GASTROINTESTINAL SYSTEM

Department of pediatrics

Development of GIT:• A gut tube can be subdivided into 3 : foregut ,

midgut , hindgut • The digestion sys. develops from the 3 parts, the

hindgut gives rise to the GI structure from the esophagus to the 2nd part of the duodenum . liver and pancreas develop as out growth from the hindgut .

• The midgut gives rise to the structures from the 2nd part of duodenum to the first 2/3 of the large intestine the hindgut then given rise to the structure from the remaining large intestine to the rectum .

Development of GIT:• A gut tube can be subdivided into 3 : foregut ,

midgut , hindgut • The digestion sys. develops from the 3 parts, the

hindgut gives rise to the GI structure from the esophagus to the 2nd part of the duodenum . liver and pancreas develop as out growth from the hindgut .

• The midgut gives rise to the structures from the 2nd part of duodenum to the first 2/3 of the large intestine the hindgut then given rise to the structure from the remaining large intestine to the rectum .

• The primitive gut begin to develop as an endodermally lined tube surrounded by mesoderm which envelopes the gut and form as dorsal mesentery

• The stomach develops from the hindgut starting at the 4th week it begin as a dilatation of the gut tube and during development it shifts position by both moving caudally and rotating

• The primitive gut begin to develop as an endodermally lined tube surrounded by mesoderm which envelopes the gut and form as dorsal mesentery

• The stomach develops from the hindgut starting at the 4th week it begin as a dilatation of the gut tube and during development it shifts position by both moving caudally and rotating

• The anterior surface and the right side of the gut tube will become the posterior surfaces of the stomach , the caudal movement of the stomach results in pyloric partum of the stomach lying at the same level as the body of the stomach .

• The anterior surface and the right side of the gut tube will become the posterior surfaces of the stomach , the caudal movement of the stomach results in pyloric partum of the stomach lying at the same level as the body of the stomach .

• The first part of the duodenum and the beginning of the 2nd part are derived from the foregut , the remaining duodenum and ilium will be derived from the midgut , the appendix , cecum , ascending , colon and the 2/9of trans colon are derived from the midgut the last 1/3 of transcolon and the descending and sigmoid are derived from the hindgut , the midgut can be divided into 2 portion:

• The first part of the duodenum and the beginning of the 2nd part are derived from the foregut , the remaining duodenum and ilium will be derived from the midgut , the appendix , cecum , ascending , colon and the 2/9of trans colon are derived from the midgut the last 1/3 of transcolon and the descending and sigmoid are derived from the hindgut , the midgut can be divided into 2 portion:

• 1-cephalic of midgut extends from the duodenum to the yolk sac , the cephalic will then form the lower duodenum and the upper ilium.

• 2-caudal will form the lower ilium . appendix , cecum , ascending colon . 2/3 of trans colon.

• 1-cephalic of midgut extends from the duodenum to the yolk sac , the cephalic will then form the lower duodenum and the upper ilium.

• 2-caudal will form the lower ilium . appendix , cecum , ascending colon . 2/3 of trans colon.

• Mesentery is the a splanchnic mesoderm that connects the primitive gut to the body wall.

• During development ventral mesentery exists only between the liver –stomach liver-duodenum.

• The ventral mesentery goes on to form the lesser omentum (liver-stomach) and the falciform ligament at liver and anterior body wall.

• The dorsal mesentery surrounds the rest of primitive gut in the region of the stomach the dorsal meso develops into spleen renal and gastrospleenal lig.

• Mesentery is the a splanchnic mesoderm that connects the primitive gut to the body wall.

• During development ventral mesentery exists only between the liver –stomach liver-duodenum.

• The ventral mesentery goes on to form the lesser omentum (liver-stomach) and the falciform ligament at liver and anterior body wall.

• The dorsal mesentery surrounds the rest of primitive gut in the region of the stomach the dorsal meso develops into spleen renal and gastrospleenal lig.

• The dorsal mesentery persists and develops into mesenteric produced between small intestine and post . body wall finally the meso of the colon develops into the trans mesocolon

• The development of the mesenteries and location of these structures are largely dictated by notation of the gut and other movement of development stomach and GIT .

