GI and NutritionGI and Nutrition

Richard L:. Mones M.D.Richard L:. Mones M.D.

Compared to human milk, cow milk Compared to human milk, cow milk formula is more likely to contain formula is more likely to contain

which one of the following?which one of the following?

A)A) More essential fatty acidsMore essential fatty acids

B)B) Higher protein concentrationHigher protein concentration

C)C) Increased lactose contentIncreased lactose content

D)D) Lower Calcium-phosphate ratioLower Calcium-phosphate ratio

E)E) Lower iron concentrationLower iron concentration

Human Milk hasHuman Milk has::

Low protein (very bio-available)Low protein (very bio-available)

High lactoseHigh lactose

Low iron (very bio-available if taken alone)Low iron (very bio-available if taken alone)

Low Calcium-Phosphate ratioLow Calcium-Phosphate ratio

Inadequate Vitamin KInadequate Vitamin K

? Adequate Vitamin D? Adequate Vitamin D

Immunoglobulins (including SIgA)Immunoglobulins (including SIgA)

A 4 mo old boy with “short gut” from extensive small A 4 mo old boy with “short gut” from extensive small bowel resection at 2 wks of life is receiving amino bowel resection at 2 wks of life is receiving amino

acids, hypertonic glucose and trace mineral by PN and acids, hypertonic glucose and trace mineral by PN and is growing well. Last week drying and thickening of is growing well. Last week drying and thickening of

skin with desquamation began.skin with desquamation began.

The most likely cause is a deficiency ofThe most likely cause is a deficiency of::

A)A) RiboflavinRiboflavin

B)B) ProteinProtein

C)C) Essential fatty acidsEssential fatty acids

D)D) Vitamin B12Vitamin B12

E)E) CopperCopper

A 4 wk old boy has diarrhea and intermittent vomiting A 4 wk old boy has diarrhea and intermittent vomiting for 2 wks. He is getting cow milk formula, 175 to 200 ml for 2 wks. He is getting cow milk formula, 175 to 200 ml q3h (8 feeds/24 hrs). Birth wt = 3.2Kg. PE = afebrile, wt q3h (8 feeds/24 hrs). Birth wt = 3.2Kg. PE = afebrile, wt 5.0Kg (905.0Kg (90thth %ile). Abdomen is slightly protuberant. No %ile). Abdomen is slightly protuberant. No

tenderness and bowel sounds are hyperactive. tenderness and bowel sounds are hyperactive.

Which is most appropriate at this timeWhich is most appropriate at this time??

A)A) Change feeds to soy-based formulaChange feeds to soy-based formula

B)B) Obtain stool culturesObtain stool cultures

C)C) Determine stool pHDetermine stool pH

D)D) Instruct parents to reduce volume of Instruct parents to reduce volume of feedsfeeds

E)E) Schedule rectal manometry Schedule rectal manometry

A 7 yr old boy who has had school problems for the A 7 yr old boy who has had school problems for the past 2 months received a megavitamin that supplies past 2 months received a megavitamin that supplies

50,000 u of Vitamin A, 100 mgs of thiamine, 100 mg of 50,000 u of Vitamin A, 100 mgs of thiamine, 100 mg of niacin, 1 g of ascorbic acid, 2000 u of Vit D, and 500 mg niacin, 1 g of ascorbic acid, 2000 u of Vit D, and 500 mg

of Vit E of Vit E The most likely effect of this regimen will beThe most likely effect of this regimen will be::

A)A) Improved school performanceImproved school performance

B)B) Flushing and sweatingFlushing and sweating

C)C) Increased thiamine level in CSFIncreased thiamine level in CSF

D)D) Increased intracranial pressureIncreased intracranial pressure

E)E) Less URIs than in his peersLess URIs than in his peers

HypervitaminosisHypervitaminosis

Vit AVit A (>20,000 IU/d) – Inc ICP (>20,000 IU/d) – Inc ICP (pseudotumor), irritability, headaches, dry (pseudotumor), irritability, headaches, dry skin, H-Smegaly, cortical thickening of skin, H-Smegaly, cortical thickening of bones of hands and feetbones of hands and feetVit DVit D (>40,000IU/d)-Hypercalcemia, (>40,000IU/d)-Hypercalcemia, constipation, vomiting, nephrocalcinosisconstipation, vomiting, nephrocalcinosisVit EVit E (100mg/kg/d) – NEC/hepatotoxicity (100mg/kg/d) – NEC/hepatotoxicity - ?due to polysorbate 80 (solubilizer)- ?due to polysorbate 80 (solubilizer)

An adolescent girl on a strict vegan diet is An adolescent girl on a strict vegan diet is most likely to develop deficiency of which of most likely to develop deficiency of which of

the following water-soluble vitamins?the following water-soluble vitamins?

