Gastrointestinal

symptoms and signs

Vomiting
Vomiting
Basic terms
 Regurgitation - return of small amounts of food

during or shortly after meal.

◦ It is normal during first 6 months of life
◦ Can be reduced by:
 helping the baby to burp during and after a meal
 preventing the baby from swallowing air during feeding
 by propping the baby after the feed
 gentle handling

 Posseting – effortles, low volume, frequent spills

of milk from mouth
Vomiting – forcible ejection of contents of stomach
through the mouth
• One of the commonest symptoms in infancy and
childhood
• Causes can be trivial, but also it can be a symptom of
serious disorder
Rumination – chronic regurgitation
• often self-induced by the baby
• if it is accompanied by growth failure, psychological
factors should be considered
Vomiting
 Common cause of vomiting in bottle-fed
infant is overfeeding
 a large amount of milk can be regurgitated

when parent tries to help baby to burp

 If the baby is gaining weight and is generally

well, parents should be reassured the baby

will grow out of it by the time he or she is
walking
Common causes of vomiting
 Gastroenteritis  Gastroenteritis
 Gastro-esophageal
 Infection
 Toxic ingestions or
reflux
medications
 Overfeeding  Whooping cough
 Anatomic obstructions
◦ Pyloric stenosis Adolescence
◦ Intussusception  Gastroenteritis
 Infection
◦ Bowel obstruction
 Migraine
 Infection (meningitis,  Pregnancy
pyelonephritis)  Bulimia

Infancy Childhood
 In infants – first step: differentiate vomiting
from simple regurgitation
 If vomiting is a problem, underlying cause

usually can be suspected by:

◦ thorough history
◦ detailed physical examination
History
Do not forget to ask!
 How well is the child?
◦ general health of the child, apettite – a guide to a severity of
the problem
◦ significant vomiting – usually accompanied by weight loss,
◦ long term vomiting - poor weight gain
◦ fever - suggests infective cause
 What is the vomiting like?
◦ Regurgitation, posseting, vomiting
◦ Projectile vomiting – pyloric stenosis
◦ Whooping cough - vomiting after paroxysm of cough
◦ Blood stained vomiting – from upper respiratory tract,
esophagus or stomach
◦ Bile stained vomit - suggests intestinal obstruction-
investigate immediately!!!
History
Do not forget to ask!
 Are there associated symptoms?
- vomiting accompanied with diarrhea –
gastroenteritis
- vomiting and constipation – suggests intestinal
obstruction, urgently investigate !!!

 Bottle-fed babies:
◦ How much milk the baby is taking? >200 ml/kg/24 h – most
likely overfeeding
 Adolescents:
◦ Ask about migraine
◦ Consider gynecological causes
◦ Bulimia- adolescents usually hide their problem
Physical examination
Do not forget to check!!!
 General examination
◦ Exclude other sites of infection except gastrointestinal
(meningitis, pyelonephritis)
◦ Exclude hypertension
 Signs of dehydration
◦ dry mucosa of mouth
◦ reduced skin turgor
◦ sunken eyes
◦ fast pulse
◦ hypotension
◦ delayed capillary refilling
◦ sunken fontanelle
◦ reduced urine output
◦ changed mental state (irritability, somnolence)
Estimating severity of dehydration
Clinical features Mild Moderate Severe
Mucosa of Dry Dry Dry
mouth
Urine output Normal or at Reduced during No urin in last
(reported by least 3 times in past 24 h 12 h
parent) past 24 h
Mental state Normal Irritable Lethargic
Pulse Normal Fast Fast
Blood pressure Normal Normal Low
Capillary Normal Slow Very slow
refilling
Fontanelle Normal Sunken Very sunken
Skin turgor Normal Reduced Very reduced
Physical examination
Do not forget to check!!!
 The abdomen
◦ Tender with increased bowel sounds – in
gastroenteritis
◦ Tinkling or absent bowel sounds – intestinal
obstruction
◦ Olive – in vomiting infant - pyloric stenosis
◦ Severe pain in lower right quadrant - appendicitis
Worrying features in a vomiting child
 Bile stained vomit – suggests intestinal
obstruction- investigate urgently
 Blood in the vomit
 Drowsiness
 Refusal to feed
 Malnutrition
 Dehydration
Investigation
 Abdominal ultrasound- if suspect pyloric
stenosis : increased thickness of the muscular
layer of the pylorus
 pH monitoring and barium meal – if

