Gastrointestinal Diseases

Experts may very occasionally ask for CT scan and MRI. These are not very routine tests in children.

One needs to approach a specialist like a pediatric Gastroenterologist for pain abdomen in children who would be able accurately assess and manage. Dr. Neelam Mohan has a very vast experience in tackling pain abdomen in children and her results are phenomenal in this  field .

Did you know ?

Pain abdomen can also result from  –

• Constipation
• Milk intolerance
• Psychological stress
• Abdominal Migraine / Epilepsy
• Food intolerance.
• Children can also suffer from ulcer disease.

Types of diarrhea:

• Diarrhea: Diarrhea  is the passage of 3 or more loose or liquid stools per day, or more frequently than is normal for the individual
• Persistent Diarrhea : Acute diarrhea episode that lasts for >  14 days.
• Chronic diarrhea :  diarrhea that lasts for more than 3 weeks.

What is not diarrhea?

• Passage of frequent formed stools
• Frequent loose greenish yellow stools on D3/D4 of life (Transitional diarrhea)
• Passage of pasty stools in a breast fed infant
• Passage of stools during / immediately after feeding due to gastrocolic reflex

Diarrhea Continues To Be An Important Contributor to Childhood Deaths in India

• NFHS 3:   9% of < 5 suffered from diarrhea in the previous 2 weeks 1
• More recent data from UNICEF 10-district survey report that 19.8% children (2-59 months) suffered from diarrhea in the previous 2  weeks

“Burden” of Diarrhea In India 

• Burden – 11 % of deaths in the age group of 0–5 years are due to diarrhea
• Lancet child survival series, using a prediction model, estimated that estimated 22% (14-30%) of all under-five deaths are attributable to diarrhea in 42 countries, where 90% of all under-five deaths occur 2
•  Five countries—India, Nigeria, Democratic Republic of the Congo, Pakistan, and China—contributed to almost half the world’s deaths in children younger than 5 years.
• It is estimated that more than 240000 children under 5 years of age die due to diarrhea in India

Global & National Diarrhea Treatment Policy

• Prevent and treat dehydration with Low osmolarity  ORS (or IVF in severe dehydration)
• Continue feeding or increase breastfeeding  & increase fluids and feeding during and after the diarrheal episode
• Give zinc in recommended doses as soon as diarrhea starts
• Abstain from giving anti-diarrheal or other drugs. Use antibiotics only when appropriate (i.e. dysentery , systemic infection, cholera, malnutrition)

What Are Our Challenges In The Treatment Of Diarrhea?

• Low ORS use rates
• Inappropriate management of dehydration
• Inadequate emphasis on feeding
• Inadequate use of zinc
• Irrational use of antimicrobials & other drugs
• Hand washing

What is WHO – ORS

WHO ORS : Potentially: “The most important medical advance of this century” – The Lancet.

The most important etiology

• There is no large-scale comprehensive community based study regarding etiology of diarrhea from India.
• Rotavirus is responsible for about 15-30% of episodes in hospitalized children; 7-15% in community. Almost all episodes leading to hospitalization are reported in children < 2 years. It is also the most commonly isolated agent in neonatal infections.
• Diarrheogenic E. coli is the most common bacterial pathogen.
• Shigella sp. is responsible for about 10-20% of episodes. Visible blood is present in stools in half to two-thirds of these episodes.
• Vibrio cholerae predominantly occurs in outbreaks. Most affected children are 2-5 yr olds
• Antimicrobials Should be given During Diarrhea Only For: Dysentery, Cholera, Severe Malnutrition, Associated systemic Infection.

Do you know that hand washing is important  way to reducing incidence of diarrhea.

• Pathogens causing diarrheal diseases . Mostly transmitted through the feco-oral route
• Interventions promoting hand washing and other hygiene measures clearly show a reduction in diarrheal risk in the short term
• The sustainability of hand washing-behavior in the communities require investigation
• The evidence of reduction in risk of diarrheal illnesses after scaling up the intervention in uncontrolled situations is not available
• India-specific data on hand washing are scarce

Zinc and Diarrhoea

• There is evidence that Zinc  supplement in diarrhea can reduce the frequency and severity of diarrhea. Therefore 20mg/day of elemental zinc is recommended in patients with diarrhea for a period of 2 weeks at least.  There is some evidence that is can improve the subsequent incidence of diarrhea and pneumonia.