A)A) Folic acidFolic acid

B)B) NiacinNiacin

C)C) RiboflavinRiboflavin

D)D) CobalaminCobalamin

E)E) ThiamineThiamine

Vitamin SourcesVitamin Sources

ThiaminThiamin – grains, cereals, legumes – grains, cereals, legumesRiboflavinRiboflavin – dairy, meat, poultry,leafy – dairy, meat, poultry,leafy vegetablesvegetablesPyridoxinePyridoxine – all foods – all foodsNiacinNiacin – meats, poultry, fish, wheat – meats, poultry, fish, wheatBiotin Biotin – yeast, liver, kidneys, legumes, nuts– yeast, liver, kidneys, legumes, nutsFolic acidFolic acid – leafy vegetables,fruits, grains – leafy vegetables,fruits, grainsB12B12 – eggs, dairy, meats ( – eggs, dairy, meats (not in plantsnot in plants))Vit CVit C – fresh fruits and vegetables – fresh fruits and vegetables

Vitamin DeficienciesVitamin Deficiencies (fat soluble)(fat soluble)

AA – night blindness, xerophthalmia, Bitot – night blindness, xerophthalmia, Bitot spots, keratomalaciaspots, keratomalacia

DD – rickets/osteomalacia, low Ca/Phosp – rickets/osteomalacia, low Ca/Phosp

EE – neurologic deficit (ataxia, ocular palsy, – neurologic deficit (ataxia, ocular palsy, decreased DTRs)decreased DTRs)

KK - coagulapathy - coagulapathy

Vitamin DeficienciesVitamin Deficiencies (water-soluble)(water-soluble)

ThiamineThiamine (B1) –beriberi, cardiac failure (B1) –beriberi, cardiac failure

RiboflavinRiboflavin (B2) – seborrheic dermatitis, (B2) – seborrheic dermatitis, cheilosis, glossitischeilosis, glossitis

PyridoxinePyridoxine (B6) – dermatitis, cheilosis, (B6) – dermatitis, cheilosis, glossitis, peripheral neuritis, irritabilityglossitis, peripheral neuritis, irritability

Vit B12Vit B12 – megaloblastic anemia, post – megaloblastic anemia, post spinal column changes spinal column changes

Vitamin DeficienciesVitamin Deficiencies (water-soluble)(water-soluble)

Vit CVit C – scurvy, poor wound healing, – scurvy, poor wound healing, bleedsbleeds

Folic acidFolic acid – megaloblastic anemia, FTT – megaloblastic anemia, FTT

NiacinNiacin – pellagra (diarrhea, dermatitis, – pellagra (diarrhea, dermatitis, dementia), glossitis, stomatitisdementia), glossitis, stomatitis

BiotinBiotin – organic acidemia,alopecia, – organic acidemia,alopecia, seizures seizures

A previously healthy 15 mo appears pale. He has been A previously healthy 15 mo appears pale. He has been fed goat milk exclusively since birth. Labs reveal: fed goat milk exclusively since birth. Labs reveal: HgB=6.1, WBC=4800, plts=144K, MCV=109. Diff is HgB=6.1, WBC=4800, plts=144K, MCV=109. Diff is

29%polys, 68%lymphs, 3%monos. Polys are 29%polys, 68%lymphs, 3%monos. Polys are hypersegmentedhypersegmented. .

What is the most likely cause of lab What is the most likely cause of lab findingsfindings??

A)A) ALLALL

B)B) Fanconi anemiaFanconi anemia

C)C) Folate deficiencyFolate deficiency

D)D) Iron deficiencyIron deficiency

E)E) Vitamin B12 deficiencyVitamin B12 deficiency

An 8 mo old white infant is noted to have An 8 mo old white infant is noted to have yellow skin. The sclerae are normal in coloryellow skin. The sclerae are normal in color

Of the following, which is the most useful Of the following, which is the most useful diagnostic testdiagnostic test::

A)A) Measure serum bilirubin levelMeasure serum bilirubin level

B)B) Measure urine urobilinogen concMeasure urine urobilinogen conc

C)C) Measure serum Vit. A levelMeasure serum Vit. A level

D)D) Evaluate dietary historyEvaluate dietary history

E)E) Measure serum T4 levelMeasure serum T4 level

A previously well 10 yr old has fever and persistent A previously well 10 yr old has fever and persistent vomiting. Initially the emesis was clear, then bile-vomiting. Initially the emesis was clear, then bile-

stained and now it contains bright red blood. Brother stained and now it contains bright red blood. Brother has AGE 1 wk ago. PE and CBC/SMA-7 are normal.has AGE 1 wk ago. PE and CBC/SMA-7 are normal.

