PEDIATRICS GASTROENTEROLOGY
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1 PEDIATRICS GASTROENTEROLOGY Atan Baas Sinuhaji Sub Division of Pediatrics Gastroentero-Hepatology Department of ChildHealth School of Medicine University of North Sumatera
2 CONTENTS 1.GIS K-11 :=Introduction =Vomiting 2.GIS K-16 :=Diarrhoea (1) 3.GIS K-20 :=Diarrhoea (2) 4.GIS K-26 :=Food Allergy 5.GIS K-32 :=Necrotizing Enterocolitis =Abdominal distention 6.GIS K-33 :=Tuberculous peritonitis =Abdominal pain =Disorder of ingestion
3 7. GIS K-34 :=Jaundice 8. GIS K-35 :=Encephalopathy =Gastrointestinal hemorrhage 9. GIS K-36 :=Constipation =Failure to thrive ( 1 ) 10.GIS K-37:=Failure to thrive ( 2 ) 11.GIS K-38:=Body fluid balance
4 PEDIATRICS GASTROENTEROLOGY SYSTEMATIC PROBLEM BASED FUNCTION DIGESTIVE SYSTEM MAJOR SIGNS & SYMPTOMS
5 DIGESTIVE SYSTEM DIGESTIVE TRACT - ORAL CAVITY - GI TRACT (ESOPHAGUS ANAL) DIGESTIVE GLANDS SALIVARY GLANDS LIVER & BILE DUCT PANCREAS PERITONEUM
6 MAJOR SIGNS & SYMPTOMS 1. DIARRHOEA 2. VOMITING 3. FAILURE TO THRIVE 6. DISORDERS OF INGESTION 7. ABDOMINAL PAIN 8. ABDOMINAL DISTENSION 9. CONSTIPATION 4. JAUNDICE 10. GASTROINTESTINAL 5. ENCEPHALOPATHY HEMORRHAGE
7 FUNCTION 1. EATING & DRINKING 2. DIGESTION & ABSORPTION 3. SECRETION 4. MOTILITY 5. ENDOCRINE 6. DEFENCE 7. EXCRETION
8 DIGESTION BREAK DOWN - PHYSIS - CHEMICAL - MECHANICAL DIETARY FOOD SMALLER PARTICLES & CAN BE ABSORBED
9 DIGESTION INTRALUMINAL -PANCREAS -LIVER -STOMACH INTRACELLULAR - PEPTIDASE - LIPASE MEMBRANE - SUCRASE - MALTASE - LACTASE - GLUCOAMYLASE
10 ABSORPTION TRANSPORT OF WATER OR DIGESTIVE PRODUCTS LUMEN MUCOSA VESSELS BLOOD LYMPH
11 DIGESTION - ABSORPTION INTRALUMINAL DIGESTION PARACELLULAR TRANSCELLULAR MEMBR. DIGESTION CELLULAR UPTAKE INTRACELL. DIGESTION INTERCELLULAR SPACE BASOLAT. MEMBRANE
12 INTERCELLULAR SPACE BASEMENT MEMBRANE INTERSTITIAL SPACE (LAMINA PROPIA) VESSELS - BLOOD - LYMPH
13 TRANSCELLULER Luminal Membrane PARACELLULER E n t e r o c y t e Basal Membrane Vessel Tight Junction Basolateral Membrane Intercelluler space Lamina propia
14 VOMITING
15 Vomiting overt reflux passage of gastric contents into the mouth
16 Reflux Movement of gastric contents retrograde Into esophagus or more proximal Food/ Drink Gases Gastric Acid
17 REFLUX OVERT OCCULT INTO THE MOUTH INTO THE ESOPHAGUS TO RESP. TRACT VOMITING LARYNGITIS PNEUMONIA ASPIRATION
18 REFLUX GASTRIC PRESS. > ESOPH. PRESS. GASTRIC PRESS. = ESOPH. PRESS. OBSTRUCTION PERISTALSIS FUNCTION HIATAL HERNIA IN OUT Lower Esophageal Sphincter (LES) RELAXATION Gastric Outlet Obstruc. Pyloric Stenosis AbdomInal Tumor
19 LES RELAXATION TRANSIENT CONTINOUS Gastroesophageal reflux Chalasia
20 SLIDING HIATUS HERNIA HIATAL HERNIA = PARTIAL THORACIC STOMACH PARAESOPHAGEAL HERNIA = ROLLING
21 REFLUX FOOD/DRINK GASES GASTRIC ACID = ACID REFLUX ERUCTATION HICCUP = SINGULTUS = CEKUKAN HEART BURN = PYROSIS = SENDAWA Metaplasia Epithel of esophagus Barret s esophagus ULCUS bleeding stricture
22 CONSEQUENCES OF REFLUX 1.- SINGULTUS - ERUCTATION 2. HEART BURN = SENDAWA 3. ESOPHAGITIS & BARRET S ESOPHAGUS 4. CHRONIC PNEUMONIA ASPIRATION 5. FAILURE TO THRIVE (FTT) 6. LARYNGITIS 7. RUMINATION 8. SANDIFER S SYNDROME 9. FOOD REFUSAL
23 VOMITING RETURN OF FOOD/DRINK FROM THE STOMACH TO THE MOUTH TRUE VOMITING REGURGITATION = SPITTING = MINTAR = GUMOH PHYSIOLOGIC GER PATHOLOGIC COMPLICATION (GASTROESOPHAGEAL DISEASE = GER Disease)