significant reflux is suspected

Management of the vomiting
 Antiemetics have no place in the management
of vomiting in children except in rare
circumstances (chemotherapy)
 Maintenance of good hydration state

◦ By offering oral rehydration solution in small

amounts frequently
◦ Significant dehydration – intravenous fluids are
required
Oral rehydration therapy
 Child only mildly dehydrated (< 5%)
◦ May be treated at home
◦ Commercially available oral rehydration solutions
(correct electrolyte balance, energy)
◦ Amount of fluid:
acute fluid loss
+
maintenance fluid requirements
+
on-going losses
 Estimate of acute fluid loss
(actual weight in grams x 105%) – actual
weight = deficit (ml)
 Estimate of maintenance requirements

it depends on age of the child

see table on next slide
 Estimate of on-going losses

Measure precisely over 4 hours

Meintenance requirements (water and sodium)

Age (months) Water (ml/kg/24 h) Sodium (mmol/kg/24

h)
0-6 150 2.5
6-12 120 2.5
12-24 100 2.5
>24 100 ml/kg for 80 2.0
first 10 kg of body weight
+
50 ml/kg for body weight from 10 to 20 kg
+
20 ml/kg for body weight above 20 kg

0-10 kg 10- 20 kg > 20 kg

100 ml/kg + 50 ml/kg + 20 ml/kg
 Brest-feeding should be maintained while
using oral solutions
 In bottle-fed babies usual formula can be

used
Intravenous rehydration
 In a child with more significant dehydration
 Amount :

◦ Estimate losses, maintenance requirements and on-

going losses

 Rehydrate over 24 hours

 Hyponatraemic and hypernatremic

dehydration – rehydrate over 48 to 72 hours

Acute diarrhea
Acute diarrhea
 Diarrhea – increase in the frequency, water
content and volume of stool
 Children are likely to experience about three

severe acute episodes of diarrhea during first

3 years of life – almost invariably infectious in
etiology (although infection can be outside of
gastrointestinal tract)
 Any form of infection can cause diarrhea in

young child (upper and lower respiratory tract

infections, otitis media, UTI)
Common causes of acute diarrhea
 Viral gastroenteritis
 Bacterial gastroenteritis

◦ Shigella
◦ Escherichia colli
◦ Salmonella
◦ Campylobacter
 Infections outside gastrointestinal tract
◦ upper and lower respiratory tract infections,
◦ otitis media,
◦ UTI
 Antibiotic induced diarrhea
History
Do not forget to ask!
 What is the illnes like?
◦ Increased frequency
◦ Increased water content
◦ Increased volume of the stools
◦ Blood, mucus in the stool
◦ Abdominal pain suggest
bacterial
◦ Fever
infection
History
Do not forget to ask!
 Is the child likely to be dehydrated?
◦ Frequency of stools
◦ Low urine output
◦ Weight loss
 Are there other symptoms?
◦ Earache suggest infection outside
◦ Dysuria of
◦ Coryza the gastrointestinal tract

◦ Convulsion, abdominal pain – suggest shigella

infection
History
Do not forget to ask!!!

 Is anyone else affected?

