THE DIGESTIVE SYSTEM

Banggollay, Faith Anne

Cafongtan, Lina
Calubaquib, Rhodellein
Canceran, Albert
Datud, Venus Lorraine
Mabbonag, Emely
Narbarte, Maria Lucille
Ramones, Planeta
Tolentino, Katrina

Normal Digestive Tract Phenomena:

1. Usually sterile at birth
 Bacteria culture in the intestinal tract within 5 hours-24 hours after birth
 Bacterial sources: airborne, vagina of mother, beddings, breast of mother to mouth
 Necessary for digestion and synthesis of vitamin K(low in milk)—necessary for coagulation

2. GI function varies with maturity

 12wk AOG—fetus can swallow amniotic fluid
 34wks AOG—development of nutritive sucking in neonates starts
 1st few months of life—development of coordinated oral and pharyngeal movements necessary
for swallowing solids
 1month of age—preference for sweet and salty foods
 6 months of age—recommended start of giving solid foods

 Capacity of stomach-60-90 ml
 Limited ability to digest fat and starch
- Due to deficiency of lipase and amylase for the first few months

3. A number of anatomic variations may be noted in the mouth

 Short lingual frenulum (tongue-tie)
 Surface furrowing of the tongue (geographic or scrotal tongue)
 Bifid uvula

4. Regurgitation occurs commonly in 1st year of life

 ~15-30mL, but may occasionally be larger
 Less than one to several times per day
 Gradually resolves in 80% of infants by 6 months of age and in 90% by 12 months
 If complications develop or regurgitation persists = further evaluation and treatment

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5. Infants and young children may be erratic eaters
 A toddler may eat insatiably or refuse to consume food during a meal, or may eat only a limited
variety of food
 Infancy and adolescence are period of rapid growth; high nutrient requirement for growth may
be associated with voracious appetites

6. The number, color and consistency of stools may vary greatly in the same infant and between
infants of similar age
 Meconium—dark, viscous material normally passed within 1 st 48hrs of life
o If unable to pass within 24-48 hours: possibility of meconium ileus, imperforate anus,
bowel obstruction are suspected
 Transitional stool
o 2nd or 3rd day of life
o green and loose
 Milk stools—soft, yellow-brown stool
o Breast fed infant(on 4th day)
o Pass 3-4 light yellow stools per day
o Sweet smelling (high in lactic acid which reduces putrefecation)
o Bottle fed infants: 2-3 bright yellow stools a day
 Slightly more noticeable odor

 Stool frequency—extremely variable from none to seven per day

 Stool color—little significance except for presence of blood or absence of bilirubin (white-gray
stool)
o May pass black tarry stool after 2-3 days due to swallowing of maternal blood
 Presence of vegetable matter in the stool of infant—suggests poor chewing and not
malabsorption

 Toddler’s Diarrhea—pattern of intermittent loose stools occurring commonly between 1-3 yrs
of age
- Limit sugar-containing beverages and increasing fat in diet often leads to resolution

7. Abdominal Exam
 Protuberant abdomen is often noted in infants and toddlers, especially after large feedings
- Due to combination of weak abdominal musculature, relatively large abdominal organs, and
lordotic stance
 Liver is palpable 1-2cm below right costal margin
 Riedel Lobe—a thin projection of the right lobe of the liver that may be palpated low in the right
lateral abdomen
 Pulsation of the aorta can be appreciated
 Normal stool can often be palpated in the LLQ in the descending or sigmoid colon

8. Jaundice
 Common in neonates, especially among premature infants
 Usually results from inability of an immature liver to conjugate bilirubin
 Persistent elevation of indirect bilirubin in nursing infant may be a result of breast milk jaundice

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  Indirect hyperbilirubinemia—occurs commonly in normal newborns  tint sclerae and skin
golden yellow
 Normal direct bilirubin fraction: <15-20% of total serum bilirubin
- Elevation suggest liver disease, extrahepatic infection, or pooling of blood with excessive
load of bilirubin being released into the circulation
- Direct hyperbilirubinemia produced a greenish yellow hue