The most likely cause of the hematemesis The most likely cause of the hematemesis isis::

A)A) Esophageal varicesEsophageal varices

B)B) EsophagitisEsophagitis

C)C) Gastric duplicationGastric duplication

D)D) Mallory-Weiss tearMallory-Weiss tear

E)E) Peptic ulcer diseasePeptic ulcer disease

Upper GI BleedingUpper GI Bleeding

Maternal blood *Maternal blood *

Stress gastritis *Stress gastritis *

CoagulapathyCoagulapathy

EpistaxisEpistaxis

Tonsillitis/ENTTonsillitis/ENT

EsophagitisEsophagitis

GastritisGastritis

Mallory-Weiss tearMallory-Weiss tear

VaricesVarices

Duplication of gutDuplication of gut

Ulcer diseaseUlcer disease

HSPHSP

HemobiliaHemobilia

HemophiliaHemophilia

Munchausen’s Munchausen’s syndrome by proxysyndrome by proxy

A 5 yr old girl was Rx with amoxicillin for OM. One A 5 yr old girl was Rx with amoxicillin for OM. One week later, she developed abd pain, and has been week later, she developed abd pain, and has been

passing 6 stools daily that contain blood and mucus. passing 6 stools daily that contain blood and mucus. PE has T of 101, abdominal distention and diffuse abd PE has T of 101, abdominal distention and diffuse abd

tenderness.tenderness.Among the following, the most appropriate Among the following, the most appropriate

initial diagnostic study to perform isinitial diagnostic study to perform is::

A)A) Barium enemaBarium enema

B)B) Colonoscopy Colonoscopy

C)C) Clostridium difficile toxin evaluationClostridium difficile toxin evaluation

D)D) Stool for O & PStool for O & P

E)E) Stool for rotavirusStool for rotavirus

For the past 6 wks, a 4 yr old has had painless, bright For the past 6 wks, a 4 yr old has had painless, bright red rectal bleeding assoc with bowel movements. PE of red rectal bleeding assoc with bowel movements. PE of

abdomen and anus are normal. The rectal vault is abdomen and anus are normal. The rectal vault is empty and no blood is noted on gross inspection. empty and no blood is noted on gross inspection.

The most likely cause of the hematochezia The most likely cause of the hematochezia isis::

A)A) Hemolytic-Uremic syndromeHemolytic-Uremic syndrome

B)B) Henoch-Schonlein purpuraHenoch-Schonlein purpura

C)C) IntussusceptionIntussusception

D)D) Juvenile PolypsJuvenile Polyps

E)E) Meckel’s diverticulumMeckel’s diverticulum

Lower GI BleedLower GI Bleed – 0 to 30 days – 0 to 30 days

Anorectal lesionsAnorectal lesions

Swallowed maternal blood (APT test)Swallowed maternal blood (APT test)

Milk allergyMilk allergy

NECNEC

Midgut volvulusMidgut volvulus

Lower GI bleedLower GI bleed – 30 days to 1 yr – 30 days to 1 yr

Anorectal lesionsAnorectal lesions

Milk AllergyMilk Allergy

IntussusceptionIntussusception

Meckel’s diverticulumMeckel’s diverticulum

Infectious diarrheaInfectious diarrhea

Lower GI BleedLower GI Bleed – 1-12 years – 1-12 years

COMMONCOMMON::

Anal fissureAnal fissure

Juvenile polypJuvenile polyp

Meckel’s diverticulumMeckel’s diverticulum

Infectious diarrheaInfectious diarrhea

IBDIBD

LESS COMMONLESS COMMON::

Henoch-Scholein Henoch-Scholein purpurapurpura

Hemolytic uremic Hemolytic uremic syndromesyndrome

Intestinal duplicationIntestinal duplication

HemorrhoidsHemorrhoids

A 3,200 gm newborn is noted to be jaundiced on A 3,200 gm newborn is noted to be jaundiced on postnatal day #10. Total Bili is 9.0 with a direct Bili of postnatal day #10. Total Bili is 9.0 with a direct Bili of

0.8 mg/dl. Hct is 48%. Baby and mom are blood type O, 0.8 mg/dl. Hct is 48%. Baby and mom are blood type O, Rh+. Baby is breast fed exclusively.Rh+. Baby is breast fed exclusively.

The most likely explanation for high Bili isThe most likely explanation for high Bili is::

A)A) Biliary atresiaBiliary atresia

B)B) ““breast milk” jaundicebreast milk” jaundice

C)C) Choledochal cystCholedochal cyst

D)D) HypothyroidismHypothyroidism

E)E) Neonatal hepatitisNeonatal hepatitis

Unconjugated Unconjugated HyperbilirubinemiaHyperbilirubinemia

Physiologic – exaggerated by hemolysis or Physiologic – exaggerated by hemolysis or CephalhematomaCephalhematomaBreast feedingBreast feedingBreast Milk (late onset)Breast Milk (late onset)AsianAsian““Near term”Near term”Prior jaundiced newbornPrior jaundiced newbornCrigler-Najjar syndrome I & IICrigler-Najjar syndrome I & IIHypothyroidHypothyroidIntestinal obstructionIntestinal obstruction

A 3 wk old girl has fever and vomiting. PE include A 3 wk old girl has fever and vomiting. PE include bulging fontanelle and hepatomegaly. The pt had bulging fontanelle and hepatomegaly. The pt had

jaundice and vomiting during the 1jaundice and vomiting during the 1stst wk after birth. She wk after birth. She has been breast-fed.has been breast-fed.