◦ Other family members
◦ Other children at child care consider food
contamination
or school
Physical examination
Do not forget to check!!!
 Asses hydration
 Signs of any infection outside of the

gastrointestinal tract – URTI, otitis media,

pneumonia
 Weight – always weigh the child !!!
Recent weight loss gives information about dehydration
Investigations
 No signs of dehydration investigations are not
 No blood in stools necessary

 Blood and mucus in stool – stool culture

 Rotavirus can be detected in stool by

immunoassay
 Other investigations – if signs of infection

outside of the GIT (blood or urine culture,

chest X-ray)
Managing acute diarrhea
 Fluids – as for management of vomiting
 Antidiarrheal drugs – no place in the

management of diarrhea in small children

Chronic diarrhea
Chronic diarrhea
 Common symptom, especially in infants and
young children
 Good description of the stool pattern –

necessary to be sure that child really has

diarrhea
 Normal stool patterns
0-4 months Breast-fed 2-4 per day (range 1-
7)
Yellow to golden,
consistency like
porridge, pH 5
Infrequency of stools
is also normal (up to
once per week)
0-4 months Bottle-fed 2-3 per day,
Pale, yellow to light
brown, firm, pH 7
4 month – 1 year 1 – 3 per day, darker,
yellow, firmer
 Clinical evaluation
◦ Must differentiate between the healthy child who
has frequent loose stools from the child who has
medical problem
Common causes of chronic or
recurrent diarrhea
 Watery  Fatty
◦ Non-specific diarrhea ◦ Cystic fibrosis
◦ Toddlers diarrhea ◦ Coeliac disease
◦ Lactose intolerance  Bloody
◦ Parasites –Giardia lamblia ◦ Ulcerative colitis
◦ Cow’s milk protein allergy ◦ Crohn’s disease
◦ Overflow diarrhea in constipation
 Infants with cystic fibrosis often present with
diarrhea and failure to thrive as a result of
pancreatic insufficiency, rather then with
respiratory symptoms seen in older children.
 Inflammatory bowel disease is a cause of chronic
diarrhea in older children and adolescence.
 Both Crohn’s disease and ulcerative colitis are
characterized by unpredictable exacerbations
and remissions.
 The soiling that results from constipation is
sometimes interpreted as being diarrhea.
History
Do not forget to ask!!!
 Ask about bowel patterns (frequency, volume,
water content) to decide whether the pattern
is normal or abnormal
◦ Presence of blood, mucus
 What precipitates diarrhea?
◦ Food – lactose intolerance, cow’s milk protein
allergy
History
Do not forget to ask!!!
 Are there associated symptoms?
◦ Diarrhea isolated problem in otherwise healthy
child – toddlers diarrhea
◦ Weight loss potential serious medical
◦ Concomitant symptoms problem

