Gastrointestinal system

Miranda
Khidesheli
 Anatomy
• Gastrointestinal System
– Begins at the mouth, continues
through the thoracic cavity, and fills
most of the abdominal cavity
– Upper gastrointestinal system
includes the structures from the
mouth through the stomach
-Lower gastrointestinal system
includes the small and large intestines
– Purpose is to digest food, absorb
nutrients, and remove undigested
material (waste) from the body.
სურათი გასტროინტესტინური სურატის
წარწერებით
Anatomy of the Gastrointestinal
System
• Oral Cavity and Pharynx
– Begins in the mouth, or oral
cavity
– Oral cavity contains the teeth;
tongue; hard palate; and soft
palate with its fleshy, hanging
uvula.
Oral Cavity and Pharynx

- There are three pairs of

salivary glands: the
parotid glands, the
sublingual glands, and
the submandibular
glands.
-
 Esophagus

• A flexible, muscular tube that

connects the pharynx to the
stomach.
 Stomach
– Divided into four areas: the
cardia, fundus, body, and
pylorus.
Small Intestine
– The small intestine is a
long, hollow tube that
receives chyme from the
stomach.
– It is divided into three
parts: the duodenum,
jejunum, and ileum
Large Intestine

–a larger, hollow tube that

receives undigested material and
water from the small intestine.
– consists of the cecum, colon,
rectum, and anus
- The colon is the longest part.
- It travels through all four
quadrants of the abdomen as the
ascending colon, transverse colon,
descending colon, and sigmoid
colon.
Liver and Gallbladder
• The liver is the largest
solid organ in the body,
located in the upper
right abdominal cavity.
• An accessory organ of
digestion that
contributes to, but is
not physically involved
in, the process of
digestion.
 Pancreas
- An accessory organ of digestion
posterior to the stomach.
- Presence of food in the
duodenum causes the pancreas
to secrete digestive enzymes
into the pancreatic duct to the
duodenum.
- Also functions as an organ of
the endocrine system.
 Physiology of Digestion
• There are two parts to digestion:
– Mechanical
– Chemical
• Mechanical digestion uses mastication, deglutition, and peristalsis
to break down foods.
• The stomach secretes the following substances that continue the
process of chemical digestion:
– Hydrochloric acid
– Pepsinogen
– Gastrin
• Chemical digestion is completed in the small intestine.
• Cholecystokinin stimulates the pancreas to secrete four digestive
enzymes into the duodenum:
– Amylase
– Lipase
– Protease
– Other enzymes that break down proteins
 Anatomical and physiological characteristics of the gastrointestinal tract in infants and children

• In infants, the mouth is small. The tongue is short, wide, fills the entire cavity of the
mouth. Sucking pads of Bisha.

• The sensation of taste is immature at birth and not fully functional until
approximately 2 years of age. Term infants also have a tongue-thrust reflex for the
first 4 months of life that aids in breastfeeding or bottle-feeding and to protect them
from choking, but it is counterproductive when trying to feed solids by spoon.

• The hard palate is flat, soft - is short, horizontally located.

• Cheeks may be particularly prominent in young children because of the buccal fat
pad.

• The mucous membrane is thin, easily damaged, dry. The transverse folds on the
inner surface of the lips, hard palate, gums. Bona’s nodules on the mucosa of the
hard palate .

• The salivary glands secrete sticky saliva contains α-amylase. Activity of it increases
with 1.5 - 2 months.

• Esophagus - poorly developed narrowing .

Anatomical and physiological characteristics of
the gastrointestinal tract in infants and children

• Features of the stomach in infants

– predisposition to regurgitation.
- The horizontal position of the stomach .
- Small volume of the stomach
- Pylorus is wide.
- The cardiac sphincter is not sufficiently
developed .
- Pyloric part is well- developed
- Crus of the diaphragm not tightly surround
the esophagus
- The muscle tone of the lower esophageal
sphincter is not fully developed until 1
month of age and may remain slightly weak
for the first year.
 Features of the stomach
 1. muscular layer is poorly developed - motor
function is reduced
2. mucus is thick
3. gastric glands anatomically and functionally
underdeveloped the relative amount 2.5 times
less than in adults
4. low concentration of hydrochloric acid (low
total acidity begins to increase after the
introduction of complementary foods)
6.Low proteolytic activity of pepsin
7. High lipase activity
8. reduced the protective function of gastric juice
Features of the intestine
• The small intestine contains a large
amount of gases.
• The duodenum is ring-shaped, mobile
up to 7years.
• The mucosa is thin, richly vascularized.
• Low activity of digestive enzymes. Milk
proteins - pinocytosys mucosal
epithelial cells in unchanged form .
High activity of maltase, lactase. Low
activity of lipase, amylase,
enterokinase.
 Liver
• Large size - 1/3-1/2 of the abdominal cavity.
Children 1 to 3 years on the edge of the liver
acts 2 - 3 cm below the costal margin.
• In newborns the liver lobule demarcated not
enough. A thin fibrous capsule.
• 5% of the mass are the blood-forming cells.
• The final formation up to 8 years.
• The concentration of bile acids is high - in the
newborn may develop obstructive cholestasis.
• Neutralizing function is not sufficiently
developed.
• The gallbladder is hidden by the liver, has a
different shape. Poor concentrates bile.
intestines:
physiological dyspepsia Meconium - 1-2 day The transitional
Stool - 3-4 days Mature Stool - after 4 days

DEFECATION :
FOR FIRST HOURS AFTER BIRTH – MECONIUM- DARK GREEN
STICKY MASS WITH PH6 .
FOR FIRST MONTH DEFECATION AFTER EVERY FEEDING – 5-7
TIMES .
AFTER 1-2 MONTH – 3-6 TIMES .
UP TO 1 YEAR – 1-2 TIMES.
MIXED AND ARTIFICIAL FEEDING – LESS DEFICATION
BREASTFEEDING: PASTY (SEMI-LIQUID) YELLOW STOOL WITH A
SOUR SMELL .
ARTIFICIAL FEEDING: STOOL IS STIFFER CONSISTENCY, LIGHTER
OR WITH A GRAYISH HUE, NEUTRAL WITH A SHARP ODOR
 Method of examination of the digestive tract

• Questioning
–presenting complaints ( regugitation, nausea, vomiting,
abdominal pain, belching, heartburn, change in appetite, anxiety,
impaired bowel movements- defication, impaired swallowing, etc.)
-Present illness history,
-history of life (anamnesis vitae, morbi)
• Examination
-Inspection( state, position, color of skin, mucous membranes,
rashes, shape of the the abdomen, symmetry, size, participation in
breathing, examination of the mouth, tongue).
- Palpation (superficial, deep, in the horizontal and vertical position
).
- Percussion.
- Auscultation.
- Rectal examination.
• Instrumental methods : ultrasound. Endoscopy. Radiography.
Radiological methods. Laparoscopy.
• Functional methods : pH metry, duodenal, gastric intubation.
Biochemical analysis of blood.
 INSPECTION
• Mouth

