PEDIATRICS

GASTROENTEROLOGY
Atan Baas Sinuhaji
Sub Division of Pediatrics Gastroentero-Hepatology
Department of ChildHealth
School of Medicine
University of North Sumatera

CONTENTS
1.GIS K-12 :=Introduction
=Vomiting
2.GIS K-17 :=Diarrhoea (1)
3.GIS K-21 :=Diarrhoea (2)
4.GIS K-27 :=Food Allergy
5.GIS K-33:=Necrotizing Enterocolitis
=Abdominal distention
6.GIS K-34:=Tuberculous peritonitis
=Abdominal pain
=Disorder of ingestion

7. GIS K-35:=Jaundice
8. GIS K-36:=Encephalopathy
=Gastrointestinal hemorrhage
9. GIS K-37:=Constipation
=Failure to thrive ( 1 )
10.GIS K-38:=Failure to thrive ( 2 )
11.GIS K-39=Body fluid balance

PEDIATRICS
GASTROENTEROLOGY

SYSTEMATIC

DIGESTIVE
SYSTEM

PROBLEM
BASED

MAJOR SIGNS
&
SYMPTOMS

FUNCTION

DIGESTIVE SYSTEM

DIGESTIVE TRACT
- ORAL CAVITY
- GI TRACT (ESOPHAGUS
DIGESTIVE GLANDS
SALIVARY GLANDS
LIVER & BILE DUCT
PANCREAS

PERITONEUM
ANAL)

MAJOR SIGNS & SYMPTOMS

1.
2.
3.
4.
5.
6.

DIARRHOEA
7.
VOMITING
8.
FAILURE TO
THRIVE
9.
JAUNDICE
10.
ENCEPHALOPATHY
DISORDERS OF
INGESTION

ABDOMINAL PAIN
ABDOMINAL
DISTENSION
CONSTIPATION
GASTROINTESTINAL
HEMORRHAGE

FUNCTION
1.

EATING & DRINKING

2.

DIGESTION & ABSORPTION

3.

SECRETION

4.

MOTILITY

5.

ENDOCRINE

6.

DEFENCE

7.

EXCRETION

DIGESTION

BREAK DOWN
- PHYSIS
- CHEMICAL
- MECHANICAL

DIETARY FOOD

SMALLER PARTICLES
&
CAN BE ABSORBED

DIGESTION

INTRALUMINAL
-PANCREAS
-LIVER
-STOMACH

INTRACELLULAR
- PEPTIDASE
- LIPASE

MEMBRANE
- SUCRASE
- MALTASE
- LACTASE
- GLUCOAMYLASE

ABSORPTION
TRANSPORT OF WATER
OR
DIGESTIVE PRODUCTS
LUMEN

MUCOSA
BLOOD
VESSELS

LYMPH

DIGESTION - ABSORPTION
INTRALUMINAL DIGESTION

PARACELLULAR

TRANSCELLULAR
MEMBR. DIGESTION
CELLULAR UPTAKE
INTRACELL. DIGESTION
BASOLAT. MEMBRANE

INTERCELLULAR
SPACE

INTERCELLULAR SPACE

BASEMENT MEMBRANE

INTERSTITIAL SPACE
(LAMINA PROPIA)

VESSELS
- BLOOD
- LYMPH

TRANSCELLULER
TRANSCELLULER

Luminal
Membrane

PARACELLULER
PARACELLULER

E
n
t
e
r
o
c
y

Tight
Junction

Intercelluler
space

Basolateral
Membrane

Basal
Membrane

Vessel

Lamina
propia

VOMITING
Atan Baas Sinuhaji
Department of ChildHealth
School of Medicine,University Of Sumatera Utara
Medan

Vomiting

overt reflux

passage of gastric contents into

the mouth

Reflux

Movement of gastric contents retrograde

Into esophagus or more proximal

Food/
Drink

Gases

-Gastric acid
-Pancreatic juice

REFLUX

OVERT

INTO THE MOUTH

VOMITING

OCCULT
INTO THE
ESOPHAGUS

LARYNGITIS

RESPIRATORY
TRACT

PNEUMONIA
ASPIRATION

REFLUX
GASTRIC PRESS. > ESOPH. PRESS.

OBSTRUCTION PERISTALSIS

IN

OUT

Gastric
Outlet
Obstruc.

AbdomInal
Tumor

Pyloric
Stenosis

GASTRIC PRESS. = ESOPH. PRESS.

FUNCTION

HIATAL
HERNIA

Lower Esophageal
Sphincter (LES)
RELAXATION

LES RELAXATION

TRANSIENT

Gastroesophageal
reflux

CONTINOUS

Chalasia

SLIDING HIATUS
HERNIA

HIATAL
HERNIA
=
PARTIAL
THORACIC
STOMACH
PARAESOPHAGEAL
HERNIA = ROLLING

REFLUX
FOOD/DRINK

ERUCTATION

GASTRIC ACID
= ACID REFLUX

GASES

HEART BURN

HICCUP
= PYROSIS
= SINGULTUS = SENDAWA
= CEKUKAN

Metaplasia
Epithel of
esophagus
Barrets
esophagus
ULCUS

bleeding

stricture

CONSEQUENCES OF REFLUX
1.- SINGULTUS
- ERUCTATION
2. HEART BURN = SENDAWA
3. ESOPHAGITIS & BARRETS ESOPHAGUS
4. CHRONIC PNEUMONIA ASPIRATION
5. FAILURE TO THRIVE (FTT)
6. LARYNGITIS
7. RUMINATION
8. SANDIFERS SYNDROME
9. FOOD REFUSAL

