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The Digestive System
Disease
Department of Pediatrics
Soochow University Affiliated Children’s Hospital
Key points
◎ The common symptoms of gastrointestinal disease in
childhood, its pathogenesis（发病机制） and
management
◎ The presentation of common infections of the
gastrointestinal tract
◎ Assessment for dehydration（脱水） in a child with
diarrhoea and how to carry out rehydration（纠正脱水）
◎ Chronic gastrointestinal disorders that can lead to
malabsorption（吸收不良） and failure to thrive
◎ Infections that can affect the liver
Aim and Claim
1. Familiar with the normal features
and assessment of digestive
system
2. Get hold of the examination of
digestive system
Normal Features and
Assessment
Mouth: Foodstuffs（食物） broken down by chewing; saliva（唾
液） added as lubricant（润滑剂）
Oesophagus: Conduit（通道） between mouth and stomach
Stomach: Digestion of proteins; foodstuffs reduced to liquid form;
storage; sterilisation（灭菌）
Pancreas: Digestive enzymes（消化酶） for digestion of fats,
carbohydrates and proteins
Liver: Bile salts for digestion/absorption of fats in small
intestine
Gallbladder: Stores and concentrates bile
Small intestine: Final stages of chemical digestion and nutrient
absorption
Large intestine: Water absorption, bacterial fermentation（发
酵） and formation of faeces
Gastrointestinal Function
Sequence of Events
Ingestion >> chewing &
moistening of food >>
swallowing >> peristalsis >>
acidifying >> initiation of
protein digestion >>
neutralization >> digestion >>
absorption >> assimilation >>
fermentation &
putrification >> elimination
Severe key points
1.
Normal function of the gastrointestinal tract
2.
Oral feeding
3.
Intestinal microflora（肠道菌群）
4.
Stool :meconium（胎粪）, green-brown transition stool,
gold-like stool, orange-like stool
5.
A palpable liver and a soft spleen tip
6.
A protuberant（彭隆的） abdomen in infant and toddlers
Intestinal Microflora
Metabolic activity of GI flora
• Vitamin synthesis
– Biotin
– Vitamin K
• Fermentation of undigested carbohydrates
• Development of mucosal immunity
– Commensal bacteria colonizing in the first 2 years of life
provide the environment for immune development
• Production of Short chain fatty acids
• Mucous production
• Bile acid deconjugation
• Detoxification（解毒）
• Elimination
Examination Of The
Gastrointestinal Tract
Examination of the
gastrointestinal tract （1）
Systemic signs of dysfunction
◎Aneamia（贫血）
◎Jaundice （黄疸）
◎Clubbing （杵状指）
◎Oedema （水肿）
◎Distended vein （静脉曲张）
◎Dehydration （脱水）
Examination of the
gastrointestinal tract （2）
Abdominal examination
• Examination secquence
inspection, palpation, auscultation, percussion
• Exposure pelvic region （会阴部） ：don‘t miss torsion
（扭转） of the testis （睾丸） or incarcerated hernia
（嵌顿疝）
• Be careful : Hernial orifices region （疝环口区） ,
Scrotum （阴囊） and anal （肛门） regions
• Rectal examination
region
right lumber
region
right iliac
region
left hypochondriac
epigastric
region
umbilieal
region
hypogastric
region
region
left lumber
region
left iliac
region
Abdominal Area:
Nine regions
right hypochondriac
Symptoms of Digestive System
Abdominal Pain
Aim and Claim
• Familiar with the causes acute abdominal
pain
• Get hold of the causes of recurrent
abdominal pain（再发性腹痛）
Acute Abdominal Pain
• Trauma（外伤）
• Inflammation （炎症）
–
–
–
–
Acute gastroenteritis
Appendicitis
Pancreatitis
Henoch-Schonlein Purpura
（过敏性紫癜）
•
• Anatomic
–
–
–
–
–
• Extra-abdominal
Bowel obstruction
Intussusception （肠套叠）
Volvulus （扭转）
Incarcerated hernia
Gallbladder disease
–
–
–
–
–
Lower lobe pneumonia
Strep pharyngitis
DKA (diabetic ketoacidosis)
UTI/pyelonephritis （肾盂肾炎）
Renal stones
Gynecologic （妇科）
– PID (pelvic inflammatory
disease)
– Mittelschmerz （经间痛）
– Dysmenorrhea （痛经）
– Ovarian cyst （卵巢囊肿）
– Ectopic pregnancy （异位妊娠）
Acute Abdominal Pain
Evaluation
• Careful history
- Quality/location/timing
