Posted in Pediatrics

Children can have a wide range of gastrointestinal disorders, and exams will require you to be able to differentiate between each one. This lesson provides a brief overview of some common pediatric GI disorders. 

Gastroesophageal reflux disease (GERD)

đź’ˇ WHAT IS GERD?
Gastroesophageal reflux disease (GERD) involves stomach acid repeatedly flowing into the esophagus, causing irritation to the mucosal tissue.

Risk factors for GERD include prematurity, cystic fibrosis, neurological impairments, scoliosis, hiatal hernia, esophageal atresia, obesity, and asthma. When GERD occurs in infants, it may resolve on its own by around 12 months of age.

Signs and symptoms of GERD

  • Crying, irritability
  • Vomiting or spitting up repeatedly
  • Poor appetite, refusal to eat or difficulty with feeding
  • Arching of the back in infants
  • Weight loss or inability to gain weight
  • Choking or difficulty swallowing
  • Coughing or wheezing
  • Abdominal pain or heartburn in older children

Complications of GERD

  • Failure to thrive
  • Esophagitis

Treatments for GERD

  • Offer infant small, frequent feedings
  • Keep the child upright for 30 to 60 minutes after eating
  • If breastfeeding, avoid foods that can cause reflux such as spicy foods or caffeine
  • Some infants benefit from avoiding soy and cow’s milk
  • Thicken formula or breastmilk
  • Medications include H2 receptor antagonists (ex: ranitidine) or a proton pump inhibitor (ex: pantoprazole)
  • In severe cases, a surgical procedure called Nissen fundoplication may be required. In this procedure, the fundus of the stomach is wrapped around the distal esophagus. The result is decreased reflux, but it also limits the child’s ability to vomit.

Hirschsprung disease

đź’ˇ WHAT IS HIRSCHPRUNG’S DISEASE?
Hirschsprung disease (HD) is a congenital disorder of the colon in which segments of the colon lack ganglionic cells. The result is decreased colonic motility and obstruction. It is often associated with other chromosomal abnormalities such as Down syndrome.

Signs and symptoms of Hirschsprung disease

  • Failure to pass meconium or stool
  • Abdominal distention
  • Bilious emesis (vomiting bile)
  • Poor feeding or refusal to eat
  • Episodes of diarrhea and constipation
  • Foul-smelling ribbon-like stools
  • Explosive passage of diarrhea and gas after digital rectal examination (also known as “squirt sign” or “blast sign.”
  • Older children may have a palpable mass and visible peristalsis

Complications of Hirschsprung disease

  • Toxic megacolon – Severe inflammation of the colon that can result in colonic rupture
  • Enterocolitis – inflammation of the bowel
  • Volvulus – A loop of intestine twists around itself to cause an obstruction
  • Anal stricture – may require dilation

Treatments for Hirschsprung disease

  • Surgery to remove the affected areas of the colon. In most cases the child’s rectum and anal sphincter function remains intact, so no colostomy is needed.
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Intussusception

đź’ˇ WHAT IS INTUSSUSCEPTION?
Intussusception is a condition in which a section of the intestine folds inside another section, causing obstruction and edema. It is most common between the ages three months to six years, and boys are four times as likely to be affected as girls. The exact cause is unknown, though viral infections are known to be responsible in some cases.

Signs and symptoms of intussusception

  • Colicky abdominal pain
  • The child may draw the knees up to the chest and cry loudly during bouts of pain
  • Vomiting
  • Red jelly-like stools (mucus and blood together)
  • A sausage-shaped abdominal mass may be palpable when the abdomen is soft
  • Abdominal distention

Complications of intussusception

  • The telescoped intestine can block blood flow to the area, leading to ischemic bowel
  • GI bleeding
  • Peritonitis

Treatments for intussusception

  • Enema to infuse fluid or air into the GI tract, which pushes the telescoped bowel back into position.
  • Surgery may be necessary if the enema is ineffective or if intussusception reoccurs.