- observe for the presence of any unusual

odor or lesions.
- Inspect the lips for color, symmetry, lesions,
swelling, dryness, and fissures. The color
should be pink at rest and with feeding or
crying.
- Note any asymmetry of movement or
drooling that might indicate nerve
impairment. Drooling during infancy from 3
to 15 months of age is normal, but drooling
later may indicate nerve damage and loss of
control of oral secretions.
 lips
- Young infants may have a callus or blister on the lip
from vigorous sucking. This is particularly common in
breastfed infants in the first few months of life.
- Swelling of the lips may be caused by injury or allergic
reaction. Cracked, dry lips can be caused by harsh
weather conditions, repeated lip licking or biting,
mouth breathing due to nasal allergy, fever, or from
illness or dehydration. Sores in the mouth or on the
lips may indicate a viral infection such as Coxsackie
virus or herpes simplex virus type 1.
- Halitosis, mouth odor or bad breath, in children may
be caused by poor oral hygiene and dental caries,
tonsillitis, or sinusitis.
- Note the frenulum of the upper lip that connects the
upper lip to the gums of the maxilla at the point of
the central incisors. It is prominent in the infant and
disappears slowly in childhood with growth and
development of the maxilla.
 tongue
• Geographic tongue, a benign inflammation of the
dorsal surface of the tongue, causes pink areas with
absent papillae and a surrounding whitish border

• Connecting the ventral surface of the tongue to the

floor of the mouth is the lingual
frenulum.Newborns with significant feeding
problems should be referred to an
otolaryngologist . A significantly shortened lingual
frenulum, ankyloglossia, is caused by an anterior
attachment of the frenulum to the tip of the tongue
It may in some cases interfere with adequate latch
and sucking in the newborn and impair the infant’s
ability to breastfeed. Surgical intervention may be
indicated in some infants and children.
 tongue
• Macroglossia, enlarged tongue,
can be congenital or acquired and
is associated with hypothyroidism,
Down syndrome, and other
congenital anomalies. Pierre
Robin syndrome is associated with
a malpositioned tongue, feeding
and breathing difficulty, and a
high arched or cleft palate.
 ABDOMEN
• Inspect the umbilicus for any signs of drainage, infection,
hernia, or mass.
• umbilical cord remnants detach by the 10th day of life but
can take up to 3 weeks to slough. Once the cord has
detached, the stump should dry and heal within a few days.
Occasionally, umbilical granulomas or granular tissue at the
base of the umbilicus can be present and drain serous or
seropurulent fluid or occasionally blood. Any prolonged
drainage should be investigated for presence of a urachal
remnant or cyst.congenital anomalies and should be
referred for further diagnosis and evaluation.
• Neonatal omphalitis is a rapidly progressing, acute, and
potentially fatal infection of the abdominal wall caused by a
bacterial pathogen. Any infant with purulent discharge or
sign of cellulitis should be treated with systemic antibiotics
and referred immediately if the infection progresses.
 PALPATION

• umbilical hernia
- in which the intestine protrudes through the
abdominal fascia, or linea alba.
- The umbilicus appears to protrude especially when
the child is crying, stooling, or coughing, but generally
it can be easily reduced when the examiner applies
light pressure with the fingertips to the umbilicus.
- Palpate the fascia below the umbilicus with the
fingertips to determine the size of the defect. If the
opening is larger than the width of two fingers or the
child is older than 3 years of age, surgical closure may
be necessary
- Incarceration of an umbilical hernia is very rare. Most
will spontaneously close by the time the child is 3 or 4
years of age.
 PALPATION
• An infant between the ages of 3 and 8
weeks of age with projectile, nonbilious
vomiting may have pyloric stenosis.
Examine the infant while the abdomen is
relaxed and palpate in the upper
abdomen, slightly right of the midline for
a firm, olive-shaped mass, which is highly
suspicious for a hypertrophic pylorus.
• If a child presents with constipation, a
sausage-shaped mass of stool may be
palpated in the left lower quadrant
(LLQ).
 PALPATION
• Hepatomegaly is an enlargement of the liver resulting
from an increase in the number or size of cells and
structures within the liver. Although hepatomegaly usually
manifests clinically as a palpable liver, not all palpable
livers result from hepatomegaly. In healthy children, the
liver edge may be palpable up to 2 cm below the right
costal margin at the midclavicular line. Clinical estimation
of the liver span has a much stronger correlation with
hepatomegaly than does reporting the liver projection
below the costal margin as a single indicator of liver
size.1 The liver span is the distance between the upper and
lower margins of the liver at the right midclavicular line.
The upper margin should be determined by percussion
and the lower edge by either percussion or palpation. Liver
span has a curvilinear relation to age, height, weight, and
body surface area. Studies have demonstrated no
consistent sex differences in liver size. A normal liver span
ranges from 5.9 cm (±0.8 cm) in the first week of life to 6.5
to 8 cm by 15 years of age.
  The causes of hepatomegaly in
young children
1.Cystic fibrosis
2.Long-term parenteral nutrition
3.Hepatitis of newborns
4.Alpha-1 antitrypsin deficiency
5.Hyperbilirubinemia of newborns
6.Reye's syndrome 7.Metabolic
diseases
8.Extrahepatic cholestasis (bile duct
atresia, etc.)
  The causes of hepatomegaly in
older children 
1.Storage diseases and metabolic
2.Violation of feeding
3.Hemolytic anemia
4.Trauma of lever
5.Reye's syndrome
6.Cirrhosis
7.Hepatitis
8.Sarcoidosis
9.Malignant diseases
10.Systemic diseases of connective tissue
 COMMON
MANIFESTATIONS OF
GASTROINTESTINAL
DISORDERS
 symptoms
• Abdominal pain
• Gastrointestinal bleeding
• vomiting
• diarrhea
• constipation
 SIMPTOMS
Abdominal pain
- detailed history of the pain
- character and severity of the pain
- onset and duration,
- location or radiation,
- position of comfort, things that alleviate or worsen the pain,
- history of trauma,
- any associated symptoms of fever, vomiting, anorexia,
constipation, diarrhea, or frequent stooling with or without
noting blood is important in narrowing the scope of the
differential diagnosis.
- recurrent pain related to meals or after meals should be
elicited in the history
- Nocturnal awakening with pain and/or stooling may be a red
flag in the school-age child and requires further assessment
and diagnostic workup as indicated.
Causes of acute abdominal pain
in children
1.Gastric and duodenal ulcers
2.Acute cholecystitis
3.Viral hepatitis
4.Acute mesenteric lymphadenitis
5.Helminthosis
6.Haemorrhagic visculitis
7.Intestinal invagination
8.Purelent peritonitis
9.Acute pancreatitis
10.Exudative pleuritis
11.Pericarditis
12.Pneumonia
13.Acetonemic vomiting
 Red Flag Symptoms and Signs in
Children with Recurrent Abdominal Pain
• Symptoms and key features in the history
-Involuntary weight loss
- Chronic severe diarrhea
- Gastrointestinal blood loss
- Gynecologic symptoms
- Family history of IBD/celiac disease
- Nighttime waking
- Significant vomiting (especially if bilious)
- Urinary symptoms
- Joint pains, mouth sores, skin rash, unexplained
fevers— extraintestinal manifestations of IBD
 Red Flag Symptoms and Signs in
Children with Recurrent Abdominal
Pain
• Red flag signs of gastrointestinal
disease
- Slowing of linear growth
- Clubbing Mouth ulcers
- Abdominal masses
- Pain radiating through to the back
(pancreatitis) or loins (renal pain)
- Anorexia/delayed puberty
- Hypertension/tachycardia
- Perineal changes (tags/fistulas)
Diagnostic Approach to Acute
Abdominal Pain
 VOMITING
• It is a common problem in children
and has many causes.
• Vomiting should be distinguished
from regurgitation of stomach
contents, also known as
gastroesophageal reflux (GER),
chalasia, or “spit-ting up.” Although
the end result of vomiting and
regurgitation is similar, they have
completely different characteristics.
 Physiological regurgitation