 A symptom diary
◦ Keeping the diary is helpful in assessing severity
and pattern of symptoms
Physical examination
Do not forget to check!!!
 Growth measures
◦ Height, weight, head circumference – measure and
compare with previous measurements
◦ Poor weight gain and linear growth – necessary
further investigation!!!
 Other features
◦ Evaluation of hydration
◦ Pallor
◦ Evaluation of abdominal distension, abdominal
tenderness
◦ Finger clubbing
Physical examination
Do not forget to check!!!
 General examination
◦ Complete physical examination
 Anorectal examination –
◦ to rule out impaction if soiling is suspected as
diagnosis
◦ Fresh blood in stool – to examine for anal fissure,
rectal polyps, hemorrhoidal nodules etc.
Clues to differential diagnosis of chronic
diarrhea
Characteristics of Associated Age of child
diarrhea features
Non specific Loose, watery Thriving child, can Any age
diarrhea stools occur after
episode of acute
gastroenteritis
Toddler diarrhea Loose, undigested Thriving child, Toddler
food in stool large fluid intake
Lactose Watery, low pH, Follows acute Baby and toddler
intolerance reducing gastroenteritis
substances in
stool
Giardiasis Watery Weight loss and Any age, common
abdominal pain in nurseries
are variable
 Clues to differential diagnosis of chronic
diarrhea (2)
Characteristics of Associated features Age of child
diarrhea
Functional Soiling, rather then Constipated stool Any age
constipation diarrhea palpable over
abdomen or in
rectum
Cystic fibrosis Fatty Failure to thrive, Usually infancy
respiratory
symptoms
Coeliac disease Fatty Failure to thrive, Usually late infancy,
irritability, muscle but can occur at any
wasting, abdominal age
distention
Inflammatory bowel Bloody in ulcerative Weight loss, Late childhood,
disease colitis exacerbations and adolescence
remissions,
abdominal pain and
Laboratory investigations
 If the child has good weight gain and growth
and there are no accompanying symptoms
and signs / laboratory investigations are
rarely necessary
Laboratory investigations
Investigation Finding Significance
Blood
Full blood count Anaemia Blood loss,
malabsorption, poor
Eosinophilia diet
Parasites or atopy
Sedimentation rate High Nonspecific finding.
Very high in
inflammatory bowel
disease
Coeliac antibiodies Present Screening test for
coeliac disease
Laboratory investigations
Investigation Finding Significance
Stool
Occult blood Positive Cow’s milk
intolerance,
inflammatory bowel
disease
Ova and parasites Positive Parasite identified
Reducing substances Positive and low pH Sugar intolerance
and pH (usually lactose)
Chymotrypsin Low Pancreatic
insufficiency
Microscopy for fat Globules seen Fat malabsorption
globules (usually pancreatic
Laboratory investigations
Investigation Finding Significance

Other
Urine culture and Positive UTI
sensitivity
Sweat test Elevated sweat Cl Cystic fibrosis
concentration
Breath hydrogen test High H2 Sugar intolerance

Jejunal biopsy Flattened villi Coeliac disease

Barium meal and Characteristic lesions Inflammatory bowel
enema disease
Endoscopy Characteristic lesions Inflammatory bowel
disease
 Malabsorption
◦ Three commonest causes
1. Pancreatic insufficiency – in cystic fibrosis:
 Low faecal elastase levels in the stool
 Fat globules on mycroscopic inspection
2. Protein intolerance – commonest in coeliac disease
 Coeliac antibodies –useful as a screening test
 If positive -jejunal biopsy is needed
3. Sugar malapsorption
 Secondary lactose intolerance commonest
 Presence of reducing substances in stool and low pH
 Breath hydrogen test /indirect measure of carobhydrate
malabsorption
 Inflammation
◦ Fecal blood loss suggest IBD or food sensitivity
◦ Very high ESR suggests IBD
◦ Endoscopy and barium studies confirm diagnosis
 Infection
◦ Repeated examination for at least three stool
specimens – Giardia lamblia (commonest)
◦ Urine culture – chronic UTI as a cause of chronic
diarrhea
Managing diarrhoea as a symptom
 If the child is well and thriving- reassurance
and monitoring of weight gain and growth
during symptoms
 Antidiarrhoeal medication – no place
 Food intolerance –often concern
 Omission of suspected food can be tried
 Be sure that the child takes all necessary

nutrients!!!
Acute abdominal pain
Acute abdominal pain
 Very common symptom in children
 Differential diagnosis of acute and severe

abdominal pain includes number of different

conditions, some of them require surgical
treatment
Common causes of acute abdominal pain

GIT Renal
Acute appendicitis Urinary tract infection
Intussusception Hydronephrosis
Mesenteric adenitis Renal calculus
Henoch-Schonlein purpura
Peptic ulceration
Inflammatory bowel disease
Intestinal obstruction
Constipation
Gastroenteritis
Other
Lower lobe pneumonia
History
Do not forget to ask!!!
 Often difficult to elicit good descriptions
about localization, nature and intensity of
abdominal pain
 Depends on child’s age and verbal skills
 In young children – often no clear history of