Hypertrophic pyloric stenosis

đź’ˇ WHAT IS HYPERTROPHIC PYLORIC STENOSIS?
Hypertrophic pyloric stenosis  (HPS) is a condition in which the pylorus thickens and becomes too large, blocking the passage of food from the stomach to the small intestine. The result is severe and forceful vomiting. It usually develops between three and five weeks of age, with males having a 5:1 incidence when compared to females.

While the cause is unclear, certain antibiotics (azithromycin and erythromycin) have been associated with increased risk for HPS when utilized in young infants. Other risk factors include maternal smoking, bottle feeding and a family history of HPS.

Signs and symptoms of hypertrophic pyloric stenosis

  • Forceful or projectile vomiting after feeding
  • Weight loss
  • Dehydration
  • Infant demanding to be fed after vomiting (always hungry)
  • An “olive-like” mass in the right upper quadrant may be present
  • Visible peristalsis

Complications of hypertrophic pyloric stenosis

  • Failure to thrive
  • Electrolyte imbalance
  • Severe dehydration

Treatment for hypertrophic pyloric stenosis

  • Surgical pyloromyotomy, in which the surgeon makes small cuts in the pylorus so that food is able to pass from the stomach into the small intestine.

Biliary atresia

đź’ˇ WHAT IS BILIARY ATRESIA?
Biliary atresia is a progressive disease of the extrahepatic biliary tree that causes biliary obstruction. It is the most common indication for liver transplantation in children.

Signs and symptoms of biliary atresia

  • Jaundice appearing any time from birth up to about eight weeks of age
  • Pale stools
  • Dark urine due to excretion of bilirubin
  • Enlarged liver and splenomegaly as the condition progresses
  • Elevated conjugated/direct bilirubin

Complications of biliary atresia

  • Failure to thrive
  • Cirrhosis occurs within 6 months if not treated
  • Liver failure occurs within 12 months if not treated

Treatments for biliary atresia

  • Kasai procedure, which is a surgical procedure to restore the proper flow of bile
  • Liver transplant if Kasai procedure is ineffective

Meckel’s diverticulum

đź’ˇ WHAT IS MECKEL’S DIVERTICULUM?
Meckel’s diverticulum is a small outputching that extends from the wall of the lower small intestine. It is a remnant of tissue from embryonic development and is the most common congenital abnormality of the gastrointestinal system. The pouch lining is made up of acid-secreting tissue or pancreatic tissue. In most individuals, the diverticulum doesn’t cause symptoms. However, acid secretion can cause intestinal ulcers in some patients.

Meckel’s diverticulum is a small outputching that extends from the wall of the lower small intestine. It is a remnant of tissue from embryonic development and is the most common congenital abnormality of the gastrointestinal system. The pouch lining is made up of acid-secreting tissue or pancreatic tissue. In most individuals, the diverticulum doesn’t cause symptoms. However, acid secretion can cause intestinal ulcers in some patients.

Signs and symptoms of Meckel’s diverticulum

  • Painless rectal bleeding (dark red or maroon stools)

Complications of Meckel’s diverticulum

  • Bleeding ulcer
  • Perforated ulcer, leading to abdominal pain and peritonitis
  • Intestinal obstruction due to intussusception
  • Volvulus

Treatment for Meckel’s diverticulum

  • Surgery to resect the diverticulum

Short bowel syndrome

đź’ˇ WHAT IS SHORT BOWEL SYNDROME?
Short bowel syndrome is a condition of malabsorption that is a result of small intestine surgical resection, diseases that cause loss of nutrient absorption (such as necrotizing enterocolitis), and congenital malformations. Children with SBS are unable to fully absorb necessary nutrients and fluids. It is the leading cause of intestinal failure in pediatrics and often results in the child receiving parenteral nutrition.

