FY1 Teaching

COMMON GIT PROBLEMS IN CHILDHOOD

DR RAVI KAKKAR
SPECIALTY DOCTOR IN PAEDIATRICS
25TH JUNE 2015
 Case 1
 5yr old boy presents with long history of soiling and
abdominal pains

 What is the likely diagnosis?

Constipation

 What important questions need to be asked?

 Passage of meconium
 Early bowel habits
 Diet
 Associated/systemic symptoms
 Triggers
Case 1 contd:

 What could the triggers be in this child?

 Diet related
 Recent illness
 School

 On examination the child has evidence of faecal

loading, how would you treat?
Case 1 contd:
 Warn families that treatment can take many months/
years

 Address lifestyle
 Good diet
 Plenty of fluids
 Avoid too much milk
 Ensure access to good toilet
 Bowel training
 Good position
 Gastro-colic reflex
 Case 1 contd:
 Aggressive treatment

 If evidence of impaction (faecal mass, overflow) then dis

impact with movicol as per cBNF

 This can take several days and be very messy – warn

parents

 Once dis impacted wean the movicol slowly over a week or

so to a good maintenance dose

 Continue this dose with advice to increase/decrease

according to stools
Few most common GIT problems of
childhood

1. Constipation with soiling

2. Dyschezia
3. Infantile colic
4. Reflux
5. Functional Abdominal Pains
Meconium within 24 hrs

 Hirschsprung disease
 Meconium plug
 Small left colon syndrome
 AR malformations
Constipation
 Quite common childhood problem

 Exact cause not fully understood

 Pain, fever, dehydration, dietary and fluid intake

 Psychological issues, toilet training, medicines

 Familial history of constipation

‘Idiopathic’ Constipation
 No anatomical / physiological abnormality
 Infrequent bowel activity, irregular stool texture,
 Passing occasional enormous stools or frequent small
pellets
 Withholding or straining to stop passage of stools,
 Soiling or overflow
 Abdominal pain, distension or discomfort
Contd:
 95% of infants pass 1 or more stools a day

 95% of children pass 3 or more stools/week

 5% - 30% of school children suffer constipation

Bristol ‘poo’ scale

 Type 1 & 2 = constipation

 Type 3 & 4 = ideal stools
 Type 5 – 7 = diarroheal stools
Aims of treatment
 Aiming for a type 4-5 at least every other day

 It should be easily passed, with no straining and not be huge

 Some children may benefit from a stimulant (senokot,

dulcolax)

 Occasionally if dis impaction/good treatment fails children

may need regular enemas
Weaning of medications

 Aim for 6 months of stability with good bowel

habit before attempting to wean

 Weaning should be done over weeks/months and

never abruptly
Causes of constipation
 Idiopathic
 Poor diet
 Lack of exercise
 Sluggish bowel (often runs in families)

 Gastro
 Hirschsprungs
 Anal disease (stenosis, ectopic, fissure)

 Non-gastro
 Hypothyroid
 Hypocalcaemia
 Neurological
 Drugs (opiods)
 Abuse
Case 2
 3 month old baby

 Mother thinks the baby is constipated

 Her baby passes a stool every day but the baby cries for at least 20 minutes
before opening her bowels and seems to be in pain

 On further questioning the mum tells you that the baby passes a soft good
sized poo at least once a day

 There are no other red flags and the baby is thriving

 What is the problem?

Infantile Dyschezia
 Baby cries for a period of time and goes red in the face before passing
a soft stool

 To open bowels there needs to be coordination between increasing the

intra-abdominal pressure and relaxing the pelvic floor

 Babies can lack this coordination leading to crying (not from pain but
to raise the intra-abdominal pressure) followed eventually by passing
a normal stool

 Reassure and no treatment – should settle after a few weeks

 Case 3
 First time mother with her 2m old baby

 She is at the end of her tether

 H/O crying excessively and mum feels she can’t cope

 On further questioning
 The baby has been crying most evenings for several hours
 This has been going on for the past month
 At other times the baby is fine, feeding well and is thriving

 The lady wonders if her baby has reflux

 What do you think the most
Likely Diagnosis

 Infantile colic
Colic
 Healthy infants between 2 weeks and 4 months

 Excessive, paroxysmal episodes of inconsolable crying for 3 hours a day, 3 times a

week for 3 weeks

 Well and thriving child

 1/3 babies can have

 Causes?
 Less than 5% have an organic cause (eg CMPI, GORD)
 No association with type of milk
 May be associated with maternal smoking, stressful births
Colic: contd
 Should be diagnosed with good history and examination

 Red flags:
 Vomiting
 Altered stools
 Irritability for large period of times
 Lethargy
 Poor weight gain

 Treatment? Unlikely to help with OTC medications

 Swaddling, dummies, trial of hydrolysed formula
 Reassurance
 CRY-SIS helpline 0845 1228 669
Case 4

 4 month old baby with “vomiting”

 the baby possets shortly after most feeds

 Bottle fed

 Thriving (weighs 7kg)

 What else do you want to know?

 Amount of feed
 How long it has been happening
 Any blood/bile
 stools
Contd:

 Possets, no bile or blood

 Happy baby

 Normal stools

 Been going on for 3 months

 Taking 8x6oz bottles

 Diagnosis?

Overfeeding (>200ml/kg/day) +/- GOR

Contd:

 Gastro-oesophageal reflux is physiological and common (up to 40%)

 Before age of 8 weeks

 Effortless bringing up of milk (ie not vomiting)

 Babies are otherwise well and thriving

 No treatment - reassurance

 Address overfeeding – common issue

GORD

 The other end of the spectrum……

Gastro-oesophageal reflux disease

 These babies have the effortless reflux of milk associated with

 food refusal
 crying
 Back arching
 Dislike of lying on back
 Poor weight gain
Reflux – contd:

 NICE guidelines for GORD

 Smaller, more frequent feeds (also ensure not over feeding)
 Try Feed thickeners for 1 – 2 weeks
 Trial of ranitidine/ omeprazole for 6 – 8 weeks
 Consider change of milk
Red flags in GORD

 Projectile vomiting if under 2 months

 Bloody or bile vomit
 Melaena
 Dysphagia
 Not responding to treatment
 Persisting beyond a year
 Poor growth
Don’t ever forget UTI
Case 5

 Joshua 9 yrs, old with tummy ache

 6 months history

 Peri-umbilical colicky pain lasting for a couple of hours

once or twice a week
 Normal Examination
What is the diagnosis?

 Functional – most common

 Constipation
 Abdominal migraine – RAP
 IBS
 Inf Bowel Disease
 Coeliac disease
Functional abd pains

 Periumbilical
 Short episodes
 No associated bowel symptoms or association with eating
 Worse at times of worry
 Seen in high achievers, anxious, pushy parents
 Thriving
 Difficult to “treat”
Cotd – fn abd pains

 IBS
 Periumbilical pain
 Often relieved by going to the toilet
 Changing bowel habit, mucous
 Evidence that peppermint can be useful
Invt Case 5

 FBC
 Renal function
 LFTs
 ESR / CRP
 Celiac screen + IgA
 TFTs
 Orosomucoids
 Iron studies / Folate / B12 levels
Lactose Intolerance

 Diagnosis frequently made

 Primary deficiency rare
 Usually secondary to previous infections, CMPI. Coeliac
disease, IBD
 Stool +ve for reducing substances, pH
 Rx – primary condition / lactose free formula
 Thanks
Any Questions