1. GMS 701
Pediatrics Module
Rashida Joemmankhan, MCMSc, PA-C, IBCLC
Gastrointestinal Tract

2. Learning Outcomes
Upon completion of this section, the student will be able to
identify:

Causes of child with vomiting

Causes of pediatric diarrhea

Gastroesophageal reflux in infancy, its relation to apnea
and its management

Common disorders of the gastrointestinal tract

Classification of acute abdomen in children

3. Topics:

Vomiting/diarrhea

Pyloric stenosis

AGE

Dehydration

Celiac Disease

Constipation

Functional constipation

Hirschsprung's disease

Acute Abdomen

Intussusception

Meckel's diverticulum

Appendicitis

Inguinal hernia

Testicular torsion

Hydrocele

Cryptorchidism

Gastroesophageal reflux in infants
– apnea

Hepatic Pathology

Hyperbilirubinemia

Viral hepatitis A and B

Hepatic toxicities
− Acetaminophen overdose
− Reye's syndrome

Special Populations

4. Vomiting: Causes

Gastroenteritis

Gastroesophageal reflux

Overfeeding

Anatomic obstruction

Systemic infection

Migraine headaches

Food poisoning

Alcoholism

Pertussis syndrome

Salt wasting in CAH

Inborn error of metabolism

Brain tumor (increased intracranial
pressure)

Subdural hemorrhage

Rumination

Renal tubular acidosis

5. Vomiting DDX

Gastroenteritis

Food Poisoning

Respiratory Illness

Metabolic Disorders

Obstruction

Appendicitis

Increased ICP

Cyclic Vomiting

Pyloric Stenosis

Pyelonephritis,

Pregnancy

Other

6. Vomiting

Complications:

Dehydration

metabolic alkalosis

esophagitis

Mallory-Weiss tears

enamel erosion

Treatment:

Treat dehydration and
underlying cause.

Use of anti-emetics
controversial

7. Pyloric Stenosis
Infantile Hypertrophic
Pyloric Stenosis (IHPS)
A narrowing of the
outlet from the
stomach to the small
intestine (pylorus)

8. Pyloric Stenosis

IHPS

Most common cause of intestinal obstruction in
infancy

Etiology unknown

Caused by hypertrophy of pyloric muscle gastric
outlet obstruction

Risk factors:

male (4:1); first born males

family history (13%)

9. Pyloric Stenosis

S & S:

Projectile nonbilious
vomiting (onset age 2-6
weeks) after feeding

Poor weight gain

“olive” palpated in RUQ

Signs of dehydration
− depressed fontanelles
− dry mucous membranes
− decreased tearing
− poor skin turgor
− Lethargy

10. Pyloric Stenosis

LABS:

Metabolic alkalosis

Hypokalemia

Hypochloremia

Increased unconjugated bilirubin
levels

DX:

Mostly clinical

UGI series

US – diagnostic modality of choice
− Reveals the thickened pylorus
− If olive mass felt on physical
exam, US not necessary

TX:

A medical emergency

Correction of fluid loss, electrolytes,
acid-base inbalance

Pyloromyotomy – definite treatment

Prognosis – Excellent

11. 
Serve 2 vital functions:

(1) differentiating from other
causes of vomiting &
diarrhea

(2) estimating the degree of
dehydration
Acute Gastroenteritis – the History

Signs of infection

Fever

Chills

Myalgias

Rash

Rhinorrhea

sore throat

Cough

Appearance and behavior

Antibiotics

Travel History

Diarrhea

Vomiting

Urination

Abdominal pain

12. Acute Gastroenteritis (AGE)

Vomiting, Diarrhea, Abdominal Pain, +/- Fever

Rotavirus:

Most common cause of AGE in children

Peak age 3m-2 yr

Fever, vomiting, watery, non bloody diarrhea

Rotavirus vaccine – safe and effective vaccine again available

Norovirus(Norwalk):

Brief illness (3-8 days)

School age children-adults

Low grade fever, vomiting, copious watery diarrhea, malaise

13. Acute Gastroenteritis

Clostridium difficile

Antibiotic-associated diarrhea in children

Penicillin, cephalosporins, and clindamycin most likely causes

Children<12 months

TX: Metronidazole (30mg/kg/d divided qid X 7 days)

