Digestive system

1. Notes for topic
The digestive system in children.
Semiotics of the digestive organs
diseases in children.

2. DIGESTIVE SYSTEM CONGENITAL ABNORMALITIES
Annular pancreas
A bilobed ventral pancreatic bud (a normal variation) can be
form, but placed in opposite directions around the duodenum
to fuse with the dorsal pancreatic duct, rather than taking its
usual dorsal route. It can cause the duodenum to be
compressed, leading to gastrointestinal obstruction.

3. Symptoms
Approximately one-third of patients with annular pancreas
develop symptoms. The time when symptoms occur depends
upon the severity of the intestinal blockage. Those with
severe blockage are present in a baby with
• vomiting,
• inability to tolerate milk or formula.
• sometimes the vomited fluid has bile (color green or
yellow).
Later signs/symptoms seen in older children include:
• abdominal pain,
• feeling full early during meals,
• vomiting,
• not wanting to eat
https://eapsa.org/

4. X-rays taken after birth
may reveal a “double-
bubble sign" or evidence
of an intestinal blockage.

5. Meckel’s diverticulum
Meckel’s diverticulum consists of an intestinal outgrowth
projecting from the mesenteric wall of the ileum near the
cecum. This is caused by failure of the vitelline duct to
complete regress.
Most cases of Meckel’s diverticulum are asymptomatic.
However, up to 3% of individuals with this condition can
develop symptoms of
• intestinal obstruction,
• gastrointestinal bleeding,
• or peritonitis.
Symptoms can also mimic an appendicitis, involving
periumbilical pain localized on the right lower quadrant.
https://www.kenhub.com/en/library/anatomy/development-of-digestive-system

7. The midgut undergoes a
physiological herniation
into the umbilicus
before retracting back
to the abdominal cavity.
If a retraction does not
occur, the infant may be
born with an umbilical
hernia or an
omphalocele.
Omphalocele

8. umbilical hernia omphalocele
In contrast to the former, an omphalocele involves a
larger herniation that may consist of an entire bowel or
a liver.

9. Gastroschisis
Gastrochisis involves the protrusion of abdominal
viscera through the anterior body wall, lateral to the
umbilicus (usually on the right).
Unlike an
omphalocele, in
gastroschisis the
umbilical ring closes,
therefore the
herniation occurs
lateral to the
umbilicus rather
than through it.

10. Cleft lip
oropharingeal membrane development anomalies

11. Rectal atresia
Rectal atresia is a rare cause of failure to pass meconium.
Symptoms:
• chronic vomiting,
• not passing meconium since birth and
• a progressive abdominal distension.
The perineal examination objectified a normally placed
anus with no perineal fistula.

12. Hypertrophic Pylorostenosis
Pyloric stenosis is a
narrowing of the opening
from the stomach to the
first part of the small
intestine (the pylorus).
Symptoms include projectile
vomiting without the
presence of bile. This most
often occurs after the baby
is fed. The typical age when
symptoms become obvious
is 2 to 12 weeks old. Weight
loss, dehydration state.

13. Gastric peristaltic wave in an infant with pyloric stenosis.

14. Barium in the stomach of an infant with projectile
vomiting. The attenuated pyloric canal is typical of
congenital hypertrophic pyloric stenosis
https://obgynkey.com/pyloric-stenosis-and-other-congenital-anomalies-of-the-stomach/

15. The further intensive
development of the
stomach occurs in
period after child birth.
It is a rule that the
stomach physiological
capacity is smaller than
its anatomical capacity
to intake the food.

16.  There is the functional insufficiency of stomach
cardiac sphincter closing function. It predisposes
small children to spitt up all the time.
Once a more serious disease (gastroesophageal reflux
disease) is ruled out, there is a number of things parents and
other caretakers can do to help prevent babies from
constantly spitting up:
• Holding the baby in an upright position when feeding.
• Feeding the baby with smaller portions at a time.
• Making a switch to a different formula.
https://www.fda.gov/consumers/consumer-updates/babies-spitting-normal-most-cases

17.  The small intestine has comparatively greater
length in calculation on body growth in early
children (aged less then 3 years) in comparison
with adult persons. This big length of intestine
reflects the low caloric and liquid type of early
children meals – mainly breast or cow milk.
 The intestinal loops lies more portably because
comparatively big liver occupies big volume of
abdominal cavity in infants and at the same
time the pelvis is not developed yet.
 The location of intestinal loops becomes
constant only in children in their second year of
life.