abdominal pain
History
Do not forget to ask!!!
 Pain
◦ In young children – intermittent episodes of
screaming for no obvious reason- in spasmodic pain
◦ Older children can localize pain, but not always
◦ Does the pain wake child at night? If yes- suspect
organic cause
◦ Is the pain related to eating particular food?
◦ Young children – pallor and screaming during an
hour – important sign!!!
◦ Older children – description of pain that migrates
from periumbilical area to the right iliac fossa – very
suggestive of acute appendicitis!!!
History
Do not forget to ask!!!
 Blood in stool
◦ Very serious sign
◦ Stool as red currant jelly – blood and mucus –
intussusception
 Associated features
◦ Anorexia – often with acute appendicitis
◦ Vomiting, diarrhea – acute gastroenteritis
◦ Joint pain and swelling – chronic inflammatory
disease
Physical examination
Do not forget to check!!!
 Must be taken very carefully, with great
sensitivity
 Most appropriate to examine young child

while lying on his mothers lap

 Most important to watch child’s face during

palpation of the abdomen - very informative

if examination elicits pain
Physical examination
Do not forget to check!!!
 General observation
◦ In peritoneal irritation – child lies very still,
movement causes severe pain
 General examination
◦ Conditions remote from abdomen can cause
abdominal pain – tonsillitis, basal pneumonia
◦ Child can have tachycardia and elevated blood
pressure in association with pain
Physical examination
Do not forget to check!!!
 Abdomen
◦ Examination of acute abdomen can cause extreme
agitation in a child who anticipates that the doctor
will cause additional pain
◦ It is very important to explain what will be done and
promise that doctor will be as gentle as possible
◦ It is important to reassure child first, but not to say
that “it will not hurt”
Physical examination
Do not forget to check!!!
 Rectal examination
◦ Important part of the physical examination, but not
routine part of all abdominal examinations
Clues to the diagnosis of acute abdominal pain

Diagnosis Clinical features

Acute appendicitis Tachycardia
Anorexia
Peritoneal irritation
Intussussception Intermittent screaming
Pallor
“Red currant jelly” stool
Mesenteric adenitis Recent viral infection
No peritoneal irritation
Henoch-Schonlein purpura Blood in stool
Purpura on extension surfaces
Urinary tract infections Dysuria
Frequency
Enuresis
 Investigations
Investigation Significance
Full blood count Leucocytosis- in acute appendicitis
and UTI
Urine microscopy and culture Pyuria, positive urine culture –UTI
Plain abdominal x-ray Intussussception
Obstruction
Abdominal ultrasound Helpful in intussussception, and to
exclude renal pathology
Contrast enema Intussussception
the child has been vomiting serum electrolytes and urea – very important!!!!
o estimate state of hydration
 ◦ A normal AXR does not exclude intussussception
 Signs of intussusception on a plain X ray
include:
◦ Target sign - 2 concentric circular radiolucent lines
usually in the right upper quadrant
◦ Crescent sign - a crescent-shaped lucency usually
in the left upper quadrant with a soft tissue mass
Target sign, crescent sign
The longitudinal section reveals hypoechoic
areas separated by linear hyperechoic strands
(Hay-fork sign)
Barium enema revealing a coil spring
appearance caused by the tracking of barium
around the lumen of the edematous intestine
in intussusception.
Management of acute abdominal
pain
 Most important question
 Does the child need laparotomy?
 Tenderness, rigidity of abdominal wall, rebound –
most likely the answer is “yes”- urgent surgical
opinion
 Expectant management is acceptable if child does
not have peritoneal irritation
 Repeated, regular abdominal examination – to
differentiate whether the condition is resolving or
getting worse
 For non surgical causes of abdominal pain
treatment depends on the underlying condition
Recurrent abdominal
pain
Recurrent abdominal pain
 One of the commonest symptoms in children
 10-15% of school-age children experience

