PEDIATRICS

GASTROENTEROLOGY

Atan Baas Sinuhaji

Sub Division of Pediatrics Gastroentero-Hepatology
Department of ChildHealth
School of Medicine
University of Sumatera Utara
CONTENT

1.GIS 1-K12 :=Introduction

=Vomiting
2.GIS 1-K17 :=Diarrhoea (1)
3.GIS 1-K21 :=Diarrhoea (2)
4.GIS 1-K27 :=Food Allergy
=NEC
5.GIS 2-K1 :=Abd.distention
=Tbc peritonitis
6. GIS 2-K2 :=Abd pain & disorders of ingestion
=Constipation
7. GIS 2-K3 :=Jaundice
8. GIS 2-K4 :=Encephalopathy
=GI hemorrhage
9. GIS 2-K5 :=FTT (1)
10.GIS 2-K6:=FTT(2)
11.GIS 2-K7:=Body fluid balance
 PEDIATRICS
GASTROENTEROLOGY

SYSTEMATIC PROBLEM FUNCTION

BASED

MAJOR SIGNS
DIGESTIVE
&
SYSTEM
SYMPTOMS
 DIGESTIVE SYSTEM

DIGESTIVE TRACT PERITONEUM

- ORAL CAVITY
- GI TRACT (ESOPHAGUS ANAL)

DIGESTIVE GLANDS
•SALIVARY GLANDS
•LIVER & BILE DUCT
•PANCREAS
 MAJOR SIGNS & SYMPTOMS

1. DIARRHOEA 7. ABDOMINAL PAIN

2. VOMITING 8. ABDOMINAL
3. FAILURE TO DISTENSION
THRIVE 9. CONSTIPATION
4. JAUNDICE 10. GASTROINTESTINAL
5. ENCEPHALOPATHY HEMORRHAGE
6. DISORDERS OF
INGESTION
FUNCTION

1. EATING & DRINKING

2. DIGESTION & ABSORPTION

3. SECRETION

4. MOTILITY

5. ENDOCRINE

6. DEFENCE

7. EXCRETION
 DIGESTION

BREAK DOWN
- PHYSIS
- CHEMICAL
- MECHANICAL

DIETARY FOOD

SMALLER PARTICLES
&
CAN BE ABSORBED
 DIGESTION

INTRALUMINAL INTRACELLULAR
-PANCREAS - PEPTIDASE
-LIVER - LIPASE
-STOMACH

MEMBRANE
- SUCRASE
- MALTASE
- LACTASE
- GLUCOAMYLASE
 ABSORPTION

TRANSPORT OF WATER
OR
DIGESTIVE PRODUCTS

LUMEN

MUCOSA

BLOOD
VESSELS
LYMPH
 DIGESTION - ABSORPTION

INTRALUMINAL DIGESTION

PARACELLULAR TRANSCELLULAR

MEMBR. DIGESTION

CELLULAR UPTAKE

INTRACELL. DIGESTION

BASOLAT. MEMBRANE

INTERCELLULAR
SPACE
INTERCELLULAR SPACE

BASEMENT MEMBRANE

INTERSTITIAL SPACE
(LAMINA PROPIA)

VESSELS
- BLOOD
- LYMPH
 TRANSCELLULER Luminal PARACELLULER
Membrane

E
n
Tight
t Junction
e
r
o Basolateral
c
y
Membrane
t Intercelluler
e space
Basal
Membrane
Vessel Lamina
propia
 VOMITING
Atan Baas Sinuhaji
Department of ChildHealth
School of Medicine,University Of Sumatera Utara
Medan
 Vomiting

overt reflux

passage of gastric contents into

the mouth
 Reflux

Movement of gastric contents retrograde

Into esophagus or more proximal

Food/ Gases Gastric

Drink Acid
 REFLUX

OVERT OCCULT

INTO THE TO RESP.

INTO THE MOUTH
ESOPHAGUS TRACT

VOMITING LARYNGITIS PNEUMONIA

ASPIRATION
 REFLUX

GASTRIC PRESS. > ESOPH. PRESS. GASTRIC PRESS. = ESOPH. PRESS.

OBSTRUCTION PERISTALSIS FUNCTION HIATAL

HERNIA

IN OUT Lower Esophageal

Sphincter (LES)
RELAXATION
Gastric AbdomInal
Outlet Tumor
Obstruc.

Pyloric
Stenosis
 LES RELAXATION

TRANSIENT CONTINOUS

“Gastroesophageal Chalasia
reflux”
 SLIDING HIATUS
HERNIA

HIATAL
HERNIA
=
PARTIAL
THORACIC
STOMACH

PARAESOPHAGEAL
HERNIA = ROLLING
 REFLUX

FOOD/DRINK GASTRIC ACID

GASES
= ACID REFLUX

HEARTBURN Metaplasia
ERUCTATION HICCUP = PYROSIS Epithel of
= SINGULTUS = “SENDAWA” esophagus
= “CEKUKAN”

Barrett’s
esophagus

Adeno Ca ULCUS

bleeding stricture
 CONSEQUENCES OF REFLUX
1.- SINGULTUS
- ERUCTATION
2. HEART BURN = “SENDAWA”
3. ESOPHAGITIS & BARRET’S ESOPHAGUS
4. CHRONIC PNEUMONIA ASPIRATION
5. FAILURE TO THRIVE (FTT)
6. LARYNGITIS
7. RUMINATION
8. SANDIFER’S SYNDROME
9. FOOD REFUSAL
 VOMITING

RETURN OF FOOD/DRINK
FROM THE STOMACH TO THE MOUTH

TRUE REGURGITATION
VOMITING = SPITTING
= “MINTAR”
= “GUMOH”

