Pediatric Gastroenterology

Contents

Foreword: The Remarkable Gastrointestinal Tract xv

Bonita F. Stanton

Preface: Pediatric Gastroenterology xvii

Steven J. Czinn and Samra S. Blanchard

Eosinophilic Gastrointestinal Disorders 475

Lisa M. Fahey and Chris A. Liacouras
Eosinophilic esophagitis (EoE) is an atopic disease that is characterized by
an isolated infiltration of eosinophils into the epithelium of the esophagus
and is triggered by specific allergens. Patients should undergo an upper
endoscopy with biopsy after 6 to 8 weeks of treatment with a proton
pump inhibitor in order to make the diagnosis of EoE. Eosinophilic gastro-
enteritis is a pathologic eosinophilic infiltration of any portion of the gastro-
intestinal tract, and eosinophilic proctocolitis is an eosinophilic infiltration
in the colon alone.

Gastroesophageal Reflux Disease 487

Hayat Mousa and Maheen Hassan
Gastroesophageal reflux (GER) is a normal physiologic process. It is
important to distinguish GER from GER disease (GERD) since GER
does not require treatment. Although a diagnosis of GERD can largely
be based on history and physical alone, endoscopy and pH impedance
studies can help make the diagnosis when there in atypical presenta-
tion. In children and adolescents, lifestyle changes and acid suppres-
sion are first-line treatments for GERD. In infants, acid suppression is
not effective, but a trial of hydrolyzed formula can be considered, as
milk protein sensitivity can be difficult to differentiate from GER
symptoms.

Caustic Ingestions and Foreign Bodies Ingestions in Pediatric Patients 507

Jacob A. Kurowski and Marsha Kay
Children inevitably swallow foreign material accidentally or intentionally.
Each type of ingestion carries their own set of risks and complications,
short and long term, some requiring immediate attention while others
close monitoring. Alkalotic household cleaning products and lithium but-
ton batteries are increasingly common and damage the esophagus
quickly. While many toys with rare-earth metals are banned, they are
already present in many households and can cause necrosis of bowel
that is between the magnets. This article reviews the incidence and
assessment along with current literature to provide guidelines for man-
agement of pediatric patients with suspected caustic or foreign body
ingestion.

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x Contents

Abdominal Pain in Children: From the Eternal City to the Examination Room 525
Donna K. Zeiter
Abdominal pain is a common presenting symptom in children. The
differential diagnosis of abdominal pain is extensive; however, a vast ma-
jority of patients ultimately are diagnosed with functional abdominal pain
disorders. Functional gastrointestinal disorders are defined using the
recently released Rome IV criteria. These are not diagnoses of exclusion.
If there are no alarm signs, the diagnosis may be made with a focused
evaluation. Treatment of these disorders requires a biopsychosocial
approach to the disorder and an individualized and multipronged treat-
ment plan.

Gastrointestinal Bleeding and Management 543

Anita K. Pai and Victor L. Fox
There is a broad clinical spectrum of gastrointestinal bleeding in chil-
dren, ranging from subtle laboratory findings to dramatic clinical pre-
sentations. This review provides a framework for the evaluation and
management of gastrointestinal hemorrhage for pediatricians. It outlines
strategies for obtaining a tailored patient history and conducting a thor-
ough physical examination that can shed light on the location, severity,
and likely etiology of bleeding. It appraises blood tests, radiologic tools,
and endoscopic modalities frequently used to identify and control a
source of bleeding.

Celiac Disease and Nonceliac Gluten Sensitivity 563

Runa D. Watkins and Shamila Zawahir
Gluten-related disorders include celiac disease (CD), wheat allergy, and
nonceliac gluten sensitivity. CD is an autoimmune enteropathy caused
by damage to small intestinal mucosa when gluten is ingested in geneti-
cally susceptible individuals. Currently, the only available treatment of
CD is gluten-free diet. Several potential treatments are being researched.
Wheat allergy is a hypersensitivity reaction caused by IgE-mediated and/or
non-IgE-mediated immune response, and can involve the gastrointestinal
tract, skin, or respiratory tract. Nonceliac gluten sensitivity is one of a va-
riety of immunologic, morphologic, or symptomatic manifestations precip-
itated by ingestion of gluten in individuals in whom CD and wheat allergy
are excluded.

Pediatric Inflammatory Bowel Disease 577

Máire A. Conrad and Joel R. Rosh
Inflammatory bowel disease (IBD), including Crohn disease, ulcerative
colitis, and IBD-unspecified, is a chronic immune-mediated condition
of the gastrointestinal tract in which the goal of treatment is to induce
and maintain durable remission. In pediatrics, there is a wide spectrum
of presenting symptoms, but esophagogastroduodenoscopy and colo-
noscopy are imperative to confirming the diagnosis. Treatment goals
include achieving mucosal healing of the gastrointestinal tract, reaching
growth potential, limiting medication toxicities, and optimizing quality of
life for all patients.

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 Contents xi

Motility Disorders in Children 593

Samuel Nurko
Gastrointestinal motility disorders in the pediatric population are common
and can range from benign processes to more serious disorders. Perform-
ing and interpreting motility evaluations in children present unique chal-
lenges. There are primary motility disorders but abnormal motility may
be secondary due to other disease processes. Diagnostic studies include
radiographic scintigraphic and manometry studies. Although recent ad-
vances in the genetics, biology, and technical aspects are having an
important impact and have allowed for a better understanding of the path-
ophysiology and therapy for gastrointestinal motility disorders in children,
further research is needed to be done to have better understanding of the
pathophysiology and for better therapies.