recurrent abdominal pain at some point

 1 in 10 have an organic problem
 Majority has no identifiable cause of the pain

 The purpose of clinical evaluation is to find

out as rapidly as possible whether there is
organic or non-organic cause of pain
 If there is no organic problem – appropriate
reassurance and support
Common causes of recurrent abodminal pain
Idiopathic UTI Gynecological
Dysmenorrhea
Pelvic inflammatory
disease
Haematocolpos
Ovarian cyst
Psychogenic Hepatic Pancreatic
Hepatitis Pancreatitis
cholelithiasis
Gastrointestinal Other
Irritable bowel Abdominal migraine
syndrome Lead poisoning
Oesophagitis
Peptic ulcer
Inflammatory bowel
History
Do not forget to ask!!!
 Take o complete history
 Review child’s lifestyle and habits
 Focus on symptoms related to each organ

system

 What is the pain like?

◦ Colicky or constant?
◦ How it is related to daily activities?
◦ How it is related to diet or bowel habits?
History
Do not forget to ask!!!
 Localization of pain
◦ non-organic pain – periumbilical
◦ The further the pain is from umbilicus, the greater
the chances to identify etiology
◦ A diary of symptoms can be very helpful (frequency
of episodes, relation to different events)
 What is the timing of pain?
◦ Temporal relation of abdominal pain and school? Is
it less at weekends?
History
Do not forget to ask!!!
 Are there other abdominal symptoms?
◦ Constipation, diarrhea, vomiting suggest a GIT
cause
◦ Frequency and dysuria suggest urinary tract cause
◦ Gynecological symptoms in adolescent girls
 Are there general constitutional symptoms?
◦ Anorexia, weight loss, fever – suggest underlying
organic cause
History
Do not forget to ask!!!
 Are there emotional or family difficulties?
◦ Emotional and family problems are often associated
with recurrent abdominal pain
◦ Find out how pain affects life at home and at school
 Family history
◦ of gastrointestinal disorders, like peptic ulcers can
be relevant
Physical examination
Do not forget to check!!!
 Always perform complete physical
examination !!!
 Height and weight – particulary important

◦ Weight loss or poor growth suggest serious

pathology

 General examination
◦ Pallor, jaundice, clubbing
Physical examination
Do not forget to check!!!
 Abdominal examination
◦ Examine for hepatomegaly, splenomegaly, enlarged
kidneys, bladder distension
 Anorectal examination
◦ Not a part of routine examination in children
◦ Necessary if there is suspicion of child abuse
◦ Should be done in constipation
 Features of organic and non-organic
abdominal pain
Organic Non-organic
Characteristics Day and night Periodic pain with
intervening good health
Characteristics depend Often periumbilical
on the underlying cause
If psychogenic- may be
related to school hours
History Weight loss and/or Otherwise healthy child
reduced appetite
Lack of energy
Recurrent fever
Organ-specific
symptoms (change in
bowel habit, polyuria,
menstrual problems,
vomiting)
 Features of organic and non-organic
abdominal pain (2)
Organic Non-organic
Physical exam Ill appearance Normal, thriving child
Growth failure
Swollen joints
Preliminary Anemia Normal
investigations Leukocytosis
Eosinophilia
Elevated ESR
Abnormal urinalysis
and/or culture
Investigations
 The diagnosis of non-organic abdominal pain
can be made on the basis of the history and
physical examination
 If in doubt – perform full blood count, ESR,