• In children of the first 6 months

of age
• Within 2 hours after a meal
• Up to 6 times per day
• Small volume
 Differential Diagnosis and Historical Features
of Vomiting
• Viral and bacterial gastroenteritis- Fever, diarrhea, sudden onset, absence
of pain
• Gastroesophageal reflux- Effortless, not preceded by nausea, chronic.
• In neonates with true vomiting, congenital obstructive lesions should be
considered-Intestinal atresia, Intussusception,Duplication cysts
• Extra-gastrointestinal infections
-Otitis media -Fever, ear pain
- Urinary tract infection -Dysuria, unusual urine odor, frequency, incontinence
- Pneumonia -Cough, fever, chest discomfort
• Allergic
- Milk or soy protein intolerance (infants) Associated with particular formula
or food, blood in stools
- Other food allergy (older children)
• Appendicitis -Fever, abdominal pain migrating to the right lower quadrant,
tenderness
• Pyloric stenosis- Nonbilious vomiting, postprandial, <4 mo old, hunger,
progressive weight loss
 The causes of vomiting in
children under 1 year
• Ilius meconium (cystic fibrosis)
• Disaccharidase deficiency
• Obstruction, invagination
• Infection (baterial, viral)
• Intestinal infections
• Renal tubular acidosis
• Malformations (atresia, stenosis, esophageal
diverticulum)
• Gastroesophageal reflux
• Cardiospasm
• Pyloristenosis
• Overfeeding
• Otitis media, pneumonia
Possible causes of vomiting in children older
than one year 

 1. Pancreatitis
2. Acute gastritis
3. Acute respiratory inf. 4.Inf.hepitiis
5. Appendicitis
6. Acetonemic vomiting
7. Neurogenic anorexia
8. Enterocolitis
9. Acute azotemia (eclampsia)
10. Diabetic coma
11. Uremic coma
 DIARRHEA
• Diarrhea may be classified by etiology or by physiologic
mechanisms (secretory or osmotic).
 Etiologic agents include viruses, bacteria or their toxins, chemicals,
parasites, malabsorbed sub-stances, and inflammation.
- Secretory diarrhea occurs when the intestinal mucosa directly
secretes fluid and electrolytes into the stool and is the result of
inflammation (e.g., inflammatory bowel disease, chemical stimulus
- Osmotic diarrhea occurs after malabsorption of an ingested
substance, which “pulls” water into the bowel lumen. A classic
example is the diarrhea of lactose intolerance. Certain
nonabsorbable laxatives, such as polyethylene glycol and milk of
magnesia, also cause osmotic diarrhea.

.
 The main causes of acute
diarrhea in children
1.Otitis media
2.Sepsis
3.Bacterial, viral enteritis
4.Parasitic enteritis (amebiasis,
giardiasis, cryptosporidiosis)
5.Inflammatory bowel disease
(ulcerative colitis, Crohn's
disease) 6.Urinary infection
7.Pseudomembranous colitis
8.Hemolytic-uremic syndrome
The causes of chronic diarrhea 
1.Irritable Bowel Syndrome
2.Cystic fibrosis
3.Food allergy
4.Intolerance to cow's milk protein 5.Violation of feeding
6.Celiac Disease
7.Malformations of the bowel (short bowel syndrome,
Hirschsprung's disease)
8.Endocrine disease (hyperthyroidism, Addison's
disease, congenital adrenal hyperplasia)
9.Disaccharidase deficiency
10.Immunodificiency
11.Chronic pancreatitis 12.Inflammatory bowel disease
(ulcerative colitis, Crohn's disease)
Constipation and Encopresis

• Constipation is a common problem in childhood.

• Straining with defecation, hard stool consistency,
large stool size, decreased stool frequency, fear of
passing stools, or any combination of these.
• Constipation- two or fewer stools per week or
passage of hard, pellet-like stools for at least 2
weeks.
• functional constipation is characterized by two or
fewer stools per week, voluntary withholding of
stool, and infrequent passage of large-diameter,
often painful stools.Children with functional fecal
retention often exhibit “retentive posturing”
(standing or sitting with legs extended and stiff or
crossed legs) and have associated fecal incontinence
caused by leakage of retained stool (encopresis).
 Constipation
• causes of constipation :Hirschsprung
disease ; spinal cord
abnormalities,hypothyroidism, some
drugs, cystic fibrosis,and
anorectalmalformations
• Symptoms usually result from low-fibre,
poor-nutrient intake, and too little water,
which leads to high levels of colonic
reabsorption of water and hardening of
the stool.
• It tends to develop during 3 stages of
childhood: weaning (infants), toilet training
(toddlers), starting school (older children).
 Intestinal colic
• Occurs at 3-4 weeks of age, usually
lasts up to 4 months
• More often occurs in the evening,
from 17 to 19 hours, lasts 15-20
minutes or more, may be
periodically resumed.
• There are anxiety of a child,
flatulence, high- pitched cry. Baby is
red. After passing flatus (gases) or
stool - pain reduces
 Oral cavity
• Gastroesophageal reflux disease (GER) can
lead to substantial enamel erosion and
caries.
• Neonatal hyperbilirubinemia can result in
bluish discoloration of the deciduous
teeth.
• Renal failure is associated with mottled
enamel of the permanent teeth.
• Congenital syphilis causes marked
abnormalities in the shape of teeth,
especially incisors and molars.
• Celiac disease can result in enamel defects
 THRUSH
• Oropharyngeal Candida albicans
infection, or thrush, is common in
healthy neonates.
• is common in breastfed infants as
a result of colonization or
infection of the mother’s nipples.
• in healthy older patients can
occur, but should suggest the
possibility of a immunodeficiency,
broad-spectrum antibiotic use, or
diabetes.
 THRUSH
• Thrush is easily visible as white plaques, often with a
“fuzzy” appearance, on oral mucous membranes.
• with a tongue depressor, the plaques are difficult to
remove.
• Clinical diagnosis is usually adequate, but may be
confirmed by fungal culture or potassium hydroxide smear.
• Thrush is treated with topical nystatin or an azole
antifungal agent such as fluconazole.
• When the mother’s breasts are infected and painful,
consideration should be given to treating her at the same
time.
• Because thrush is commonly self-limited in newborns,
withholding therapy in asymptomatic infants and treating
only persistent or severe cases is a reasonable
approach.
 CLEFT LIP AND PALATE