Parasites: Giardia and Cryptosporidium most common in US

Giardia acquired throug infected water, day care center outbreaks;
afebrile, watery diarrhea

Watery stools but can be differentiated from viral by prolonged course
or history of travel to endemic areas

TX: Metronidazole (30-50 mg/kg/d divided q8h) – drug of choice

14. Acute Gastroenteritis

E.coli, Salmonella, Shigella:

High fever, vomiting, bloody diarrhea, shaking chills, bacteremia

Spread via meat, eggs, poultry, animals

Rx:
• E.coli: TMP/SMX
• Salmonella typhi or infants <3 months: TMP/SMX
• Shigella: ampicillin, cipro in all cases

Supportive care

Campylobacter,

Fever, bloody stools, abdominal pain

Spread via meat, eggs, poultry, animals

Rx: erythromycin/azithromycin in severe cases

Supportive care

15. Acute Gastroenteritis

Toddlers Diarrhea

Non-ill, good nutritional status, large “soupy” stools

Caused by fruit juice excess.

16. Other Causes of Diarrhea

Antibiotic therapy

Pseudomembranous colitis (C. difficile)

Diet

Protein allergy

Malabsorption (Celiac Disease, CF, short
gut)

Metabolic

IBD

Carbohydrate intolerance.

17. AGE – Treatment Guidelines

Correct dehydration with oral rehydration

Treat specific causes appropriately

For non-dehydrating AGE, continue formula

May give oral electrolyte solution for large,
watery stools

Anti-diarrheal medications never indicated

Probiotics.

18. Dehydration

19. Dehydration

Any clinical state which causes excessive fluid
losses, decreased fluid intake or fluid shifts
can cause dehydration.

2 classification by AAP, CDC and WHO (see
tables)

SX/PE

Dry mucous membranes, decreased skin turgor,
sunken eyes, tachycardia, decreased urine output,
prolonged capillary refill time, lethargy, sunken
fontanelle

20. Assessment of Dehydration – AAP, CDC
Symptom or Sign No or Minimal
Dehydration
Mild to Moderate
Dehydration
Severe Dehydration
Mental status Alert Restless, irritable Lethargic, unconscious
Thirst Drinks normally Drinks eagerly Drinks poorly
Heart rate Normal Normal to increased Tachycardia
Quality of pulses Normal Normal to decreased Weak or unpalpable
Breathing Normal Normal or fast Deep
Eyes Normal Slightly sunken Deeply sunken
Tears Present Decreased Absent
Mouth and tongue Moist Dry Parched
Skin fold Instant recoil Recoil <2 seconds Recoil >2 seconds
Capillary refill Normal Prolonged Prolonged or minimal
Extremities Warm Cool Cold, mottled, cyanotic

21. Assessment of Dehydration - WHO

Severe dehydration - two of the following signs:

Lethargic or unconscious

Sunken eyes

Not able to drink or drinking poorly

Skin pinch goes back very slowly

Some dehydration – two of the following signs:

Restless, irritable

Sunken eyes

Thirsty, drinks eagerly

Skin pinch goes back slowly

No dehydration – not enough of the above signs to classify
as some or severe dehydration.

22. Dehydration - Treatment

Mild/ Moderate:

Oral rehydration solutions (ORS) containing 45 –
50 MEQ/L Na and 25-30g/L glucose (i.e. pedialyte,
infalyte)

Give 50 – 100ml/kg over 4 hours, 5 ml q1-2
minutes.

If well tolerated, increase slowly

Severe: medical emergency

IVF

23. Celiac Disease

24. Celiac Disease

Malabsorptive
disorder

Proximal small bowel
mucosa damage due
to dietary exposure to
gluten (wheat, rye,
barley)

Presents most often
at 6 months – 2 yrs of
age.

