agnieszka wegner klinika neurologii dziecięcej warszawski

agnieszka wegner klinika neurologii dziecięcej warszawski

Jaundice, diarrhoea and
other gastroenterological
symptoms in childhood
AG N I ESZ K A WEG N ER K LI N I K A N EURO LO G I I DZ I EC I ĘC EJ
WA RSZAWSK I UNIWERSYT ET MEDYCZ NY
Gastrological symptoms in children
q Vomi%ng
q Jaundice
q Abdominalpain
q Diarrhoea
q Cons%pa%on
VomiJng
1.  Vomi%ngisthemeansbywhichtheuppergastrointes%naltractridsitselfofitscontents
whenalmostanypartoftheuppertractbecomesexcessivelyirritated,overdistended,or
evenoverexcitable.Vomi%ngisasymptom,presen%ngcomplaintinmul%tudeofdisorders.
Rangefromgastrointes%nalpathologytodiseaseindistantorgan(o%%smediaorintracranial
lesion)
2.  Nausea:Theunpleasantsensa%onoftheimminentneedtovomit,usuallyreferredtothe
throatorepigastrium;asensa%onthatmayormaynotul%matelyleadtotheactofvomi%ng
3.  Regurgita%on:Theactbywhichfoodisbroughtbackintothemouthwithouttheabdominal
anddiaphragma%cmuscularac%vitythatcharacterizesvomi%ng.
VomiJng- causes
Common
Infant
Child
•  Gastroenteri%s
•  Gastroesophageal
reflux
•  Overfeeding
•  Anatomic
obstruc%on
•  Systemicinfec%on
•  Pertussissyndrome
•  O%%smedia
•  Pyloricstenosis
• 
• 
• 
• 
• 
• 
• 
Gastroenteri%s
Gastri%s
Reflux(GERD)
Systemicinfec%on
Pertussissyndrome
Sinusi%s
O%%smedia
Adolescent
• 
• 
• 
• 
• 
• 
• 
• 
• 
Gastroenteri%s
GERD
Gastri%s
Inflammatorybowel
disease
Appendici%s
Systemicinfec%on
Sinusi%s
Migraine
Pregnancy
VomiJng- causes
•  Rare
Infant
Child
Adolescent
• CAH
• Inbornerrorof
metabolism
• Braintumor
(increasedintracranial
pressure)
• Subduralhemorrhage
• Foodpoisoning
• Renaltubularacidosis
• Reyesyndrome
• Hepatitis
• Pepticulcer
• Pancreatitis
• Braintumor
• IncreasedICP
• Middleeardisease
• Achalasia
• Cyclicvomiting
Esophagealstricture
• Duodenalhematoma
• Inbornerrorof
metabolism
• Reyesyndrome
• Hepatitis
• Pepticulcer
• Pancreatitis
• Braintumor
• IncreasedICP
• Middleeardisease
• Cyclicvomiting
• Biliarycolic
• Renalcolic
Interview
q Ageofthepa3ent
q Respiratory–cough,chestdiscomfort
q Dura3on/Frequency
q Urinary–dysuria,hematuria
q Onset
q Associatedwithfoodintake
ü  instantly:esophagealobstruc%on
ü  ATerawhile:stomachorduodenalobstruc%on
q Nature(projec3le/nonprojec3le)
q CNS–irritability,alteredsensorium,drowsy,necks%ffness,headache,
visualdisturbance
q Pastmedicalhistory
Anyknownmedicalillnesssuchasmetabolicinbornerror,cerebral
palsy,downsyndrome,neurologicaldeficit
q Colorandcontents
ü  Nondigestedfood:proximalobstruc%on
ü  Semidigestedfood:distalobstruc%on
ü  Billouscontent:distalto2ndpartofduodenum
ü  Fecalmaterial:obstruc%onatthelargeintes%ne
q Drugandallergyhistory
q Associatedsymptoms
ü  Fever/AbdominalPain/Diarrhea/cons%pa%on/dysphagia
q Otherrelevanthistory
Recentea%ngoutside,recenttravelling,familymemberorfriendsin
