1. Common Pediatric Gastrointestinal Problems
Hossam Al-Homaidhi, MD
Consultant Pediatrician & Gastroenterologist
Al-Yamamah Hospital – Riyadh
MB BS – College of Medicine / King Saud University
DCH – Diploma of Child Health / Edinburgh – UK
ABP – Arab Board of Pediatrics
Fellowship of Pediatric Gastroenterology / Pittsburgh – USA
Fellowship of Pediatric Gastroenterology / Detroit – USA

2. Constipation in infancy and childhood
Normal frequency of bowel movements
Definition of constipation
Warning signs for Organic causes of constipation
Findings consistent with Functional constipation
Differential diagnosis of constipation in infancy and childhood
Treatment and long term prognosis
Hirschsprung’s Disease (Introduction, Pathophysiology, Clinical presentation, Diagnosis, Management)

3. Constipation in infancy and childhood
Normal Frequency of Bowel Movements in Infants and Children:
Mean # of bowel movements per day
Mean # of bowel movements per week
Age
2.9
5 to 40
0-3 months:
breastfed
2.0
5 to 28
Formula-fed
1.8
6-12 months
1.4
4 to 21
1-3 years
1.0
3 to 14
> 3 years
Constipation section is From:
titled “Evaluation and Treatment of Constipation in Infants and Children”

4. Constipation in infancy and childhood
Constipation defined as “ a delay or difficulty in defecation, present for two or more weeks, sufficient to cause significant distress to the patient “.*
Constipation is responsible for about 3-5% of primary care visits.
Many parents worry that a child’s constipation is the sign of a serious medical problem.
Constipation generally first appears between the ages of two and four years.**
Organic causes of constipation most commonly are found in neonates.*
Constipation in children is usually Functional and the result of stool retention. However, you must be alert for warning signs that may indicate the presence of an uncommon but serious organic cause of constipation (such as Hirschsprung’s dis, pseudoobstruction, apinal cord abn., hypothyroidism, ect).
* Baker SS, Liptak GS. Constipation in infants and children: A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition.
** Rubin G. Constipation in children. Clin Evid. 2004;11:385–90

5. Constipation in infancy and childhood
Warning Signs for Organic Causes of Constipation (in Infants and Children)
Suggested diagnosis
Warning signs or symptoms
Hirschsprung’s disease
Passage of meconium more that 48 hours after delivery, small-caliber stools, failure to thrive, fever, bilious vomiting, tight anal sphincter, empty rectum with palpable abdominal fecal mass
Pseudo-obstruction
Abdominal distention, bilious vomiting, ileus
Spinal cord abnormalities: tethered cord, spinal cord tumor, myelomeningocele
Decreased in lower extremity reflexes or muscular tone, absence of anal wink, presence of pilonidal dimple or hair tuft
Hypothyroidism
Fatigue, cold intoleranec, bradycardia, poor growth
Diabetes insipidus
Polyuria, polydipsia
Gluten enteropathy
Diarrhea/constipation after introducing wheat in diet
Congenital anorectal malformation: imperforate anus, anal stenosis, anteriorly displaced anus
Abnormal position or appearance of anus on physical examination

6. Constipation in infancy and childhood
Findings Consistent with Functional Constipation
History:
Meconium passed within 48 hours of birth
Extremely hard stools, large-caliber stools
Fecal soiling (encopresis)
Pain or discomfort with stool passage; withholding of stool
Blood on stools; perianal fissures
Decreased appetite, waxing and waning of abdominal pain with stool passage
Diet low in fiber or fluids, high in dairy products
Hiding while defecating before toilet training is completed; avoiding the toilet ..

7. Constipation in infancy and childhood
Findings Consistent with Functional Constipation (cont.)
Physical examination:
Mild abdominal distention; palpable stool in left lower quadrant
Normal placement of anus; normal anal sphincter tone
Rectum packed with stool; rectum distended
Presence of anal wink and cremasteric reflex

8. Constipation in infancy and childhood (D. Dx.)
In Infants :
Hirschsprung’s disease.
Congenital anorectal malformations.
Neurologic disorders.
Encephalopathy.
Spinal cord abnormalities: myelomeningocele, spina bifida, tethered cord.
Cystic fibrosis.
Metabolic causes: hypothyroidism, hypercalcemia, hypokalemia, diabetes insipidus.
Heavy-metal poisoning.
Medication side effects. ..