Dysentery

• Dysentery is passage of blood in stool resulting from infection . It is usually associated with mucosal stools, abdominal cramps and fever. It is common cause of dysentery are shigillia salmonilla, Ecoli and campylobacter.
• Antibiotics are indicated in dysentery.

Probiotic and Diarrhoea

• Probiotics are living microorganisms when ingested in sufficient large amount have a health promoting effect on the host
• The various type of probiotics are :-

1. Bacterial Probiotics [Lactobacilli rhamnosus GG, Bifidobacteria, Non-pathogenic E. Coli (E. Coli Nissle 1917),  Enterococci (plasmid transfer ++) ]
2. Yeast  Probiotic  (Saccharomyces boulardii )

Anti motility durgs and Dirrhoea

• ?3 mushy or watery stools per day and is otherwise unexplained diarrhoea that occurs in association with the administration of antibiotics.
• Develop from a few hours up to 2 months after antibiotic intake.
• The incidence of diarrhoea varies between different antibiotics.
• Drugs that affect the anaerobic flora are prone to cause anti motility durgs.

Rotavirus and Diarrhoea

Rota virus diarrhea leads to

• Profuse dehydrating watery diarrhea
• Rotavirus is a democratic virus, affects children both in developed and developing countries alike
• Hygiene and sanitation make limited difference
• It is associated with significant vomiting, making oral rehydration difficult
• Evidence that natural infection results in protection
• Two natural infections nearly 100% protection against subsequent moderate/severe disease. But as per recent Indian data even three infections are not 100% protective
• Rota virus vaccine mimic protection conferred by natural infection

20% of all deaths in childern < 5 years of age from India are due to diarrhea.

Deaths due to rotavirus annually in India : 122,270 and in World : 527,000

• Rotavirus accounted for: 39.2% of all diarrhea-related hospital admissions among childern aged < 5 years in India (range from 35% in Mumbai to 53% in Trichy).
• 23% of deaths due to rotavirus

There is a vaccine available against rota viral diarrhea. The efficacy of vaccine is less in developing countries  like India. There are 2 vaccines are available :-

There are 2 vaccines are available. 

• Rotaxir (Monovalent) – 2doses

1. 1st dose:  age of 6 weeks and no later than at  the age of 12 weeks.
2. The interval between the 2 doses should be at least 4 weeks.

• otaTeq (pentavalent) – 3 doses

1. 1 st dose : between ages 6–12 weeks
2. Min interval between doses 4 weeks . 3rd dose not after 32 weeks
3. The manufacturer does not recommend re administration of vaccine if a dose is spit out or regurgitated.

Did you know ?

• Rotaviral diarrhea is one of the common causes of watery diarrhea, requiring hospital admission.
• Antibiotics are not routinely required in all cases of diarrhea.
• We do not like to use drugs like loperamide in diarrhea in children.

Vomiting is a highly coordinated process in which contents of stomach and upper small intestine are forced out through mouth. Vomiting is caused by a myraid of causes both gastrointestinal and non gastrointestinal. Common causes of vomiting in infant and children are :-

Common GI causes are

• Gastroenteritis
• GERD – Gastro Esophageal Reflux Disease
• Over feeding / forced feeding
• Gastritis
• Intestinal obstruction
• Appendicitis
• Hepatitis
• Pancreatitis, etc.

Common Non GI causes are

• Systemic infections
• Medications
• Migraine
• Ear, Nose, throat infection
• Kidney ailments

Persistent and recurrent vomiting not responding to medication from your pediatrician need to be evaluated by a pediatric gastroenterologist.