• The dorsal mesentery persists and develops into mesenteric produced between small intestine and post . body wall finally the meso of the colon develops into the trans mesocolon

• The development of the mesenteries and location of these structures are largely dictated by notation of the gut and other movement of development stomach and GIT .

• Organs that were originally in the dorsal mesentery came to retroperitoneal position are part of duodenum, the blood supply to the GI structure Langley along with developed from the foregut it receives blood supply from colic a , if from the midgut blood supply from sup mesenteric a.

• Pancreas:• the pancreas develops as organ growth of duodenum

, it develops as to pancreatic ( dorsal , ventral ).

• Organs that were originally in the dorsal mesentery came to retroperitoneal position are part of duodenum, the blood supply to the GI structure Langley along with developed from the foregut it receives blood supply from colic a , if from the midgut blood supply from sup mesenteric a.

• Pancreas:• the pancreas develops as organ growth of duodenum

, it develops as to pancreatic ( dorsal , ventral ).

• Liver :• develops from diverticulum , the portion of the

diverticulum to duodenum develops into hepatic duct , bile duct and gall bladder .

• the remaining portion becomes the epithelial plates of the liver

• the vital line veins become incorporated and give rise to hepatic sinusoids.

• Liver :• develops from diverticulum , the portion of the

diverticulum to duodenum develops into hepatic duct , bile duct and gall bladder .

• the remaining portion becomes the epithelial plates of the liver

• the vital line veins become incorporated and give rise to hepatic sinusoids.

GIT complaints are common pediatric problem central history and physical examination are necessary to determine the symptoms are due to primary GI illness or to systemic disease and manifestation that are associated.

GIT complaints are common pediatric problem central history and physical examination are necessary to determine the symptoms are due to primary GI illness or to systemic disease and manifestation that are associated.

Techniques of examination : -inspection: skin , these include color , scars , dilated veins of hepatic , destruction , inflammation , hernia , abdomen ( flat rounded , protuberant , symmetrical ) visible organs liver or spleen that has descended below the ribs cage , peristalsis , observe for several minutes in a suspicion of OBS , peristalsis may be visible normally in very thin people , pulsation ( increase pressure , increase aortic pulsation , epigastrium can be visible )

Techniques of examination : -inspection: skin , these include color , scars , dilated veins of hepatic , destruction , inflammation , hernia , abdomen ( flat rounded , protuberant , symmetrical ) visible organs liver or spleen that has descended below the ribs cage , peristalsis , observe for several minutes in a suspicion of OBS , peristalsis may be visible normally in very thin people , pulsation ( increase pressure , increase aortic pulsation , epigastrium can be visible )

auscultation: listen bowel sounds , frequency characteristics , normal sound consist of click , the frequency has been estimated 5-35/min . the bowel sound may be altered on diarrhea , peritonitis.

percussion :the liver measure vertical high of the liver , liver dullness of the R midclavicular line , the liver dullness is decrease when the liver is small , it may also decrease when free air is present below the diaphragm , enlargement of the liver in hepatitis , CHF .

auscultation: listen bowel sounds , frequency characteristics , normal sound consist of click , the frequency has been estimated 5-35/min . the bowel sound may be altered on diarrhea , peritonitis.

percussion :the liver measure vertical high of the liver , liver dullness of the R midclavicular line , the liver dullness is decrease when the liver is small , it may also decrease when free air is present below the diaphragm , enlargement of the liver in hepatitis , CHF .

in suspicion of splenomegaly to try 2 :1- percusion lower its the if ant axillary line thus area is usually tympanic then ask the patient to take deep breath and to percuss again normally the percussion remains tympanic2- percusion in several direction from tympanic toward the estimated area of splenic dullness so that you can outline its edgescan be determine also the size , impaired by varying contents of stomach and colon but may be suggest splenomegaly even before the organ becomes palpate

-palpation: superficial palpation is specially helpful identifies the muscular resistance of the abdomen.deep palpation :is usually required to determine abdominal masses , location , size , shape , tenderness , pulsationLIVER : palpation of liver is done by placing the fingers supporting 4-12 ribs , remind the patient to relax . to place the R hand on the patient abdomen to ask the patient for deep breath to describe the liver edges and measure them .

