Blok Gastroenterologi Anak

GASTROINTESTINAL GASTROINTESTINAL PROBLEMS IN PEDIATRICPROBLEMS IN PEDIATRIC

Department of PediatricDepartment of PediatricFaculty of MedicineFaculty of Medicine

Tarumanagara UniversityTarumanagara University20102010

http://www.calm-your-screaming-baby.com/images/crying-baby.jpg

PediatricPediatricGastroenterologyGastroenterology

BioBioChemistryChemistry

Departments involved to Gastrointestinal ProblemsDepartments involved to Gastrointestinal Problems

ParaParasitologysitology

MicroMicrobiologybiology

ClinicalClinicalPharmaPharmacologycology

PatologyPatology

PhysiologyPhysiology

HistologyHistology

AnatomyAnatomy

CommunityCommunityMedicineMedicine

ClinicalClinicalPharmacyPharmacyPatologyPatology

AnatomiAnatomiNutritionNutrition

●● Upper Gastrointestinal TractUpper Gastrointestinal Tract

●● Lower Gastrointestinal TractLower Gastrointestinal Tract

●● Border upper-lower: ligamentum Border upper-lower: ligamentum Treitz. Treitz.

Gastrointestinal / digestive tractGastrointestinal / digestive tract

* Upper Gastrointestinal Tract


Esophagus, stomach (gaster), proximal Esophagus, stomach (gaster), proximal small intestine (duodenum and proximal small intestine (duodenum and proximal jejunum above ligamentum Treitz).jejunum above ligamentum Treitz).

* * Upper Gastrointestinal TractUpper Gastrointestinal Tract * * Lower Gastrointestinal TractLower Gastrointestinal Tract


distal small intestine (distal jejunum below distal small intestine (distal jejunum below ligamentum Treitz), ileum, colon, rectum, ligamentum Treitz), ileum, colon, rectum, and anus.and anus.

Gastrointestinal / Digestive tractGastrointestinal / Digestive tract

Disphagia & Disphagia & RegurgitasiRegurgitasi

Emesis / Emesis / VomitingVomiting

Gut Gut InfectionInfection

Abdominal Abdominal PainPain

ConstipationConstipationGut BleedingGut Bleeding

Common Common Gastrointestinal Gastrointestinal

Problems in Problems in PediatricPediatric

Allergic gut Allergic gut problemsproblems

Intolerance / Intolerance / MalabsorpsiMalabsorpsi

Inflamatory Inflamatory Bowel DiseaseBowel Disease

Infantile Infantile ColicColic

GastroesophagealGastroesophageal RefluxReflux

Functional bowel disorders in childrenFunctional bowel disorders in children

Dysphagia ?Dysphagia ?Regurgitation ?Regurgitation ?

DysphagiaDysphagia

● Problems / dificultty in swallowing Problems / dificultty in swallowing food or liquidfood or liquid

●● or Refers to the sensation of food or Refers to the sensation of food being hindered in its passage being hindered in its passage from the mouth to the stomachfrom the mouth to the stomach..

DysphagiaDysphagia

Act ofAct of swallowingswallowing ● ● oral preparation phaseoral preparation phase

●● oral transfer phaseoral transfer phase

●● pharyngeal phasepharyngeal phase

●● esophageal phase.esophageal phase.

Causes of Dysphagia (mechanical)Causes of Dysphagia (mechanical)■ Structural defectStructural defect • • typical cause more problems in typical cause more problems in

swallowing solids than liquids.swallowing solids than liquids. • • cause a fixed impediment to food cause a fixed impediment to food

bolus arise from narrowing within bolus arise from narrowing within the esophagus (e.g. stricture, web, the esophagus (e.g. stricture, web, tumor, etc).tumor, etc).

■■ Motility disodersMotility disoders •• motility abnormalities of the motility abnormalities of the

oropharynx or esophagus.oropharynx or esophagus.

DysphagiaDysphagia

Term of DysphagiaTerm of Dysphagia

■ Oropharyngeal dysphagia Oropharyngeal dysphagia → transfer → transfer dysphagia.dysphagia.

■■ Esophageal dysphagia Esophageal dysphagia → → non-transfer dysphagia.non-transfer dysphagia.

DysphagiaDysphagia

♦ Oropharyngeal dysphagia- Neuromuscular diseases: CVA, Neuromuscular diseases: CVA, Parkinson’s disease, Myasthenia gravis, Parkinson’s disease, Myasthenia gravis, etc. etc. - Local mechanical lesions: inflammation - Local mechanical lesions: inflammation (pharyngitis, absces etc), neoplasm, (pharyngitis, absces etc), neoplasm, congenital webs, etc. congenital webs, etc.- Upper esophageal sphincter (UES) - Upper esophageal sphincter (UES) disoders. disoders.