- Relieving/aggravating
• Associated symptoms
• Physical
– Abdominal exams – serial
• Distention/BS
• Rebound （反跳痛）
/rigidity （强直）
/guarding （肌紧张）
• Tenderness （压痛）
– Rectal exam
– Pelvic exam
• Abdominal X-ray
– Flat：obstruction （梗阻）
– Upright： perforation （穿
孔）
• Specific imaging
– CT scan
– Ultrasound （超声波）
• Lab tests
– CBC/diff, ESR, CRP
– Urinalysis
– Serum amylase （淀粉酶）
/lipase （脂肪激酶）
Recurrent Abdominal Pain
• Inflammatory
– Crohn’s Disease
– Ulcerative Colitis
– Celiac disease
• Acid peptic disease
–
–
–
–
Esophagitis（食管炎）
Gastritis
Gastric/duodenal ulcer
GE Reflux
• Anatomic
– Intrabdominal tumor (Wilms,
neuroblastoma)
– Meckel’s diverticulum （麦克尔
憩室）
– Malrotation （旋转不良）
• Bloating/gas/diarrhea
– Lactose intolerance
– Giardiasis （鞭毛虫病）
• Functional （90%）
– Irritable Bowel Syndrome
– FRAP （功能性再发性腹痛）
Symptoms of Digestive System
Vomiting
Aim and claim
• Understand the causes of vomiting
• Familiar with the evaluation of vomiting
Vomiting
• Anatomic
– Pyloric stenosis（幽门肥
厚性狭窄）
– Bowel obstruction
– Malrotation
– Intussusception
– Ulcer
– GE Reflux（胃食管反流）
• Inflammatory
–
–
–
–
–
–
Gastroenteritis
Systemic infection
Appendicitis
Pancreatitis
Hepatitis
Milk protein allergy
• Metabolic
– Inborn errors
– DKA
• CNS
– Increased ICP（颅压）
– Migraine（腹型偏头痛）
• Post-tussive（咳嗽诱
发）
• Toxic ingestion
• Chemotherapy
• Pregnancy（妊娠）
Vomiting
Evaluation
• Bile-stained vomiting suggests obstruction distal to
ampulla of Vater
• Abdominal plain film
– Flat: look for dilated loops of bowel
– Upright: look for free air under diaphragm（横膈）
• Contrast radiograph (UGI series, barium enema)
• Electrolyte panel – look for acidosis, disturbance
• Other labs: UA（尿素氮）, amylase/lipase, LFT（肝
脏功能检查）
• Appendicitis: CBC/diff, CT w/contrast
Gastro-Esophageal
Reflux
Aim and claim
•
Familiar with the clinical features of gastroesophageal reflux
•
Get hold of the diagnosis of gastro-esophageal
reflux
•
Understanding management of gastroesophageal reflux
Introduction
• Definition
 Gastroesophageal reflux (GER), passage of gastric
materials into the esophagus, is a normal physiologic
process that can progress to gastroesophageal reflux
disease (GERD) when the expelled gastric materials
produce undesirable symptoms and complications
 GER as a normal
 GERD, a pathologic process
Pathophysiology
1.
A decrease in lower esophageal sphincter (LES)
tone –-- the most important factors
2.
Changes in the pressure gradients between the
esophagus and stomach
3.
Stress maneuvers include straining, crying,
coughing, eating, or the valsalva maneuver
4.
Other factors include gastric distention, delayed
esophageal clearance and gastric emptying,
neurologic disease, and hiatal hernia
Pathophysiology
The pathogenesis of GERD is involving
•
The frequency of reflux
•
Gastric acidity and gastric emptying
•
Esophageal clearing mechanisms
•
The esophageal mucosal barrier
•
Visceral hypersensitivity
•
Airway responsiveness
•
PH (<4) in the refluxate
Clinical Features
• Regurgitation—mild symptoms—no treatment
• Oesophagitis—failure to thrive or recurrent
aspiration pneumonia—severe and
complications—need to treat
• Risk of severe GER —premature infants,infants
with cerebral palsy,and infants with congenital
oesophageal anomalies
Complications of
gastroesophageal reflux
•
•
•
•
•
•
•
•
•
•
•
Recurrent vomiting
Weight loss or poor weight gain
Irritability in infants
Regurgitation
Heartburn or chest pain
Hematemesis（呕血）
Dysphagia(吞咽困难) or feeding refusal
Apnea呼吸暂停
Wheezing or stridor（喘鸣）
Hoarseness（声音嘶哑）
Cough
Diagnosis（１）
• Upper GI Series
 Ｎor specific for the diagnosis of GER, but is useful for the
evaluation of the presence of anatomic abnormalities
 pyloric stenosis
 malrotation
 annular pancreas
 hiatal hernia
 esophageal stricture
Diagnosis （２）
Esophageal pH Monitoring
• Esophageal pH monitoring is a valid and reliable
measure of acid reflux.