-palpation: superficial palpation is specially helpful identifies the muscular resistance of the abdomen.deep palpation :is usually required to determine abdominal masses , location , size , shape , tenderness , pulsationLIVER : palpation of liver is done by placing the fingers supporting 4-12 ribs , remind the patient to relax . to place the R hand on the patient abdomen to ask the patient for deep breath to describe the liver edges and measure them .

SPLEEN: LF hand reach over and around the patient to support and press forward the lower IF ribs cage, the R hand below the costal margin press in toward the spleen . Ask the patient to take deep breath and try to feel the edges of the spleen. tenderness , splenic can measure the distance between lower points and LF costal margin ,in children the liver is easily palpated in most children the edge is normally felt 1-2cm below costal margin sharp.

SPLEEN: LF hand reach over and around the patient to support and press forward the lower IF ribs cage, the R hand below the costal margin press in toward the spleen . Ask the patient to take deep breath and try to feel the edges of the spleen. tenderness , splenic can measure the distance between lower points and LF costal margin ,in children the liver is easily palpated in most children the edge is normally felt 1-2cm below costal margin sharp.

THE SIZE OF THE LIVER : AGE MALE female5 m 2.4 2.81 y 2.8 3.15 y 4.8 4.510y 6.1 5.416y 7.1 6.0adults 7.7 6.3

THE SIZE OF THE LIVER : AGE MALE female5 m 2.4 2.81 y 2.8 3.15 y 4.8 4.510y 6.1 5.416y 7.1 6.0adults 7.7 6.3

ACUTE ABDOMINAL PAIN

In children acute gastroenteritis is one the most common cause of acute abdominal pain , in infants

less than 2 years , ( trauma , UT infection ) in between 2-5 ( lower lobe pneumonia , UT infection ) in older

and adolescents appendicitis is more common may be difficult to distinguish from gastroenteritis in

adolescent pelvic inflammatory disease .

ACUTE ABDOMINAL PAIN

In children acute gastroenteritis is one the most common cause of acute abdominal pain , in infants

less than 2 years , ( trauma , UT infection ) in between 2-5 ( lower lobe pneumonia , UT infection ) in older

and adolescents appendicitis is more common may be difficult to distinguish from gastroenteritis in

adolescent pelvic inflammatory disease .

CHRONIC ABDOMINAL PAINIts defined as 3 or more episodes of pain , sever pain affects activities for ex in irritable bowel syndrome many associated symptoms such as pallor , nausea

headache , diarrhea . sleep disturbances , are seen be due to colic lactose intolerance , colic disease , tumors

in order children in lactose intolerance , IBO , esophagitis .

CHRONIC ABDOMINAL PAINIts defined as 3 or more episodes of pain , sever pain affects activities for ex in irritable bowel syndrome many associated symptoms such as pallor , nausea

headache , diarrhea . sleep disturbances , are seen be due to colic lactose intolerance , colic disease , tumors

in order children in lactose intolerance , IBO , esophagitis .

DIARRHEA:MECHANISM Defect Stool

1 secretory decrease absorption

watery , appear in E. coli , cholera .

2 osmotic maldigestion , transport defect

Watery , acidic ,reduce in sub . ↑osmolarity appears in lactose def. , glucose , galactose .

3 increase motility decrease transit , stasis

like stimulate gastro colic reflex

4 decreased surface area

decrease functional capacity

watery short bowel syndrome

5 mucosal invasion

inflammation , decrease colic reabsorption , ↑motility

Blood appear in salmonella , shigella , eserina …

CONSTIPATION:is defined as infrequent passage of hard dry stools , causes ,

non organic or functional.organic include :

1-intestinal - stenosis2-drugs- narcotics

3-metabolic dehydration , hypokalemia4- neuromuscular

stool retention may be due to toilet training or pain in defection and create in future retention of stool,

consequences intoxication , abdominal pain , UT infection.