DysphagiaDysphagia

♦ Esophageal dysphagia

- Motility disorders: Achalasia, - Motility disorders: Achalasia, Scleroderma, Diffuse esophagea Scleroderma, Diffuse esophagea spasm, etc. spasm, etc.- Intrinsic mechanical lesions : Benign - Intrinsic mechanical lesions : Benign stricture (peptic, radiation), Carcinoma, stricture (peptic, radiation), Carcinoma, etc. etc. - Extrinsic mechanical lesions: Vascular - Extrinsic mechanical lesions: Vascular compression, Mediastinal abnormalities, compression, Mediastinal abnormalities, etc. etc.

DysphagiaDysphagia

♦ Functional dysphagiaFunctional dysphagiaDiagnostic criteria* Must include Diagnostic criteria* Must include all all of the of the following (Rome III)following (Rome III)

•• Sense of solid and/or liquid foods Sense of solid and/or liquid foods sticking, lodging, or passing sticking, lodging, or passing abnormally through the esophagusabnormally through the esophagus

•• Absence of evidence that gastroeso-Absence of evidence that gastroeso-phageal reflux is the cause of the phageal reflux is the cause of the symptom.symptom.

•• Absence of histopathology-based Absence of histopathology-based esophageal motility disordersesophageal motility disorders

DysphagiaDysphagia

DysphagiaDysphagiaDifficulty Difficulty initiating swallow initiating swallow (coughing, (coughing, choking, nasal choking, nasal regurgitation)regurgitation)

Orofaring dysphagia


Orofaring Orofaring dysphagiadysphagia

Food stop after swallowingFood stop after swallowing

Oesophageal dysphagiaOesophageal dysphagia

Solid food onlySolid food only Solid or liquid foodSolid or liquid food






Mechanical Mechanical obstructionobstruction

ProgressiveProgressive IntermitentIntermitent

Chronic heartburnChronic heartburn

Peptic stricturePeptic stricture

Age > 50 yrAge > 50 yr

CarcinomaCarcinoma






Mechanical Mechanical obstructionobstruction

ProgressiveProgressive IntermitentIntermitent

Chronic heartburnChronic heartburn

Peptic stricturePeptic stricture

Age > 50 yrAge > 50 yr

CarcinomaCarcinoma

Neuromuscular disoderNeuromuscular disoder

IntermitentIntermitentProgressiveProgressive

Chronic Chronic heartburnheartburn

Chest Chest PainPain

Respiratory Respiratory symptomssymptoms

SclerodermaScleroderma AchalasiaAchalasia Diffuse Diffuse esophageal esophageal

spasmspasm

RegurgitationRegurgitation

● The effortless movement of stomach The effortless movement of stomach contents into the esophagus and contents into the esophagus and mouth.mouth.

● expulsion of material from the expulsion of material from the mouth, pharynx, or esophagus, mouth, pharynx, or esophagus, usually characterized by theusually characterized by thepresence of undigested food or presence of undigested food or blood.blood.

●● Passive retrograde flow of Passive retrograde flow of esophageal contents.esophageal contents.

RegurgitationRegurgitation

●● Spitting up of food from the Spitting up of food from the esophagus or stomach without esophagus or stomach without nausea or forceful contractions of nausea or forceful contractions of the abdominal muscles. the abdominal muscles.

Causes of regurgitationCauses of regurgitation♦♦ incompeten lower esophageal incompeten lower esophageal

sphinctersphincter..♦♦ immature lower esophageal immature lower esophageal

sphincter (infant).sphincter (infant).

Vomiting / Vomiting / Emesis ?Emesis ?

Vomiting- - Vomiting is the forceful contraction of the Vomiting is the forceful contraction of the

stomach that propels its contents up stomach that propels its contents up the the esophagus and out through the esophagus and out through the mouth mouth and sometimes the nose. and sometimes the nose.

- or - or coordinated motor response of the GI coordinated motor response of the GI tract, abdominal and thoracic tract, abdominal and thoracic muscles muscles that results in forceful that results in forceful expulsion of expulsion of stomach contents stomach contents

Vomiting / emesisVomiting / emesis

- Vomiting is different from regurgitation, - Vomiting is different from regurgitation, although the two terms are often used although the two terms are often used interchangeably. interchangeably.

- Regurgitation is the return of - Regurgitation is the return of undigested undigested food back up the esophagus food back up the esophagus to the to the mouth, without the force and mouth, without the force and displeasure displeasure associated with vomiting. associated with vomiting.

- The causes of vomiting and - The causes of vomiting and regurgitation regurgitation are generally different. are generally different.


- Vomiting in infant and children is - Vomiting in infant and children is frequently found and as first frequently found and as first

symptom of symptom of infection of gastrointestinal infection of gastrointestinal or extra or extra gastrointestinal. gastrointestinal.

- Management is directed to the - Management is directed to the etiology etiology of vomiting. of vomiting.

- The use of antiemetic drugs are - The use of antiemetic drugs are indicated only for functional indicated only for functional disturbances of disturbances of

gastrointestinal and gastrointestinal and contraindication contraindication for mechanical for mechanical abnormality abnormality of gastrointestinal.of gastrointestinal.