Common chronic
disorder - 1%-2%

Mostly northern
European descent,
but in all ethnic
groups

1/1000 in Europe
− 1/150 in Ireland

1/100 in America

Higher incidence in IDDM,
autoimmune thyroiditis,
Down's syndrome

25. Celiac Disease

Requires long term
exposure to gluten

Activity resides in the
gliadin fraction of
protein

Gliadin deaminated by
tissue transglutaminase
(tTG)

This product is presented
to human leukocyte
antigen (HLA) DQ2/DQ8

T- cell mediated
inflammatory
response

Villus atrophy

Crypt hyperplasia

Lymphocytic infiltration of
epithelium and lamina
propria

Proximal to distal, variable

↓ absorptive/digestive
capacity

↓pancreatic secretion

Anti tTG, anti-gliadin
AB

26. Celiac Disease

Presentation

FTT (Height <25th%; weight
<25th%)

Diarrhea

Irritability

Vomiting

Anorexia

Pallor

Abdominal distention

Wasted muscle

Neurological – ataxia due to
nutritional deficiencies

Osteopenia

Celiac crisis

27. Celiac Disease Presentation

Dermatitis
herpetiformis

Maculopapular rash
localized to extremities,
buttocks, face, neck and
trunk

Due to anti epidermal
transglutaminase.

10-20% of patients

All patients with rash have
celiac disease

28. Celiac Disease evalutation

CBC/CMP

Iron studies

Thyroid studies

Folate, b12, fat soluble
vitamins

tTG IgA

Endomysial IgA

Anti-gliadin Ig A/Ig M

Less specific

Small bowel biopsy X 4

29. Celiac Disease treatment

Lifelong, strict gluten
free diet

wheat, barley, rye,
contaminated oats

Found in many processed
foods

Gastroenterology

Nutrition

Initial poor weight gain
may be treated with
pancreatic NZ
Prognosis is good

Changes within 1 week of
therapy

Once in remission – well
child

Teenagers non-compliant
− Growth failure/delayed
sexual maturation

Associated
malignancies

Non-hodgkins lymphoma
(6x risk)

Esophagus, pharynx,
stomach, intestines

30. Celiac Disease

Consider offering serological testing for
celiac disease to children and adults
with any of the following:

Addison's disease

Amenorrhoea

Aphthous stomatitis (mouth ulcers)

Autoimmune liver conditions

Autoimmune myocarditis

Chronic thrombocytopenia purpura

Dental enamel defects

Depression or bipolar disorder

Down's syndrome

Epilepsy

Low-trauma fracture

Lymphoma

Metabolic bone disease (such as rickets or
osteomalacia)

Microscopic colitis

Persistent or unexplained constipation

Persistently raised liver enzymes with unknown
cause

Polyneuropathy

Recurrent miscarriage

Reduced bone mineral density

Sarcoidosis

Sjögren's syndrome

Turner syndrome

Unexplained alopecia

Unexplained subfertility

31. Functional Constipation

Idiopathic constipation or fecal
withholding

Starts after neonatal period

Cause:

painful bowel movements
with voluntary withholding
of feces to avoid painful
stimulus

Perianal inflammation from
milk protein allergy

S&S:

Typical behaviors

Daytime encopresis

BRB in the stool

TX

Patient education

Relief of impaction
− Miralax -polyethylene
glycol

Softening of stool
− Mineral oil

Bowel training

Maintenance therapy (stool
softeners) for several months
after regular bowel pattern
has been established

32. Hirschsprung's Disease

A cause of constipation early in infancy

33. Hirschsprung's Disease

Congenital aganglionic megacolon ( Meissner and Auerbach
plexus)

Absence of enteric neurons within the myenteric and
submucosal plexus of the rectum and/or colon

Abnormal innervation beginning in the anal sphincter,
extending up

75% limited to rectosigmoid

10% involve entire colon

1-5000 live births

25-30% mortality

4:1 M:F

Diagnosed in first 2 years of life.