What is the most likely DxWhat is the most likely Dx??

A)A) Fructose aldolase deficiencyFructose aldolase deficiency

B)B) Fructose 1,6 diphosphatase deficiencyFructose 1,6 diphosphatase deficiency

C)C) Glycogen Storage Disease type 1Glycogen Storage Disease type 1

D)D) Neonatal adrenoleukodystrophyNeonatal adrenoleukodystrophy

E)E) GalactosemiaGalactosemia

Direct BilirubinemiaDirect Bilirubinemia

ExtrahepaticExtrahepatic

1.*** Extrahepatic Biliary Atresia1.*** Extrahepatic Biliary Atresia

2. ***Choledochal Cyst2. ***Choledochal Cyst

3. Choledocholithiasis3. Choledocholithiasis

4. Extrinsic bile duct compression4. Extrinsic bile duct compression

Direct BilirubinemiaDirect Bilirubinemia

IntrahepaticIntrahepatic1.1. MetabolicMetabolic (A1ATD, CF, Tyros., etc) (A1ATD, CF, Tyros., etc)

2.2. FamilialFamilial intrahepatic cholestasis intrahepatic cholestasis

3.3. InfectiousInfectious

4.4. AnatomicAnatomic – Paucity of intrahepatic – Paucity of intrahepatic bile ductsbile ducts

5.5. MiscMisc – TPN, Neonatal Lupus – TPN, Neonatal Lupus

A 12 yr old girl has recurrent bouts of scleral icterus, A 12 yr old girl has recurrent bouts of scleral icterus, often after viral illnesses. She is otherwise well and is often after viral illnesses. She is otherwise well and is

taking no meds. Labs reveal: Total Bili of 3.4 mg/dl with taking no meds. Labs reveal: Total Bili of 3.4 mg/dl with direct Bili of 0.3 mg/dl. ALT/PT/APPT are all normaldirect Bili of 0.3 mg/dl. ALT/PT/APPT are all normal

The most like cause of the The most like cause of the hyperbilirubinemiahyperbilirubinemia

A)A) Chronic active hepatitisChronic active hepatitis

B)B) Dubin-Johnson syndromeDubin-Johnson syndrome

C)C) Gilbert syndromeGilbert syndrome

D)D) Hepatitis AHepatitis A

E)E) Infectious MononucleosisInfectious Mononucleosis

Severe RUQ pain, intense jaundice and dark Severe RUQ pain, intense jaundice and dark urine in a 9 yr old girl w chronic mild jaundice urine in a 9 yr old girl w chronic mild jaundice

from spherocytosisfrom spherocytosis..

Which diagnostic test is most likely to give Which diagnostic test is most likely to give correct diagnosis of her current statecorrect diagnosis of her current state::

A)A) Determine AST/ALT levelsDetermine AST/ALT levels

B)B) Determine presence of Hepatitis B Determine presence of Hepatitis B surface Agsurface Ag

C)C) Radionuclide scan of liverRadionuclide scan of liver

D)D) Ultrasound of abdomenUltrasound of abdomen

E)E) PAPIDA scanPAPIDA scan

A seven year old is seen for a bicycle accident. A seven year old is seen for a bicycle accident. He is fine other than a few abrasions and an He is fine other than a few abrasions and an

ecchymotic area on his abdomen where he hit ecchymotic area on his abdomen where he hit the handlebars. 24 hours later, he has the handlebars. 24 hours later, he has

significant abdominal and back pain and significant abdominal and back pain and recurrent non-bilious vomiting. recurrent non-bilious vomiting. You make the You make the

diagnosis with:diagnosis with:Further family and social historyFurther family and social history

Liver chemistries, amylase and lipaseLiver chemistries, amylase and lipase

An upper GI seriesAn upper GI series

Stool for guaiacStool for guaiac

A 2 year old is brought to you for trouble stooling. A 2 year old is brought to you for trouble stooling. Over the last 18 hours he has become “tired and Over the last 18 hours he has become “tired and

miserable”. He now seems to vomit when straining to miserable”. He now seems to vomit when straining to pass stool. On exam you notice that he appears pass stool. On exam you notice that he appears lethargic and has a palpable mass in the mid-lethargic and has a palpable mass in the mid-

abdomen. abdomen. Your next intervention isYour next intervention is::

disimpaction dose of PEG (polyethelene disimpaction dose of PEG (polyethelene glycol) glycol) counseling on toilet trainingcounseling on toilet trainingstat abdominal CT scan for appendicitisstat abdominal CT scan for appendicitisbarium enemabarium enemaultrasoundultrasound

An 11 year old girl comes to see you for recurrent An 11 year old girl comes to see you for recurrent periumbilical pain for the last 9 months. It is worse in periumbilical pain for the last 9 months. It is worse in the morning, especially on school days. There is no the morning, especially on school days. There is no vomiting or weight loss but she does frequently have vomiting or weight loss but she does frequently have non-bloody diarrhea with resolution of the pain. Her non-bloody diarrhea with resolution of the pain. Her

exam is benign and stool is guaiac negative. exam is benign and stool is guaiac negative.