Causes of vomiting in childrenCauses of vomiting in children

♦♦ Inborn eror of metabolismInborn eror of metabolism ♦ ♦ Medication (chemotherapy, Medication (chemotherapy, erythromycin) ♦erythromycin) ♦ Increased intracranial Increased intracranial pressurepressure ♦ ♦ InfectionInfection

♦ ♦ PsychogenicPsychogenic ♦ ♦ Abdominal Abdominal

migrainemigraine ♦ ♦ ToxinsToxins ♦ ♦

LabirynithtisLabirynithtis ♦ ♦Adrenal insufificiencyAdrenal insufificiency


ComplicationComplication

•• Aspiration of vomitAspiration of vomit

•• EsophagitisEsophagitis

•• Dehydration and electrolyte imbalanceDehydration and electrolyte imbalance

•• Mallory Weiss tear (Mallory Weiss tear (small tears at lesser small tears at lesser curve of gastroesophageal junction).curve of gastroesophageal junction).

•• Malnutrition or “failure to thrive”.Malnutrition or “failure to thrive”.


Differential Diagnosis of Emesis During ChildhoodDifferential Diagnosis of Emesis During ChildhoodInfantInfant ChildChild AdolescentAdolescent

CommonCommon

GastroenteritisGastroenteritis GastroenteritisGastroenteritis GastroenteritisGastroenteritis

Gastroesophageal Gastroesophageal RefluxReflux

Systemic infectionSystemic infection Reflux (GERD)Reflux (GERD)

OverfeedingOverfeeding GastritisGastritis Systemic infectionSystemic infection

Anatomic obstructionAnatomic obstruction Toxic ingestionToxic ingestion Toxic ingestionToxic ingestion

Systemic infectionSystemic infection Pertusis SyndromePertusis Syndrome GastritisGastritis

Pertusis SyndromePertusis Syndrome MedicationMedication Sinusitis/otitis mediaSinusitis/otitis media

Otitis mediaOtitis media Reflux (GERD)Reflux (GERD) Inflamatory Bowel Inflamatory Bowel DiseaseDisease

Milk AllergyMilk Allergy SinusitisSinusitis AppendicitisAppendicitis

Otitis media/faringitisOtitis media/faringitis MigraineMigraine

Psychologic distressPsychologic distress PregnancyPregnancy

MedicationMedication

Psychologic distressPsychologic distress

Functional Vomiting (Rome III)Functional Vomiting (Rome III)))

Diagnostic criteria : Pelajari Rome III:Diagnostic criteria : Pelajari Rome III:●● The new criteria of Functional The new criteria of Functional

Gastrointestinal Disoders (FGIDs) Gastrointestinal Disoders (FGIDs)

●● Diagnostic Criteria for Functional Diagnostic Criteria for Functional Gastrointestinal DisodersGastrointestinal Disoders


Gastroesophageal Reflux ?Gastroesophageal Reflux ?

Gastroesophageal Reflux

PhysiologicalPhysiologicalGastroesophagealGastroesophageal

Reflux - GERReflux - GER

GastroesophagealGastroesophagealReflux Disease - GERDReflux Disease - GERD

(Symptomatic)(Symptomatic)

Primary GERD :Primary GERD :motility problemmotility problemaffecting loweraffecting lower

esphageal sphincteresphageal sphincter

Secondary GERD :Secondary GERD :external factor causingexternal factor causingtransient relaxation oftransient relaxation of

lower esophageal sphincterlower esophageal sphincter(e.g. Food Allergy)(e.g. Food Allergy)

Physiological Gastroesophageal Reflux Physiological Gastroesophageal Reflux (GER)(GER)

●● is a symptom, not a disease.is a symptom, not a disease.

●● refers to the involuntary retrograde refers to the involuntary retrograde flow of gastric contents across the flow of gastric contents across the

lower esophageal sphincter (LES) lower esophageal sphincter (LES) into the oesophagus.into the oesophagus.

●● present in the majority of infants → present in the majority of infants → first year of life (common).first year of life (common).

Gastroesophageal RefluxGastroesophageal Reflux

● By 12 months majority with symptoms resolve (maturation of oesophageal

sphincter, upright posture, incr solids in diet).

● Complications : failure to thrive, oesophagitis, pulmonary aspiration.


Gastroesophageal Reflux Disease (GERD)Gastroesophageal Reflux Disease (GERD)

DefinitionDefinition●● The upper gastrointestinal tract The upper gastrointestinal tract

diseases which causes by the diseases which causes by the reflux of the gastro-duodenal reflux of the gastro-duodenal content to esophagus.content to esophagus.

DividedDivided●● Erosive typeErosive type●● Non-erosive typeNon-erosive type


Gastroesophageal Reflux Disease/GERDGastroesophageal Reflux Disease/GERD

Complication Complication ●● Barrett’s esophagus (BE) is one of Barrett’s esophagus (BE) is one of

the GERD complications the GERD complications (metaplastic collumnar epithelial (metaplastic collumnar epithelial replaces the normal esophageal replaces the normal esophageal squamous epithelial).squamous epithelial).


Constipation ?Constipation ?

