Pediatric Gastrointestinal Diseases By Dr Ashraf Radwan MD

Pediatric Gastrointestinal Diseases By Dr. Ashraf Radwan, MD Pediatric Department

CONISTIPATIO N

CONISTIPATION Definition Delay or difficulty in defecation with or without pain Causes • Neonatal • Underfeeding • Meconium plug Meconium ileus • Congenital anomalies -Anal atresia - Anal stenosis -Imperforate anus - Congenital megacolon • Hypothyroidism

• Infants and older children • Organic constipation • Acute • Intestinal obstruction • Painful anal conditions -Anal fissure -Perianal abscess -Napkin dermatitis • Chronic -Underfeeding -Low residue diet -Congenital megacolon -Mental retardation -Hypotonia -Hypothyroidism • Functional constipation

FUNCTIONAL CONISTIPATION (RETENTIVE) Constipation for 2 weeks or more in apparently normal infants and children ( No organic cause can be detected ) It is the most common cause of acquired constipation in childhood. Can occur at one of the following times 1 - Weaning 2 - Toilette training 3 - School entrance 4 - Travel

FUNCTIONAL CONISTIPATION (RETENTIVE) Onset 2– 3 years growth Normal Soiling Intermittent or constant Rectal examination full with stool ( may be followed by passage of a large volume stool ) Fecal masses Abdominal examination

Treatment of Functional constipation 1 - Diet Increased intake fresh fruits, and vegetables may be sufficient therapy in mild constipation. . B- Medications 1 - Stool softeners (lactulose ) 2 -Stimulant laxatives ( senna) C- Evacuation Rectal enema

Painful anal conditions Anal fissure Tear in the anal mucosa Painful constipation with fresh blood over the stool

Congenital megacolon Definition Congenital absence of parasympathetic ganglion cells from the intramuscular and submucosal plexuses of the intestine , usually the rectum or rectosigmoid.

Congenital megacolon Clinical manifestations A-Neonatal a- Failure to pass Meconium b- Abdominal distension B- Older infants and children a- Constipation b- Abdominal distension C –Malnutrition D- No response to therapy

Congenital megacolon Diagnosis 1 - clinical manifestations 2 - Rectal examination(Narrow high pressure zone &Empty rectum) 3 - Barium enema(Demonstrates a funnel shaped colon (transition zone between the narrow distal segment and the dilated proximal segment) 4 -Rectal biopsy demonstrates the absence of ganglion cells 5 -Anal manometry(failure of sphincter relaxation on distention of the rectum. ) Treatment Surgery(Colostomy &Rectosigmoidectomy

Differences between functional Constipation and Hirschsprung Disease Retentive Constipation Onset 2– 3 years Abdominal Rare distention Nutrition Normal and growth Soiling Usually present Hirschsprung Disease At birth Present Poor Rare

Differences between Retentive Constipation and Hirschsprung Disease Retentive Constipation Hirschsprung Disease Rectal Ampulla full examination Ampulla may be empty Rectal biopsy Ganglion cells absent Ganglion cells present Rectal Normal manometry Barium enema Non relaxation of internal anal sphincter Distended rectum Narrow distal segment with proximal dilatation

Anal stenosis Diagnosed by rectal examination Treated by rectal dilatation

Imperforate anus Present at birth Diagnosed by inspection of the anus

Infantile Dyschesia A normal phenomenon in some healthy children in the first 6 months of life - The bowel movements are associated with 1 - Excessive crying for 20 – 30 seconds 2 - Red face -The stools are soft -Normal growth -Normal physical and rectal examination

Abdominal pain

Abdominal pain is a very common complaint in child hood. may be acute or recurrent I- Surgical Appendicitis Pancreatitis Intestinal obstruction Intussusception Urolithiasis peritonitis

II-Medical CAUSES 1 -Henoch-Schönlein purpura 2 -Sickle cell crisis 3 - Abdominal epilepsy 4 - Abdominal migraine 5 - Mediterranean fever

Acute abdominal pain III- Refered abdominal pain 1 - Pneumonia 2 - Testicular torsion 3 - Hip lesions

Recurrent abdominal pain is classified into 1 - Non organic ( functional ) > 90 % 2 -Organic Depending on whether a specific cause of the pain is identified

Functional abdominal pain Represent > 90 % of cases It refers to pain that cannot be explained on a structural, physiologic, or biochemical basis. Etiology Unknown Possible relation to stress and emotional disturbances

Functional abdominal pain The characteristic features includes : 1 -Onset later than 6 yr of age 2 - The pain a-Paroxysmal episodes of pain occurring at least monthly for 3 consecutive months b- periumbilical. c- interrupts normal activity, d- has no relationship TO meals. 3 - Normal growth 4 - Absent constitutional manifestations

Recurrent abdominal pain(organic) 1 - Gastrointestinal A- Constipation b-GER c- peptic ulcer 2 - Renal a- UTI b- Stone 3 - Hepatitis 4 - pancreatitis

Recurrent abdominal pain(organic) Represent less than 10 % Should be suspected in 1 - young age 2 - persistent pain 3 - Pain away from the umbilicus 4 - Abdominal tenderness 5 - Growth failure 6 – Associated manifestations fever, Anorexia , vomiting , diarrhea , GIT bleeding , urinary manifestations

Infantile colic A very common problem In the first 6 months of life characterized by Paroxysmal episodes of crying The infant draws legs up Fisting Red face May be relieved by the passage of flatus

Evaluation of abdominal pain. I- History Symptoms suggestive of an organic etiology include : Vomiting, diarrhea, blood in the stool joint symptoms, Pain localized away from the umbilicus Pain awaken the patient from sleep. II- Signs Fever , weight loss & abnormal growth Abdominal tenderness

Evaluation of abdominal pain III-Laboratory studies may be unnecessary if the history and physical examination clearly lead to a diagnosis of functional abdominal pain. The following may be needed 1 - complete blood cell count 2 - Stool examination 3 - urinalysis

Evaluation of abdominal pain 4 - Sedimentation rate AND other acute phase reactant. 5 - ultrasound examination of the abdomen 3 - upper gastrointestinal tract x-ray series 4 -Esophagogastroduodenoscopy

Treatment of abdominal pain 1 - Organic treatment of the cause 2 - Functional a- Assurance b- Drugs Play a little role

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