stools for ova and parasites, urinalysis

 Consider further investigations if there are

findings suggestive of a particular disease

process
Clues to the diagnosis of recurrent
abdominal pain
Features of the pain Associated symptoms
Idiopathic recurrent Periodic Well between episodes
abdominal pain Periumbilical
Psychogenic pain Periodic Other psychogenic
symptoms
Irritable bowel Non-specific Flatus and variable
syndrome pattern
Peptic ulcer Epigastric In children < 5 yr pain
Relieved by food and is often exacerbated
antacids by food- opposite to
adult pattern
Gastroesophageal May be chest pain Vomiting
reflux Failure to thrive
Clues to the diagnosis of recurrent abdominal pain
Features of the pain Associated symptoms
Constipation Colicky Hard, infrequent stools
Parasitic infections Variable Variable
(eg. Giardiasis)
Urinary tract infection Back, or loin pain Dysuria, frequency,
enuresis
Dysmenorrhea Varies with menstrual
cycle
Pelvic inflammatory Low abdominal pain Vaginal discharge
disease
Lead poisoning Variable, generalized Anorexia and
irritability
Pica
Hypochromic,
microcytic anemia
Management of recurrent abdominal
pain
 Non-organic abdominal pain
◦ Reassure parents and child that no major illness
appears to be present
◦ Explain to parents that child is not malingering
◦ Ask child and parents to keep diary of symptoms,
schedule return visits
◦ Provide emotional and psychological support
◦ Encourage child and family to normalize life, attend
school, participate in age appropriate activities
 Organic abdominal pain
◦ Management depends on particular diagnosis
Blood in the stool
Causes of blood in the stool

Infancy
Anal fissure
Dysentery, salmonella infection
Milk allergy
Intussusception
Swallowed maternal blood at birth
Older children
Anal fissure
Dysentery, salmonella infection
Inflammatory bowel disease
Intussusception
Henoch-Schonlein purpura
Intestinal polyp
History
Do not forget to ask!!!
 What is the stool like?
◦ Constipation and dysentery are easily differentiated
on history
◦ Blood outside the stool – site of bleeding is lower
bowel (usually constipation)
◦ Blood mixed with stool – pathology higher in the
GIT
◦ Stool like “red currant jelly” – mucus and blood –
suggests intussusception
◦ Stool is black, tarry consistency, specific odor –
bleeding from upper parts of GIT
History
Do not forget to ask!!!
 Is there pain?
◦ Pain is very useful symptom
◦ Pain with defecation, very hard stool- significant
constipation
◦ Periodic screaming – think of intussusception
 Is there bleeding from other sites?
◦ Bleeding from other sites – more generalized
bleeding disorder
Physical examination
Do not forget to check!!!
 General examination
◦ High fever – in dysentery
◦ Pallor – if blood loss is significant
◦ Purpura on extension surfaces – in Henoch-
Schonlein purpura
 The abdomen
◦ Tenderness
◦ Palpable feces in lower left quadrant and above – in
constipation
Physical examination
Do not forget to check!!!
 Anal and rectal examination
◦ Inspect the anus – anal fissure –commonest finding
◦ Gross trauma – abuse
◦ Rectal examination – of there is no fissure
(impacted stool, polyp)
Investigations
 Constipation – no need for investigations
 Dysentery – stool culture
 Intussusception – ultrasound, barium enema
 Inflammatory bowel disease – radiological

studies and endoscopy

constipation
 Wide range of frequency of bowel movements
in normal children
 More than two stools per day to one stool in

several days
 The diagnosis of constipation is based on

hardness of stool and pain with defecation,

and not alone on frequency of bowel
movements
 Constipation is common
 Almost always functional in nature
 Constipation can occur with fluid depletion

during hot weather or after febrile illness

 It can be resolved by increasing fluid intake
 Episode of constipation can lead to a more

chronic problem
 Organic causes of constipation – rare
 Most important – Hirsprung’s disease
 Constipation from infancy
 Failure to thrive think of
 Distended abdomen Hirsprung’s disease

 Bowel obstruction from congenital

malformations – rare, usually as acute abdomen
History
Do not forget to ask!!!
 What are the symptoms?
◦ Is child really constipated or have normal but
infrequent stools
◦ Hard stool
◦ Painful defecation
◦ Crampy abdominal pain constipation
◦ Blood on the stool or
toilet paper

◦ Longstanding constipation can be painless

History
Do not forget to ask!!!
 Constipation history
◦ Constipation is often precipitated by fluid depletion
 During hot weather
 During febrile illness
 After vomiting
◦ When constipation is chronic, it is often not
possible to recall the onset
◦ Mismanagement of toilet training can be the cause
of constipation
◦ Hirsprung’s disease – constipation from infancy
◦ Functional constipation – later onset – previous
history of anal fissure is important factor
History
Do not forget to ask!!!
 Are there associated symptoms?
◦ Bowel obstruction – constipation but associated
with vomiting and abdominal pain

 What is the diet like?