ConstipationConstipation

DefinitionDefinition ●● Decrease in stool frequency →Decrease in stool frequency →

fewer than 3 stools per week and fewer than 3 stools per week and incomplete passing incomplete passing stoll → hard stoll → hard stool.stool.

●● or Decreased fluidity of Bowel or Decreased fluidity of Bowel movements → most stools are movements → most stools are

hard, hard, pebble-like or scybalous.pebble-like or scybalous.


Mean stool frequencyMean stool frequency ** Breastfed infants under age months: Breastfed infants under age months:

2.9 stools / day.2.9 stools / day.** Formula-fed infants under age 3 Formula-fed infants under age 3

months: 2 stools / day.months: 2 stools / day.** Age 6 to 12 months: 1.8 stools per Age 6 to 12 months: 1.8 stools per

day.day.** Age 1 to 3 years: 1.4 stools per day .Age 1 to 3 years: 1.4 stools per day .** Age over 3 years: 1.0 stools per day Age over 3 years: 1.0 stools per day

Ref. Baker, J. Pediatr Gastrol Nutr, 1999, 29:612Ref. Baker, J. Pediatr Gastrol Nutr, 1999, 29:612..


Etiology of constipationEtiology of constipation■ Dietary ■ Dietary ■ Functional ■ Functional ■ Medications■ Medications■ Structural defects ■ Structural defects ■ Metabolic / endocrine disorders■ Metabolic / endocrine disorders■ Acute febrile illness■ Acute febrile illness■ Acute abdomen with palpable fecal■ Acute abdomen with palpable fecal


Etiology of constipationEtiology of constipation■■ DietaryDietary - - excessive cows milkexcessive cows milk

- - transition form breast milk to transition form breast milk to formula formula or table foodor table food

- - lack of fiberlack of fiber - - dehydrationdehydration

■■ FunctionalFunctional -- lack of privacy (eg. start of daycare lack of privacy (eg. start of daycare

or school).or school).


Etiology of constipationEtiology of constipation■■ MedicationsMedications

-- opiatesopiates - - anticholinergicsanticholinergics - - lead poisoningslead poisonings..

■ Structural defects - intussusception - volvulus - anal fissure.


Etiology of constipationEtiology of constipation■ Metabolic/Endocrine disordersMetabolic/Endocrine disorders -- cystic fibrosiscystic fibrosis - - increases calciumincreases calcium - - decreased kaliumdecreased kalium - - uremiauremia - - hypothyroidismhypothyroidism. .

■■ Acute febrile illnessAcute febrile illness■■ Acute abd. with palpable fecal Acute abd. with palpable fecal masses. masses.


Functional Constipation (Rome III)Functional Constipation (Rome III)

Diagnostic CriteriaDiagnostic CriteriaFunctional ConstipationFunctional Constipation →→ ????? ?????

Ileus ?Ileus ?

Definition of Ileus■■ Hypomotility of the gastrointestinal tract Hypomotility of the gastrointestinal tract in the absence of mechanical bowel in the absence of mechanical bowel obstruction. obstruction.

■■ Failure of intestinal peristalsis without Failure of intestinal peristalsis without evidence of mechanical evidence of mechanical obstruction.obstruction.

IleusIleus

Clinical manifestationClinical manifestation■■ Abdominal distentionAbdominal distention■■ EmesisEmesis■■ Minimal pain, increases with Minimal pain, increases with

increasing distention.increasing distention.■■ Bowel sounds are minimal or Bowel sounds are minimal or

absent.absent.■■ Plain abdominal radiographs Plain abdominal radiographs

demonstrate multiple air-fluid demonstrate multiple air-fluid levels levels throughout the abdomen.throughout the abdomen.

IleusIleus

Differentiated of Ileus, Pseudo Obstruction and Mechanical Differentiated of Ileus, Pseudo Obstruction and Mechanical ObstructionObstruction

Ileus Pseudo Obstruction Mechanical Obstruction

Symptom Mild abdominal pain, bloating, nausea, vomiting, obstipation, constipation.

Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia.

Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia.

Physical Examina-tion

Silent abdomen, distention, tympanic

Borborygmi, tympanic, peristaltic waves, hypoactive or hyperactive bowel sounds, distention, localized tenderness

Borborygmi, peristaltic waves, high-pitched bowel sounds, rushes, distention, localized tenderness

Plain Radio-graphs

Large and small bowel dilatation, diaphragm elevated

Isolated large bowel dilatation, diaphragm elevated

Bow-shaped loops in ladder pattern, paucity of colonic gas distal to lesion, diaphragm mildly elevated, air-fluid levels

Abdominal radiograph shows ileusAbdominal radiograph shows ileus

Abdominal radiograph shows low Abdominal radiograph shows low intestinal obstructionintestinal obstruction

EtiologyEtiology●● Abdominal surgery Abdominal surgery ●● Infection (pneumonia, gastroenteritis, Infection (pneumonia, gastroenteritis,

peritonitis)peritonitis)●● Metabolic abnormalities (hypokale-Metabolic abnormalities (hypokale-

mia, mia, hypercalcemia, hypermagnese-hypercalcemia, hypermagnese-mia, acidosis)mia, acidosis)

●● Drugs (opiates and vincristine)Drugs (opiates and vincristine)●● Antimotility drugs (loperamide).Antimotility drugs (loperamide).