9. Constipation in infancy and childhood (D. Dx.)
In Children (older than 1 year) :
Functional constipation (>95 percent of cases)
Organic causes:
Hirschsprung’s disease
Metabolic causes: hypothyroidism, hypercalcemia, hypokalemia, diabetes insipidus, diabetes mellitus
Cystic fibrosis
Gluten enteropathy
Spinal cord trauma or abnormalities
Neurofibromatosis
Heavy-metal poisoning
Medication side effects
Developmental delays
Sexual abuse

10. Constipation in infancy and childhood
Treatment of functional constipation:
Disimpaction.
Maintenance therapy
High fiber diet
Toilet training
Exercise
Long term prognosis of functional constipation:
Despite treatment, only 50%*-70%** of children with functional constipation demonstrate long-term improvement.
* Staiano A, Andreotti MR, et al. Long-term follow-up of children with chronic idiopathic constipation. Dig Dis Sci. 1994;39:561–4
** Sutphen JL, Borowitz SM, et al. Long-term follow-up of medically treated childhood constipation. Clin Pediatr [Phila]. 1995;34:576–80

11. Hirschprung’s Disease
Introduction
Pathophysiology
Clinical Presentation
Diagnosis (Radiology Findings)
Management

12. Hirschprung’s Disease (Introduction)
Hirschsprung’s disease is the most common cause of lower intestinal obstruction in neonates.
Hirschsprung’s disease (aganglionic megacolon) is a congenital anomaly caused by migratory failure of neural crest cells leading to abnormal innervations of the bowel.
The defect begins in the internal anal sphincter and extends proximally for a variable length of gut.
INCIDENCE: 1\5000 live birth newborn
70-80% is boys. (M/F 4: 1)

13. Hirschprung’s Disease (Pathophysiology)
The neuroenteric ganglion cells migrate from the neural crest to the upper end of the alimentary tract and then follow the vagal fibers caudally. Delay or arrest in this migration results in the neural crest cells failing to reach the distal bowel
The fundamental pathology in HD is the absence of ganglion cells in the submucosal and intermuscular nerve plexuses and is associated with an increase in the nerve fibers in the affected segment.
That aganglionic segment usually involves the terminal intestine, i.e. the rectum or rectosigmoid. The aganglionic segment may, however, include the entire large bowel and even small bowel.
The gross pathologic feature of HD is a dilated proximal intestine with gradual or abrupt transition to normal calibrated distal intestine. The Trasitional Zone is typically funnel like or cone shaped.
The colon proximal to the aganglionic segment, in an effort to overcome the partial obstruction, becomes distended and its wall markedly thickened because of muscle hypertrophy. The degree of hypertrophy and dilatation depends upon the duration and degree of obstruction and thus, indirectly to the age of the patient.

14. Hirschprung’s Disease (Clinical Presentation)
1. Failure to pass meconium in the 1st 24h of life: • 98% of neonates pass meconium in the first 24 hours of age. Any newborn who fails to pass meconium in the first hours of life should be evaluated for possible Hirschsprung's disease. 2. Neonatal Intestinal obstruction: • Symptoms include bilious vomiting, abdominal distension and refusal to feed. 3. Recurrent Enterocolitis mainly in the 1st three months of life. 4. TOXIC MEGACOLON: • Fever. Abdominal distension. • Bile stained vomitus. Explosive diarrhea. • Dehydration. Shock. 5. Spontaneous perforation occurs in 3%, especially if long segment aganglionosis. 6. Chronic constipation patients may have chronic constipation in response to changes in feeding. And may have growth retardation. Multiple fecal masses on abdominal examination.

15. Hirschprung’s Disease (Diagnosis)
History :
• Failure to pass meconium, painless abdominal distension & constipation.
Physical examinations :
• Distended abdomen with Multiple fecal masses on abdominal examination
• On Rectal Exam characteristically there is:
- Tight anal sphincter.
- Rectum is typically empty.
- Hard fecal mass.
- Large amount of stool and air upon withdrawal of finger

16. Hirschprung’s Disease (Diagnosis)
Radiology : • Plain x-rays of the abdomen :Erect & supine • Contrast Enema : Shows narrow distal segment, funnel-shaped dilatation at level of transition zone with marked dilatation of the proximal colon. • 24-hr delayed films is important in diagnosis; it shows poor emptying with barium throughout the colon, as opposed to the child with psychogenic stool holding in whom the barium generally collects in the distal rectosigmoid. Contrast enema should be done without preparation of bowel.

17. Hirschprung’s Disease (Diagnosis)
Rectal biopsy : • Rectal biopsy is the definitive diagnostic test and demonstrates absence of ganglion cells, nerve hypertrophy and stains indicating increased acetylcholinesterase activity. • Suction mucosal biopsy (at different levels). Can be done without anesthesia • Full thickness biopsy is done under general anesthesia.

18. Hirschprung’s Disease (Management)
Manegement of HD differs according to the presentation form and clinical situation of the patients: • Acute Intestinal Obstruction : if the patient presents with acute intestinal obstruction in the early life the management will be: - resuscitation - NGT, NPO - IVF - Antibiotics - Rectal tube, irrigations - The initial treatment requires performing a "leveling" colostomy in the most distal colon with ganglion cells present. This requires exploration with multiple seromuscular biopsies of the colon wall to determine the exact extend of the aganglionosis. The colostomy is placed above the transition zone. Placement of the colostomy in an area of aganglionosis will lead to persistent obstruction - When the patient becomes stable, then the definitive treatment will be planned. • Chronic constipation : - laxatives and saline enema. - Work up to establish the diagnosis. - then the definitive treatment will be planned.