schoolhavesimilarillness
q Birthhistory
q Nutri%onalhistory
Recentlychangeintocowmilk/foodallerrgy/typeoffood
VomiJng- examinaJon
q Generalcondi%on
§  Comparisonofpa%ent’sweightbeforeandaTer
onsetofillness
q Hydra%onstatus
§  Sunkenfrontanelle
§  Eyessunkenandtearless
§  Drymucousmembrane
§  Prolongedcapillaryrefill%me
§  Reducedskinturgor
§  Tachycardia,tachypnea
q AbdominalExamina%on
◦  Distension,Visibleperistalsis,Tenderness,
hepatospelnomegaly,abdominalmasses,Bowel
sounds
q CNSExamina%on
 Power,Tone,reflexes
 Changesinvision
q RespiratoryExamina%on,Earexamina%on
 Rehydrateaccordingly-encourageoralintake
 Correctelectrolyteimbalances
 Treataccordingtotheunderlyingcause
Jaundice
 Jaundiceisayellowishpigmenta%onoftheskin,theconjunc%valmembranesoverthesclerae
(whitesoftheeyes),andothermucousmembranescausedbyhighbloodbilirubinlevels.
q  Thecondi%onforthecrea%onofjaundiceisanincreasedbilirubinserum.
q  Normallevelsofbilirubininthebloodserumrangesfrom0.3-1.0mg/dl,withnearly90%of
conjugatedbilirubin.
q  Bilirubiniscreatedinliver,spleenandbonemarrowasaproductofthecatabolismof:
q  hemoglobinfromerythrocytes80-85%
q  othercombina%onsofcompoundscontainingheme/myoglobin,cytochromes,especiallyCP-450,otherenzymes
containingheme
q  hemoglobinderivedfromineffec%veerythropoiesis/maturingerythrocytes/
ClassificaJon of jaundices
 Liverplaysamailroleinbilirubinmetabolism.Therearethreestagesofbilirubinmetabolismin
liver:
1.  uptakeofbilirubin
2.  conjuga%onwithglucuronicandsulfericacid
3.  excre%onofconjugatedbilirubinintobile
Classifica%onofthejaundice
 Pre-hepa%c/hemoly%c-Intrinsicdefectsinredbloodcellsorextrinsiccausesexternaltoredblood
cells
 Hepa%c/hepatocellular–liverdisease
 Post-Hepa%c/cholesta%c-obstruc%onofbiliarypassage
HemoliJc jaundice
Ø Structuralerythrocytesanomalies-defects
inmembrane/sicklecellanemia/,
enzymopa%e,hemoglobinopathies,
thalassemia
Ø extrinsiccauseshaemolysis
-  immunological/auto-,izoan%bodies/
Diagnosis
Ø FamilyhistorY,drugs,
Ø weakness,worseexercisetolerance
Ø normalurine,darkstools,strawyellow
discolora%onoftheskin
-  chemical/intoxica%onPb,Cu,drugs/
Ø tachycardia,hypersplenism
-  mechanical/valvularprosthesis/
Ø predominanceofindirectbilirubin/unbound/
-  infec%on/bacterialsespis/
Ø anemia,re%culocytosis
-  Hipersplenizm,metabolicaldisorders/
uricemia/
Ø amarkedincreaseinLDH,aslightincreasein
transaminases
Ø lackofserologicalmarkersofviralinfec%ons
Unconjugated bilirubin predominance
Ø Increasedproduc%on
-  Intra-andextravascularhemolysis
-  Ineffec%veerythropoiesis
Ø Impaireduptakebilirubinbyhepatocytes
-  Sepsis,drugs,long-termhunger,hyperthyroidism
Ø Imapiredconjuga%onofbilirubin
-  Gilbert'ssyndrome,Crigler-Najjarsyndrome,neonataljaundice
Jaundice caused by congenital enzymaJc
defects of hepatocytes
Ø GilbertSyndrome
Ø Dubin-JohnsonSyndrome