Major Symptoms and Signs of Digestive Tract Disorders

1. DYSPHAGIA
 Difficulty swallowing
 Causes:
a. Structural defect = Nontransfer dysphagia
- narrowing within esophagus (stricture, web, tumor)
- extrinisic obstruction—most often caused by vascular ring
- foreign body or stricture secondary to caustic ingestion
- (+) more problems in swallowing solids than liquids
b. motility disorders = Transfer dysphagia
- Due to abnormalities of the muscles involved in the ingestion process, their innervations,
strength or coordination
- associated with neuromuscular disorders (cerebral palsy)
 Sensation that something is stuck in the upper esophagus is called Globus
 When dysphagia is associated with delay in passage through the esophagus, a child may be able
to point to the level of the chest where the delay occurs
- When the child points to the suprasternal notch, the impaction can be found anywhere
in the esophagus

2. REGURGITATION
 Effortless movement of stomach contents into the esophagus and mouth
 Not associated with distress
 Infants are often hungry immediately after an episode
 Results of gastroesophageal reflux through an incompetent or immature LES
 Resolves with maturity
 Should be differentiated from vomiting

3. ANOREXIA
 Afferent nerves from GIT to the brain’s hunger and satiety centers located in the hypothalamus
are important determinants
- Satiety is stimulated by distension of the stomach or upper small bowel
- Chemoreceptors in the intestine, influenced by the assimilation of nutrients, also affect
afferent flow to the appetite centers
 Other regulatory factors include hormones, ghrelin, leptin, and plasma glucose, which in turn
reflect intestinal function

4. VOMITING
 Highly coordinated reflex pro cess that may be preceded by increased salivation and begins
with involuntary retching

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  Violent descent of the diaphragm and constriction of the abdominal muscles with relaxation of
the gastric cardia actively force gastric contents back up the esophagus
 Process is coordinated in the medullary vomiting center, which is influenced directly by afferent
innervations and indirectly by the chemoreceptor trigger zone and higher CNS centers
 Many acute or chronic processes can cause vomiting
 Cyclic vomiting—syndrome with numerous episodes of vomiting interspersed with well
intervals
- Onset between 2-5 yrs of age , lasts 2-3 days with 4 or more emesis per hour
- Precipitated by infection, stress, or excitement
- Idiopathic cyclic vomiting may be a migraine equivalent (abdominal migraine)

5. DIARRHEA
 Excessive loss of fluid and electrolyte in the stool
 Normal stool output in an infant = 5g/kg
 Disorders that interfere with absorption in the small bowel tend to produce voluminous
diarrhea, whereas disorders comprising colonic absorption produce lower volume diarrhea
 The basis for all diarrhea is disturbed intestinal solute transport
 The pathogenesis of most episodes can be explained by secretory, osmotic, or motility
abnormalities or a combination of these

6. CONSTIPATION
 Any definition is relative and depends on stool consistency, stool frequency, and difficulty in
passing the stool
 Can arise from defects either in filling or emptying the rectum
- Defective rectal filling occurs when colonic peristalsis is ineffective (ex: Hirschsprung
disease)
- Stool retention can also result from lesions involving rectal muscles, the sacral spinal cord
afferent and efferent fibers, or the muscles of the abdomen and pelvic floor
 Constipation itself does not have deleterious systemic organic effects, but urinary stasis can
accompany severe long-standing cases and constipation can generate anxiety, having a marked
emotional impact on the patient and family

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7. ABDOMINAL PAIN
 Individual children differ greatly in perception and tolerance for abdominal pain
 2 types of nerve fibers:
a. A fibers—sharp, localized pain; from skin and muscle
b. C fibers—poorly localized, dull pain; from viscera, peritoneum and muscle
 Visceral Pain—experienced in the dermatome from which the affe cted organ received
innervations
- Painful stimuli originating in the liver, pancreas, biliary tree, stomach, or upper bowel are
felt in the epigastrium
- Pain from the distal small bowel, cecum, appendix, or proximal colon is felt at the umbilicus
- Pain from the distal large bowel, urinary tract, or pelvic organs is usually suprapubic
 Parietal Pain—tends to be more localized and intense than visceral pain