19. Hirschprung’s Disease (Management)
Definitive procedures
Once the child has reached an adequate size and age (6-12 months; 20 pounds or more), a formal pull-through procedureis done
There are many surgical options for Pull-through operation. All aiming at resection of aganglionic segment and anastomosing the two normal ganglionic ends. They give excellent result in 90%.

20. Gastrointestinal bleeding
introduction
Common causes of upper and lower GI bleeding
Intussusception (Introduction, Pathogenesis, Clinical presentation, Diagnosis – Radiological findings, Management)
Medscape has better article at :

21. Gastrointestinal bleeding
GI bleeds are classified into upper or lower in regards to the location of the bleeding.
Upper GI bleeding is defined as blood loss proximal to the ligament of Treitz in the distal duodenum, this includes bleeding from the esophagus, stomach or duodenum.
Lower GI bleeding is defined bleeding distal to the ligament of Treitz and consists of small bowel, the colon, the rectum and the anus.
Upper GI bleeding is often more severe than lower GI bleeds.
GI bleeding accounts for 10-15% of referrals to pediatric gastroenterologists. ..
This section “Gastrointestinal bleeding” From:

22. Gastrointestinal bleeding
Common causes of upper and lower GI bleeding
Lower GI bleeding
Upper GI bleeding
Age group
Swallowed maternal blood
Anorectal fissures
Necrotizing enterocolitis
Malrottaion with midgut volvulus
Coagulopathy , Hirschsprung’s dis
Hemorrhagic dis. of newborn
Coagulopathy
Esophagitis , Stress Gastritis
Duplication cyst
Neonates
Anal fissures , Intussusception
Allergic colitis (cow’s milk protein allergy
Gastrointestinal duplication
Ischemic bowel 2nd to volvulus
Esophagitis
Gastritis
1 month to 1 year
Polyps
Meckel’s diverticulum
Gastroduodenal ulcer
Foreign body ingestion
1-2 years
Infectious diarrhea
Juvenile polyps , IBD , Vascular lesions
Hemolytic uremic synd. (HUS)
Henoch schonlein purpura (HSP)
Esophageal/Gastric varices
Mallory weiss tears
Dieulafoy’s lesions
2 years and older
This section “Gastrointestinal bleeding” From:

23. Intussusception Introduction Pathogenesis Clinical Presentation
Radiology Findings
Management

24. Intussusception (Introduction)
Telescoping of a proximal segment of the intestine (intussusceptum) into a distal segment (intussuscipien)
It is the most common abdominal emergency in early childhood, particularly in children younger than two years of age.
The majority of cases in children are idiopathic
Most common cause of intestinal obstruction in infants between 6 and 36 months of age
Approximately 60% in children less than 1 yr. old, and % in children less than 2 yr. old.
Intussusception is less common before three months and after 6 years of age.
Male: Female ratio is 3:2
Ileocolic intussusception is the most common type in children.

25. Intussusception (Pathogenesis)
Approximately 75% of cases are idiopathic because there is no clear disease trigger or pathological lead point.
Viral infections can stimulate lymphatic tissue in the intestinal tract, resulting in hypertrophy of Peyer patches in the lymphoid rich terminal ileum which may act as a lead point for ileo-colic intussusception.

26. Intussusception (Pathogenesis)
Lead Point: is a lesion or variation in the intestine that is trapped by peristalsis and dragged into a distal segment of the intestine causing intussusception.
Common lead points: Meckel’s diverticulum, Intestinal polyp, Intestinal duplication, Hemangioma, tumor (lymphoma).
25% of cases have pathological lead point.

27. Intussusception (Clinical Presentation)
* Early: - Patients with intussusception typically develop the sudden onset of intermittent severe, crampy, progressive abdominal pain accompanied by inconsolable crying and drawing up of the legs toward the abdomen. - Between symptoms child will be playing and doing normal activity - Vomiting. * Later: - Continuous abdominal pain. - The stool may contains gross or occult blood or be a mixture of blood and mucous and sloughing mucosa, giving it the appearance of Currant Jelly. - Lethargy. - Palpable abdominal mass (sausage shaped mass).

28. Intussusception (Diagnosis)
Abdominal plain film: (Low sensitivity and specificity)
Show signs of intestinal obstruction.

29. Intussusception (Diagnosis)
Contrast X-ray: Barium enema study has the advantage of being diagnostic and therapeutic. It may show:
- Coil spring appearance: Trapping of barium between the edematous mucosal folds of the retuning limb of intussusceptum and wall of intussuscepian.
- Meniscus sign: Convex intraluminal mass

30. Intussusception (Diagnosis)
Ultrasonography: It is the method of choice to detect intussusception. A Donut or target sign is seen, representing layers of the intestine within the intestine.

31. Intussusception (Management)
NPO
NGT aspiration
IV antibiotics
If in shock: Resuscitate.
Barium enema reduction, Pneumo. Reduction
Laparotomy and Manual Reduction (In case of viable bowels)
Laparotomy and Resection of gut with anastomosis (In case of ischemic/gangrenous bowel)

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