The document discusses common childhood gastrointestinal problems such as gastroenteritis, diarrhea, intestinal obstruction, and appendicitis. It provides details on the causes, symptoms, diagnosis, and treatment of each condition. For diarrhea specifically, it describes the various types, causes, assessment techniques involving dehydration status, and treatment approaches including oral rehydration and continued feeding. Intestinal obstruction is classified and common causes in children like intussusception are explained. For appendicitis, it notes the signs, diagnostic tests, and surgical treatment required.
2. Gastroenteritis
Gastroenteritis is an inflammatory disease of the
gastric, and enteric sites of the GIT.
It is characterized by a sudden onset of diarrhea
with or without vomiting.
Causes include; virus, bacteria, protozoa, and non
infectious causes.
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3. Diarrhea
Definition
Passage of loose stool > 3x/24hrs (WHO) or
watery stool of any frequency
Is abnormally liquid or unformed stools
associated with increased frequency of defecation.
The recent change in consistency and character
of stool is more important than number of stool.
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4. Causes
Viral: account for the largest causes of diarrhea in pediatrics
Rotavirus is the leading viral pathogen worldwide.
Others; Cali virus, astovirus, and adenovirus in gastroenteritis.
Bacterial: the second leading cause of diarhea in peadiatrics.
Compylobacter Jejuni is the leading bacterial cause of
gastroenteritis
Other forms of bacteria include; shigella, Enterohemorhagic E.
coli.
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6. Con…
Parasites: A number of protozoans like; Giardia
lamblia and Entamoeba hystolitica, remain the
leading cause of gastroenteritis in pediatrics.
Symptoms include; watery stool and hx of travel
to an endemic area.
Non-infectious causes. Include medications like
NSAIDS, Crowns disease.
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8. Types Greatest Danger
1. Acute watery diarrhea (80%
of cases)
Dehydration
K +loss
2. Bloody diarrhea
(Dysentery) 10% of cases
Tissue damage
Toxemia(sepsis)
3. Persistent diarrhea(> 2 wks.)
10% of cases
Malnutrition
4. Chronic diarrhea
(6wks or more)
Malnutrition
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9. Assessment of Diarrhea
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— Is your child have Diarrhea?
— If yes, ask for how long?
— Is there blood in the stool?
— Assess for sign of DHN
— Look at the child’s general condition. Is the child:
Lethargic or unconscious? Restless and irritable?
— Look for sunken eyes.
— Offer the child fluid. Is the child: Not able to drink
or drinking poorly? Drinking eagerly, thirsty?
— Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)? Slowly?
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10. Assessment Con…
• Severe dehydration will have two of these signs:
– Abnormally sleepy or lethargic
– Sunken eyes
– Drinking poorly or not at all
– Very slow skin pinch
• Some dehydration will have two of these signs:
– Restlessness or irritability
– Sunken eyes
– Drinking eagerly
– Slow skin pinch
• No dehydration
– None of these signs
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12. Treatment of diarrhea
Main principle in management of acute
diarrhea is:
1. Replace lost water and salts.
2. Continue to feed to prevent malnutrition.
3. Antibiotics & antiprotozoals when needed.
4. Prevention of diarrhea
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13. Treatment Con…
• No sign of DHN Plan A
– Fluid deficit < 5 %
– Can be treated at home
– More fluid than usual to prevent DHN
– Appropriate supply of foods to prevent malnutrition
– Bring back the baby to the health institution, if
diarrhea doesn’t get better or gets worse.
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14. Con...
How much fluid to give in addition to the usual
fluid intake/loose stool?:
– Up to 2 years 50 to 100 ml after each loose stool
– 2 years or more 100 to 200 ml after each loose stool
Give frequent small sips from a cup.
If the child vomits, wait 10 minutes, continue,
but slowly.
Continue giving extra fluid until the diarrhea stops.
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15. Some DHN Plan B
Fluid deficit 5-10%
ORS 75ml/kg over 4-6 hrs.
Reassess the degree of DHN
If no sign of DHN home Rx with
replacement of on going losses.
If sign of some DHN repeat plan B
If worse IV RX
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16. Severe DHN Plan C
Fluid deficit 10-15%.
IV fluid RL
Ringer's lactate 100ml/kg
o For infants:
• 30 ml/kg in the first hour
• 70 ml/kg in the next 5 hours
o For children( >1yr)
• 30 ml/kg in the first 30 min
• 70 ml/kg in the next two and half hours
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17. Treatment Con…
Antimicrobial therapy is administered to
selected patients.
Give antiprotozoal for patients with proven
ameabiasis and no response to treatment for
shigella.