Cyclical Vomiting

CVS is characterized by episodes or cycles of severe nausea and vomiting that last for hours, or even days, that alternate with intervals with no symptoms. Although originally thought to be a pediatric disease, CVS occurs in all age groups. Medical researchers believe CVS and migraine headaches are related.

Each episode of CVS is similar to previous ones, meaning the episodes tend to start at the same time of day, last the same length of time, and occur with the same symptoms and level of intensity. Although CVS can begin at any age, in children it starts most often between the ages of 3 and 7.

Episodes can be so severe that a person has to stay in bed for days, unable to go to school or work. The exact number of people with CVS is unknown, but medical researchers believe more people may have the disorder than commonly thought. Because other more common diseases and disorders also cause cycles of vomiting, many people with CVS are initially misdiagnosed until other disorders can be ruled out. CVS can be disruptive and frightening not just to people who have it but to family members as well.

This could result from lesions in oral cavity, pharynx or food pipe disorders.  Common food pipe or oesophageal causes in children are oesophagitis resulting from gastro-esophageal reflux disease / hiatus hernia/esonophilic oesophagitis / milk protein allergy or inflammatory disorders.

Sometimes ingestion of acid or alkali can give rise to erosions / ulcers and subsequently oesophageal strictures which can result in dysphagia.  Congenital oesophageal narrowing /stenosis or webs can result in dysphagia. If a foreign body gets stuck in oesohagus or food pipe, it can result in dysphagia.  Rarely motility disorders and achalasia ((failure or relaxation  of gastro oesophageal junction ) can result in dysphagia.

Tumors are not common in children

Did you Know ?

• Gastro oesophageal reflux disease (GERD) is also common in infants and young children also. In adults its very common and non medical language used by patients for this symptoms is acidity.

Blood in child’s vomit or stool can be a sign of gastrointestinal (GI) bleeding. GI bleeding can be scary for you and your child. Many times, the cause of the bleeding is not serious. Still, your child should ALWAYS be seen by a doctor if GI bleeding occurs.

The GI Tract

The GI tract is the path that food travels through the body. Food passes from the mouth down the esophagus (the tube from the mouth to the stomach).

Food begins to break down in the stomach and then moves through the duodenum, the first part of the small intestine. Nutrients are absorbed as food travels through the small intestine. Undigested food passes into the large intestine (colon) as waste.

The colon removes water from the waste. Waste continues from the colon to the rectum (where stool is stored). Waste then leaves the body through the anus.

What is Celiac disease?

Celiac disease is a digestive disease that damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate a protein called gluten, found in wheat, rye, and barley. Gluten is found mainly in foods, but is also found in products we use every day, such as stamp and envelope adhesive, medicines, and vitamins.

When people with celiac disease eat foods or use products containing gluten, their immune system responds by damaging the small intestine. The tiny, fingerlike protrusions lining the small intestine , called villi, are damaged or destroyed .They normally allow nutrients from food to be absorbed into the bloodstream. Without healthy villi, a person becomes malnourished, regardless of the quantity of food eaten.

Because the body’s own immune system causes the damage, celiac disease is considered an autoimmune disorder. However, it is also classified as a disease of malabsorption because nutrients are not absorbed. Celiac disease is also known as celiac sprue, nontropical sprue, and gluten-sensitive enteropathy.

Is this disease has genetic tendency?

Celiac disease is a genetic disease, meaning it runs in families. The commonest gene implicated are HLA DQ2 AND DQ8. The incidence of sibling of the index patient developing coeliac disease is ~10%. Sometimes the disease is triggered-or becomes 2 active for the first time-after surgery, pregnancy, childbirth, viral infection, or severe emotional stress.

What are the symptoms of a child with celiac disease?