34. Hirschsprung's Disease

Delayed passage of meconium at birth

99% full term pass within 48 hours

Chronic constipation

FTT, hypoproteinemia(less common)

Failure to pass leads to bowel dilation, leading to
bacterial overgrowth – sepsis

Bowel obstruction

Rectal exam can lead to explosive discharge

Down's Syndrome

5-15%

35. Hirschsprung's Disease

S &S

Distension

Delayed passage of meconium

Soiling and overflow incontinence

Chronic constipation

Malnourishment – secondary to abdominal
discomfort and distention

Hirschsprung enterocolitis – complication
− Abdominal pain, fever, foul-smelling and/or bloody
diarrhea, vomiting
− May lead to sepsis if not recognized early

36. Hirschsprung's Disease

Physical exam

Tympanic abdominal distention

Marked abdominal distension with palpable dilated
loops of colon

Empty rectal vault

Forceful expulsion of material after rectal exam

37. Hirschsprung's Disease

Imaging

Plain abdominal radiography – distended loops

Single contrast barium enema
− Transition zone

Procedures
– Full thickness rectal biopsy

Definitive diagnosis

Absence of ganglion cells

38. Hirschsprung's Disease

Treatment
– reestablishing normal fluid and electrolyte
balance
– IVF, nasogastric decompression, and, as
indicated, IV antibiotics

Operative intervention

Excise aganglionic segment

Broad spectrum abx– for enterocolitis
prevention

Prognosis

Most achieve fecal continence

39. Intussusception

Common cause of bowel obstruction in
children. It occurs when a segment of small of
bowel “telescopes” on itself, thus causing
swelling, obstruction, and eventually intestinal
gangrene

40. Intussusception

Telescoping of part of the alimentary tract into
an adjacent segment

Most common cause of acute intestinal obstruction
under age 2
− Age range between 3 months – 5 years
− 80% cases <2 yrs (rare in neonates
− 4x more common in males

Cause mostly unknown

5-10% with recognizable lead points (intestinal
polyp, Meckel's diverticulum, cystic fibrosis)

41. Intussusception

Pathophysiology: the
upper portion of the
bowel, the invaginates
into the lower portion,
dragging the mesentary.
Constriction causes
venous obstruction,
engorgement, edema,
and bleeding

42. Intussusception
signs and symptoms

Classic Triad

sudden severe paroxysmal
colicky pain,

bilious vomiting early

Currant jelly stools – a late
finding

Decreased stools, then blood
passed usually first 12 hours up to
1-2 days.

Dance sign: abdominal mass in
RUQ with empty RLQ

Increasing abdominal tenderness
and distension

Late sign – lethargy, shock-like
syndrome with high fever

43. Intussusception

DDX

Enterocolitis, Meckel's
diverticulum, Henoch-
Schonlein Purpura

Diagnosis

Plain abdominal radiographs

Contrast enema

Ultrasound – test of choice –
shows “target” or “donut sign”

Treatment

Reduction by air enema
− Failure -immediate surgery

Patient with shock, signs of
intestinal perf – surgery

10% recurrence with reduction

44. Meckel's diverticulum

Remnant of embryonic yolk sac

2-3% of all infants

Symptoms arise during 1st 2 yr of life,
common during 1st decade.

Lined with ectopic acid secreting
mucosa, causing ulceration of
adjacent normal ileal mucosa

S&S painless rectal bleeding, brick or
current jelly stools

Complications: anemia,
intussusception, volvulus,
diverticulitis – presenting like
appendicitis

DX- difficult – most sensitive is
radionuclide scan.

TX- surgery.

45. Appendicitis

46. Appendicitis

Most common condition requiring emergency
surgery in children

Perforation rates of 30-60%(50% whom have been
seen by a pediatrician)

70-75% of children 1- 4 years perforate

Obstruction of the appendix results in a marked
increase in intraluminal pressure

Due to fecalith, may calcify appendicolith (15-20%)

Classic triad – pain, vomiting, and fever

Periumbilical then migrates

47. Appendicitis

Clinical diagnosis

Labs – to rule out other diagnosis

CT scan & US

Indicated for patients in whom diagnosis is
equivocal – not a requirement for all patients.

CT – 97% accurate – radiation exposure.