• Clefting occurs with two possible

patterns: isolated soft tissue cleft
palate or cleft lip with or without
associated clefts of the hard palate.
• Isolated cleft palate is associated
with a higher risk of other congenital
malformations.
• Surgical closure of the cleft lip is
usually done by 3 months of age.
• Closure of the palate follows, usually
before 1 year of age.
• Missing teeth are replaced by
prostheses.
Oral cavity
Oral cavity
GASTROESOPHAGEAL REFLUX ( GER)
• is defined as the effortless retrograde
movement of gastric contents upward into the
esophagus or oropharynx.
• In infancy, GER is not always an abnormality.
• Physiologic GER (“spitting up”) is normal in
infants younger than 8 to 12 months old.
• Infants who regurgitate meet the criteria for
physiologic GER so long as they maintain
adequate nutrition and have no signs of
respiratory complications or esophagitis.
• As infants grow, they spend more time upright,
eat more solid foods, develop a longer and
larger diameter esophagus, have a larger and
more compliant stomach.
• most infants stop spitting up by 9 to 12 months
of age.
 (GERD)
• Gastroesophageal reflux disease
(GERD) occurs when GER leads to
troublesome symptoms or
complications such as poor growth,
pain, or breathing difficulties.
• normal protective mechanisms against
GER include antegrade esophageal
motility, tonic contraction of the LES,
and the geometry of the
gastroesophageal junction.
 symptoms
While they may vary, the 10 most common signs
of acid reflux or GERD in infants include:
• spitting up and vomiting.
• refusal to eat and difficulty eating or swallowing.
• irritability during feeding.
• wet burps or hiccups.
• failure to gain weight.
• abnormal arching.
• frequent coughing or recurrent pneumonia.
• gagging or choking.
 TREATMENT
• In otherwise healthy young infants ("well-nourished,
happy spitters"), no treatment is necessary, other than
a towel on the shoulder of the caretaker.
• For infants with complications of GER, pharmacologic
therapy with a proton-pump inhibitor should be
offered
• Lesser benefits are obtained with H2 receptor
antagonists.
• Prokinetic drugs, such as metoclopramide,
occasionally may be helpful by enhancing gastric
emptying
• When severe symptoms persist despite medication, or
if life-threatening aspiration is present, surgical
intervention may be required.
 ESOPHAGEAL FOREIGN BODIES

• Young children often place nonfood items in

their mouths.
• When these items are swallowed, they may
become lodged in the upper esophagus at
the thoracic inlet.
• The most common objects are coins.
• Smaller coins may pass harmlessly into the
stomach, where they rarely cause symptoms.
• Other common esophageal foreign bodies
include food items, small toys or toy parts,
disc batteries, and other small household
items.
 Clinical Manifestations
Diagnosis

• Some children are asymptomatic, but most exhibit some

degree of drooling, food refusal, or chest discomfort.
• Older children usually can point to the region of the chest
where they feel the object to be lodged.
• Respiratory symptoms tend to be minimal, but cough may
be present.

• Plain chest and abdominal radiographs should be taken

when foreign body ingestion is suspected.
• Metallic objects are easily visualized.
• A plastic object often can be seen if the child is given a
small amount of dilute x-ray contrast material to drink,
although endoscopy is probably safer and more definitive.
 Pyloric stenosis
• Pyloric stenosis is an acquired
condition caused by hypertrophy
and spasm of the pyloric muscle,
resulting in gastric outlet
obstruction.
• Its cause is unknown, but it
seems that a deficiency in
inhibitory neuronal signals,
mediated by nitric oxide, is likely.
 Pyloric stenosis
• Infants with pyloric stenosis typically
begin vomiting during the first month of
life, but onset of symptoms may be
delayed.
• The emesis becomes increasingly more
frequent and forceful as time passes.
• Vomiting in pyloric stenosis differs from
spitting up because of its extremely
forceful and often projectile nature.
• The vomited material never contains bile
because the gastric outlet obstruction is
proximal to the duodenum.
•
 Pyloric stenosis
Laboratory and Imaging Studies
• Repetitive vomiting of purely gastric contents results in
loss of hydrochloric acid; the classic laboratory finding
is a hypochloremic hypokalemic metabolic alkalosis.
• Jaundice with unconjugated hyperbilirubinemia also
occurs.
• Plain abdominal x-rays typically show a huge stomach
and diminished or absent gas in the intestine
• Ultrasound examination of the pylorus shows marked
elongation and thickening of the pylorus .
• A barium upper GI series also may be obtained
whenever doubt about the diagnosis exists; this shows
a "string sign" caused by barium moving through an
elongated, constricted pyloric channel
Treatment of pyloric stenosis

Treatment of pyloric stenosis

includes IV fluid and electrolyte
resuscitation followed by surgical
pyloromyotomy.
 ESOPHAGEAL ATRESIA AND
TRACHEOESOPHAGEAL FISTULA

• The esophagus and trachea develop

in close proximity to each other
during 4 to 6 weeks of fetal life.
• Defects in the mesenchyme
separating these two structures
result in a tracheoesophageal fistula
(TEF), often in association with other
anomalies (renal, heart, spine, limbs).
• TEF is not thought to be a genetic
defect because concordance
between monozygotic twins is poor.
 Treatment and Prognosis

The treatment of TEF is surgical. A

thoracotomy provides access to
the mediastinum via extrapleural
dissection. The fistula is divided
and ligated. The esophageal ends
are approximated and anas.
 CELIAC DISEASE