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18. Zinc supplementation
Reduce duration and severity of diarrhea
Prevents recurrence.
promotes ion absorption, restores epithelial proliferation,
and stimulates immune response.
Children with diarrhea should receive oral zinc for 10-
14 days during and after diarrhea (10 mg/day for infants
<6 mo of age and 20 mg/day for those >6 mo).
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19. Intestinal obstruction
Is a partial or complete blockage of
the bowel
It prevents the contents of the
intestine from passing through.
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21. Classi…
Dynamic : where peristalsis is working against a
mechanical obstruction.
Adynamic (paralytic ileus):Ineffective motility
without any physical obstruction.
Acute obstruction: sudden onset of severe colicky
central abdominal pain, distention and early vomiting
&then, constipation
Usually occur in small bowel obstruction)
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22. Clasi…
Chronic obstruction :lower abdominal colic &
absolute constipation, followed by distention.
Usually seen in large bowel obstruction with
Simple mechanical obstruction:
In which there is obstruction but blood supply to
intestine remains intact.
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23. Cont …
Strangulated obstruction : Mesentric blood vessel are
blocked besides the usual mechanical obstruction.
Closed loop obstruction:Specific type of obstruction in
which two points along the course of a bowel are
obstructed at a single location & forming a closed loop.
Usually this is due to adhesions.
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24. Common causes of IO in children
Intussusception
Hirschsprung’s disease
Band of adhesions
Necrotizing enterocolitis
Pyloric stenosis
Hernia
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25. Intusisupation
An intussusceptions is a medical
condition in which a part of the
intestine has invaginated into another
section of intestine.
Usually proximal loop invaginate in to
the distal bowel.
Rarely distal loop may invaginate into
the proximal loop( retrograde
intussusceptions)
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26. Epidemiology
Most common cause of intestinal obstruction in
infants between 6 and 36 months of age.
Approximately 60% < 1 year &
80 to 90% <2 years old
Intussusception is less common before three
months and after six years of age
Male: female ratio of approximately 4:1
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27. Clinical presentation
The first sign of intussusception may be sudden, loud
crying caused by abdominal pain.
Infants who have abdominal pain may pull their knees to
their chests when they cry.
The pain of intussusception comes and goes, usually every
15 to 20 minutes
Vomiting
Lethargic
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28. Con…
Stool mixed with blood
and mucus (also known
as “redcurrant jelly"
because of its appearance
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29. Diagnosis
U/S of the abdomen identify target sign.
Longitudinal scan reveal tubular mass
Barium enema reveal coiled spring sign
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31. Management
Air or hydrostatic enema reduction
Surgical reduction if enema fails
Surgical resection and anastmosis in late
presentation
Antibiotics in case of surgical intervention
Adequate fluid resuscitation to correct the often severe
dehydration caused by vomiting
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32. HIRSCHSPRUNG’S DISEASE
It is a blockage of the large intestine due to improper muscle
movement in the bowel
• CAUSES:
Muscle contractions in the gut help digested materials move through
the intestine.
Nerves in between the muscle layers trigger the contractions.
Areas without such nerves cannot push material through.
This causes a blockage.
Intestinal contents build up behind the blockage, causing the
bowel and abdomen to become swollen
33. Symptoms
.
Difficulty with bowel movements
Failure to pass meconium shortly after birth
Poor feeding
Poor weight gain
Vomiting
Constipation
Fecal impaction
Malnutrition
34. Dx
During a physical examination, the doctor may be able to
feel loops of bowel in the swollen belly.
A rectal examination may reveal a loss of muscle tone in the
rectal muscles.
tests
Abdominal x—ray
Barium enema
Rectal biopsy
35. TREATMENT
Colostomy
A variety of subsequent corrective operations
Are carried out at approximately 1 year of age
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36. Pyloric Stenosis
Is hypertrophy & spasm of the pyloric
muscle, resulting in narrowing of the
pyloric sphincter
Causing partial obstruction of the
gastric oulet.
– It is common in male (m :F= 6:1)
– Onset: b/n 2- 6 wks.
Etiology: The exact cause is unknown.
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37. Pyloric stenos …
C/M
Vomiting(after feeding)(postprandial), non-bilious, often
projectile & demands to be re-fed soon afterwards (a
"hungry vomiter"). (classic presentation)
Excessive hunger
Crying with out tear (sign of dehydration)
Loss of Wt. or failure to gain wt.
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38. DX
Usually based on clinical manifestations
-projectile vomiting(non bilious)
-Palpation of pyloric mass can be felt.
Abdominal U/S (the enlarged thickened pylorus is seen on U/S monitor)
confirms the diagnosis
pyloric thickness >4 mm or an overall pyloric length >14 mm.