24 Gastroesophageal reflux (GER) Physiologic passage of gastric content to esophagus Transient LES relaxation
25 Gastroesophageal reflux - 50% of infant 0-3 months of age - 25% of infant 3-6 months of age - 5% of infant months of age Resolving in most by 12 months and nearly all by 24 months
26 Gastro Esophageal Reflux Disease (GERD) GER that causes symptoms or complications that effect quality of life
27 GERD VOMITING - Not all vomiting are GERD - Many GERD children do not vomit
28 TRUE VOMITING NAUSEA RETCHING FORCEFUL GASTRIC CONTENTS/ INTRA ABDOMINAL PRESSURE SYMPTOMS OF AUTONOMIC NERVUS SYSTEM (+)
29 REGURGITATION THE YOUNG BABY NOT MATURE L.E.S. NAUSEA (-) NOT FORCEFUL SYMPTOMS OF ANS (-)
30 RUMINATION - RETURN OF FOODS INTO THE MOUTH - FOODS RECHEWED - FOODS REINGESTED
31 NAUSEA - UNPLEASANT SENSATION & OFTEN CULMINATING IN VOMITING - CONTRACTION OF PYLORIC ANTRAL - SYMPTOMS OF ANS (+)
32 VOMITING IN INCREASE INTRACRANIAL PRESSURE - PROJECTILE - NAUSEA (-) - RETCHING (-)
33 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) GOLD STANDARD - Scintigraphy - Endoscopy complication
34 TREATMENT GER 1. Conservative therapy 2. Pharmacotherapy 3. Surgery Nissen Fundoplication
35 Conservative Therapy 1. Prone position and upright position : - The infant is awake and observed SIDS 2. Small frequent feeding 3. Thickening of formula
36 Pharmacotherapy 1. Acid Neutralization : Antacids 2. Antisecretory ( Cimetidine, Ranitidine, 3. Prokinetic Omeprazole, etc) - Metoclopramide Extrapyramidal Symptoms - Bethanechole Bronchospasme - Cisapride : 0,2 mg/kg/dose 3 or 4 x daily Arrythmia
37 VOMITING SURVIVAL VALUE DEFENSE - UNDERLYING - COMPLICATION TOXIC THREATENING
38 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
39 Na + VOMITING H + Water K + Cl - Hyponatremia Met. Alk. dehydration hypovolemia Hypokalemia Hypochloremia hypocalcemia RBF Renin Loss of H + Aldosteron Loss of K + Retention of Na + & Water
40 VOMITING DIGESTIVE TRACT OUTSIDE Surgery - obstruction - inflammation - perforation Medical - gastritis - peptic ulcer - Gastroenteritis - psychogenic - neurogenic: int.cran. press. - systemic:sepsis - hemodynamic
41 1. STABILIZATION OF GENERAL CONDITION MANAGEMENT 2. PROTECTION AGAINST ASPIRATION Body Fluids Imbalance 3. CAUSAL ABDOMINAL EMERGENCY 4. CALORI/ PROTEIN 5. COMPLICATIONS 6. ANTIEMETIC DRUGS PNEUMONIA ASP. CEREBRAL EDEMA NO RECOMMENDED
42 ANTI EMETIC 1. DOPAMINE receptor antagonist - metoclopramide - domperidone 2. Cannabinoid (dronabinol) 3. Anticholinergic (Scopolamine) 4. 5 HT 3 receptor antagonist - ondansetron 5. Phenothiazine dan anti histamin - phenergan, benadryl - largactil 6. Corticosteroid
43 COMPLETE INVAGINATION BOWEL OBSTRUCTI0N INCOMPLETE PYLORIC STENOSIS
44 INVAGINATION = INTUSSUSCEPTION PROXIMAL BOWEL (INTUSSUSCEPTUM) DISTAL BOWEL (INTUSSUSCIPIENS) SPONTANEUS REDUCTION CONTINUING 3 months - 3 years
45 TYPE OF INVAGINATION - ILEOCOLIC > > > - ILEOILEIC - CECOCOLIC - COLICOCOLIC - ILEOILEOCOLIC
46 SIGNS & SYMPTOMS - SUDDEN ONSET - PAROXYSMAL PAIN - VOMITING - BLEEDING PERANUM - TUMOR - SIGNE de DANCE - ABDOMINAL DISTENTION - DEFECATION & FLATUS (-) Th / : - WATER & ELECTROLYTES - HYDROSTATIC - OPERATIVE
47 CLINIC PLAIN OF ABDOMINAL PHOTO DIAGNOSTIC RADIOLOGIC SIGN OF OBSTRUCTION BARIUM ENEMA - CUPPING - COIL SPRING
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