• Celiac disease, or celiac sprue, is an injury to the

mucosa of the small intestine caused by the
ingestion of gluten ( a toxic protein
component) from wheat, rye, barley, and related
grains.
• Rice does not contain toxic gluten and can be
eaten freely, in its severe form, celiac disease
causes malabsorption and malnutrition.
• Diagnosis was based on the presence of typical
symptoms, followed by small bowel biopsy.
• The availability of more sensitive and specific
serologic testing has revealed a "celiac iceberg"
of many patients with few or no symptoms who
have early, attenuated, or latent disease.
 CELIAC DISEASE
• Symptoms can begin at any age when gluten-
containing foods are given.
• Diarrhea, abdominal bloating, failure to
thrive, irritability, decreased appetite, and
ascites caused by hypoproteinemia are
classic.
• Children may be minimally symptomatic or
may be severely malnourished.
• A careful inspection of the child's growth
curve and determination of reduced
subcutaneous fat and abdominal distention
are crucial.
• Celiac disease should be considered in any
child with chronic abdominal complaints
 CELIAC DISEASE
Laboratory and Imaging Studies
• Serologic markers include IgA anti endomysial
antibody(EMA) and IgA tissue transglutaminase
antibody. (tTG)
• Because IgA deficiency is common in celiac
disease, total serum IgA also must be measured
to document the accuracy of these tests.
• An endoscopic small bowel biopsy is essential
to confirm the diagnosis and should be
performed while the patient is still taking
gluten.
• When there is any question about response to
treatment, a repeat biopsy specimen may be
obtained several months later.
 CELIAC DISEASE
• Treatment is complete elimination of gluten
from the diet.
• The role of gluten in causing intestinal injury
must be explained carefully.
• Lists of prepared foods that contain hidden
gluten are particularly important for patients
to use.
• Starchy foods that are safe include rice, soy,
tapioca, buckwheat, potatoes, and (pure) oats.
• Most patients respond clinically within a few
weeks with weight gain, improved appetite,
and improved sense of well-being.
 Intussusception
• Occurs when a proximal segment of the
intestine telescopes into the lumen of an
immediately distal segment
• Most commonly seen in infants between 3
and 18 months of age; In most cases, the
intussusception is in the ileocaecal area.
• In infants <2 years of age, episodes of
intussusception are most likely caused by
mesenteric lymphadenopathy secondary to an
associated illness (e.g., viral gastroenteritis). In
older children, mesenteric lymphadenopathy
is still the most likely cause, but other
aetiologies should be considered (e.g.,
intestinal lymphomas, Meckel's diverticulum).
 Intussusception
• Stool mixed with blood and mucus
(sometimes referred to as "currant
jelly" stool because of its appearance)
• Vomiting
• a palpable abdominal mass-
sausage-shaped mass in the upper
right quadrant od the abdomen
• Lethargy
• Diarrhea
• Fever
 Intussusception
• Laboratory investigation is usually not helpful in
the evaluation of patients with intussusception,
although leukocytosis can be an indication of
gangrene if the process is advanced. With
persistent vomiting and sequestration of fluid in
the obstructed bowel, dehydration and electrolyte
imbalance occur.
• Ultrasonographic imaging has been found to have
a high sensitivity and specificity in the detection of
ileocolic intussusception. Abdominal radiographs
can also reveal diagnostic characteristics of
intussusception, but their sensitivity and specificity
has been called into question.
 Hirschsprung's disease
• Hirs is the most commonly diagnosed in
the first year of life, but can present
later in childhood; slightly higher male
preponderance.
• Congenital condition characterised by
partial or complete colonic obstruction
associated with the absence of
intramural ganglion cells. Because of
the aganglionosis, the lumen is tonically
contracted, causing a functional
obstruction. The aganglionic portion of
the colon is always located distally, but
the length of the segment varies.
 cystic fibrosis .
• The cause of inadequate pancreatic digestive
function in 95% of cases is cystic fibrosis .
• The defect in CFTR chloride channel function
results in thick secretions in the lungs,
intestines, pancreas, and bile ducts.
• Children with pancreatic exocrine
insufficiency have many bulky, foul-smelling
stools each day, usually with visible oil or fat.
• Appropriate testing should be performed to
rule out conditions such as celiac disease and
IBD if any doubt about the state of pancreatic
sufficiency exists.
 cystic fibrosis
• Testing of pancreatic function is difficult.
• Stools can be tested for the presence of
maldigested fat.
• The presence of fecal fat usually indicates
poor fat digestion.
• Of these, measuring fecal elastase-1 seems to
be the most accurate method of assessment.
Replacement of missing pancreatic enzymes is
the best available therapy.
• In children younger than 4 years old, 1000
U/kg/meal is given. For older children, 500
U/kg/meal is usual.
 APPENDICITIS
• Appendicitis is the most common surgical emergency in
childhood.
• Appendicitis begins with obstruction of the lumen, most
commonly by fecal matter (fecalith), but appendiceal
obstruction also can occur secondary to hyperplasia of
lymphoid tissue associated with viral infections or the
presence of neoplastic tissue, commonly an appendiceal
carcinoid tumor.
• Trapped bacteria proliferate and begin to invade the
appendiceal wall, inducing inflammation and secretion.
• The obstructed appendix becomes engorged, its blood
supply is compromised, and it finally ruptures.
• The entire process is rapid, with appendiceal rupture
usually occurring within 48 hours of the onset of
symptoms.
APPENDICITIS
Raised white cell count and neutrophils
Urinalysis-normal or leucocyte in the urine, without organisms.
Plan radiographs are usually normal
Ultrasound-can confirm diagnosis of apendicitis but can miss an
inflamed appendix,particularly if the subject is obese.
Treatment of appendicitis is surgical.
Simple appendectomy is curative if performed before perforation.
With perforation, a course of postoperative IV antibiotics is required.
Broad-spectrum coverage is necessary to cover the mixed bowel
flora.
parasitic diseases in children
 Giardiasis( lambliasis)
• Giardiasis is a major diarrheal disease found
throughout the world.
• The flagellate protozoan Giardia intestinalis,its
causative agent
•  Infection is transmitted through ingestion of
infectious G lamblia cysts. 
• A history of contact with contaminated water, such
as swallowing water while swimming, drinking
untreated tap water, eating lettuce, and contact
with recreational fresh water, should be noted.
• Giardiasis symptoms vary from asymptomatic
passage of cysts to acute self-limiting diarrhoea or
chronic diarrhoea.
 Giardiasis( lambliasis)
investigations
• Initial diagnosis of giardiasis is made by stool microscopy
• Part of the initial workup should include a full blood count,
but this is likely to be normal with no eosinophilia.
• direct fluorescence antibody (DFA) that detects soluble stool
antigens, should be requested.
Standard therapy
• Nitroimidazoles are first-line therapy for giardiasis.
• Tinidazole can be offered as a single dose and has an efficacy
of 90% to 98%.[
•  Metronidazole is given for 7 days and has an efficacy of 80%
to 95%.
• In areas where G lamblia is endemic, treatment may not be
desirable because the children are likely to become rapidly
reinfected following treatment.
 Inguinal hernia
•  Inguinal hernia is a type of ventral hernia that occurs when an
intra-abdominal structure, such as bowel or omentum, protrudes
through a defect in the abdominal wall. Most hernias that are
present at birth or in childhood are indirect inguinal hernias.
• The infant or child with an inguinal hernia generally presents
with an obvious bulge at the internal or external ring or within
the scrotum. The parents typically provide the history of a
visible swelling or bulge, commonly intermittent, in the
inguinoscrotal region in boys and inguinolabial region in girls
• The bulge commonly occurs after crying or straining and often
resolves during the night while the baby is sleeping.
• The swelling may or may not be associated with any pain or
discomfort.
• Fifty per cent of inguinal hernias present in the first year of life,
most by the age of 6 months.
 Inguinal hernia
• Preterm infants – especially those with
very low birth weight
• Boys
• Infants with chronic lung diseas
• Children with conditions associated
with abnormal abdominal fluid or
increased intra-abdominal pressure
•  Children with
developmental urogenital anomalie
• Treatment is surgical.
Foto Questions
 1. Normal
2. Acute appendicitis;