Symptoms of celiac disease may include one or more of the following:

• Recurring abdominal bloating and pain
• Chronic diarrhea (constipation in atypical celiac disease)
• Pale, foul-smelling, or fatty stool
• Weight loss / poor weight gain
• Failure to thrive in infants
• Delayed growth
• Fatigue / lethargy
• Unexplained anemia ( low hemoglobin levels)
• Bone or joint pain
• Osteoporosis, osteopenia
• Behavioral changes
• Tingling numbness in the legs (from nerve damage)
• Muscle cramps
• Sseizures
• Missed menstrual periods (often because of excessive weight loss)
• Infertility, recurrent miscarriage
• Pale sores inside the mouth, called aphthous ulcers
• Tooth discoloration or loss of enamel
• Itchy skin rash called dermatitis herpetiformis

In babies, symptoms may develop after weaning onto cereals which contain gluten. Other symptoms in young children include:

• Muscle wasting in the arms and legs
• Bloated tummy
• Irritability
• Failure to gain weight or lose weight after previously growing well Symptoms in older children vary as they do in adults.

What are the clinical menifastation?

The clinical presentation of coeliac disease are classified as typical (presenting with features of malabsorption such as diarrhoea, abdominal distension) or atypical (those cases without diarrhoea. Common presentations with atypical CD include refractory anaemia, short stature, constipation, rickets, pain abdomen.

What test need to be done?

There are specific blood tests used to diagnose coeliac disease. They look for antibodies that the body makes in response to eating gluten. Antibodies are protective proteins produced by the immune system in response to substances that the body perceives to be threatening. Autoantibodies are proteins that react against the body’s own molecules or tissues.

To diagnose celiac disease, physicians will usually test blood to measure levels of

• Immunoglobulin A (IgA)
• anti-tissue transglutaminase antibody (tTGA)
• IgA anti-endomysial antibodies (AEA)

Before being tested, one should continue to eat a regular diet that includes foods with gluten, such as roti, maida, breads and pastas. If a person stops eating foods with gluten before being tested, the results may be negative for celiac disease even if celiac disease is actually present.

If the tests and symptoms suggest celiac disease, the doctor will perform a small bowel biopsy. During the biopsy, the doctor removes a tiny piece of tissue from the small intestine to check for damage to the villi. To obtain the tissue sample, the doctor eases a long, thin tube called an endoscope through the mouth and stomach into the small intestine. Using instruments passed through the endoscope, the doctor then takes the sample. The procedure is done under-sedation in children and is not painful.

What is the treatment?

The only treatment for celiac disease is to follow a gluten-free diet. A gluten-free diet means not eating foods that contain wheat, rye, and barley. The foods and products made from these grains such as atta, maida sooji, bakery products are not allowed.

Checking labels for “gluten free” is important since many corn and rice products are produced in factories that also manufacture wheat products. Hidden sources of gluten include additives such as modified food starch, preservatives, and stabilizers. Wheat and wheat products are often used as thickeners, stabilizers, and texture enhancers in foods.

Foods To Omit: Bread, cereal

heat, maida, sooji, Barely, oats, rye, malt. Usually all bakery products bread biscuits, burgers, pastas, spaghetti, contain gluten unless specified

Foods To Omit : Vegetable

Any creamed or breaded vegetables (unless allowed ingredients are used); and canned baked beans Some french fries- these are coated with flour.

Foods To Omit : Fruits

Some commercial fruit pie fillings

Foods To Omit : Milk Yogurt and cheese

Malted milk , Some milk drinks, flavoured or frozen yogurt which may contain malt

Foods To Omit : Meat, poultry, fish, dry beans and peas, eggs and nuts

Any prepared with wheat, rye, oats, barley, gluten stabilizers, fillers including some frankfurters, cold cuts, sandwich spreads, sausages, canned meats Self-basting turkey. Some egg substitutes

Foods To Omit : Fats, snacks, sweets, condiments and beverages

Since Pancreas is a 15 centimetre (six inches) long organ which is part of digestive system. It’s found just in front of spine (back bone), behind stomach, at the level where the two sides of rib cage join together. It’s connected to the duodenum (small bowel) by a duct (tube) called the pancreatic duct.

Pancreas produces enzymes (digestive juices) which break down food, particularly fatty foods. These digestive juices pass down the

pancreatic duct into the duodenum which contains food to be digested. The pancreas also produces insulin, a hormone that helps to keep the level of sugar in blood constant.