Ø abnormalbindingofbilirubinwithglucuronideacid
Ø secre%ondisorderassociatedbilirubinpole
–deficiencyofUDPG
gallhepatocytes
Ø Familycharacter,thepredominanceofindirect
Ø familycharacter,thepredominaneof
bilirubin,normallevelsofliverenzymes,no
conjugatedbilirubin,
evidenceofhemolysis,bilirubinrarelyexceeds5
Ø bilinubinuria,thepresenceofthedyein
mg/dl
hepatocytesmelanin-like
Ø Crigler-NajjarSyndrome
Ø bilirubinmetabolismdefectassociatedwith
deficiencyofUDPG
Ø TypeI-childrendieinthefirst2yearsoflife
Ø TypeII-normallevelsofenzymes,<20mg/dl
bilirubin
Ø predominanceofindirectbilirubin
Ø RotorSyndrome
Ø VarietyofDubin-Johnsonsyndrome,the
absenceofthedyedepositsinhepatocytes
Ø Newbornsjaundice
Ø immaturityofenzyma%chepatocytesdeficiencyUDPGtransferase
HepaJc jaundice- causes
Ø Infec%on
Ø viral:HAV,HBV,HCV,HDV,HEV,EBV,TORCH,
Echo,Parvo,
Ø listeriosis
Ø Toxic
Ø drugs-cytosta%cs,paracetamol,TPN
Ø Chemicalcompounds-carbontetrachloride
Ø mushrooms-Amannitaphalloides
Ø Alcohol
Ø Metabolical
Ø Wilsondisease-disordersofCumetabolism
Ø hemochromatosis-disordersofFemetabolism
Ø alfa-1antytrypsindeficiency
Ø Galactozemia,fructozemia,glycogenosisIV,tyrosinemia,
cys%cfibrosis
Ø Autoimmunological/AIH/
Ø AIHtypI,IIa,IIb,III
Ø Primarybilliarycirrhosis/PBC/
Ø Primarysclerosingcholangi%s/PSC/
Ø other-Alagille’asyndrome,Aegenessydrome
Diagnosis
Ø interview-surgery,bloodtransfusion,alcohol,
drugs,chemicals
Ø serologicalmarkersofinfec%onHAV,HBV,HCV,
HDV,CMV,EBV
Ø darkurine,stooldiscolora%on
Ø autoan%bodiesANA,AMA,ANCA,LKM,SLA
Ø Cutaneous/vascularspiders,palmarerythema, Ø reduc%oninthelevelofceruloplasmin,
purpuraflaw/
Ø enlargedliverandspleen
Ø highcopperconcentra%onsinserumanddaily
urinecollec%on
Ø predominanceofdirectbilirubin/connected/
Ø elevatedlevelsofFe
Ø asignificantincreaseinthelevelofALT,ASTin
serumlesspronouncedFA,GGT
Ø Elevetadurobilinogeninurine,bilirubinuria
Ø leukopeniaandthrombocytopenia/
hypersplenism/
Ø decreaseinalbumin,gammaglobulinincrease
Jaundice extracellular- cholestasis
 Congenitalobstruc%onofextrahepa%croadsżółciowych-biliaryatresia
 Cystofcommonbileduct
 Narrowingofthebileducts
 Urolithiasisand/orspontaneousperfora%onofthecommonbileduct
Diagnosis
Ø interview-symptomsofbiliarycholelithiasis, Ø Abdominalultrasound-thelackof
itching,weightloss
gallbladder
Ø darkurine,stooldiscolora%on
Ø Biopsywątroby-to3weeksoflife->GOLD
Ø enlargementofthegallbladder,Chełmoński
STANDARDDIAGNOSISbiliaryatresia
symtome,liverenlarged,hard,withuneven
shore
Ø ERCP
Ø predominanceofdirectbilirubin/related
Ø CT,MR
Ø asignificantincreaseinGGT,FA,smallALT,
AST
Ø PTC-percutaneouscholangiografia
Ø leukocytosis,increasedESR,anemia
Ø lackofserologicalmarkersofhepa%%s
infec%on
Abdominal pain
 Abdominalpaininchildrencanbeasymptomofpsychosocialstress,asinadults
tensionheadacheintheoccipitalregion.