IleusIleus

TreatmentTreatment● ● Correction of the underlying abnormalityCorrection of the underlying abnormality● ● Nasogastric decompression Nasogastric decompression ● ● Prokinetic agents : metoclopramide.Prokinetic agents : metoclopramide.

IleusIleus

Hirschsprung’s Disease ? (mechanical obstruction)

Congenital Aganglionic Megacolon Congenital Aganglionic Megacolon (Hirschsprung’s Disease)(Hirschsprung’s Disease)

Abnormal Abnormal innervation of the innervation of the bowel, beginning in bowel, beginning in the internal anal the internal anal sphincter and sphincter and extending extending proximally to proximally to involve a variable involve a variable length of gut.length of gut.

Hirschsprung’s Disease

Healthy large intestine. Nerve cells are found throughout the large intestine

Short-segment HD. Nerve cells are missing from the last segment of the large intestine

Long-segment HD. Nerve cells are missing from most or all of the large intestine and sometimes the last part of the small intestine

Hirschsprung’s DiseaseHirschsprung’s Disease

Clinical ManifestationClinical Manifestation♦♦ Delayed meconium (99% passed within Delayed meconium (99% passed within 48 hr of birth). 48 hr of birth).♦♦ Failure to thrive, with hypoproteinemia Failure to thrive, with hypoproteinemia from a protein-losing enteropathy. from a protein-losing enteropathy.♦♦ Dilatation of the proximal bowel and Dilatation of the proximal bowel and abdominal distention. abdominal distention.♦♦ A large fecal mass, the rectum is A large fecal mass, the rectum is usually empty of feces. usually empty of feces.♦♦ The stools consist of small pellets, be The stools consist of small pellets, be ribbon-like, or have a fluid consistency. ribbon-like, or have a fluid consistency.


TreatmentTreatment Operative interventionOperative intervention

ComplicationComplication- Ulcerative colitis- Ulcerative colitis- Colonic rupture- Colonic rupture


Inflamatory Bowel Disease ? Inflamatory Bowel Disease ? (IBD)(IBD)

Inflamatory Bowel Disease (IBD)Inflamatory Bowel Disease (IBD)

- Ulcerative Colitis- Ulcerative Colitis

- Crohn Disease- Crohn Disease


Ulcerative ColitisUlcerative Colitis●● Idiopathic chronic inflamatory disoderIdiopathic chronic inflamatory disoder

●● Usually begins in the rectum (ulecera-Usually begins in the rectum (ulecera- tive proctitis) and extends proximally for tive proctitis) and extends proximally for variable distance. variable distance.

●● Continuous inflammation confined to Continuous inflammation confined to the large intestine the large intestine →→ pancolitis pancolitis (characterized ).


● Distal colon is most severely affected, and the rectum is involved.

● Inflammation is limited primarily to the mucosa and does not extend through all layers.


Granular mucosa with edema,

erythema and rarefied vessels.

Hemorrhagic mucosa with

mucosal edema.

Edematous mucosa with ulcerations, stenosis and

absent peristaltic movements. Ulcerative

ColitisSumber : The Gastrolab Image Library (hhtp://www.gastrolab.net)

Crohn disease (CD)Crohn disease (CD) ●● Account for the disorders that represent Account for the disorders that represent the Inflamatory Bowel Disease the Inflamatory Bowel Disease. .

●● Characterized by a chronic inflamma-Characterized by a chronic inflammatory process that may affect any tory process that may affect any segment of the gastrointestinal tract, segment of the gastrointestinal tract, from mouth to anus, in a discontinuous from mouth to anus, in a discontinuous fashion.fashion.


Crohn disease (CD)Crohn disease (CD) ● ● Inflammatory process usually extends through all layers of the intestinal wall.

● Associated with remissions and relapses and often recurs following surgery.


Crohns disease can

affect the gastrointestinal channel from the lips to the

anus

LIPS

TONGUE

ORAL CAVITY

ESOPHAGUS

STOMACH

DUODENUM

ILEUM

ILEUM TERMINAL

VALVULA BAUHINI

ASCENDING COLON

CAECUM

Crohn´s disease, as described by Crohn, Ginzburg and Oppenheimer in 1931, was a disease confined to the distal part of the small bowel, and hence called "regional ileitis" or "terminal ileitis".

Crohn's Disease Illustration

Causes of Inflamatory Bowel DiseaseCauses of Inflamatory Bowel Disease

Inflammation in IBD involves a complex Inflammation in IBD involves a complex interaction of several factors: interaction of several factors:

* genes * genes * environment * environment * immune system.* immune system.