• Esophageal pH monitoring is useful to establish the
presence of abnormal acid reflux, and to assess the
adequacy of therapy in patients.
• Esophageal pH monitoring may be normal in some
patients with GERD, particularly those with
respiratory complications.
Diagnosis （３）
Endoscopy and Biopsy
• Endoscopy with biopsy can assess the presence
and severity of esophagitis, strictures and Barrett’s
esophagus.
•
Exclude other disorders, such as Crohn’s disease
and eosinophilic or infectious esophagitis.
• A normal appearance of the esophagus during
endoscopy does not exclude histopathological
esophagitis; subtle mucosal changes such as
erythema.
Management （１）
Diet Changes in the Infant
• There is evidence to support a one to two-week trial
of a hypoallergenic formula in formula fed infants
with vomiting.
•
Milk-thickening agents do not improve reflux index
scores but do decrease the number of episodes of
vomiting.
Management （２）
Positioning in the Infant
• Supine positioning（仰卧位） confers the lowest risk
for SIDS（sudden infant death syndrome，婴儿猝死
综合症 ）and is preferred.
• Prone positioning（俯卧位） during sleep is only
considered in unusual cases.
• When prone positioning is necessary, it is particularly
important that parents be advised not to use soft
bedding, which increases the risk of SIDS in infants
placed prone.
Management （３）
Positioning in the Child & Adolescent
• In children older than one year it is likely that there is
a benefit to left side positioning during sleep and
elevation of the head of the bed.
• Lifestyle Changes in the Child & Adolescent
• Children and adolescents with GERD avoid caffeine,
chocolate and spicy foods that provoke symptoms.
Management （４）
Acid-suppressant Therapy
• Histamine-2 receptor antagonists (H2RAs)
produce relief of symptoms and mucosal
healing.
• Proton pump inhibitors (PPIs), the most
effective acid suppressant medications, are
superior to H2RAs in relieving symptoms and
healing esophagitis.
Management （５）
Prokinetic Therapy
•
Cisapride reduces the frequency of symptoms,
including regurgitation and vomiting.
•
The potential for serious cardiac arrhythmias in
patients receiving cisapride, appropriate patient
selection and monitoring as well as proper use
• Other prokinetic agents have not been shown to be
effective in the treatment of GERD in child.
Management （６）
Surgical Therapy
• Surgery is often considered for the child with GERD
who has persistence of symptoms following medical
management or who is unable to be weaned from
medical therapy.
• Recently experience with laparoscopic procedures
has been reported.
Summary
• Very common during 1st year of life
• Reduced LES pressure or greater LES relaxation
• GERD = Aspiration (chronic cough or wheeze),
Esophagitis, failure to thrive
• Dx: Clinical, Esophageal pH probe, UGI series
(anatomy)
• Medical tx: Thickened feeds, position, acid suppression,
pro-kinetic agent
• Surgical tx: Nissen fundoplication
Quiz
•
Which one of the following is not organic causes of
recurrent abdominal pain：
•
A.
Urinary tract infections
B.
Inflammatory bowel disease
C.
Irritable bowel syndrome*
D.
Obstructive uropathy
E.
Malrotation
True/False: Surgical causes of abdominal pain are
much less common than non-surgical causes. True
Quiz
• Gastroesophageal reflux(GER )is
A. GER in infancy is that it is usually abnormal
(Pathologic), unlike older children and adults.
B. Nature of emesis（呕吐） in GER is effort ,
and is preceded by nausea (pallor, anorexia,
excessive salivation).
C. Increased intraabdominal pressure - Cough,
physical effort and Slow gastric emptying.
D. Complicated GER in infants is termed
"physiologic GER" or simply "spitting up".*
E. Emesis is not usually post-prandial.