8. GI HEMORRHAGE
 Bleeding can occur anywhere along the GIT, identification of the site may be challenging
 Erosive damage to the mucosa of the GIT is the most common cause
 When bleeding originates in the esophagus, stomach or duodenum, it may cause hematemesis
 When exposed to gastric or intestinal juices, blood quickly darkens to resemble coffee grounds
 Massive bleeding is likely to be red
 Red or maroon blood in stools (hematochezia) signifies either a distal bleeding site or massive
hemorrhage above the distal ileum
 Moderate to mild bleeding from above distal ileum tends to cause blackened stools of tarry
consistency (melena)
 Complication: iron-deficiency anemia, hypotension, tachycardia, rarely causes GI symptoms

9. Abdominal Distention and Abdominal Masses

 Enlargement can result from diminished ton of the wall musculature or from increased content
 Ascites—accumulation of fluid in the peritoneal cavity
- Fluid is usually a transudate with low-protein concentration resulting from reduced plasma
colloid osmotic pressure of hypoalbuminemia, from raised portal venous pressure or from
both
 When fluid distends the gut, either obstruction or imbalance between absorption and secretion
should be suspected
 Factors causing fluid accumulation frequently cause gas to accumulate too
- (+)audible gurgling noises
- Source of gas is usually swallowed air, but endogenous flora can increase considerably in
malabsorptive states and produce excessive gas
 An abdominal organ can enlarge diffusely or be affected by a discrete mass

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THE ORAL CAVITY
Development and Developmental Anomalies of the Teeth
INITIATION
 20 primary teeth form in dental crypts that arise from a band of epithelial cells incorporated into
each developing jaw
 Another generation of tooth buds form lingually (toward the tongue), which will develop into
the succeeding permanent incisors, canines and premolars that eventually replace the primary
teeth

HISTODIFFERENTIATION
 Epithelial cells differentiate into ameloblasts that lay down an organic matrix that forms enamel
 Mesenc hyme forms the dentin and dental pulp

CALCIFICATION
 Deposition of inorganic mineral crystals
 Begins at 3-4 months in utero and concludes postnatally at 12 months with mineralization of the
2nd molars

ERUPTION
 At the time of tooth bud formation, each tooth begins a continuous movement toward the oral
cavity
 Times of eruption:
Primary Dentition Permanent Dentition

ANOMALIES ASSOCIATED WITH TOOTH DEVELOPMENT

 Anodontia—absence of teeth, occurs when no tooth buds form (ectodermal dysplasia, or
familial missing teeth) or when there is a disturbance of a normal site of initiation (the area of a
palatal cleft).

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 - most commonly the 3rd molars, the maxillary lateral incisors, and the mandibular 2nd
premolars