 Childrenusuallylocalizedpainaroundthenavel.
 Division
•  acute
•  chronic
•  recurrent
Acute abdominal pain
q mayhaveamildstart,thengraduallythepainincreases
q themomentofhisappearancecanbeappliedtoaspecificdate
q painwakesthechildorpreventssleep,interruptsplay
q itisnon-recurring
q rarelysubsideswithouttreatment
q oTenaccompaniedbyothersymptoms:nausea,vomi%ng,diarrhea,fever,lackofappe%te
q thepa%entisanxious,unwillingnesstoinves%gate
q posi%onwithcurledlegs-protectsthestomach,decreasingmuscletensionofthestomach
Acute abdominal pain- causes
SURGICAL
NON-SURGICAL
 appendeci%s
 cons%pa%on
 intussep%on
 gastroenteri%s
 cystorovariantorsion
 ovulatorypain
 simula%on
 urinarytractinfec%on
 haemoly%curaemicsyndrome
 hepa%%s
Chronic abdominal pain
q prevelence20-30%ofchildren5-14
q restrictsthenormalac%vityofthechild-only1/10pa%entsregularlygotoschool
q to9yearsofageoccurswithequalfrequencyinboysandingirls,olderchildrenmoreoTeningirls
q maybealsorelapsing
q theremaylastforseveraldaysorweeks
q individualepisodeslastupto3hours,morethanhalfofchildrenabout1hour
q seizuresusuallyoccurindroves
q paininterfereswithfallingasleep,butdoesnotraiseachild
q inmostchildrendis%nctperiodswithoutabdominalpain,butoccasionallythepaincanbecon%nuous
q Itcanbeassociatedwithothersymptoms:nausea,vomi%ng,diarrhea,headache,dizziness,fa%gue
The causes of chronic abdominal pain
q Themostcommoncause-func%onalabdominalpain
q Infec%on-yersiniosis,giardiasis,H.pyloriinfec%on,UTI
q cons%pa%on
q Foodalergy
q Foodintolerance-disaccharidoses-fructose,lactose,sucrose
q celiacdisease
q Anatomicalchanges-ovariancyst,pancreasdivided,gastrointes%nalileus/subileus
q Inflammatoryboweldisease-ulcera%vecoli%s,Crohn'sdisease
q Epilepsy,migraine
q Drugs:NSAIDs,steroids,ironprepara%ons
Chronic abdominal pain
FUNCTIONALABDOMINALPAIN
 propergrowth
 lackoflocalizedsymptoms
 painspilled
 painaroundthenavel
ORGANICABDOMINALPAIN
 painradia%ngtotheback,chest,hips,associated
withtheintakeoffoodorflushing
 painawakensthechildfromsleep
 painlocated,limited
 inhibi%onofbodyweightgain
 Othersymptoms-fever,vomi%ng,jointpain,
gastrointes%nalbleeding,painaroundlumbararea,
changesontheskinaroundtheanusoranalfissure,
analincon%nence,abdominaltumors,
hepatosplenomegaly
Abdominal pain- diagnosJcs
 Laboratorytests:bloodcount,ESR,CRP,ALT,AST,amylase,crea%nine
 Urinetest
 Stooltest:culture,viruses,occultblood,parasites,H.pylorian%geninstooltestELISA-Giardia
intes%nalis
 abdominalultrasound
Diarrhoea- diagnosis
 Thehigherthannormalnumberofstoolsperday(oTenmorethentwice),or
changeinthenatureofstool(theyarewateryorsemi-liquid),orthechild's
stoolscontainmucus,bloodorsputum