PATHOLOGIC
PHYSIOLOGIC

COMPLICATION
GER
(GASTROESOPHAGEAL
DISEASE = GER Disease)
Gastroesophageal reflux (GER)

Physiologic passage of gastric

content to esophagus

Transient LES relaxation

 Gastroesophageal reflux

- 50% of infant 0-3 months of age

- 25% of infant 3-6 months of age
- 5% of infant 10-12 months of age

Resolving in most by 12 months and

nearly all by 24 months
 Gastro – Esophageal Reflux Disease
(GERD)

GER that causes symptoms or complications that

effect quality of life
 GERD ≠ VOMITING

- Not all vomiting are GERD

- Many GERD children do not vomit

 TRUE VOMITING

 NAUSEA
 RETCHING
 FORCEFUL GASTRIC CONTENTS/
INTRA ABDOMINAL PRESSURE ↑↑
 SYMPTOMS OF AUTONOMIC
NERVUS SYSTEM (+)
 REGURGITATION
 THE YOUNG BABY
 NOT MATURE L.E.S.
 NAUSEA (-)
 NOT FORCEFUL
 SYMPTOMS OF ANS (-)
RUMINATION

- RETURN OF FOODS INTO THE MOUTH

- FOODS RECHEWED
- FOODS REINGESTED
 NAUSEA

- UNPLEASANT SENSATION & OFTEN

CULMINATING IN VOMITING
- CONTRACTION OF PYLORIC
ANTRAL
- SYMPTOMS OF ANS (+)
VOMITING IN INCREASE
INTRACRANIAL PRESSURE
- PROJECTILE
- NAUSEA (-)
- RETCHING (-)
 DIAGNOSIS GER

1. History
2. Body weight  poor weight gain ?
3. Diagnostic Test
- Upper GI series  rule out anatomical
abnormalities
- pH probe (12-24 hours)  Acid refluxGold
Standard
- Scintigraphy
- Endoscopy  complication
TREATMENT GER

1. Conservative therapy
2. Pharmacotherapy
3. Surgery  Nissen Fundoplication
 Conservative Therapy

1. Prone position and upright position :

- The infant is awake and observed

SIDS
2. Small frequent feeding
3. Thickening of formula
 Pharmacotherapy
1. Acid Neutralization : Antacids
2. Antisecretory ( Cimetidine, Ranitidine,
Omeprazole, etc)
3. Prokinetic
- Metoclopramide  Extrapyramidal
Symptoms
- Bethanechole  Bronchospasme
- Cisapride : 0,2 mg/kg/dose 3 or 4 x daily

Arrythmia
 VOMITING

SURVIVAL VALUE

DEFENSE
- UNDERLYING
- COMPLICATION

TOXIC THREATENING
COMPLICATION OF TRUE VOMITING

1. Body Fluids Imbalance

- dehydration
- hyponatremia
- hypokalemia
- hypochloremia
- hypocalcemia ==> tetany
- metabolic alkalosis
2. Mallory Weiss Syndrome
3. Pneumonia aspiration
4. Intake - hypoglicemia
- starvation
- Failure To Thrive
- Metabolic acidosis
 VOMITING
Na+ H+ K+ Cl-
Water

Hyponatremia
dehydration Hypokalemia Hypo-
chloremia
Met. Alk.
hypovolemia

hypocalcemia RBF

Renin

Loss of H+ Aldosteron  Loss of K+

Retention of Na+ & Water

 VOMITING

DIGESTIVE TRACT OUTSIDE

Surgery Medical
- psychogenic
- neurogenic:
- obstruction - gastritis int.cran. press.
- inflammation - peptic ulcer - systemic:sepsis
- perforation - Gastroenteritis - hemodynamic
 MANAGEMENT

1. STABILIZATION OF
Body Fluids Imbalance
GENERAL CONDITION
2. PROTECTION AGAINST ASPIRATION

3. CAUSAL ABDOMINAL EMERGENCY

4. CALORI/ PROTEIN
PNEUMONIA ASP.
5. COMPLICATIONS
CEREBRAL EDEMA

6. ANTIEMETIC DRUGS NO RECOMMENDED

ANTI EMETIC
1. DOPAMINE receptor antagonist
- metoclopramide
- domperidone
2. Cannabinoid (dronabinol)
3. Anticholinergic (Scopolamine)
4. 5HT3 receptor antagonist
- ondansetron
5. Phenothiazine dan anti histamin
- phenergan, benadryl
- largactil
6. Corticosteroid
 COMPLETE INVAGINATION

BOWEL
OBSTRUCTI0N
INCOMPLETE PYLORIC
STENOSIS
INVAGINATION = INTUSSUSCEPTION

PROXIMAL BOWEL
(INTUSSUSCEPTUM)

DISTAL BOWEL
(INTUSSUSCIPIENS)

SPONTANEUS CONTINUING
REDUCTION

3 months - 3 years
 TYPE OF INVAGINATION

- ILEOCOLIC > > >

- ILEOILEIC
- CECOCOLIC
- COLICOCOLIC
- ILEOILEOCOLIC
SIGNS & SYMPTOMS
- SUDDEN ONSET
- PAROXYSMAL PAIN
- VOMITING
- BLEEDING PERANUM
- TUMOR
- SIGNE de DANCE
- ABDOMINAL DISTENTION
- DEFECATION & FLATUS (-)
Th / :
- WATER & ELECTROLYTES
- HYDROSTATIC
- OPERATIVE
 CLINIC

PLAIN OF ABDOMINAL
PHOTO

DIAGNOSTIC
SIGN OF
OBSTRUCTION
RADIOLOGIC

BARIUM ENEMA
- CUPPING
- COIL SPRING