CONSTIPATION:is defined as infrequent passage of hard dry stools , causes ,

non organic or functional.organic include :

1-intestinal - stenosis2-drugs- narcotics

3-metabolic dehydration , hypokalemia4- neuromuscular

stool retention may be due to toilet training or pain in defection and create in future retention of stool,

consequences intoxication , abdominal pain , UT infection.

at term infants meconium shoulder be passed within the first 24h of life failure to pass meconium suggest can

underlying disorder, frequency of bowel movement vary greatly in the individual child among different children. the breast fed infants produce stool every feeding but

many produce 1-2 time-day. formula fed -produce daily but may be 2-3t day .

the range of normal for infant is 5 stool/day .failure to defecate may be due to decrease peristalsis in

spinal cord defect.

at term infants meconium shoulder be passed within the first 24h of life failure to pass meconium suggest can

underlying disorder, frequency of bowel movement vary greatly in the individual child among different children. the breast fed infants produce stool every feeding but

many produce 1-2 time-day. formula fed -produce daily but may be 2-3t day .

the range of normal for infant is 5 stool/day .failure to defecate may be due to decrease peristalsis in

spinal cord defect.

VOMITING:

a forced ejection of gastric content is often preceded by nausea is due to the coordination of gastric atony except pyloric stenosis , relaxation of gastroesophageal junction

increase intragastric pressure from abdominal wall contraction

regurgitation a passing nonforce of gastric content due to reflex through a relaxed lower esophageal sphincter .

VOMITING:

a forced ejection of gastric content is often preceded by nausea is due to the coordination of gastric atony except pyloric stenosis , relaxation of gastroesophageal junction

increase intragastric pressure from abdominal wall contraction

regurgitation a passing nonforce of gastric content due to reflex through a relaxed lower esophageal sphincter .

The differential diagnosis of vomiting should be appreciated by considering age specific disease during

neonatal period GI obstruction is often causes of regurgitation. gastroenteritis, overfeeding , gastro

esophageal reflux, food allergy , milk protein intolerance.

In children and adolescent vomiting is caused by gastroenteritis , systemic infection , appendicitis , IBO .

The differential diagnosis of vomiting should be appreciated by considering age specific disease during

neonatal period GI obstruction is often causes of regurgitation. gastroenteritis, overfeeding , gastro

esophageal reflux, food allergy , milk protein intolerance.

In children and adolescent vomiting is caused by gastroenteritis , systemic infection , appendicitis , IBO .

GI HEMORRAHAGE Hemorrhage may occur of any location in GIT,

hematemesis , the blood emesis results hemoprofused bleeding proximal to the ligament treitz , less sever appear

GI bleeding results in a coffee-ground . melena: refer to soft usually black or dark color stool it is suggestive of bleeding from the oropharynx to the colon , stasis of blood in the R colon , bleeding lesion in that area

may appear as melena.Hematochezia : refer to bright red or marrow colored

stools , typically the lesion is colored .

GI HEMORRAHAGE Hemorrhage may occur of any location in GIT,

hematemesis , the blood emesis results hemoprofused bleeding proximal to the ligament treitz , less sever appear

GI bleeding results in a coffee-ground . melena: refer to soft usually black or dark color stool it is suggestive of bleeding from the oropharynx to the colon , stasis of blood in the R colon , bleeding lesion in that area

may appear as melena.Hematochezia : refer to bright red or marrow colored

stools , typically the lesion is colored .

GI bleeding:defined as significant blood loss in the absence disernable change in the color , loss many produce iron deficiency ,

anemia .differential diagnosis of GI hemorrhage based on a carful

history and physical examination of the child site of bleeding.

MANEGMENT:1-correct hypovolemia

2-correct anemia3-stop bleeding

4-prevent recurrence5-diagnose the cause

6-applay specific therapy.

GI bleeding:defined as significant blood loss in the absence disernable change in the color , loss many produce iron deficiency ,

anemia .differential diagnosis of GI hemorrhage based on a carful

history and physical examination of the child site of bleeding.

MANEGMENT:1-correct hypovolemia

2-correct anemia3-stop bleeding

4-prevent recurrence5-diagnose the cause

6-applay specific therapy.