Intestinal Transplant in Children 613

Nidhi Rawal and Nada Yazigi
The past decade has seen major advances in the field of transplantation; it
is the treatment of choice for many with intestinal failure. One-year mortal-
ity from pediatric intestinal transplantation has significantly declined, from
30% to 10% to 15% nationally, mainly due to a multidisciplinary approach
in transplant centers. Pediatric age carries special considerations along
the spectrum of care that continue to cause challenges but also offers
growth opportunities. Pediatric intestinal transplantation indications and
timing are changing as a result of new developments in diagnostic and
treatment tools. This article reviews updates on pediatric intestinal trans-
plantation and highlights future directions.

Neonatal Cholestasis 621

Erin Lane and Karen F. Murray
Neonatal jaundice is common and usually not concerning when it is
secondary to unconjugated hyperbilirubinemia, below the neurotoxic level,
and resolves early. Primary care providers should be vigilant, however,
about evaluating infants in whom jaundice presents early, is prolonged
beyond 2 weeks of life, or presents at high levels. Even in well-appearing
infants, fractionated (direct and indirect) bilirubin levels should be obtained
in these clinical scenarios to evaluate for potential cholestasis. This review
presents an approach to the evaluation of a jaundiced infant and discusses
diagnosis and management of several causes of neonatal cholestasis.

Hepatitis B and C 641

Wikrom Karnsakul and Kathleen B. Schwarz
Chronic viral hepatitis is a global health threat and financial burden. Hep-
atitis B and C viruses (HBV and HCV) are the most common causes of
chronic viral hepatitis in the United States. Most cases are asymptomatic
before adulthood. Research has resulted in effective therapy for HCV
and the promise of effective therapies for HBV. For HCV, therapy is pegy-
lated interferon and ribavirin. Clinical trials with effective direct-acting anti-
viral agents are underway in pediatrics. For HBV, approved agents are
alpha-interferon, lamivudine, adefovir, tenofovir, and entecavir. However,

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xii Contents

treatment seldom results in functional cure and more effective therapies

are urgently needed.

Nonalcoholic Fatty Liver Disease in Children: Hepatic and Extrahepatic

Complications 659
Praveen Kumar Conjeevaram Selvakumar, Mohammad Nasser Kabbany,
Valerio Nobili, and Naim Alkhouri
Nonalcoholic fatty liver disease (NAFLD) is considered the hepatic mani-
festation of metabolic syndrome and has become the most common
form of chronic liver disease in children and adolescents. The histologic
spectrum of NAFLD is broad ranging, from the relatively benign form of
simple steatosis to the aggressive form of nonalcoholic steatohepatitis,
eventually leading to fibrosis and cirrhosis. NAFLD has also been recog-
nized as an independent risk factor for extrahepatic complications, such
as cardiovascular disease, type 2 diabetes mellitus, sleep disorders, and
osteoporosis. In this review, we discuss both the hepatic and extrahepatic
complications of NAFLD in children.

Pediatric Liver Transplantation 677

Nidhi Rawal and Nada Yazigi
Excellent outcomes over the last 3 decades have made liver transplanta-
tion the treatment of choice for many advanced liver disorders. This suc-
cess also opened liver transplantation to new indications such as liver
tumors and metabolic disorders. The emergence of such new indications
for liver transplantation is bringing a new stream of patients along with
disease-specific challenges. The cumulative number of liver transplant re-
cipients is peaking, requiring novel systems of health care delivery that
meet the needs of this special patient population. This article reviews up-
dates and new development in pediatric liver transplantation.

Pancreatic Disorders 685

Aliye Uc and Douglas S. Fishman
Once considered uncommon, pancreatic diseases are increasingly recog-
nized in the pediatric age group. Acute pancreatitis, acute recurrent
pancreatitis, and chronic pancreatitis occur in children with an incidence
approaching that of adults. Risk factors are broad, prompting the need
for a completely different diagnostic and therapeutic approach in children.
Although cystic fibrosis remains the most common cause of exocrine
pancreatic insufficiency, other causes such as chronic pancreatitis may
be as common as Shwachman Diamond syndrome. Long-term effects
of pancreatic diseases may be staggering, as children suffer from signifi-
cant disease burden, high economic cost, nutritional deficiencies, pan-
creatogenic diabetes, and potentially pancreatic cancer.

The Transition of the Gastrointestinal Patient from Pediatric to Adult Care 707
Punyanganie S.A. de Silva and Laurie N. Fishman
Transition is the long process of developing independent self-management
skills whereas transfer is the actual move from pediatric to adult-centered

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 Contents xiii

provider. Structured anticipated transition works best with timelines of

tasks to master and discussion of the stylistic differences between pediat-
ric and adult practices. Disease-specific issues need to be addressed,
such as earlier timelines for diet-based therapies, parental support for crit-
ical illnesses, and differences in therapeutic strategies.

Index 721

Descargado para Emeric Jorge Macedo Vendezu (emeric_macedo@usmp.pe) en San Martin de Porres University de ClinicalKey.es por
Elsevier en noviembre 10, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020.
Elsevier Inc. Todos los derechos reservados.