1. Paediatric Gastroenterology
Dr Shoana Quinn
September 2009
Trinity College Dublin

2. Paediatric Gastroenterology
Recurrent Abdominal Pain of Childhood
Constipation
Gastroesophageal Reflux

3. Recurrent Abdominal Pain of Childhood
Very Common
Especially 7-14 years
Periumbilical
Present all the time
Missing school
Sensitive, perfectionistic children

4. RAP Severe, doubled over Pallor Persistent for months
Well in between episodes
No nocturnal symptoms
Reassurance
Minimal Investigation

5. Constipation Very Common Hard, sore stools
Frequency prior to toilet training is very variable
Withholding
Faecal overload and overflow
Perianal tears

6. History and Examination
Withholding behaviour often mistaken for straining
Bright red blood on stool or on wiping
Children unaware of stool, not behavioural
Faecal masses on palpation of abdomen
Perianal inspection. Rectal examination should never be performed in paediatrics

7. Constipation treatment
Child needs to gain confidence
Get rid of hard impacted stool
Soften stool adequately so not sore
Regular toileting with foot support
Continue treatment through toilet training as this is often a time of trouble.
Star charts and reinforcement

8. Constipation treatment
Bisacodyl (Dulcolax) for 3 days AM
Liquid Paraffin at night
Lactulose if younger than 1 year
Movicol
Suppositories should only be used as last resort
Diet in children not a big contribution, excess milk can cause constipation and iron deficiency

9. Ddx Constipation
Hirschsprung Disease aganglionosis in intramuscular and submucous plexuses of the bowel
Always involves anus and extends proximally
Surgical treatment
Risk of enterocolitis

10. Gastroesophageal Reflux
GOR a normal physiological event
50% children in first 3 months
Fewer than 5% age 1 year
Well, thriving, happy child
Happy to feed post vomit

11. GOR Clinical diagnosis
pH probe probably only useful investigation but need consistent operator and acidic refluxate
Barium studies are never appropriate

12. Management of GOR Parental reassurance and centiles
Lie flat after a feed
Feed thickeners?
No medications

13. Gastrooesophageal Reflux Disease
Completely different condition
Characterised by food refusal, haematemesis, irritability and failure to thrive
Clinical diagnosis unless suspicion of obstruction
Trial of PPI then endoscopy and biopsy
Fundoplication vs longterm PPIs