Acute appendicitis was diagnosed when

an appendix was enlarged, wall
differentiation was not preserved,
associated localized tenderness was
seen, secondary signs (hyperemia, free
fluid or collection) was observed,
increase diameter and fecolith seen . 
hirschsprung's disease xray
intussusception in children
 Gastroesophagal reflux

 Oesophageal reflux. Frontal (left) and oblique

(right) X-rays of the chest and upper abdomen
of a 10-month-old infant with oesophageal
reflux. The arrow at left points to the cardia,
the region where the contents of the
oesophagus empties into the stomach (across
bottom). A contrast medium (white) shows the
outline of the stomach and the oesophagus.
Gastroesophageal reflux is where the contents
of the stomach (including stomach acid) rise
upwards into the oesophagus.
 CASE 1
History
T. is a 7-week-old infant who presents to
the our department with a 1-week history
of non-bilious vomiting. His mother
describes the vomit as ‘shooting out’. He
has a good appetite but has lost 300 g since
he was last weighed a week earlier. He has
mild constipation. There is no vomiting in
any other members of the family. His sister
suffers from vesicoureteric reflux and
urinary tract infections.
 CASE 1
Examination
T. is apyrexial and mildly
dehydrated. His pulse is 170
beats/min, blood pressure 82/43
mmHg, and peripheral capillary
refill 2 s. There is no organomegaly,
masses or tenderness on
abdominal examination. There are
no signs in the other systems.
 CASE 1
INVESTIGATIONS
• Haemoglobin, White cell count Platelets – normal
• Sodium , Potassium , Chloride –decreased
• Urea 9.0 mmol/L –N(1.8–6.4 mmol/L)
Creatinine 60 µmol/L-N ( 18–35 µmol/L )
• Capillary gas
pH 7.56 – N(7.36–7.44 )
PCO2 6.0 kPa –N(4.0–6.5 kPa )
PO2 3.2 kPa –N(12–15 kPa )
HCO3 38 mmol/L –N (22–29 mmol/L )
• Urine dipstick No abnormality detected

Questions
• What is the likely diagnosis?
• What is the differential diagnosis?
• How would you confirm the diagnosis?
• What is the treatment?
 CASE 1
• In an infant this age with non-bilious projectile
vomiting, pyloric stenosis is the most likely diagnosis.
This condition presents between 2 weeks and 5
months of age (median 6 weeks) and projectile
vomiting is typical. The vomitus is never bile-stained
as the obstruction is proximal to the duodenum. As
in this case, infants may also be constipated. The
hypochloraemic alkalosis is characteristic and is due
to vomiting HCl. The low potassium is due to the
kidneys retaining hydrogen ions in favour of
potassium ions. The raised urea and creatinine
suggest that there is also mild dehydration. The
male-to-female ratio is 4:1 and occasionally there is a
family history (multifactorial inheritance).
 CASE 1
Differential diagnosis
• Gastro-oesophageal reflux
• Gastritis
• Urinary tract infection
• Overfeeding
Gastro-oesophageal reflux usually presents from
or shortly after birth. Gastritis usually occurs with
an enteritis and diarrhoea. A urinary infection at
this age may present in a very non-specific way
and therefore it is mandatory to test the urine.
The absence of nitrites and leucocytes in the urine
dipstick makes a urinary infection very unlikely.
Overfeeding should be elucidated from a careful
history.
 CASE 1
The diagnosis could be clinically confirmed by carrying out a
test feed. A feed leads to peristalsis which occurs from left to
right. The abdominal wall is usually relaxed during a feed,
making palpation easier. A pyloric mass, which is the size of a
2-cm olive, may be felt in the right hypochodrium by careful
palpation. An ultrasound is also usually done for further
confirmation. Tom is slightly tachycardic (pulse rate 1 year,
110–160 beats/min) with a normal blood pressure and
capillary refill time. His urea is slightly elevated. Initial
treatment consists of treating the dehydration, acid–base and
electrolyte abnormalities with intravenous fluids (0.9 per cent
saline with 5 per cent dextrose and added KCl would be the
appropriate starting fluid in this infant with a low sodium and
potassium). Feeds should be stopped, a nasogastric tube
inserted and the stomach emptied. The definitive operation is
Ramstedt’s pyloromyotomy.
 CASE 1
KEY POINTS
• The peak age of presentation
of pyloric stenosis is 6 weeks.
• The typical biochemical picture
is a hypochloraemic alkalosis.
• The definitive treatment is
Ramstedt’s pyloromyotomy.
 CASE 2
• A 3½-week-old male infant presents to your office with a
history of 2 to 3 days of vomiting. He was born at term and his
birth weight was 3,250 g. He is breastfed. He has been
exhibiting no bilious vomiting after each feeding, and
according to his mother, the emesis now appears to "shoot
out of his mouth." After vomiting, he seems eager to resume
feeding. Over the past 24 hours, his mother has noted fewer
wet diapers and fewer stools than usual. The baby has
experienced no diarrhea or upper respiratory tract symptoms.
Physical examination demonstrates an alert, afebrile infant
who weighs 3,550 g and is sucking vigorously on a pacifier. His
skin turgor is normal. The remainders of the examination
findings are unremarkable, except for slight abdominal
distention. You refer the baby to the local emergency
department and order measurement of serum electrolytes.
Results include: • Sodium, 132 mEq/L • Potassium, 3.2 mEq/L
• Chloride, 95 mEq/L • Bicarbonate, 30 mEq/L
 CASE 2
• 1-What is the most likely
diagnosis?
• 2-Mention 3 differentials
diagnoses?
• 3- What is the most
appropriate initial treatment
for this infant?
 CASE 2
• 1- Infantile hypertrophic pyloric stenosis
(HPS).
• 2- Other, less common causes of gastric
outlet obstruction include duodenal stenosis,
gastric duplication, antral web, and annular
pancreas.
• 3- Based on the serum electrolyte data, fluid
therapy should be nitiated with 5% dextrose
and 0.45% sodium chloride at approximately
1.5 times the calculated maintenance rate
(~400 mL per 24 hours, based on the infant’s
hydrated weight) or 25 mL/hr.
 HISTORY TAKING OSCE
STATIONS
• A 14-month-old boy has started
vomiting and has loose watery
stools up to eight times a day.
He has a low grad fever and is
rather quiet. Other mothers at
the nursery report similar
findings in their children.
• Task -Take a focused history and
suggest 2 diagnoses.
 HISTORY TAKING OSCE
STATIONS
1. Greet the mother and Introduce himself
2. Ask about age and residence?
3. Ask about frequency of bowel motion per day, amount, and
character?
4. Ask if there is any blood in the stools?
5. Ask about associated fever, vomiting, or abdominal pain?
6. If the vomiting is bile-stained, consider obstruction?
7. Ask about similar condition in the family?
8. Ask about recent travel and drug history?
9. Ask about type of feeding?
10.Ask about previous attack and past medical history?
11.Ask about vaccination?
12.Thank the mother and tell her if she has any question
D.D Food poisoning 14 Gastro-enteritis
 Suggested Check list for gastointestinal
system examination
Before starting ;
1. Introduce yourself and greet the child and parent .
2 Explain the examination and ask for consent to carry it out 3 Wash
hands thoroughly and dry them
4 Position the child so that he is lying flat and expose his abdomen as
much as possible
5 Stand by the right side of the patient (unless you are left handed)
General inspection
1. Inspect the abdomen noting any: • Distension ,umbilicus, and
pulsations •Localized masses •Scars and distended veins •Any bulge
elicited by flexion of the trunk
Inspection and examination of the hands
for Clubbing ,Koilonychia ,Palmar erythema Pulse (at least 15 seconds)
Inspection and examination of the head, neck, and upper body
1.Inspect the sclera and conjunctivae for signs of jaundice or anemia
Inspect the mouth, looking for ulcers ((Crohn's disease), angular
stomatitis (nutritional deficiency), atrophic glossitis (iron deficiency,
vitamin B12 deficiency, folate deficiency), furring of the tongue (loss of
appetite), and the state of the dentiti. Examine the neck for
lymphadenopathy.
 Suggested Check list for gastointestinal system examination

