Gastrointestinal diseases in children

Question 1

What are main causes of acute diarrhea in children?

Answer 1

Infections.
Medications, e.g. antibiotics.
Surgical conditions, e.g. appendicitis, intussusception, Mb. Hirschprung.
Allergic reactions and intolerance.
Vasculitis, e.g. Henoch-Schoenlein purpura.

Question 2

How many episodes of infectious gastroentiritis are common during the first year of kindergarten?

Answer 2

1-3 episodes.

Question 3

What are reasons for hospital admission in patients with gastroenteritis?

Answer 3

Moderate to severe dehydration.

Signs of complication.

Question 4

Name some examples of viral agents causing gastroenteritis.

Answer 4

Norovirus, rotavirus and adenovirus.

Question 5

What is it important to consider when making an estimation on the amount of fluid needed in rehydration therapy?

Answer 5

Basal need - Normal fluid intake.

Consecutive losses - How big is the loss of fluids.

Question 6

How should oral rehydration therapy be managed?

Answer 6

Non-hypertonic fluid. Oral rehydration salts.

Small, frequent intake of fluids.

Question 7

What is it important to monitor in children with vomiting and/or diarrhea?

Answer 7

Weight (at least daily).
Liquid balance. Intake: PO or IV. Loss: Urine output, stools and/or vomiting.
Vital parameters: RR, pulse and BP.
Electrolytes, creatinine and blood glucose.

Question 8

What is the definition of functional diarrhea?

Answer 8

Painless passage of three or more large, unformed stools for four or more weeks, with onset in infancy or the preschool years, and without failure to thrive or a specific definable cause.

Question 9

What are mechanisms of chronic diarrhea?

Answer 9

Sectretorial diarrhea (secretion > absorption).
Osmotic diarrhea (malabsoption).
Dysmotility.
Combination causes (most common).

Question 10

What is the most common type of chronic diarrhea in children?

Answer 10

Functional diarrhea.

Question 11

What is the most common clinical presentation of constipation in children?

Answer 11

Soiling/encopresis (most common).
Defecation frequency < 3 times per week.
Large stools.

Question 12

What are the criteria for functional constipation in children?

Answer 12

Less than 3 stools per week.
At least 1 episode of soiling per week.
History of excessive stool retention.
History of painful hard bowel movement.
Presence of large fecal mass in the rectum.
History of large diameter stools. 

At least 2 of the criteria must be fulfilled for a duration of 1 month in children under the of 4 and 2 months in children over the age of 4.

Question 13

What is the most common cause of constipation in children?

Answer 13

Functional cause. (90-95 % of cases are functional.)

Question 14

What are indications of surgery as treatment of constipation in children?

Answer 14

Mb. Hirschprung.

Anorectal malformations.

Question 15

When dealing with chronic/recurrent abdominal pain in children, what are some potential causes?

Answer 15

Intestinal conditions/diseases: Inflammation (IBD), infection, malabsorption (Celiac), constipation/obstruction, acid reflux (GERD).

Extra-intestinal intra-abdominal: Inflammation, tumor, kidney and gallstones, etc.

Extra-intestinal extra-abdominal: Systemic disease, e.g. leukemia.

Functional disorders (IBS, etc.)

Psychosomatic disorders.

Question 16

True or false: Visceral pain is associated with lower levels of anxiety and vasovagal reactions compared to somatic pain.

Answer 16

False. Visceral pain is associated with higher levels of anxiety and vasovagal reactions compared to somatic pain.

Question 17

What are examples of functional abdominal pain disorders in children?

Answer 17

Irritable bowel syndrome (IBS).
Functional dyspepsia (FD).
Abdominal migraine (AM). 
Functional abdominal pain syndrome (FAPS).

Question 18

Are functional abdominal pain disorders more common in girls or boys?

Answer 18

In girls.

Question 19

What is the typical pain location in children with functional abdominal pain disorders?

Answer 19

The periumbilical region is common, although the location of pain often is diffuse.

Question 20

What are warning signs/symptoms related to children with recurrent/chronic abdominal pain?

Answer 20

Apley’s law.
Atypical pain history, e.g. nightly pain, long duration of episodes, non-paroxysmal symptoms.
Progressive symptoms.
Permanent change of stool (with rectal bleeding or bloody stool).
Vomiting and/or reflux symptoms.
Fever.
Dysuria or other organ specific symptoms.
Failure to thrive.
Onset of symptoms before 3-4 years of age.