18. The maturation of large intestine becomes
similar to the maturation in adults only in
children aged 3-4 years.
The caecum of newborn has a cone-shaped or
cratered form and is situated higher then in
adults.
The bowel mesentery is most mobile.
The higher mobility of the caecum mesentery
predisposes young children to intestinal
intussusceptions.
The ascendant part of colon (colon ascendens)
is very short in newborn.

19. The sigmoid colon in early children is situated
usually in abdominal cavity instead of pelvis.
Reсtum is also comparatively long and can
occupy all the small pelvis in infants.
The fatty cellular masses surrounding the rectum
seem to be absent. It leads to high mobility of
the rectum and predisposes to easy organs`
prolapses.
The rectum gets a good fixation only in children
older than 2 years.

20. The bowel of embryo is sterile in uteri. The
colonization by necessary microbiota starts
immediately after birth and lasts about one
week in infants in breast feeding.
The Lactobacillus and Bifidobacteriaceae play
the most comprehensible role in bowel because
they help to accept milk.
It is necessary to help to the baby to create his
or her own desirable bowel microbiota
immediately after birth making all the best for
accurate nursing and colostrum intake. The baby
mouth has to contact only with mothers` breast
skin.

21. During the first months of life the physiological role
of salivary glands in children is very small.
The condition of digestive organs at the moment of
the human baby birth is characterized by their
common immaturity and only breast (or milk)
feeding can provide for newborns acceptable
possibilities to survive.

22. The amylolytic activity of pancreas is getting
mature only in 4-5mo aged children.
The liver function is lower.
The bile contains less amount of bilious acids. Its
predispose physiological steatorrhea in newborns.
In children aged less then one year the activity of
gastric lipase is comparatively higher then in
adults because of its ability to hydrolyze milk fats
in stomach in conditions of liver bile acids
absence.

23. Meconium (Newborn poop) is the earliest poop.
meconium is composed of intestinal epithelial
cells, lanugo, mucus, amniotic fluid, bile and
water. Its color is usually very dark olive green.

24. The baby's poop
breastfed poop
is yellow or slightly green and have a mushy or
creamy consistency. Its smell isn't half bad.

25. formula-fed poop
is pasty, peanut butter-like poop on the brown
color spectrum: tan-brown, yellow-brown, or
green-brown.

26. Solid-food poop
Is brown or dark brown and thicker than peanut
butter, but still mushy. It's also smellier.

27. The Bristol Stool Form Scale
This scale is a useful tool to evaluate stool.

28. Characterization of signs and symptoms:
• identify factors that trigger or alleviate the
symptom,
• the timing,
• frequency,
• duration of symptoms;
• relationship to meals and defecation;
• and associated symptoms (e.g., fever or weight
loss).

29. Inspection:
the oral cavity:
• mucosa,
• throat,
• tonsils (color –
• normal, pink, hyperemia)
• dry or moist mucous
• coated tongue, follicles, fissures,
• geographic tongue
• teeth (temporary, permanent,
teeth formula, caries)

30. Shape and size of the abdomen:
• flat,
• size,
• symmetrical abdomen
• bulges|masses,
• distention, or diastasis recti;
• distended abdomen,
• scaphoid abdomen,
• board-like rigidity,
• frog abdomen,
• peristalsis,
• respiratory movement,
• umbilical veins,
• hernia.

31. Ascites
is accumulation of fluid in the abdominal cavity.
Common causes of ascites are liver disease or
cirrhosis, cancers, and heart failure, nephrotic
syndrome.

32. abdomen is scaphoid

33. board-like rigidity is spastic rigidity of abdominal
wall muscles induced by acute peritonitis.

34. Examination of the perianal area
• gaping anus,
• mucosal prolapse of the rectum,
• fissures of the anus.
mucosal prolapse of the rectum

35. Vomiting and regurgitation (spitt up)
Causes:
• pyloric stenosis
• pylorospasm
• passage lesion in the intestine
• overfeeding
• intoxication
• brain disorders

36. Diarrhea
Diarrhea is when stools (bowel movements) are
loose and watery.
Short-term (acute). Diarrhea that lasts 1 or 2 days
and goes away.
This may be caused by food or water that was
contaminated by bacteria or virus.
Long-term (chronic). Diarrhea that lasts for a few
weeks. This may be caused by another health
problem such as irritable bowel syndrome, celiac
disease, malabsorption.

37. Diarrhea may be accompanied by
• anorexia,
• vomiting,
• acute weight loss,
• abdominal pain,
• fever,
• passage of blood.
Acute diarrhea is severe or prolonged,
dehydration is likely.
Chronic diarrhea usually results in weight loss or
failure to gain weight.