The definitive treatment for appendicitis is
appendectomy

48. Indirect inguinal hernia

49. Inguinal hernia

1-2% full term births
(30% perterm)

4x more common in
males

Most in the first 6
months of life

Indirect due to
patency of
processus vaginalis

50. Inguinal hernia

Bulge in the inguinal region
that extends towards or into
the scrotum

Painless

Increases with crying

Operative repair roon after
diagnosis

30% will develop contralateral
hernia

If boy<1 year, girls <2
years – so explore
contralateral side

51. Inguinal hernia

Complications

Incarceration, when
the hernia sac
cannot be reduced

First year of life (6m)

Females- ovaries
can become
incarcerated

Sings of abdominal
obstruction
− Vomiting,
constipation

52. Inguinal hernia

Reduce manually

Place patient in trendelenburg position,
sedation

After reduction – surgical correction 24-48 hours

If can't reduce or male with undescended testis,
prompt surgery

53. Testicular Torsion

54. Testicular torsion

Most common cause of testicular pain in boys
12 yeas and older (uncommon <10 years)

Can occur in fetus or neonate

Due to inadequate fixation of the testes to the
scrotum allowing for excessive movement

Venous obstruction, edema, interrupted arterial
flow, necrosis

55. Testicular Torsion

S &S – acute pain, scrotal
swelling, absent cremasteric
reflex

Diagnosis:Untrasound with
doppler scanning for blood
flow

Treatment: surgical detorsion
<4-6 hours, can try manuel
detorsion. Also fix
contralateral testis

90% survival in testis torsion
<6 hours

56. Testicular Torsion

57. Hydrocele

58. Hydrocele

Accumulation of fluid in the tunic vaginalis

1-2% of males

Communicating processus vaginalis vs non
communicating (most common)

Noncommunicating resolves by 1 yr

If communicating will persists, larger during the
day, small in the morning.

59. Hydrocele

Smooth and non-tender

transillumination

Differentiate from an
inguinal hernia

If persists 12-18 months,
likely communicating,
correct surgically (ligate the
processus vaginalis)

60. Cryptorchidism

61. Cryptorchidism

3-4% full term males

30% preterm

Usually in the inguinal canal

Most descend spontaneously
by 9 months, if not by 1 year –
needs careful evaluation

Intraabdominal or high up in
inguinal canal

May only find a remnant that
results from torsion in utero

62. Cryptorchidism

Treat at 9-15 months by orchipexy

If testis not palpable, assess via ultrasound or
laparoscopy

Sequelae

Infertility

Malignancy
− Risk is 1 in 80 in unilateral diseae, 1 in 40 in bilateral
− Seminoma, peak 15-45 yrs

Associated heria

torsion

63. Gastroesphageal Reflux
Retrograde movement of gastric contents across the
lower esophageal sphincter into the esophagus
Most common esophageal disorder in children of all ages
Pathologic when
-Episodes are frequent or persistent
-Esophagitis/esophageal symptoms
-Respiratory sequelae

64. Gastroesophageal Reflux
Cause:
Insufficient LES tone
Abnormal frequency of LES relaxations
Hiatal herniation
History:
Infants; Symptomatic in first year of life, peaks at 4
months, resolves by 12 months.
Older children; chronic, waxing and waning

65. Gastroesophageal reflux
Signs and symptoms:
-Regurgitation
-Esophagitis; irritability, arching, choking, gagging,
feeding aversion
-Abdominal pain and chest pain in older children
-obstructive apnea
-stridor

66. Gastroesophageal Reflux
Diagnosis:
-Contrast radiographic study (barium) – barium swallow
• Rule out achalasia, strictures, hiatal hernia, gastric
outlet obstructions
-Esophageal pH monitoring
• Distal esophagus
• To monitor treatment efficacy
• Esophageal pH<4 only 5-8%
- EGD- esophagogastroduodenoscopy
• Erosive esophagitis, strictures or Barrett esophagus
-Laryngotracheobronchoscopy
• Extraesophageal GERD

67. Barium Esophagram

68. Gastroesophageal Reflux
Treatment:
Conservative lifestyle changes
• Positioning:
– Elevate head of bed
– Prone better – BUT NOT TO SLEEP – BACK TO
SLEEP to prevent SIDS
• Dietary:
– Scheduled feedings
– Smaller more frequent feeds
– Hypoallergenic diet
– Avoid acidic foods and drinks
– Thickened formula
» 1 tbsp of rice cereal per oz of formula
» Formulas thickened with rice starch

69. Gastroesophageal Reflux
Treatment
Pharmacotherapy
• Antacids – not recommended
• Histamine – 2 receptor antagonists
• PPI
• Prokinetic agents
Surgery
• fundoplication