Palpation of the abdomen

Ask the child if he has any tummy pain and keep your eyes on his
face as you begin palpating his abdomen.
Light palpation - begin by palpating furthest from the area of pain
or discomfort and systematically palpate in the four quadrants and
the umbilical area. Look for tenderness, guarding, and any masses
Deep palpation - for greater precision. Describe and localize any
masses.
Palpation of the organs
Liver- starting in the right lower quadrant, feel for the liver
edge( regular or irregular )using the flat of your hand, surface
(smooth or nodular ) , texture ( firm or hand ) , and tenderness
Spleen - palpate for the spleen as for the liver, starting in the right
lower quadrant
Kidneys - position the child close to the edge of the bed and ballot
each kidney using the technique of deep bimanual palpation
 Suggested Check list for gastointestinal
system examination

Percussion
Percuss the liver area. also remembering to detect its
upper border Percuss the suprapubic area for dullness
(bladder distension) If the abdomen is distended, test
for shifting dullness (ascites)
Auscultation
Auscultate in the mid-abdomen for abdominal sounds.
listen for 30 seconds at least before concluding that
they are hyperactive, hypoactive or absent
Examination of the groins and genitalia
Inspect the groins for hernias and, in boys, examine the
testes (this is particularly important in younger infants)
Cover the abdomen and thank the patient
1.Answer the following questions regarding
acute abdomen.

a. What is the age of peak incidence of

appendicitis?
b. What is the classic triad for intussusception?
c. What laboratory tests are satisfactory as an
initial screen in patients with abdominal
pain?
d. What is the treatment of choice for
intussusception?
e. Name three causes of abdominal pain
arising from a gonad in a young girl
f. What is the classic finding on appendicitis?
g. How do you test for peritoneal irritation?
 1.Answer
a. Teenage and young adult years (12-18 years); males
slightly more than females.
b. Severe episodic pain, ”currant jelly” stool, transverse
tubular abdominal mass.
c. CBC, BUN, creatinine, electrolytes, blood sugar, urine
analysis. Serum amylase, lipase, aminotransferase.
Examination of stool. Chest X-ray and flat and upright film
of abdomen.
d. Hydrostatic reduction. However in patients with
prolonged intussuception with signs of shock, peritoneal
irritation, intestinal perforation or pneumatosis
intestinalis, reduction should not be attempted.
e. Ovarian tumor, torsion of an ovary, ruptured ovarian cyst.
f. Right lower quadrant tenderness.
g. Rebound tenderness
 2. A 3-year-old infant presented with
failure to thrive, recurrent diarrhea,
irritability and pain abdomen. On
examination, he was found to be
wasted with edema and finger
clubbing. His tTG ELISA for both IgA
and IgG was positive
a. What is this condition?
b. Name other serological tests done to
diagnose this condition.
c. What will you do to confirm the diagnosis?
d. Name three conditions associated with
high frequency of this disease.
 2.Answer
a. Celiac disease.
b. Antigliadin and
antiendomyseal antibodies.
c. Small bowel biopsy.
d. Down’s syndrome, Turner’s
syndrome, William’s
syndrome, thyroiditis,
selective IgA deficiency.
 3. A 8-year-old girl has periumbilical pain that began 8 hours ago;
since then she has vomited once and has had one small, loose,
bowel movement. Her last meal was 12 hours ago, and she is not
hungry. She denies dysuria and urinary frequency. On examination,
she is lying quietly in bed with temperature of 101.5°F. Her other
vital signs are normal. Her abdominal examination reveals few
bowel sounds, rectus muscle rigidity, and tenderness to palpation,
particularly periumbilically. There is some abdominal tenderness
with gentle bimanual palpation. She has pain on digital rectal

examination. Breath sounds are clear and she has no rashes .

a. What is the most likely diagnosis?
b. What is the single most reliable clinical
finding for diagnosing this?
c. What are the sonographic criterias to
diagnose this condition?
 3.Answer
a. Acute appendicitis .
b. Localized abdominal tenderness is the single
most reliable finding in the diagnosis.
c. The ultrasound criteria for appendicitis include:
• Wall thickness <6 mm • Luminal distention •
Lack of compressibility • Complex mass in the
right lower quadrant • Fecalith. Findings
suggestive of advanced appendicitis on
ultrasound include: • Asymmetric wall thickening.
• Abscess formation. • Associated free
intraperitoneal fluid. • Surrounding tissue edema.
• Decreased local tenderness to compression
 4 .An 18-month-old boy is receiving
‘Augmentin’ for otitis media. Now he
has diarrhea and a diaper rash. There
is no fever or vomiting.

a. What is the most likely cause for

the diarrhea?
b. Define persistent diarrhea.
c. How do you differentiate
between osmotic and secretory
diarrhea?
 4.Answer
a. Antibiotic induced diarrhea due to
‘Augmentin’.
b. Diarrhea persisting for 14 days or beyond and
associated with malnutrition.
c. Diarrhea.