Your preferred working diagnosisYour preferred working diagnosis::

school avoidanceschool avoidance

Crohn DiseaseCrohn Disease

irritable bowel syndromeirritable bowel syndrome

ulcerative colitisulcerative colitis

Her symptoms persist so you plan an evaluation Her symptoms persist so you plan an evaluation that should include all of the following EXCEPT:that should include all of the following EXCEPT:

celiac serologyceliac serology

lactose breath testlactose breath test

abdominal CT scanabdominal CT scan

stool for ova and parasitesstool for ova and parasites

Reasonable interventions for this patient would Reasonable interventions for this patient would not include:not include:

Cognitive behavioral therapyCognitive behavioral therapy

Dietary manipulationDietary manipulation

Trial of low dose Tri-cyclic antidepressantsTrial of low dose Tri-cyclic antidepressants

Empiric therapy for Helicobacter pyloriEmpiric therapy for Helicobacter pylori

Symptom-based therapySymptom-based therapy

RAPRAP—Red Flag Symptoms—Red Flag Symptoms

Nocturnal awakeningNocturnal awakeningPersistent VomitingPersistent VomitingDysphagiaDysphagiaBleedingBleedingSystemic Signs (Fever, Rash, Arthritis)Systemic Signs (Fever, Rash, Arthritis)Affected Growth/DevelopmentAffected Growth/DevelopmentFamily Hx of IBDFamily Hx of IBDAbnormal LabsAbnormal Labs

Organic Causes of RAPOrganic Causes of RAP

Crohn’s DiseaseCrohn’s Disease

Celiac DiseaseCeliac Disease

Acid-Peptic/GERDAcid-Peptic/GERD

Carbohydrate malabsorptionCarbohydrate malabsorption

Infection (e.g., Giardia)Infection (e.g., Giardia)

Symptom Based DiagnosesSymptom Based Diagnoses

Irritable Bowel Syndrome:Irritable Bowel Syndrome:Diarrhea PredominantDiarrhea PredominantConstipation PredominantConstipation PredominantAlternating Stool PatternAlternating Stool Pattern

Functional DyspepsiaFunctional DyspepsiaFunctional Abdominal PainFunctional Abdominal PainAbdominal MigraineAbdominal MigraineAerophagiaAerophagia

IBS--TreatmentIBS--Treatment

Education and reassuranceEducation and reassuranceProper nutrition/food avoidanceProper nutrition/food avoidanceCounseling/Cognitive-BehaviorCounseling/Cognitive-BehaviorMedications:Medications:– AntispasmodicAntispasmodic– Anti-diarrhealAnti-diarrheal– Tricyclic antidepressantsTricyclic antidepressants– Serotonin receptor agentsSerotonin receptor agents

A concerned 22 year old first time mom brings in A concerned 22 year old first time mom brings in her 6 week old “vomiter”. After every feed her son her 6 week old “vomiter”. After every feed her son

“vomits the whole thing”. You note the child is “vomits the whole thing”. You note the child is slightly above birth weight and the mother states slightly above birth weight and the mother states

he seems to be urinating less. You make the he seems to be urinating less. You make the diagnosis with: diagnosis with:

A metabolic evaluationA metabolic evaluation

Stat head CT scanStat head CT scan

Upper endoscopy by your local Pediatric Upper endoscopy by your local Pediatric GIGI

Abdominal sonographyAbdominal sonography

Your previous patient is now 2 and accompanies his Your previous patient is now 2 and accompanies his mother with his 6 week old brother who has “vomiting”. mother with his 6 week old brother who has “vomiting”.

This has increased over the last 24 hours. The mother is This has increased over the last 24 hours. The mother is tired, overwhelmed and complains of her increased dry tired, overwhelmed and complains of her increased dry cleaning expenses as she shows you her vomit stained cleaning expenses as she shows you her vomit stained white blouse that now has green and yellow stains. As white blouse that now has green and yellow stains. As

your nurse provides her a sympathetic ear, youyour nurse provides her a sympathetic ear, you

Get samples of a low allergy formulaGet samples of a low allergy formula

Order a pyloric sonogramOrder a pyloric sonogram

Call the ED to alert them of a neonatal Call the ED to alert them of a neonatal bowel obstruction patientbowel obstruction patient

Send in your junior partner “to deal with it”Send in your junior partner “to deal with it”

Once in the emergency room, proper management Once in the emergency room, proper management of this infant would include:of this infant would include:

Intravenous fluid resuscitationIntravenous fluid resuscitation

Stat pediatric surgical consultationStat pediatric surgical consultation

Contrast imaging of the bowelContrast imaging of the bowel

Nasogastric decompressionNasogastric decompression

All of the aboveAll of the above

The previous mother is grateful and sends her own 45 The previous mother is grateful and sends her own 45 year old post-partum mother to see you with her Trisomy year old post-partum mother to see you with her Trisomy

21 infant who was just sent home from the hospital 21 infant who was just sent home from the hospital “vomiting”. The child is just at birth weight. You send her “vomiting”. The child is just at birth weight. You send her

to the ED and a series of radiographs do not show an to the ED and a series of radiographs do not show an obstructive pattern. Rather, there are only two pockets of obstructive pattern. Rather, there are only two pockets of air in the epigastric region. You are again the star as you air in the epigastric region. You are again the star as you

diagnose:diagnose:

Vulnerable child syndromeVulnerable child syndrome

Celiac diseaseCeliac disease

Milk protein allergyMilk protein allergy

Duodenal atresiaDuodenal atresia

Gastroesohageal RefluxGastroesohageal Reflux

All you need to knowAll you need to know

Prevalence of RegurgitationPrevalence of Regurgitationin Healthy Infantsin Healthy Infants

Nelson et al. Arch Pediatr Adolesc Med. 1997;151:569

Infa

nts

(%

)

100

0

50

0-3 4-6 7-9 10-12

Age (months)

≥ 1 time a day≥ 4 times a day

n = 948

Delayed gastric emptying time

Transient lower esophageal sphincter relaxation; decreased LES pressure

Impaired esophageal clearance

Pathophysiology of GERDPathophysiology of GERD

Orlando et al, eds. Textbook of Gastroenterology: JB Lippincott Co;1995:1214. Fennerty et al. Arch Intern Med. 1996;156:477.

Kawahara et al. Gastroenterology 1997;113:399.

InfantsInfantsFeeding refusalFeeding refusal

Recurrent vomitingRecurrent vomiting

Poor weight gainPoor weight gain

IrritabilityIrritability

Sleep disturbanceSleep disturbance

Apnea or Apparent Life-Apnea or Apparent Life-Threatening Event (ALTE)Threatening Event (ALTE)

Rudolph et al. J Pediatr Gastroenterol Nutr. 2001;32:S1.

Older child/adolescent Recurrent vomiting Heartburn Dysphagia Asthma Recurrent pneumonia Upper airway symptoms

(chronic cough, hoarse voice)

Presenting Symptoms Presenting Symptoms and Signs of GERDand Signs of GERD

Barium swallow/Upper gastrointestinal Barium swallow/Upper gastrointestinal series (anatomy)series (anatomy)

Ambulatory single or dual-channel pH Ambulatory single or dual-channel pH monitoringmonitoring

Endoscopy and biopsyEndoscopy and biopsy

Radionuclide scanningRadionuclide scanning

Hx and P.E.Hx and P.E.Eid et al. Pediatric Respiratory Reviews 2004;5:Supplemet A.

Wasowska-Krolikowska et al. Med Sci Monit. 2002;8:RA64.Sermon et al. Dig Liver Dis. 2004;36:102.

Diagnosis of GERDDiagnosis of GERD

Erosive esophagitisErosive esophagitis

Peptic stricturePeptic stricture

Barrett’s esophagusBarrett’s esophagus

AdenocarcinomaAdenocarcinoma

Rudolph et al. J Pediatr Gastroenterol Nutr. 2001;32:S1.

Complications of GERDComplications of GERD

FOR INFANTSFOR INFANTSNormalize feeding volume Normalize feeding volume and frequencyand frequencyConsider thickened formulaConsider thickened formulaPositioningPositioningConsider trial of Consider trial of hypoallergenic formulahypoallergenic formula

FOR OLDER CHILDRENFOR OLDER CHILDRENAvoid large mealsAvoid large mealsDo not lie down Do not lie down immediately after eatingimmediately after eatingLose weight, if obeseLose weight, if obeseAvoid caffeine, chocolate, Avoid caffeine, chocolate, and spicy foods that and spicy foods that provoke symptomsprovoke symptomsEliminate exposure to Eliminate exposure to cigarette smokecigarette smoke

Shalaby et al. J. Ped. 2003;142:57.

Step-Up Therapy for GERDStep-Up Therapy for GERD

Rudolph et al. J Pediatr Gastroenterol Nutr. 2001;32:S1.Gold. Paediatric Drugs 2002;4:673.

Gibbons et al. Paediatric Drugs 2003;5:25.