Foreign substances (antigens) in the environment Foreign substances (antigens) in the environment may be the direct cause of the inflammation or they may be the direct cause of the inflammation or they may stimulate the body's defenses to produce may stimulate the body's defenses to produce inflammation that continues without controlinflammation that continues without control..


Gastroenteritis ? (Diarrhea)

■ To increase in the frequency of bowel movements or a decrease in the form of stool (greater looseness of stool). This condition of having three or more loose or liquid bowel movement per day.

■ when stools are softer and more frequent then normal,usually more than three bowel movements each day.

Diarrhea

Diarrhea

To be distinguised To be distinguised

•• Incontinence of stoolIncontinence of stool

•• Rectal urgencyRectal urgency

•• Incomplete evacuationIncomplete evacuation

•• Bowel movements immediately Bowel movements immediately after eating a meal.after eating a meal.

DiarrheaDiarrhea

DiarrheaDiarrhea** Acute diarrheaAcute diarrhea* Chronic diarrhea* Chronic diarrhea

Acute diarrheaAcute diarrheaan episode that has an acute onset and an episode that has an acute onset and

lasts no longer than 14 days.lasts no longer than 14 days.

Chronic or persistent diarrheaChronic or persistent diarrheaan episode that lasts longer than 14 an episode that lasts longer than 14

days.days.

DiarrheaDiarrhea

Mechanism of diarrheaMechanism of diarrhea* osmotic diarrhea* osmotic diarrhea* secretory diarrhea* secretory diarrhea

DiarrheaDiarrhea

Causes of DiarrheaCauses of Diarrhea

♦♦ Bacterial infectionsBacterial infections

♦♦ Viral infectionsViral infections

♦♦ Parasite infectionsParasite infections

♦♦ Food intolerancesFood intolerances

♦♦ Reaction to medicine (drug)Reaction to medicine (drug)

♦♦ Intestinal diseasesIntestinal diseases

♦♦ Functional bowel disordersFunctional bowel disorders

Assesment of dehydrationAssesment of dehydrationModerate dehydration

Severe dehydration

Body weight loss 5-10% >10%General appearance Thirsty, drowsy Drowsy, limp, cold, sweaty,

cyanotic extremities

Respiration* Deep, may be rapid Deep and rapidEyes Sunken Grossly sunkenTears Reduced/ absent AbsentMucous membranes Dry Very dry

Cap refill time* > 2 seconds > 2 secondsTissue turgor* Retracts slowly Retracts very slowlyRadial pulse Rapid and weak Rapid, thready, may be

impalpableAnterior fontanelle Sunken Very sunkenUrine output Reduced Marked oliguria

DiarrheaDiarrhea

Reduced skin turgor in severe dehydrationReduced skin turgor in severe dehydration

CATAGORY SIGN & SYMPTOMSevere dehydrationSevere dehydration Two or more signs or symptoms :Two or more signs or symptoms :

Lethargy, depressed consciousnessLethargy, depressed consciousness deeply sunken eyes (and/or fontanel deeply sunken eyes (and/or fontanel in a baby) in a baby) extreme thirstextreme thirst recoil on skin turgor test in more than recoil on skin turgor test in more than 2 seconds2 seconds

Mild – moderate Mild – moderate dehydrationdehydration

Two or more signs or symptomsTwo or more signs or symptoms IrritabilityIrritability slightly sunken eyes (and/or fontanel slightly sunken eyes (and/or fontanel in a baby)in a baby) thirstthirstrecoil on skin turgor test < 2 secondsrecoil on skin turgor test < 2 seconds

Non dehydrationNon dehydration No signs or symptoms of dehydrationNo signs or symptoms of dehydration

Levels of dehydration (Gastro–Hepatologi IDAI,2009)Levels of dehydration (Gastro–Hepatologi IDAI,2009)

Pediatrics GI Tract BleedingPediatrics GI Tract Bleeding ?

●● Fairly common problem.Fairly common problem.●● Differentiates upper vs. lower GI Differentiates upper vs. lower GI Tract Tract bleeding. bleeding.●● Upper GITract bleeding Upper GITract bleeding →→hematemesis hematemesis and melena and melena •• HematemesisHematemesis

- bright red or coffee ground color- bright red or coffee ground color •• MelenaMelena

- - black, blood tarry stools; digested black, blood tarry stools; digested blood blood

Site of bleeding :proximal to ligament of Site of bleeding :proximal to ligament of Treitz Treitz

Gastrointestinal Tract BleedingGastrointestinal Tract Bleeding

●● Lower Gastrointestinal Tract bleeding Lower Gastrointestinal Tract bleeding → hematochezia→ hematochezia •• HematocheziaHematochezia

- bright red bleeding per rectum - bright red bleeding per rectum - site of bleeding is usually - site of bleeding is usually anorectal area anorectal area

Gastrointestinal Tract BleedingGastrointestinal Tract Bleeding

Differential Diagnosis of GI Tract BleedingDifferential Diagnosis of GI Tract BleedingNew BornNew Born Pre - School AgePre - School Age School AgeSchool Age