Osmotic Secretory
Volume of stool < 200 mL/24 hr >200 mL/24 hr
Response to Diarrhea stops Diarrhea continues
fasting
Stool Na+ <70 mEq/L >70 mEq/L

Reducing Positive Negative

substances
Stool pH <5 >6
5. A 12-year-old female has had diarrhea,
abdominal pain and flatulence. She often
notices some abdominal pain in the late
mornings and early afternoon. She has
not noticed blood in her stool . The
situation worsens on taking milk.

a. What is the likely cause?

b. How do you make a diagnosis
in this case?
c. Name 2 conditions where this
condition can occur
transiently?
 5.Answer
a. Lactose intolerance.
b. Measurement of carbohydrate in the stool,
using a clinitest reagent, which identifies
reducing substances, is a simple screening test. •
Acidic stool with reducing substance > 2+
suggests carbohydrate malabsorption. (Sucrose
or starch in the stool is not recognized as a
reducing sugar until after hydrolysis with
hydrochloric acid, which converts them to
reducing sugars). • Breath hydrogen test. • Small
bowel biopsies can give a confirmatory evidence.
c. Celiac disease and after Rota virus infection.
1. All of the following are typically noted in a
young adult with the diagnosis of acute
appendicitis except:

1. Marked febrile response

2. Epigastric pain
3. Rebound tenderness
4. Tenesmus.
2. Which of the following best represents the
peak ages for occurrence of acute
appendicitis?

1. 1-10
2. 2-5
3. 10-18.
3. 0-1
  
3.Which of the following is associated with bilious vomiting?

 
A. Volvulus.
B. Intussusception
C. Intestinal obstruction
D. GERD
 4. What is the most frequent cause of
intestinal obstruction in the first two
years of life?
 
A.Constipation
B. Intussusception.
C. Volvulus
D. Low fiber diet
5. What is the most common cause of
anal itching in children?

A. Diarrhea
B. Cleansing the area with hot water or
strong soap
C. Yeast infection
D. Pinworms.
6. Regarding pyloric stenosis, which of
the following statements is correct?

A. Bilious vomiting is a feature

B. It is more common in girls
C. There is often a palpable olive
sized mass in the right
hypochondrium
D. Metabolic acidosis is a common
metabolic complication of
pyloric stenosis.
7. You see a baby boy in your GP surgery. He is 1 week old
and has bilious vomiting that started suddenly. He was
born at term after an uncomplicated pregnancy and was
previously feeding well. Antenatal scans were normal and
he passed meconium within 24 hours of birth. On
examination he is afebrile and a little dehydrated, and he
has a soft, non-distended abdomen.

A. Hirschsprung’s disease
B. Malrotation with volvulus.
C. Gastroenteritis
D. Meconium ileus
 8.You think that the baby may have Hirschsprung’s
disease. Which of the following investigations is the
gold standard for the diagnosis of Hirschsprung’s
disease?

A. Plain abdominal x ray

B. Contrast enema
C. Rectal biopsy.
D. Real time ultrasound
E. Anal manometry
 9. You are called to the emergency department to
see a 9 year old girl who has developed abdominal
pain and vomiting. She is lying flat and looks pale.
On examination there is tenderness in the right iliac
fossa, and you think she may have appendicitis.
Which of the following signs is NOT suggestive of
appendicitis?

A. A palpable mass in the right iliac fossa

B. Rebound tenderness
C. Guarding
D. Microscopic haematuria
E. An olive sized mass in the right
hypochondrium.
(An olive sized mass in the right
hypochondrium is suggestive of pyloric
stenosis.)
 10. Angela brings her 3 month old son Jack to your
surgery, as he has been vomiting intermittently after
feeds since he was about 4 weeks old, and seems to
be in pain and distress at times. He is growing
normally, his bowel motions are normal, and he has
no significant previous medical history. Angela says
that he occasionally coughs, usually after meals, but
he has no wheeze or fever.

A. Upper respiratory tract infection

B. Gastro-oesophageal reflux disease
C. Cow’s milk protein intolerance
D. Gastroenteritis
E. Asthma
11. A barium swallow is also known as
a (an)

A. Upper GI series
B. ERCP
C. Colonoscopy
 Pharyngohinoscopy

12. Examination of the upper

gastrointestinal tract with a fiberoptic
instrument is called
A. Cystoscopy
B. Esophagogastroduodenoscopy
C. Nasopharyngoscopy
D. Pharyngohinoscopy
 13.An abnormal twisting of the
intestines resulting in intestinal
blockage is a (an)

A. Intussusception
B. Hernia
C. Prolapse
D. Volvulus
A: Plain abdominal x ray
Plain film x rays are non-diagnostic for Hirschsprung’s disease
but will show evidence of bowel obstruction.
b : Contrast enema
A contrast enema might show the extent of the disease and help to
determine the level of bowel affected, but it is not the gold
standard for diagnosis.
c : Rectal biopsy
Rectal biopsy is the gold standard investigation for
Hirschsprung’s disease. The rectal biopsy is able to determine if a
region is aganglionic.
d : Real time ultrasound
A real time ultrasound is of no benefit in this patient. Real time
ultrasound is useful in patients with suspected pyloric stenosis.
e : Anal manometry
Anal manometry might show a lack of anal relaxation but is non-
specific and of little help.
CASE:
You see a 4 week old boy in your GP surgery.
Over the last two days he has projectile
vomited after feeding. The vomit is non-
bilious and the boy has an immediate desire
to feed again. On examination he is afebrile,
severely dehydrated, and lethargic. There is
no abdominal distension, but a palpable
mass is present in the right hypochondrium.
Which of the following is the most likely
diagnosis?

a. Malrotation volvulus
b. Intussusception
c. Pyloric stenosis.
d. Gastro-oesophageal reflux disease
a : Malrotation volvulus
Malrotation volvulus occurs when the bowel rotates around its mesentery, secondary to
malrotation of the midgut during fetal development. Children with malrotation volvulus can
present at any age, but the diagnosis is less likely as the child becomes older. Children with
malrotation volvulus typically present with bile stained vomiting, so this diagnosis is less likely
in this patient.
b : Intussusception
Intussusception usually presents in children aged between 6 months and 2 years with abdominal
colic, an abdominal mass, and redcurrant jelly stools (although the latter is a late sign).
c : Pyloric stenosis
This baby boy is most likely to have pyloric stenosis as this typically presents in babies aged
between 3 and 5 weeks who have vomiting that is non-bilious. It is more common in males and
the first born.
d : Gastro-oesophageal reflux disease
Gastro-oesophageal reflux disease is extremely common in children under 1 year of age, but it
rarely results in dehydration, projectile vomiting, or a palpable mass.
• Peculartes gavaketo mere
• Gastriti da ulcer