38. Red flags of Diarrhea
• Tachycardia,
• hypotension, and lethargy (significant
dehydration)
• Bloody stools
• Bilious vomiting
• Extreme abdominal tenderness and/or
• distention
• Petechiae and/or pallor
https://www.msdmanuals.com/professional/pediatrics/symptoms-in-infants-and-
children/diarrhea-in-children

39. Dehydration (exicosis)
Dehydration occurs when too much fluid has been
lost from the body.
SIGNS OF DEHYDRATION
• Dry mucous of mouth and lips
• Reduced turgor
• Increased thirst
• Decreased urine output (dark urine)
• Lack of tears when crying
• Sunken eyes
• Sunken fontanelle

41. ABDOMINAL PAIN
Abdominal pain can result from injury to
the intraabdominal organs or overlying
somatic structures in the abdominal wall,
or from extraabdominal diseases.

42. REFERRED PAIN
is a painful sensation in a body region distant from
the true source of pain.
Stomach pain is referred to the epigastric and retrosternal regions. liver and
pancreas pain is referred to the epigastric region. Gallbladder pain often is referred
to the region below the right scapula.

43. ACUTE ABDOMINAL PAIN is presence of a
dangerous
• intraabdominal process (e.g., appendicitis or
bowel obstruction)
• or may originate from extraintestinal sources
(e.g., lower lobe pneumonia or urinary tract
stone).
Not all episodes of acute abdominal pain require
emergency intervention.

44. Surgical emergencies, such as bowel
obstruction or appendicitis, must be
identified rapidly in children with acute
abdominal pain.
Common distinguishing characteristics
include pain that is accompanied by
• vomiting,
• tenderness,
• abdominal wall rigidity.

45. INTUSSUSCEPTION
is the invagination (telescoping) of a proximal
segment of bowel into the distal bowel lumen.
https://www.rch.org.au/clinicalguide/guideline_index/Intussusception/

46. • Most cases occur in infants 1-2 years old.
• In young children, ileocolonic intussusception is
common; the ileum invaginates into the colon,
beginning at or near the ileocecal valve.
• This process leads to bowel obstruction, venous
congestion and bowel wall ischaemia. Perforation can
occur and lead to peritonitis and shock.

47. Clinical Manifestations of the Intussusception
• Intermittent acute abdominal pain
• Episodes can increase in frequency over the next 12–
24 hours. The child may appear very well between
episodes
• Pallor, especially during episodes
• Lethargy may be the only presenting symptom. It may
be profound, episodic or persistent
• Vomiting is usually a prominent feature (but bile
stained vomiting is a late sign and indicates a bowel
obstruction)
• Diarrhea is quite common initially and can lead to a
misdiagnosis of gastroenteritis.

48. Rectal bleeding or the classic “red currant jelly”
stool are late signs suggesting bowel ischemia
and infarction

49. • Abdominal mass may be palpated – typically a
sausage shaped mass in the right abdomen,
crossing the midline in the epigastrium or behind
umbilicus (in 2/3 of children). The abdominal mass
may be subtle and examination is best performed
when the child is settled in between episodes

50. • Abdominal distension
suggests bowel
obstruction
• Tenderness or guarding
may suggest perforation
and peritonitis
Abdominal guarding is the
tensing of the abdominal
wall muscles to guard
inflamed organs within the
abdomen from the pain of
pressure upon them.
The tensing is detected
when the abdominal wall is
pressed.

51. APPENDICITIS
a serious surgical condition in which the
appendix becomes inflamed and painful.
It occurs usually after 3-4 years of age.

52. • acute abdominal pain,
localized to the periumbilical
region and then it migrates
to the right lower abdominal
region (Kocher symptom)
• nausea and vomiting
triggered by the appendiceal
distention
• tender right lower quadrant
• guarding is present
initially, progressing to
rigidity

54. FUNCTIONAL ABDOMINAL PAIN
• typical for children between ages 7 and 12 years
• the pain is not associated with meals or relieved
by defecation
• the pain is associated with stress at school
• the pain often is worst in the morning and often
prevents or delays children from attending school
• use Rome III Criteria for Pediatric Functional
Gastrointestinal Syndromes diagnostics

55. COLIC PAIN IN INFANTS
Wessel’s rule of threes for colic diagnostic
crying for more than 3 hours per day,
at least 3 days per week,
for more than 3 weeks.
Infantile colic does not have untoward longterm effects.

56. Colicky crying is often described as paroxysmal
and may be characterized by facial grimacing, leg
flexion, and passing flatus. NELSON ESSENTIALS OF PEDIATRICS, EIGHTH EDITION
INTERNATIONAL EDITION Copyright © 2019 by Elsevier, Inc.