contd…. Clinical features: – Child around 1 yr of age presents with acute onset – Vomiting – Severe colicy abdominal pain – Episodic excessive crying – Attacks at varying interval of time – Followed by stool containing blood and mucus (Red currant jelly)

Intussusception contd…. Sausage-shaped mass lying transverse across the abdomen with features of acute abdominal obstruction Rt iliac fossa may appear empty DRE (digital rectal examination)—tip of intussusceptum

Intussusception contd…. Investigations: --USG abd-100% diagnostic for an expert eye --Barium enema X-Ray film—Claw sign ↓ Cupping (as obstructed by the intussusceptum) So pressure may reduce obstruction

Intussusception contd…. Treatment: --surgical emergency --treatment of shock and rehydration --if it’s of short duration hydrostatic pressure of barium enema may relieve intussusception but not so in ileoilial intussusception.

Intussusception contd….

GI Allergy Example– allergy to cow’s milk protein in the first few months of age Clinical features may be – Diarrhea – Nausea – Vomiting – Abdominal pain

GI Allergy… 3 main factors responsible are – Genetic predisposition – Allergen exposure – Contributory factors Immunological defects G I diseases Infections Non specific irritants

Management of GI Allergy Find out the allergen Avoid the exposure to allergen Desensitization may be the last resort