Pharmacologic Management of Pharmacologic Management of Moderate-to-Severe GERDModerate-to-Severe GERD

ProkineticsProkinetics– MetoclopramideMetoclopramide

Many possible side effects which may include tardive dyskinesis Many possible side effects which may include tardive dyskinesis (may be irreversible) (may be irreversible)

– Other agents include domperidone, bethanechol* and Other agents include domperidone, bethanechol* and erythromycinerythromycin

HH22RAsRAs– Available in tablet, elixir, or rapid dissolve form (must be Available in tablet, elixir, or rapid dissolve form (must be

dissolved in water, not on tongue)dissolved in water, not on tongue)– Pediatric safety, dosing data for ranitidine and famotidinePediatric safety, dosing data for ranitidine and famotidine

PPIsPPIs– Available in capsule, liquid suspension, or rapid dissolve formAvailable in capsule, liquid suspension, or rapid dissolve form– Pediatric safety, dosing data for lansoprazole and omeprazolePediatric safety, dosing data for lansoprazole and omeprazole

*Bethanechol not approved for pediatric GERD.

Diarrhea--InfectiousDiarrhea--Infectious

Viral—less than one weekViral—less than one week

Bacterial—sick, bloodBacterial—sick, blood

Parasitic—persistentParasitic—persistent

**C. Difficile:**C. Difficile:– After antibiotics/hospitalizationAfter antibiotics/hospitalization– Check for toxin A and BCheck for toxin A and B– Colonization not pathogen in neonates.Colonization not pathogen in neonates.

E. Coli 0157:H7: associated E. Coli 0157:H7: associated Hemolytic Uremic SyndromeHemolytic Uremic Syndrome

Often presents with colitis (bloody Often presents with colitis (bloody diarrhea)diarrhea)

Hemolysis, uremia developHemolysis, uremia develop

Poly-- then oligouric renal failurePoly-- then oligouric renal failure

ThrombocytopeniaThrombocytopenia

**associated with anti-diarrheal and **associated with anti-diarrheal and antibiotic use***antibiotic use***

Toddler’s—Dietary DiarrheaToddler’s—Dietary Diarrhea

Clinically well – no blood, fever, etc.Clinically well – no blood, fever, etc.

Low fat dietLow fat diet- - most commonly due to milk restrictionmost commonly due to milk restriction

High osmolarity fluidsHigh osmolarity fluids

- - juice, gatorade, powerade, ice tea, etc.juice, gatorade, powerade, ice tea, etc.

ThereforeThereforeoften iatrogenic!often iatrogenic!

Lactose IntoleranceLactose Intolerance

DiagnosisDiagnosis– ClinicalClinical– Breath testBreath test– Disaccharidase levels in tissueDisaccharidase levels in tissue– ??genetics??genetics

ManagementManagement– Restriction v. supplementRestriction v. supplement– If restrictionIf restriction supplement calcium supplement calcium

A 4 week old is brought to you for streaks of bright A 4 week old is brought to you for streaks of bright red blood in the stool. Child is breast fed, thriving red blood in the stool. Child is breast fed, thriving

and content. Exam shows seborrhea, benign and content. Exam shows seborrhea, benign abdomen and perianal exam. abdomen and perianal exam. Your next Your next

interventionintervention::

Remove milk and soy from the maternal Remove milk and soy from the maternal dietdiet

GI referral for colonoscopyGI referral for colonoscopy

Call child welfare for possible abuseCall child welfare for possible abuse

Celiac DiseaseCeliac Disease

AutoimmuneAutoimmune

Triggered by gluten Triggered by gluten

Not rare—1:133 in general populationNot rare—1:133 in general population

Association w IgA deficiencyAssociation w IgA deficiency

Association w Type I Diabetes, Williams Association w Type I Diabetes, Williams syndrome, Downs syndrome, Turner’ssyndrome, Downs syndrome, Turner’s

Gastrointestinal ManifestationsGastrointestinal Manifestations(“Classic” Celiac)(“Classic” Celiac)

Most common age of presentationMost common age of presentation: 6-24 months: 6-24 months

Chronic or recurrent diarrheaChronic or recurrent diarrhea

Abdominal distensionAbdominal distension

AnorexiaAnorexia

Failure to thrive /weight lossFailure to thrive /weight loss

RarelyRarely: Celiac crisis: Celiac crisis

• Abdominal pain• Vomiting• Constipation• Irritability

Non-Gastrointestinal Non-Gastrointestinal ManifestationsManifestations

• Dermatitis HerpetiformisDermatitis Herpetiformis• Dental enamel hypoplasia Dental enamel hypoplasia

of permanent teethof permanent teeth• Osteopenia/OsteoporosisOsteopenia/Osteoporosis• Short StatureShort Stature• Delayed PubertyDelayed Puberty

• Iron-deficient anemia resistant to oral Fe• Hepatitis• Arthritis• Epilepsy with occipital calcifications

Most common age of presentation: older child to adult

Listed in descending order of strength of evidence

Serological Tests - CDSerological Tests - CD

Antigliadin antibodies (AGA)Antigliadin antibodies (AGA)

Antiendomysial antibodies (EMA)Antiendomysial antibodies (EMA)

**Anti tissue transglutaminase antibodiesAnti tissue transglutaminase antibodies (tTG) (tTG)

HLA typing (DQ2, DQ8 only)HLA typing (DQ2, DQ8 only)

Histological FeaturesHistological Features

Normal 0 Infiltrative 1 Hyperplastic 2

Partial atrophy 3a Subtotal atrophy 3b Total atrophy 3c

Horvath K. Recent Advances in Pediatrics, 2002.