 WHO-acondi%oninwhichachild<2yearsofage,ar%ficiallyfedormixedhas
 threeormoreliquidorsemi-liquidstoolsper24hours
 or
 1abnormalstoolhavingbloodormucusorpuswithin24hours
Diarrhoea- classificaJon
 Divisionduetodura%on:
◦  Acutediarrhea<14days(usually3-5days)
◦  Prolongeddiarrhoea14-30days
◦  Chronicdiarrhea>30days(>14days)
 Thedivisionbecauseofthee%ology
◦  Noninfec%ousdiarrhea
◦  Infec%ousdiarrhea,fever,bloodinthestool,nauseaand/orvomi%ng,
◦  an%bio%cs
 Thedivisionduetothemechanism
◦  Osmo%cdiarrheacausedbyintes%nalinabilitytoabsorbexcessiveamountsofsubstancesthatretain
water,therebyincreasingstoolvolume(eg.lactoseintolerance)
◦  Secretorydiarrheacausedbyac%vesecre%onintotheintes%neoflargeamountsofsalt,waterand
othersubstances(infec%onagents,laxa%ves)
Acute diarrhoea- causes
 Infec%onsenteral->viruses,bacteria,exotoxins,protozoa
 Infec%onsoutsidethegastrologicaltract->UTI,o%%smedia,pneumonia
 Surgicaldiseases->appendici%s,intussuscep%on,obstruc%on
 Drugs:->An%bio%cs
Viral diarrhoea
 HRV(Rhinoviruses)ofgroupA,BandC
◦ 
◦ 
◦ 
◦ 
◦ 
◦ 
◦ 
infec%onthroughoral-faecal
infec%oniscomprisedofsmallintes%ne
shortincuba%onperiod(1-3days)
oTenexcessivevomi%ng(1-2days)
Acutewaterydiarrhea(usually2-7days)
oTenfever
20-40%-rhini%ssymptomsofupperrespiratory
tract
◦  Diagnosis:ELISAoralatexagglu%na%onassay
 Adenoviruses
◦  tendencytoprolongthediarrhea
◦  OTenaccompaniedbysymptomsofupper
respiratorytractinfec%ons
◦  clinicalcourseisusuallymild
◦  severedehydra%on,acidosis-inthecaseofsevere
vomi%ngand/ordiarrheawithoutproper
treatment
 Rotavirus
◦  Themaincauseofseverediarrheainyoung
children
◦  Europe:-autumn-winterseason
◦  Childrenaged6-24months
◦  Oralanddroplet
◦  OTenasnosocomialinfec%onsandepidemics
◦  vaccina%on
Bacterial diarrhoea
 Thecourseisself-limi%ng!
 Waterystoolswithmucus,pusorblood
 Thetendencytothreading(Salmonella,Shigella,Yersinia,Campylobacter,EPEC)
 Cancallsep%cemiaandsystemicinfec%ons(Salmonella,Yersinia)
 Traveler'sdiarrhea(ETEC,Shigella,Salmonella,Campylobacterjejuni,Vibriocholerae,
Cryptosporidiumparvum,Giardiaintes%nalis,Entamoebahistoly%ca)
ETEC
 EnterocytotoxicalE.coli;ETEC,Shiga-liketoxinproducingE.coli;verotoxinproducingE.coli
◦  Produc%onverocytotoxins(VT1,VT-2)
◦  Clinically:bloodydiarrhea,usuallywithoutfever
◦  E.coliO157:H7-afrequentcauseofbloodydiarrheaindevelopedcountries
◦  undercookedorundercookedbeef,hamburgers,drinkingwater,unpasteurizedmilk,
yogurt,vegetables
◦  Lackofsensi%vitytochemotherapy
◦  Complica%on:Hemoly%curemicsyndrome(upto10%infectedwithE.coliO157:H7
Salmonella
q Infec%onofatyphoidcancausebacteremiaandfocusofinfec%onintheGItract(bones,joints,CNS)-S.