Question 21

What is Apley’s law (in pediatrics)?

Answer 21

In pediatrics, the farther a chronically recurrent abdominal pain is from the umbilicus, the greater the likelihood of an organic cause for the pain.

Question 22

What is treatment of functional abdominal pain disorders in children?

Answer 22

Peripheral mechanisms can be treated with dietary changes, like fiber and probiotics, and medications (to treat constipation/diarrhea).

Central mechanisms can be treated through reduction of “triggers” and psychotherapy, like psychoeducation, cognitive behavioral therapy (CBT), hypnosis or treatment of comorbid anxiety or depression.

Question 23

What are the two main categories of causes for failure to thrive? What is the most common cause?

Answer 23

Organic and non-organic causes.

The cause is most commonly multifactorial. Only 10 % of causes are solely organic.

Question 24

What are causes of malnutrition in children?

Answer 24

High energy demand, as in chronic disease.
Poor appetite due to illness, treatment or emotional distress.
Eating difficulties due to illness, treatment of care-failure.
Idiopathic (most common).

Question 25

What are some examples of organic causes for failure to thrive in children?

Answer 25

All chronic disease that potentially increase the energy demand, e.g. heart failure, renal disease, cancer, etc.
Intestinal diseases such as Celiac disease, cystic fibrosis, severe food allergy, IBD, etc.

Question 26

What are tips to encourage children to eat/try new foods?

Answer 26

Reduce stress during meals, avoid distraction and never use force.
It is often necessary repeated tasting
Let the child be in control; pick and play. Positive experience!
3 main meals per day; not too much on plate and max. 30 min per meal.
Reduce high-carb snacks in-between meals.
Reduce amount milk to max. 500 ml/d.
Reduce amount beverages/fruit juice.

Question 27

Is celiac disease more common in boys or in girls? What group of children are at increased risk of celiac disease?

Answer 27

It is more common in girls.

Children with other autoimmune disorders or siblings with celiac disease.

Question 28

What is the classic clinical presentation of celiac disease?

Answer 28

Chronic diarrhea.
Anorexia.
Weight loss.
Lethargy/Irritability.
Abdominal distention.
Vomiting.

Question 29

How is celiac disease diagnosed?

Answer 29

Through a combination of clinical symptoms and biochemistry analyses (incl. serology - TTG - and HLA), in addition to treatment response. Otherwise: Duodenal biopsy.

Question 30

What are clinical features consistent with the diagnose of cystic fibrosis?

Answer 30

Chronic sinopulmonary disease.
Endobronchial disease with cough and sputum, wheezing and air trapping, clubbing, etc.
Chronic sinus disease.
Gastrointestinal/nutritional abnormalities, such as meconium ileus, exocrine pancreas insufficiency, failure to thrive, hypoproteinemia and edema, etc.

Question 31

How is cystic fibrosis diagnosed?

Answer 31

Symptoms in two organs +
Positive sweat-test x 2 (chloride > 60 mmol/l sweat).
and/or
CFTR mutation analysis (rare with negative test).

There is a newborn screening for cystic fibrosis.

Question 32

What children are at increased is of GERD?

Answer 32

Children with celiac disease, neurological diseases/disorders, Down’s syndrome, and asthma/cystic fibrosis.

Question 33

What is the main difference between GER and GERD?

Answer 33

GERD = GER + reflux related symptoms.

Question 34

What are gastrointestinal symptoms of GERD in infants?

Answer 34

Frequent regurgitation.
Irritability/discomfort.
Eating difficulties or refusal.
Failure to thrive.
Sleep disturbance.
Hematemesis and anemia.

Question 35

What are gastrointestinal symptoms of GERD in children?

Answer 35

Intermittent regurgitation.
Abdominal pain.
Heartburn.
Nausea.

Question 36

What are warning signs of secondary GERD? (Hint: Surgical conditions, allergic conditions, CNS conditions, and non-specific illness.)

Answer 36

Surgical conditions: Acute/subacute symptoms:
Vomiting/projectile-GER.
Hematemesis.
Distended abdominal wall.
Progressive and intermittent abdominal-pain symptoms.
Fever.

Allergic:
Diarrhea/enterocolitis.
Eczema.
Family history.
Eosinophilic esophagitis.

CNS:
Macro/microcephaly
Hypotonia.
Abnormal development and neurological examination.

Non-specific; illness, including infections:
Nutritional and growth problems.
Fever.