Practical Approach to Paediatric Gastroenterology, Hepatology and Nutrition

Ronald Bremner, Jane Hartley, Diana Flynn, Deirdre A. Kelly

• Publisher: Wiley-Blackwell
• Year: 2013
• Print ISBN: 9780470673140
• eBook ISBN: 9781118778821
• Edition: 1
• Topic: Medicine
• Subtopic: Gastroenterology & Hepatology

Practical, handy and succinct, this full colour pocketbook provides clear-cut clinical guidance to the main symptoms that infants and children commonly present with in both primary and secondary care.

Clearly divided into specific sections covering the GI tract, liver and nutrition, Professor Kelly and her team discuss how best to investigate and manage specific clinical problems such as vomiting, abdominal pain, acute diarrhoea, constipation and jaundice using a highly clinical problem-orientated approach. 

They cover the management of important clinical problems such as chronic liver disease, ascites, malnutrition, obesity, coeliac disease and inflammatory bowel disease, and provide advice on nutritional problems in premature infants and children including weaning and food aversion.

Key points, potential pitfalls, and management algorithms allow for rapid-reference, and link with the latest evidence, guidelines and protocols from ESPGHAN and NASPGHAN providing coverage of the major professional society recommendations for clinical practice.

 Brought to you by the experts, Practical Approach to Gastroenterology, Hepatology and Nutrition is the perfect accompaniment for trainees in gastroenterology, hepatology and pediatrics, as well as nutritionists, GI nurses and GPs.

PART I

Gastroenterology

Abdominal symptoms are often non-specific, with a wide differential diagnosis. We aim to provide a framework for evaluation, with information for both common and important rare conditions. A multidisciplinary model of care supports optimal management and outcomes. Specialist nursing, dietetics and psychology are central to supporting therapy, especially in chronic illness. Specialist advice and management for rare or complex problems are important, as is recognising non-gastrointestinal illness and conditions requiring surgical intervention, often provided through a defined network of units with pathways for referral, and shared-care with community and hospital teams.

CHAPTER 1

The infant with abdominal pain

It can be difficult to distinguish between ‘normal’ colic and pathological conditions.

Infantile colic is common in the first months of life. Babies scream, draw up their knees and experience severe pain. Episodes may last up to 3 hours and occur several times per week. Causes are listed in Table 1.1.

Table 1.1 Causes, cardinal signs and diagnostic investigations in a child with abdominal pain

Causes	Cardinal features	Diagnostic test
Infantile colic	No abnormal findings	None
Gastro-oesophageal reflux	Regurgitation, back arching	Trial of acid suppression Oesophageal (+gastric) pH probe Oesophageal impedance study Endoscopy and histology
Milk or soya allergy/intolerance	Diarrhoea, rashes	See Chapter 12
Gastroenteritis	Watery stools, fever	Stool virology/microbiology
Constipation	Straining, hard stool, retentive behaviour	See Chapter 14
Urinary tract infection	Fever, pyuria	Urine dipstick test for leukocytes and nitrites, or microscopy Microbial culture
Intussusception	Ill child, red currant jelly stools (late sign) Blood on digital rectal examination	Fluoroscopy with air enema reduction
Volvulus	Distension, bilious vomiting	Abdominal radiograph
Incarcerated hernia	Tender groin swelling	Ultrasonography
Testicular torsion	Scrotum swollen and/or discoloured and/or tender	Ultrasonography
Hirschsprung's disease	Delayed passage of meconium, ribbon stools	Full thickness rectal biopsy
Renal pelviceal/ureteric obstruction	Recurrent urinary tract infection, episodic pain	Ultrasonography
Metabolic disease (e.g. Reye's syndrome, MCADD)	Acidosis, encephalopathy	Blood gases, glucose, ammonia, lactate, serum amino acids, urine amino and organic acids, acyl carnitines

MCADD, medium-chain acyl-CoA dehydrogenase deficiency.

Pathological pain from any site may be interpreted as abdominal in origin, e.g. corneal abrasion, renal tract obstruction, bony fracture.

Investigations

Normal results from screening blood tests can help reassure that underlying renal, liver or metabolic diseases are unlikely.

• FBC, renal, liver and bone biochemistry, blood gases
• Urine analysis and culture
• Plain abdominal radiograph: volvulus in the ill child or with bilious vomiting
• Abdominal ultrasound scan: when intussusception suspected
• Barium swallow and follow to the duodenal–jejunal flexure: to exclude malrotation
• Endoscopy is rarely indicated

Management

In the absence of other obvious cause, a time-limited trial of hypoallergenic feed can be useful to exclude milk allergy/intolerance (see Chapter 12), and antacid therapy can be used if there is acid reflux-related oesophagitis. Most often, colic settles within a few weeks or with changes in routine.

---

Red flags: When colic is concerning

• Abdominal distension (see Chapter 6)
• Faltering growth: feeding problem (see Chapters 37, 38 and 39) or malabsorption (see Chapter 9)
• Abnormal developmental progress: severe oesophagitis more likely, underlying metabolic disorder

---

CHAPTER 2

The child with abdominal pain

Abdominal pain is common in school-aged children and is rarely organic.

History

• Duration and location [right upper quadrant pain in hepatitis, Gilbert's syndrome and non-alcoholic steatohepatitis (NASH)]
• Associated symptoms: vomiting, dyspepsia, diarrhoea, fever, groin pain, urinary symptoms
• Blood in stool
• Vaginal discharge
• Foreign travel
• Gynaecological and sexual history
• Family history: inflammatory bowel disease, coeliac disease, migraine, irritable bowel syndrome, gallstones, pancreatitis

Investigations

• Urinalysis: haematuria in renal stones, pyuria in urinary tract infection
• Urine microscopy, culture, sensitivities
• Blood tests: blood glucose, FBC, renal function, liver function, inflammatory markers, amylase, cholesterol, triglycerides
• Other blood tests if indicated, e.g. paracetamol levels, thyroid function tests
• Stool samples if diarrhoea: microscopy, culture, sensitivity, ova, cysts, parasites
• Abdominal imaging:
  • Abdominal X-ray, e.g. if looking for obstruction
  • Chest X-ray, e.g. for pneumonia or air under the diaphragm
  • Ultrasound scan of the abdomen, kidneys, pelvis (females) and testes (males)
  • CT scan may also be appropriate, especially if there is a mass, trauma, jaundice or pancreatitis
• Endoscopy: will depend upon preliminary findings and history; in the absence of any abnormality on blood screen and imaging, negative endoscopy is very likely

Causes

Well child

• F...

Table of contents

• Cover
• Title page
• Copyright page
• Preface
• Acknowledgements
• PART I: Gastroenterology
• PART II: Hepatology
• PART III: Nutrition
• Index