VOMITING
RETURN OF FOOD/DRINK
FROM THE STOMACH TO THE MOUTH
TRUE
VOMITING

PHYSIOLOGIC
GER

REGURGITATION
= SPITTING
= MINTAR
= GUMOH
PATHOLOGIC
COMPLICATION
(GASTROESOPHAGEAL
DISEASE = GER Disease)

Gastroesophageal reflux (GER)

Physiologic passage of gastric
content to esophagus
Transient LES relaxation

Gastroesophageal reflux
- 50% of infant 0-3 months of age
- 25% of infant 3-6 months of age
- 5% of infant 10-12 months of age
Resolving in most by 12 months and
nearly all by 24 months

Gastro Esophageal Reflux Disease

(GERD)

GER that causes symptoms or complications that

effect quality of life

GERD VOMITING
- Not all vomiting are GERD
- Many GERD children do not vomit

TRUE VOMITING
NAUSEA
RETCHING
FORCEFUL GASTRIC CONTENTS/
INTRA ABDOMINAL PRESSURE
SYMPTOMS OF AUTONOMIC
NERVUS SYSTEM (+)

REGURGITATION
THE YOUNG BABY
NOT MATURE L.E.S.
NAUSEA (-)
NOT FORCEFUL
SYMPTOMS OF ANS (-)

RUMINATION
- RETURN OF FOODS INTO THE MOUTH
- FOODS RECHEWED
- FOODS REINGESTED

NAUSEA
- UNPLEASANT SENSATION & OFTEN
CULMINATING IN VOMITING
- CONTRACTION OF PYLORIC
ANTRAL
- SYMPTOMS OF ANS (+)

VOMITING IN INCREASE
INTRACRANIAL PRESSURE
- PROJECTILE
- NAUSEA (-)
- RETCHING (-)

DIAGNOSIS GER
1. History
2. Body weight poor weight gain ?
3. Diagnostic Test
- Upper GI series rule out anatomical
abnormalities
- pH probe (12-24 hours) Acid refluxGold
Standard
- Scintigraphy

TREATMENT GER
1. Conservative therapy
2. Pharmacotherapy
3. Surgery Nissen Fundoplication

Conservative Therapy
1. Prone position and upright position :
- The infant is awake and observed
SIDS
2. Small frequent feeding
3. Thickening of formula

Pharmacotherapy
1. Acid Neutralization : Antacids
2. Antisecretory ( Cimetidine, Ranitidine,
Omeprazole, etc)
3. Prokinetic
- Metoclopramide Extrapyramidal
Symptoms
- Bethanechole Bronchospasme
- Cisapride : 0,2 mg/kg/dose 3 or 4 x daily
Arrythmia

VOMITING

SURVIVAL VALUE
DEFENSE

- UNDERLYING
- COMPLICATION

TOXIC

THREATENING

COMPLICATION OF TRUE VOMITING

1. Body Fluids Imbalance
- dehydration
- hyponatremia
- hypokalemia
- hypochloremia
- hypocalcemia ==> tetany
- metabolic alkalosis
2. Mallory Weiss Syndrome
3. Pneumonia aspiration
4. Intake
- hypoglicemia
- starvation
- Failure To Thrive
- Metabolic acidosis

VOMITING
Na+

H+

Water

Hyponatremia
Met. Alk.

hypocalcemia

K+

Cl-

dehydration Hypokalemia Hypochloremia

hypovolemia
RBF
Renin

Loss of H+

Aldosteron

Retention of Na+ & Water

Loss of K+

VOMITING
DIGESTIVE TRACT

Surgery

- obstruction
- inflammation
- perforation

OUTSIDE

Medical

- gastritis
- peptic ulcer
- Gastroenteritis

- psychogenic
- neurogenic:
int.cran. press.
- systemic:sepsis
- hemodynamic

MANAGEMENT
1. STABILIZATION OF
GENERAL CONDITION

Body Fluids Imbalance

2. PROTECTION AGAINST ASPIRATION

3. CAUSAL

ABDOMINAL EMERGENCY

4. CALORI/ PROTEIN
PNEUMONIA ASP.
5. COMPLICATIONS
CEREBRAL EDEMA
6. ANTIEMETIC DRUGS

NO RECOMMENDED

ANTI EMETIC
1. DOPAMINE receptor antagonist
- metoclopramide
- domperidone
2. Cannabinoid (dronabinol)
3. Anticholinergic (Scopolamine)
4. 5HT3 receptor antagonist
- ondansetron
5. Phenothiazine dan anti histamin
- phenergan, benadryl
- largactil
6. Corticosteroid

COMPLETE

INVAGINATION

INCOMPLETE

PYLORIC
STENOSIS

BOWEL
OBSTRUCTI0N

INVAGINATION = INTUSSUSCEPTION
PROXIMAL BOWEL
(INTUSSUSCEPTUM)
DISTAL BOWEL
(INTUSSUSCIPIENS)
SPONTANEUS
REDUCTION

CONTINUING

3 months - 3 years

TYPE OF INVAGINATION

- ILEOCOLIC > > >

- ILEOILEIC
- CECOCOLIC
- COLICOCOLIC
- ILEOILEOCOLIC

SIGNS & SYMPTOMS

- SUDDEN ONSET
- PAROXYSMAL PAIN
- VOMITING
- BLEEDING PERANUM
- TUMOR
- SIGNE de DANCE
- ABDOMINAL DISTENTION
- DEFECATION & FLATUS (-)

Th / :

- WATER & ELECTROLYTES

- HYDROSTATIC
- OPERATIVE

CLINIC
PLAIN OF ABDOMINAL
PHOTO

DIAGNOSTIC
SIGN OF
OBSTRUCTION

RADIOLOGIC
BARIUM ENEMA
- CUPPING
- COIL SPRING