Stress gastritisStress gastritis Juvenile polypsJuvenile polyps Juvenile polypsJuvenile polypsHaemorrhagic Haemorrhagic diseasedisease

Infectious colitisInfectious colitis Inflammatory bowel Inflammatory bowel diseasedisease

Swallowed Swallowed Maternal maternal Maternal maternal (APT tes)(APT tes)

Anal fissuresAnal fissures Anal fissuresAnal fissures

Allergic/infectious Allergic/infectious colitiscolitis

Foreign bodyForeign body HemorrhoidsHemorrhoids

Anal fissuresAnal fissures Vascular lesionsVascular lesions Drug ingestionDrug ingestion

Intussusception, Intussusception, volvulusvolvulus

Henoch-Scholein Henoch-Scholein purpura, HUSpurpura, HUS

Infectious DiseasesInfectious Diseases

Meckel's Meckel's DiverticulumDiverticulum

Infectious DiseaseInfectious Disease Haemorrhagic Haemorrhagic diseasedisease

Abdominal Pain ? Abdominal Pain ?

Chronic or recurrent abdominal pain.Chronic or recurrent abdominal pain.● ● Very common 10 – 15% of childrenVery common 10 – 15% of children● ● Duration longer than 3 months, affecting Duration longer than 3 months, affecting normal activity. normal activity.● ● Range of anatomic, infectious, Range of anatomic, infectious, inflammatory, biochemical disorders inflammatory, biochemical disorders● ● Presents in 3 main patterns.Presents in 3 main patterns. - Isolated paroxysmal abdominal pain- Isolated paroxysmal abdominal pain - Abdominal pain with dyspepsia.- Abdominal pain with dyspepsia. - Abdominal pain with altered bowel - Abdominal pain with altered bowel

pattern. pattern.

Abdominal PainAbdominal Pain

Causes of Recurrent Abdominal PainCauses of Recurrent Abdominal Pain

CommonCommonParasitesParasitesFaecal loadingFaecal loadingFunctional abdominal pain (Rome III)Functional abdominal pain (Rome III)

Less commonLess commonInfectionsInfectionsInflammatory disordersInflammatory disordersRenal causeRenal cause


Dyspepsia in childrenDyspepsia in children● ● Not as common as in adultsNot as common as in adults

● ● Relationship to eating not volunteredRelationship to eating not voluntered

● ● Character of abdominal pain differentCharacter of abdominal pain different

● ● CausesCauses - Oesophagitis - Oesophagitis - Ulcer dyspepsia - Ulcer dyspepsia - Non-ulcer dyspepsia- Non-ulcer dyspepsia


Dyspepsia in children (2)Dyspepsia in children (2)●● Abdominal pain localized to theAbdominal pain localized to the

epigastrium, right or left upperepigastrium, right or left upperquadrants, and episodic vomiting arequadrants, and episodic vomiting arecharacteristic features of dyspepsiacharacteristic features of dyspepsia

●● Temporal relationship between mealTemporal relationship between mealingestion and the symptoms.ingestion and the symptoms.

●● Presence of anorexia, nausea, oral Presence of anorexia, nausea, oral regurgitation, early satiety, post-regurgitation, early satiety, post-prandial abdominal bloating, prandial abdominal bloating, indigestion, and belching.indigestion, and belching.


Red FlagsRed Flags in Pediatric Abdominal Painin Pediatric Abdominal Pain• Persistent right upper or Persistent right upper or

right lower quadrant right lower quadrant painpain

• Pain that wakes the Pain that wakes the child from sleep child from sleep

• DysphagiaDysphagia• Arthritis Arthritis • Persistent vomitingPersistent vomiting• Perirectal disease Perirectal disease • Gastrointestinal blood Gastrointestinal blood

lossloss

• Involuntary weight loss Involuntary weight loss • Nocturnal diarrheaNocturnal diarrhea• Deceleration of linear Deceleration of linear

growth growth • Family history of Family history of

inflammatory bowel inflammatory bowel disease, celiac disease, disease, celiac disease, or peptic ulcer diseaseor peptic ulcer disease

• Delayed puberty Delayed puberty • Unexplained feverUnexplained fever

Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III.Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III.The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006

Abdominal painAbdominal pain

Childhood Functional Childhood Functional Gastrointestinal Disoders Gastrointestinal Disoders

Rome III ?Rome III ?

Functional Gastrointestinal Disoders (Rome III)Functional Gastrointestinal Disoders (Rome III)

GG. Functional disoders : neonates and todders. Functional disoders : neonates and todders G1G1. Infant regurgitation. Infant regurgitationG2G2. Infant rumination syndrome. Infant rumination syndromeG3G3. Cyclic vomiting syndrome. Cyclic vomiting syndromeG4G4. Infant colic. Infant colicG5G5. Functional diarrhea. Functional diarrheaG6G6. Infant dyschezia. Infant dyscheziaG6G6. Functional constipation. Functional constipation


HH. . Functional disoders : children and adolescentsFunctional disoders : children and adolescents H1H1.. Vomiting and aerophagiaVomiting and aerophagia

H1a. Adolescent rumination syndrome.H1a. Adolescent rumination syndrome.H1b. Cyclic vomiting syndromeH1b. Cyclic vomiting syndromeH1c. AerophagiaH1c. Aerophagia

H2H2. Abdominal pain related FGIDs. Abdominal pain related FGIDsH2a. Functional dyspepsiaH2a. Functional dyspepsiaH2b. Irritable bowel syndromeH2b. Irritable bowel syndromeH2c. Abdominal migraineH2c. Abdominal migraineH2d. Childhood functional abdominal painH2d. Childhood functional abdominal pain

H2d1. Childhoood functional H2d1. Childhoood functional abdominal pain syndrome. abdominal pain syndrome.


