COMMON PROBLEMS IN PAEDIATRIC GASTROENTEROLOGY AKSHAY BATRA CONSULTANT PAEDIATRIC GASTROENTEROLOGIST

Paediatric Gastroenterology : Referral Base

Common problems Feeding difficulties in infancy Recurrent abdominal pain in children Coeliac disease Constipation

Feed Intolerance in infancy Feeding difficulty is a common complaint in first 3 months Approximately 42% of mothers in UK have consulted a health professional for difficulty around feeding

Causes Infantile colic Mechanical GOR / GORD Poor Suck / swallow Delayed gastric emptying Intestinal dysmotility Immune mediated Cow s milk protein intolerance Food protein intolerance Enzyme deficiency Lactose intolerance Glucose Galactose intolerance

Infant Colic Excessive and inconsolable crying in an otherwise healthy and thriving infant Affects 5 20% of infants Causes significant distress and suffering to the parents Diagnosis Starts in the first weeks of life and resolves by 4months of age. Crying most often occurs in the late afternoon or evening. The baby draws its knees up to its abdomen or arches its back when crying.

Management Reassurance / Peer support Non pharmacological strategies Only consider medical treatments if parents unable to cope Reason for referral Failure to thrive Blood in stools No improvement after 4 months

Gastro Oesophageal Reflux Disease GOR Physiological process Most pronounced in post prandial period Associated with Transient relaxation of lower oesophageal sphincter Resolves in 85% by 6months and 94% by 1 year of life GORD Prolonged duration of TRLES / Delayed gastric emptying Associated with FTT Discomfort after feed Refusal to feed Back arching Respiratory complications Does not resolve spontaneously

Management Non Pharmacological measures Infant Gaviscon H2 Blockers Proton Pump Inhibitors Prokinetics

Indications for referral Failure to thrive Refusal to feed No improvement with age No response to treatment

Cow s milk protein allergy Between 2-7.5% have diagnosis of CMPA in UK 5-15% children on cow s milk free formula Can be IgE or non IgE mediated Increasing prevalence noted 12 12 milk

Symptoms Gastrointestinal (50-60%) Diarrhoea Vomiting Constipation Blood in stools Iron deficiency anaemia Food refusal Respiratory (20-30%) Runny nose Chronic cough Wheeze Dermatological (50-60%) Dermatitis Urticaria Severe eczema 13 13

Algorithm for management of CMPA Suspicion of cow s milk allergy Mild to moderate disease Elimination diet for 2 weeks No improvement Improvement Severe disease Start on AAF and refer to paediatric gastroenterology Persistent blood in stools Failure to thrive Oedema Severe skin disease Keep on normal diet No recurrence of symptoms Re challenge with cows milk Recurrence of symptoms Confirmed CMPA - reintroduce 9-12 months

Recurrent Abdominal Pain in children Affects about 10-20% of school-aged children. Leads to increased functional impairment in everyday life and to school absence. Only 8% of patients with RAP had any organic pathology. Diagnostic uncertainty, chronicityand increasing parental anxiety make management very difficult, time-consuming and expensive

Assessment

Red Flags Age <5 years Abdominal mass Fever Weight loss Passage of blood or mucus Localised pain?? Nocturnal Symptoms

Functional Recurrent Abdominal Pain

Management of FRAP Pharmacotherapy Dietary management Psychology

Coeliac Disease Autoimmune systemic disorder Adaptive and Innate immune response Occurs in genetically susceptible individuals Triggered and maintained by Gluten Best recognized as enteropathy

20 Prevalence 16 percentage 12 8 4 0 Relatives IDDM Thyroiditis Down syndrome General Population 21

CLINICAL PRESENTATION P atients (% ) Classic Celiac GI Symptoms Extra-intestinal Silent 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% < 3 3-9 10-17. Female Male Age (years) Classic Coeliac Diarrhoea Weight Loss Lemon on matchstick Gastrointestinal symptoms Abdominal Pain, Bloating Constipation Vomiting Extra Intestinal manifestation Tiredness Short Stature Iron deficiency anaemia Dermatitis Herpetiformis Enamel Hypoplasia Osteopenia Calgary Clinic data 2000-2006

SEROLOGICAL TESTING 100 100 80 80 60 60 40 40 20 20 0 0 AGA-IgG AGA-IgA EMA TTG Sensitivity AGA-IgG AGA-IgA EMA TTG Specificity

Genetics DQ2 found in 95% of celiac patients; DQ8 in rest DQ2 found in ~30% of general population High negative predictive value Genes?? HLA? + HLA Gluten Celiac Disease 24

Constipation

Paris consensus on childhood constipation terminology (2004) 2 or more of the following characteristics during the last 8 weeks : Frequency of bowel movement s <3 per week >1 episode of faecal incontinence per week Large stools in the rectum or palpable on abdominal examination Passing of stools so large they may obstruct the toilet Display of retentive posturing and withholding behaviours Painful defecations

Constipation in children and young people (NICE guidance) Diagnostic clues for identifying between idiopathic constipation & underlying disorder http://www.nice.org.uk/nicemedia/live/12993/48721/48721.pd f (full document reference)

Challenges Non Adherers Non Believers InConsistent Non responders

Improved Diet Laxative Medication Improved Fluid intake Regular Exercise Regular toileting

1 st and 3 rd Tuesday +Friday of Month + every Wednesday PM

Dr Akshay Batra Consultant Paediatric Gastroenterologist Mick Cullen Children s Nurse Specialist in Paediatric Gastroenterology Spire Southampton Hospital

Thank You Any Questions?