◦ Low fluid intake
◦ Low dietary fiber intake
Physical examination
Do not forget to check!!!
 Growth
◦ Poor growth with Hirsprung’s disease
 General examination
◦ Hard, palpable feces in lower left quadrant and
above
 Anorectal examination
◦ Inspection of anus – anal fissure, signs of abuse
◦ Hard stool palpable in ampula recti
Investigations
 Rectal biopsy – Hirsprung’s disease
 Plain x-ray of the abdomen – large quantities of the feces
in colon
Jaundice
 Accumulation of yellow pigment bilirubin in
the skin
 After neonatal period, jaundice is very

important sign
 Must be investigated immediately
Bilirubin metabolism
 Unconjugated bilirubin is produced as a
result of metabolism of haem from
hemoglobin
 Unconjugated bilirubin is insoluble
 It is metabolized in liver to become soluble –

conjugated
 Conjugated bilirubin is excreted via bile and

hepatic ducts to duodenum

 Bilirubin and bile salts help fat and fat-

soluble vitamins absorption in small bowel

 Conjugated bilirubin is metabolized by
bacteria, and urobilinogen is produced
 A half of conjugated bilirubin is reabsorbed

as urobilinogen in the enterohepatic

circulation
 Urobilinogen can be excreted by urine or

metabolized in liver
 In jaundice, excessive conjugated bilirubin

can be excreted in the urine- urine dark as

dark tea
Common causes of jaundice in childhood

Predominantnly unconjgated Predominantly conjugated

Haemolysis Hepatic
Haemolytic disease of newborn Hepatitis
Sickle cell disease Cystic fibrosis
Spherocytosis Cirrhosis

Hepatic Obstructive
Rare Hepatitis
Biliary atresia
History
Do not forget to ask!!!
 Features of jaundice
◦ Insidious onset – yellow sclerae, first sign
◦ Rapid onset – hemolysis
 Malaise
◦ Duration of malaise, abdominal pain, anorexia
 Symptoms of anemia
◦ Anemia occurs with hemolysis
◦ Breathlessness, pallor
History
Do not forget to ask!!!
 Pruritus
◦ Occurs as a result of deposition of bile salts in the
skin
 Urine
◦ Color of the urine
◦ Very dark (coca cola) –conjugated
hyperbilirubinemia
 Steatorrhoea
◦ Frothy, foul smelling stool, floats in the toilet pan
◦ Can be seen in cirrhosis
Physical examination
Do not forget to check!!!
 Growth
◦ Failure to thrive, poor growth – in longstanding
liver disease
 Skin signs
◦ Scratch marks
◦ Spider naevi, clubbing, ascites
 Hepatosplenomegaly
◦ Hard liver – cirrhosis
◦ Splenomegaly – hemolysis or cirrhosis
Investigations
Investigation What are you looking for
Haemoglobin Low Hb with reticulocytosis-
hemolysis
Bilirubin Unconjugated excess – hemolysis
Conjugated excess – hepatic
disease or posthepatic obstruction
Liver enzymes Elevated in hepatitis
Alkaline phosphatase Elevated in cirrhosis or long-
standing jaundice
Serology Identification of hepatitis viruses
Clues to the differential diagnosis of jaundice

Haemolysis Infective Cirrhosis

hepatitis
Onset of jaundice Acute Acute Insidious
Dark urine - + +++
Anorexia - +++ +
Pruritus - - +++
Anaemia +++ - +
Hepatosplenomeg +++ - ++
aly
Liver tenderness + ++ -