 Supernumerary teeth—dental lamina produces more than the normal number of buds
- most often in the area between the maxillary central incisors
- tend to disrupt the position and eruption of the adjacent normal teeth
- occur with cleidocranial dysplasia and in the area of cleft palates
 Twinning—two teeth are joined together
- most often observed in the mandibular incisors of the primary dentition
- can result from gemination, fusion, or concrescence:
a. Gemination—division of one tooth germ to form a bifid crown on a single root with
a common pulp canal; an extra tooth appears to be present in the dental arch
b. Fusion—joining of incompletely developed teeth that, owing to pressure, trauma, or
crowding, which continue to develop as one tooth
c. Concrescence—attachment of the roots of closely approximated adjacent teeth by
an excessive deposit of cementum; found most often in the maxillary molar region
 Disturbances during differentiation
- macrodontia (large teeth) or microdontia (small teeth)
- maxillary lateral incisors may assume a slender, tapering shape (peg-shaped laterals)
 Amelogenesis imperfecta
- group of hereditary conditions that manifest in enamel defects of the primary and
permanent teeth without evidence of systemic disorders
- teeth are covered by only a thin layer of abnormally formed enamel through which the
yellow underlying dentin is seen
- primary teeth are generally affected more than the permanent teeth
- Susceptibility to caries is low, but the enamel is subject to destruction from abrasion
 Dentinogenesis imperfecta, or hereditary opalescent dentin
- odontoblasts fail to differentiate normally, resulting in poorly calcified
- autosomal dominant disorder
- The enamel-dentin junction is altered, causing enamel to break away. The exposed
dentin is then susceptible to abrasion, in some cases worn to the gingiva
- The teeth are opaque and pearly, and the pulp chambers are generally obliterated by
calcification.
- Both primary and permanent teeth are usually involved.
 Localized disturbances of calcification
- correlate with periods of illness, malnutrition, premature birth, or birth trauma
- Hypocalcification—appears as opaque white patches or horizontal lines on the tooth
- Hypoplasia—manifests as pitting or areas devoid of enamel.
- Systemic conditions, such as renal failure and cystic fibrosis, are associated with enamel
defects
- Local trauma to the primary incisors can also affect calcification of permanent incisors
 Fluorosis (mottled enamel)
- can result from systemic fluoride consumption >0.05 mg/kg/day during enamel
formation  affects ameloblastic function, resulting in inconspicuous white, lacy
patches on the enamel to severe brownish discoloration and hypoplasia
 Discolored teeth
- can result from incorporation of foreign substances into developing enamel
- Neonatal hyperbilirubinemia = blue to black discoloration of the primary teeth

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 - Porphyria = red-brown discoloration
- Tetracyclines = brown-yellow discoloration and hypoplasia of the enamel

 Delayed eruption of the 20 primary teeth

- can be familial or indicate systemic or nutritional disturbances
- Failure of eruption of single or small groups of teeth can arise from local causes such as
malpositioned teeth, supernumerary teeth, cysts, or retained primary teeth
- Premature loss of primary teeth is most commonly caused by premature eruption of the
permanent teeth
 Natal teeth
- observed in ≈1/2,000 newborn infants
- They may be a supernumerary or a prematurely erupted primary tooth
- associated with cleft palate, Pierre Robin syndrome, Ellis–van Creveld syndrome,
Hallermann-Streiff syndrome, pachyonychia congenita, and other anomalies
- can occasionally result in pain and refusal to feed and, at times, can produce maternal
discomfort because of abrasion or biting of the nipple during nursing
- There is a remote danger of detachment, with aspiration of the tooth
 Exfoliation failure
- occurs when a primary tooth is not shed before the eruption of its permanent successor
- occurs most commonly in the mandibular incisor region

Disorders of the Oral Cavity Associated with Other Conditions

Disorders of the teeth and surrounding structures may occur in isolation or in combination with other
systemic conditions. Most commonly, medical conditions that occur during tooth development may
affect tooth formation or appearance. Damage to teeth during their development is permanent.

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Malocclusion
Establishing a proper relationship between the mandibular and maxillary teeth is important for
physiologic and cosmetic reasons. The purpose of the anterior teeth is to bite off portions of large
amounts of food. The posterior teeth reduce foodstuff to a soft, moist bolus. The cheeks and tongue
force the food onto the areas of tooth contact.

Class I malocclusion
 the cusps of the posterior mandibular teeth interdigitate ahead of and inside the corresponding
cusps of the opposing maxillary teeth
 normal facial profile

Class II malocclusion
 “buck teeth”
 the cusps of the posterior mandibular teeth are behind and inside the corresponding cusps of
the maxillary teeth
 found in ≈45% of the population
 facial profile may give the appearance of a “receding chin” (retrognathia) or protruding front
teeth
 resultant increased space between upper and lower anterior teeth encourages finger sucking
and tongue-thrust habits

Class III malocclusion

 “underbite”
 the cusps of the posterior mandibular teeth interdigitate a tooth or more ahead of their
opposing maxillary counterparts.
 The anterior teeth appear in cross bite with the mandibular incisors protruding beyond the
maxillary incisors
 The facial profile gives the appearance of a “protruding chin” (prognathia)

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