HH. Functional disoders : children and adolescents (2). Functional disoders : children and adolescents (2)H3H3.. Constipation and incontinenceConstipation and incontinence

H3a. Functional constipationH3a. Functional constipationH3b. Nonretentive fecal incontinenceH3b. Nonretentive fecal incontinence

ReferencesReferences : :1.1. Talley NJ et.al. Consensus Asia-Pacific for dyspepsia.Journal Talley NJ et.al. Consensus Asia-Pacific for dyspepsia.Journal

Gastroentero – Hepatology, 1998;13; 335 - 53.Gastroentero – Hepatology, 1998;13; 335 - 53.

2.2. Drossman DA : Rome III; The New Criteria. Chinese Journal of Drossman DA : Rome III; The New Criteria. Chinese Journal of Digestive Diseases 2006; 7; 181 – 185.Digestive Diseases 2006; 7; 181 – 185.

3.3. Wyllie R. The digestive system. In: Kliegman RM, Behrman RE, Wyllie R. The digestive system. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson’s Texbook of Pediatrics, 18 Jenson HB, Stanton BF. Nelson’s Texbook of Pediatrics, 18 thth, , Ed. Philadelphia: WB Saunders Co. 2007 ; 152 – 645.Ed. Philadelphia: WB Saunders Co. 2007 ; 152 – 645.

4.4. Sondheimer JM, Sundaram S. Gastrointestinal tract. In:Hay Sondheimer JM, Sundaram S. Gastrointestinal tract. In:Hay WW, WW, Levin MJ, Sondheimer JM, Deterding RR. Current Diagnosis & Levin MJ, Sondheimer JM, Deterding RR. Current Diagnosis &

Pediatrics, 19 Pediatrics, 19 thth. Ed. New York: The Mcgraw-Hill W, 2009;577–. Ed. New York: The Mcgraw-Hill W, 2009;577–608.608.

5.5. Buku Ajar Gastroentero – hepatologi, Ikatan Dokter Anak Buku Ajar Gastroentero – hepatologi, Ikatan Dokter Anak Indonesia, edisi 1, Balai Penerbit FKUI, Jakarta. 2010.Indonesia, edisi 1, Balai Penerbit FKUI, Jakarta. 2010.

G1. Infant RegurgitationDiagnostic criteria Must include both of the following in otherwise healthy infants 3 weeks to 12 months of age:

▪ Regurgitation two or more times per day for or more weeks▪ No retching, hematemesis, aspiration, apnea, failure to thrive, feeding or swallowing difficulties, or abnormal posturing.

G. Childhood Functional GI Disorders: Infant/Toddler

G2. Infant Rumination SyndromeDiagnostic criteria Must include all of the following for at least 3 months:

▪ Repetitive contractions of the abdominal muscles, diaphragm, and tongue▪ Regurgitation of gastric content into the mouth, which is either expectorated or rechewed and reswallowed

AND …..


G2. Infant Rumination Syndrome…. AND

▪ Three or more of the following: a. Onset between and months b. Does not respond to management for

gastroesophageal reflux disease,or to anti-cholinergic drugs, hand restraints, formula changes, and gavage or gastrostomy feedings.

c. Unaccompanied by signs of nausea or distress

d. Does not occur during sleep and when the infant is interacting with individuals in the environment.


G3. Cyclic Vomiting SyndromeDiagnostic criteria Must include both of the following:

▪ Two or more periods of intense nausea and unremitting vomiting or retching lasting hours to days.▪ Return to usual state of health lasting weeks to months.


G4. Infant ColicDiagnostic criteria Must include all of the following in infants from birth to 4 months of age:

▪ Paroxysms of irritability, fussing or crying that starts and stops without obvious cause.▪ Episodes lasting or more hours/day and occurring at least days/wk for at least week.▪ No failure to thrive


G7. Functional ConstipationDiagnostic criteria Must include one month of at least two of the following in infants up to 4 years of age:

▪ Two or fewer defecations per week▪ At least one episode/week of incontinence after the acquisition of toileting skills▪ History of excessive stool retention▪ History of painful or hard bowel movements▪ Presence of a large fecal mass in the rectum▪ History of large diameter stools which may obstruct the toilet.

Accompanying symptoms may include irritability, decreased appetite, and/or early satiety. The accompanying symptoms disappear immediately following passage of a large stool .


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