X-ray examination with barium meal.
-Narrowing of pyloric canal.
-Enlarged stomach
RX-
RX may be surgical or medical.
- Surgical(pyloromyotomy) is the best management.
- Medical Rx :like gastric lavage 38
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39. Preventive Strategies
• Promotion of Exclusive Breastfeeding
• Improved Complementary Feeding Practices
• Immunization(measles , cholera, rotavirus)
• Improved Water and Sanitary Facilities
• Promotion of Personal and Domestic Hygiene
• Improved Case Management of Diarrhea
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40. Acute appendicitis
It refers to inflammation of the
appendix.
Epidemiology
The leading acute abdomen in
children : 4/1000
Peak age between 12-18
age(adolescent )
But rare below 5 years (5%) and
extreme rare below 3 year.
• .
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41. Cause
An obstruction: Food waste or a hard piece of stool
(fecal stone),tumor etc can block the opening of the
cavity
An infection: May also follow an infection, such as a
gastrointestinal infections, or it may result from other
types of inflammation.
In both cases, bacteria inside the appendix multiply
rapidly, causing the appendix to become inflamed,
swollen and filled with pus.
If not treated promptly, the appendix can rupture.
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42. Pathophysiology
Appendix become obstructed
Increase intra-luminal pressure
Decrease venous drainage, thrombosis, edema,
and bacterial invasion of bowel wall.
Appendix become increasingly hyperemic, warm
and covered with exudate.
Perforation and gangrene of appendix
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44. Clinical manifestation
Peri-umblical pain
Shift of maximal pain to right lower abdomen
Early malaise and anorexia
Low grade fever and vomiting
Severe RLQ pain which limits movement
Perforation after 36-48 hours (65%)
High grade fever and rigid abdomen is a sign of
peritonitis due to perforation
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45. Physical examination
Mild fever and tachycardia
Child walks bending down
Direct tenderness over RLQ area
Positive psoas and obturator sign
Positive rovsing sign (rebound tenderness)
Point of maximal pain at McBurny’s point.
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49. Alvarado Scale for the Diagnosis of Appendicitis
Value
Manifestations
1
Migration of pain
Symptoms
1
Anorexia
1
Nausea and/or vomiting
2
Right lower quadrant
tenderness
Signs
1
Rebound
1
Elevated temperature
2
Leukocytosis
Laboratory values
1
Left shift in leukocyte count
52. Treatment
Pain control and hydration
Keep NPO for surgery
Antibiotics to cover GIT flora
Ceftriaxone and Metronidazole OR
Ampicillin, Gentamycin
Emergency operation(appendectomy )
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54. Umbilical hernia
Hernia: Is the protrusion/projection of an organ or a part of an
organ through abnormal opening in the wall of the cavity that
normally contains it.
Umbilical hernia: Protuberant umbilicus
Diagnosis: Soft reducible swelling at umbilicus covered with skin
Treatment
• Most close spontaneously
Apply adhesive tape (2 inches)
• Repair if not closed by age 6 years, or if there is a history of the
hernia being difficult to reduce.
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55. Inguinal hernia
Swelling or bulge at inguinal area.
Diagnosis
Intermittent reducible swelling in the groin that is observed when the
child is crying or straining.
Occurs where the spermatic cord exits the abdomen (inguinal canal).
Distinguish from a hydrocele (fluid that collects around testicle).
Hydrocele trans illuminates and usually do not extend up into the
inguinal canal.
Can also occur rarely in girls.
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56. Inguinal hernia ---
Treatment
Uncomplicated inguinal hernia: elective surgical
repair to prevent incarceration.
Hydrocele: repair if not resolved by age 1 year.
Unrepaired hydroceles will turn into inguinal
hernias.
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57. Incarcerated hernias
These occur when the bowel or other intra-abdominal structure is trapped
in the hernia.
Diagnosis
Non-reducible tender swelling at the site of an inguinal or umbilical
hernia.
There may be signs of intestinal obstruction (vomiting and abdominal
distension) if the bowel is trapped in the hernia.
Treatment
Attempt to reduce by steady constant pressure.
If the hernia does not reduce easily, an operation will be required.
Give the child nothing orally.
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58. RX Incarcerated hernias---
Give intravenous fluids.
Pass a nasogastric tube if there is vomiting or
abdominal distension.
Give antibiotics if compromised bowel is suspected:
Ampicillin (25–50 mg/kg IM or IV four times a day),
gentamicin (7.5 mg/kg IM or IV once a day) and
metronidazole (7.5 mg/kg three times a day).
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