typhi,S.paratyphiA,B,C
q gastroenteri%s(salmonellosis)-S.enteri%dis,S.typhimurium,S.agonae
q asymptoma%ccarriers
q onsetusually<6yearsofage
q oralinfec%on->contaminatedwater,food(icecream,mayonnaise)
q fever,nausea
q many,plen%fulsmellystools(mucus,pus,blood)
q Theywereusuallyself-limited
q sheddinginfecesisusuallyapprox.3weeks.
q an%bio%cspromotesprolongedcarriage
Clostridium difficile q ToxinA-enterotoxinsimilartothetoxinsofV.cholerae
q ToxinB-cytotoxin
q Approx.50-70%ofnewborns;20-50%<1r.ż.;approx.3%ofadults-
contaminatedwithC.difficile
q SymptomsaTeran%bio%cstherapy:clindamycin,ampicillin,amoxicillin,
cephalosporins
q Thebroadspectrumofclinicalsymptoms:
◦  milddiarrheawithwatery-brownstools
◦  severehemorrhagicdiarrhea
◦  pseudomembranouscoli%s
q posi%vebacteriologicalexamina%oncannotbethebasisforthediagnosis!
q goldstandard-cellculture,demonstratethecytotoxicityofC.difficiletoxinA
andB
Giardia intesJnalis
q themostcommoncauseofparasi%cdiarrhea
q developedcountriesapprox.2-5%ofthepopula%on,developingcountries
approx.20%
q Itisintheformtrofozoitandcysts
q oralinfec%on->intakeofwaterorproductscontainingcysts
q mileagevaries(asymptoma%ccarriers,acuteself-limiteddiarrhea,chronic
diarrheawithmalabsorp%on
q fecesorduodenalcontentstothepresenceofcystsortrophozoites
q ELISAtestforGiardiaintes%nalisantygen
Laboratory test
 Specificdiagnos%ctestsimmunosorbentassay(ELISA)orlatexagglu%na%on-detectedinasampleof
stoolan%gens:HRVgroupA,adenovirus,rotavirus
 Inmostchildrenwithoutimmunodeficiencymicrobiologicaldiagnosisitisnotnecessary-doesnot
changethebasicprinciplesoftreatment
 Indica%onsformicrobiologicalexamina%on:
◦  Bloodydiarrhea(Salmonella,Shigella,Campylobacter,E.coliO157:H7,Yersiniaenteroli%ca,Clostridium
difficile-toxinAandB)
◦  Diarrheawithveryseveredehydra%on≥10%orseriouscondi%on
◦  Prolongeddiarrhea(>10-14days)
◦  Alargenumberofleukocytesinthestool(>5hpf)
◦  Immunosuppressioninchild
◦  epidemiologicalconsidera%ons
◦  Suspectedcholera
Diarrhoea treatment
 Theresultofdiarrhoea-dehydra%on
 Lossofwaterandelectrolytesinthefaeces
(Na,K,Cl,HCO3)
 Thedegreeofdehydra%onisdefinedasa
percentageofweightloss
 Comparisonofcurrentweightandbefore
thediarrhoeaonset
 Primarytreatmentofacutediarrheaisoral
irriga%on(DPN)orintravenous(depending
ontheextentofdehydra%on)andfeeding
(earlyrealimenta%on)
GRADE
(weigh
loss)
GENERAL
CONDITI
ON
EYEBALLS
Noor
small
(<5%)
Calm,
concious
Proper
tension
Intermed
iate
(5-10%)
restless
Sunken ,
dark circles
Severe
(>10%)
Drowsy
or
unconsci
ous ,
limp
More
sunken
TEAR
S
MOUTH
AND
TONGU
E
THIRST
SKIN
FOLD
+
Wet
Normal
Straighte
nupfast
Dry
drinks
greedily
thirsty
Straigten
sup
slowly
Verydry
Drinks
poorly or
unable to
drink
independ
ently
Straighte
ns up
very
slowl
-
-
Acute diarrhoea treatment
Oralfluids-prepara%onswithalowercontentofsodium(60mmol/l)andalowerosmolarity(245
mmol/l)
Smec%te(Smecta)-reducesthedura%onofdiarrheaWed.17-24hrs.,noeffectonfaecaloutput
Probio%cs-LactobacillusrhamnosusGG,Saccharomycesboulardishortensthedura%onofacute
diarrheaininfantsandyoungchildrenapprox.for24hours.Efficiencyisstrainspecific.More
efficientinviraldiarrhea(diarrheainthee%ologyHRV)andinearlyuse.