70. Gastroesophageal Reflux
Complications:
• Esophagitis
• Barrett esophagus
• Adenocarcinoma
• FTT
• Respiratory (atypical )presentations
– aspiration
• Apnea
– Laryngospasm as a protective reflex
• Stridor
• Dental erosions

71. Hyperbilirubinema
● Bilirubin is a tetrapyrrole
created by the normal
breakdown of heme, it
is insoluble in water if
not conjugated.
● Jaundice is the yellowish
pigmentation of the
skin and conjunctiva
due to excess bilirubin

72. Hyperbilirubinemia

73. Hyperbilirubinemia

Conjugated due to impaired excretion(cholestasis) – hepatobiliary disease

Infectious

Toxic

Metabolic

Intra hepatic

Extrahepatic
− Biliary atresia
Unconjugated (deficient conjugation/hemolysis)
●
Physiologic of newborn
●
Breastfeeding jaundice
●
Crigler-Najjar
●
Gilbert’s Syndrome
●
Metabolic (Galactosemia)
●
Endocrine (Hypothyroidism)
●
ABO incompatibility

74. Viral Hepatitis

Hepatitis B vaccine given at birth, 2 and 6
months

Perinatal exposure to an HbsAg-positive mother.

Hepatitis A

Fecal-oral route

vaccine given at 12 months and 4 years

75. Hepatic Toxicities

Acetaminophen (paracetamol) overdose

Found in over 200 OTC preparations

most common cause of acute liver failure and overdose deaths

children younger than 12 years and/or less than 50 kg in weight, the maximum
daily dosage is 80 mg/kg (not to exceed a cumulative daily dose of 2.6 g).

Therapeutic dosing for children younger than 12 years is 10-15 mg/kg every 4-
6 hours with a maximum of 5 doses per 24-hour period. Weight-based rectal
suppository dosing for children is higher at 15-20 mg/kg per dose.

minimum toxic dose of acetaminophen (APAP) for a single acute ingestion is
150 mg/kg. Medical toxicologists recommend increasing this threshold to 200
mg/kg in healthy children aged 1-6 years.

Children who have acutely ingested 250 mg/kg or more of acetaminophen
(APAP) pose significant concern for acetaminophen (APAP)-induced
hepatotoxicity. Patients who ingest more than 350 mg/kg develop severe
hepatotoxicity, if they are not appropriately treated.

N-acetylcysteine administered with 16hr and even up to 36 hr after ingestion
is effective in preventing hepatotoxicity

76. Hepatic Toxicities

Reye's syndrome

Acute encephalopathy and fatty degeneration of the liver

Associated with influenza B and varicella infection

40% mortality rate

Rare today

Abrupt onset of protracted vomiting within 5-7 days of viral illnes,
delirum, combative behavior and stupor ensue rapidly
progressing to seizure, coma, and death

Suggested etiologic link among Reye's, viral infection and aspirin
use – AVOID THE USE OF ASPIRIN AS AN ANTIPYRETIC IN
THE PEDIATREIC PATIENTS WITH INFLUENZA B OR
VARICELLA

77. Special Populations

Down's syndrome

Intestinal malabsorption

Diabetes mellitus

Duodenal atresia

Hirschsprung's

Celiac disease

Cystic Fibrosis
– exocrine pancreatic
insufficiency
• Diabetes

Liver failure

Biliary cirrhosis

Pancreatitis

Cholelithiasis

Chronic diarrhea

Intestinal obstruction -
intussusception

Rectal prolapse

78. Summary:

Vomiting/diarrhea

Pyloric stenosis

AGE

dehydration

Constipation

Functional constipation

Hirschsprung's disease

Acute Abdomen

Intussusception

Meckel's diverticulum

Appendicitis

Inguinal hernia

Testicular torsion

Hydrocele

Cryptorchidism

Hepatic Pathology

Hyperbilirubinemia

Viral hepatitis A and B

Hepatic toxicities
− Acetaminophen overdose
− Reye's syndrome

Special Populations

79. Nutrition
Kwashiokor/marasmus
Vitamin deficiencies
C, D, A, zinc, B
complex
Foreign body aspiration
Esophageal/duodenal/
biliary atresia
Failure to thrive.
Short gut syndrome
Lactase deficiency