Signs and symptoms of short bowel syndrome

  • Poor weight gain and growth
  • Dehydration
  • Electrolyte imbalance
  • Watery diarrhea

Complications of short bowel syndrome

  • Severe dehydration and electrolyte imbalance
  • Failure to thrive
  • Intestinal failure-associated liver disease
  • Development of oral aversion and poor appetite

Treatments for short bowel syndrome

  • Parenteral nutrition initially, followed by slow introduction of enteral feeding
  • Optimize fluids
  • Vitamin and mineral supplementation
  • Appetite stimulant may be utilized for children with poor appetite
  • Medications to alleviate or reduce diarrhea such as loperamide or cholestyramine
  • Surgical intervention may be utilized in some cases to lengthen or reconstruct the intestine
  • Some children may be candidates for small bowel transplantation

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Quiz time!

🧠 Quiz time!

Q: What condition involves red jelly-like stools and the child drawing their knees up to their chest when in pain?

Q: What condition involves an “olive-like” mass and projectile vomiting?

Q: What condition is treated with a liver transplant?

Q: What condition can cause esophagitis, failure to thrive, and swallowing difficulties?

Q: What condition involves bilious emesis and foul smelling, ribbon-like stools?

Q: What condition is treated with a fluid or air enema?

Q: What condition involves painless rectal bleeding?

Q: What condition requires at least temporary parenteral nutrition?

Q: What condition involves a failure to pass meconium?

Q: What condition is associated with jaundice of the newborn?

Q: What condition is treated with a Nissen fundoplication?

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References:

American Academy of Otolaryngology–Head and Neck Surgery Foundation. (2019, July). Pediatric Gastroesophageal Reflux Disease (GERD). ENT Health. https://www.enthealth.org/conditions/pediatric-gastroesophageal-reflux-disease-gerd/

Boston Children’s Hospital. (n.d.). Intussusception. Boston Children’s Hospital. Retrieved March 18, 2024, from https://www.childrenshospital.org/conditions/intussusception

Caporilli, C., Giannì, G., Grassi, F., & Esposito, S. (2023). An Overview of Short-Bowel Syndrome in Pediatric Patients: Focus on Clinical Management and Prevention of Complications. Nutrients, 15(10), 2341. https://doi.org/10.3390/nu15102341

Chahine, A. A. (2023, November 7). Intussusception Clinical Presentation. MedScape. https://emedicine.medscape.com/article/930708-clinical

Cincinnati Children’s. (2024). Meckel’s Diverticulum. Cincinnati Children’s. https://www.cincinnatichildrens.org/health/m/meckels-diverticulum

Endom, E. E., Dorfman, S. R., & Olive, A. P. (2023). Infantile hypertrophic pyloric stenosis. UpToDate. https://www.uptodate.com/contents/infantile-hypertrophic-pyloric-stenosis?search=hypertrophic%20pyloric%20stenosis&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1

Javid, P. J., & Pauli, E. M. (2023). Meckel’s diverticulum. UpToDate. https://www.uptodate.com/contents/meckels-diverticulum?search=meckel%20diverticulum%20children&source=search_result&selectedTitle=1%7E43&usage_type=default&display_rank=1

Johns Hopkins Medicine. (2019, November 19). Toxic Megacolon. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/toxic-megacolon

Mayo Clinic. (n.d.). Pyloromyotomy. Mayo Clinic. Retrieved March 18, 2024, from https://www.mayoclinic.org/diseases-conditions/pyloric-stenosis/multimedia/pyloromyotomy/img-20006399

NIDDK. (2020, November). Symptoms & Causes of GER & GERD in Infants. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-infants/symptoms-causes

Philadelphia, T. C. H. of. (2014, March 30). Intussusception [Text]. https://www.chop.edu/conditions-diseases/intussusception

SickKids. (2009, November 10). Pyloromyotomy: Surgery for pyloric stenosis. SickKids. https://www.aboutkidshealth.ca:443/article?contentid=1017&language=English

Wendt, T. (n.d.). What to Know About Pyloromyotomy in Children. WebMD. Retrieved March 18, 2024, from https://www.webmd.com/children/what-to-know-about-pyloromyotomy-children

Last Updated on May 2, 2024 by Maureen Osuna, MSN, RN