If you have acute pancreatitis, the enzymes produced in the pancreas start to digest and damage the pancreas before reaching the duodenum. Pancreatitis is an inflammation of the pancreas.

Acute Pancreatitis

Acute pancreatitis usually begins with pain in the upper abdomen that may last for a few days. There are a number of symptoms of acute pancreatitis, including:

• Severe pain around the upper part of abdomen (tummy) and/or back which is worse when you lie down
• Feeling sick
• Vomiting
• A high temperature
• Jaundice – which is when the whites of your eyes and skin look yellowed
• Abdomen (tummy) is larger than usual
• The skin on lower back or abdomen may be blue-grey

Complications

The sooner acute pancreatitis is treated, the less likely complications will occur. Complications include:

• Damage to the pancreas
• Benign growths called cysts can grow in the pancreas
• An abscess
• A fistula – which is when a channel or hole develops in the pancreas
• Bleeding
• Blocked blood flow to the pancreas
• High blood sugar levels

Cause:

Common causes of acute pancreatitis in children are:

• Abdominal injuries
• Gallstones in the bile duct – this is the most common cause
• Choledochal cyst
• Certain medicines (eg azathioprine, corticosteroids)
• Idiopathic
• After an ERCP
• Infection
• Increased calcium or lipid (fat) levels in the blood
• Pancreas divisum – this is when you are born with ducts in the pancreas which don’t function properly
• Genetics – you may inherit a faulty gene from your parents, this is called hereditary pancreatitis
• Inflammation of the blood vessels in the pancreas or reduced blood flow to the pancreas
• Renal failure
• Rarely a tumor

Diagnosis : Besides asking about a person’s medical history and doing a physical exam, a doctor will order a blood test to diagnose acute pancreatitis. A doctor may also order an abdominal ultrasound or a CT scan.

Treatment : Treatment depends on the severity of the attack and hospitalization is required if pain is severe, oral intake is inadequate or any complications are suspected.

Chronic Pancreatitis

If injury to the pancreas continues, chronic pancreatitis may develop. Chronic pancreatitis occurs when digestive enzymes attack and destroy the pancreas and nearby tissues, causing scarring and pain. Chronic pancreatitis is rare in children. Trauma to the pancreas and hereditary pancreatitis are two known causes of childhood pancreatitis.

Other causes are congenital conditions such as pancreas divisum , cystic fibrosis, high levels of calcium in the blood, high levels of blood fats, some drugs, certain autoimmune conditions.

Diagnosis : Diagnosis depends on demonstrating abnormality in pancreatic gland or duct. Diagnosis may be difficult, but new techniques can help using ultrasonic imaging, MRCP (MRI) endoscopic retrograde cholangiopancreatography (ERCP), and CAT scans.

Treatment includes relieving pain, a diet low in fat, alcohol must be avoided, +/- pancreatic enzymes supplements. In some cases, ERCP, stenting, lithotripsy or surgery may be required.

Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine. The major types of IBD are Crohn’s disease and ulcerative colitis.Common presentation of these disorders include bleedind per rectum, chronic diarrhea, pain abdomen and growth. Failure. Crohn’s disease and ulcerative colitis may present with extra-intestinal manifestations (such as liver problems, arthritis, skin manifestations and eye problems) in different proportions.

The main forms of IBD are Crohn’s disease and ulcerative colitis (UC) The main difference between Crohn’s disease and UC is the location and nature of the inflammatory changes. Crohn’s can affect any part of the gastrointestinal tract, from mouth to anus (skip lesions), although a majority of the cases start in the terminal ileum. Ulcerative colitis, in contrast, is restricted to the colon and the rectum.

Microscopically, ulcerative colitis is restricted to the mucosa (epithelial lining of the gut), while Crohn’s disease affects the whole bowel wall (“transmural lesions”). Rarely, a definitive diagnosis of neither Crohn’s disease nor ulcerative colitis can be made because of idiosyncrasies in the presentation. In this case, a diagnosis of indeterminate colitis may be made. Although a recognised definition, not all centres refer to this.