TreatmentTreatment

Only treatment for Only treatment for celiac disease is a celiac disease is a gluten-free diet gluten-free diet (GFD)(GFD)– Strict, lifelong dietStrict, lifelong diet– Avoid:Avoid:

WheatWheat

RyeRye

Barley Barley

A six year old is brought to you for diarrhea. Child A six year old is brought to you for diarrhea. Child stools multiple times during the day—seems to be stools multiple times during the day—seems to be all day. Often there is stool in the underwear. Your all day. Often there is stool in the underwear. Your exam is notable for a tympanitic abdomen and LLQ exam is notable for a tympanitic abdomen and LLQ

mass. mass. Your diagnosisYour diagnosis::

NeuroblastomaNeuroblastoma

GiardiasisGiardiasis

Lactose intoleranceLactose intolerance

Fecal overflow incontinenceFecal overflow incontinence

Treatment of ConstipationTreatment of Constipation

Stimulant laxatives—Stimulant laxatives—– Senna, bisacodylSenna, bisacodyl

Stool softners/osmoticsStool softners/osmotics– PEGPEG– LactuloseLactulose– ducosateducosate

LubricantsLubricants– Mineral oilMineral oil

Hirschsprung’s DiseaseHirschsprung’s Disease

History of delayed passage of meconiumHistory of delayed passage of meconium

Failure to thriveFailure to thrive

Abdominal distensionAbdominal distension

Vomiting/obstructive pictureVomiting/obstructive picture

Potential complications:Potential complications:– Perforation esp. cecalPerforation esp. cecal– Enterocolitis/sepsisEnterocolitis/sepsis– deathdeath

Hirschsprung’s DiseaseHirschsprung’s Disease: : DiagnosisDiagnosis

CLINICAL SUSPICIONCLINICAL SUSPICION

Obstructive series radiographsObstructive series radiographs

Barium enema (older child)Barium enema (older child)

Suction rectal biopsy—gold standardSuction rectal biopsy—gold standard

Rectal ProlapseRectal Prolapse

CF till proven otherwiseCF till proven otherwise

Constipation more common causeConstipation more common cause

IBD

INFECTION?

SMOKING

GENETIC

PSYCHOGENIC

ENVIORNMENTAL DIETARY

DRUGS?

Crohns DiseaseCrohns Disease

Auto-immuneAuto-immune

Associated symptom—GI/systemicAssociated symptom—GI/systemic

33% with physical findings33% with physical findings– ClubbingClubbing– Peri-anal changesPeri-anal changes– Aphthous stomatitisAphthous stomatitis

Crohn’s and Growth FailureCrohn’s and Growth Failure

Can be presenting symptomCan be presenting symptom

Multi-factorialMulti-factorial– Nutritional ie. Poor intakeNutritional ie. Poor intake– MalabsorptionMalabsorption– Direct cytokine/inflammatory effect on boneDirect cytokine/inflammatory effect on bone

Ulcerative ColitisUlcerative Colitis

““the bloody diarrhea”the bloody diarrhea”Limited to colonLimited to colonContinuous diseaseContinuous disease

In a child with failur to thrive, which In a child with failur to thrive, which is most likely to to provide an is most likely to to provide an

etiologyetiology

Bone ageBone age

HistoryHistory

LabsLabs

Physical exam Urine culturePhysical exam Urine culture

Infant colic is more common in Infant colic is more common in bottle fed babies vs. breast fed bottle fed babies vs. breast fed

babiesbabies

T or FT or F

A 6 week old comes to your office A 6 week old comes to your office for a well baby exam. You note for a well baby exam. You note

jaundice. You should:jaundice. You should:

A. D/C breast feedingA. D/C breast feeding

B.Test stool for occult bloodB.Test stool for occult blood

C.Get fractionated bilirubinC.Get fractionated bilirubin

D.Send LFT’sD.Send LFT’s

The organism most likely to cause The organism most likely to cause traveler’s diarrhea is:traveler’s diarrhea is:

A. Campylobacter spp.A. Campylobacter spp.

B. RotavirusB. Rotavirus

C. E. ColiC. E. Coli

D. SalmonellaD. Salmonella

H. Pylori is associated with all H. Pylori is associated with all except:except:

A. GastritisA. Gastritis

B. Duodenal ulcerB. Duodenal ulcer

C.GERDC.GERD

D.All of the aboveD.All of the above

THE ENDTHE END