Notrecommended:
• drugsabsorbingbacterialtoxins(ac%vatedcharcoal).
• drugsinhibi%ngperistalsisp.p.(Eg.Loperamide)
• an%secre%ondrugs(bismuthsubsalicylate)
• Torehydratenotuseacommerciallyavailableclearfruitjuices,ordrinkslike"cola"
AnJbioJcs in diarrhoea
Inmostcases,acuteinfec%ousdiarrhoea(viralandbacterial)resolvesspontaneouslyanddoes
notrequirean%microbialagents
Indicatedan%bio%ctherapyandmodifica%onoftreatmentaTercollec%ngstoolculturewhen:
fever(>380C)andatleastoneofthefollowingsymptoms:
->Bloodydiarrhea
->Largenumberofleukocytesand/orlactoferrininthestool
Chronic diarrhoea- causes
 Frequentcausesofchronicdiarrhoea
◦  post-infec%ousdiarrhoea,toddler’sdiarrhoea,foodallergy,coeliacdisease,cys%c
fibrosis,disaccharideintolerance
 Rarecausesofchronicdiarrhea
◦  diarrhoeachloride,diarrhoeasodium,congenitalatrophyofmicrovilli,epithelial
dysplasia,autoimmunediarrhoea
Food allergy
 Themostcommonallergens
 Childhood-90%offoodallergiesarecausedbyproteinsofcow'smilk,eggs,peanuts,wheat
 Teens,youngadultsandlaterage-85%peanuts,fish,shellfish
 Allergytocow'smilkproteins
 Formulafeeding:1,9-4,4%
 Breast-feeding:0.5%
Food allergy- causes
 Diges%vetract
◦ 
◦ 
◦ 
◦ 
◦ 
◦ 
◦ 
◦ 
◦ 
◦ 
Vomi%ng(approx.25-75%)
Acutediarrhea
Chronicdiarrhea(approx.25-75%)
Lossofbodymass
Enteropathy-malabsorp%on
Irondeficiencyanemia
Abdominalpain,abdominalcolic(babies)
Coli%s,proctocoli%s
gastroenteropathyeosinophilic
cons%pa%on
 Skin
 Respiratorysystem
Food allergy
 DIAGNOSIS
 TREATMENT
q Interview
q Elimina%ondiet
q Oralfodchallenge
q Proteinhydrolysates(Bebilonpep%,
Nutramigen)
•  open
•  blind
•  double-blind
q skintests
q TotalIgEandspecific
q Dietselementary(Bebilonamino,
Neocate)
q Soyformula
Lactose intolerance
 Primarylactosedeficiency–veryrare!
Secondarylactasedeficiency
•  acuteandchronicgastrointes%nalinfec%ons
•  foodalergy
•  celiacdisease
•  an%bio%corchemotherapy
•  immunedisorders
•  malnutri%on
 Hypolactasiaadulttype
◦  InPolandapprox.35%
Coeliac disease
 Celiacdiseaseisimmune-mediated,causedbygluten,andthegluten-likeprolamins.
 This disease affects people with a gene%c predisposi%on, and is characterized by clinical
symptomsglutenodependant,enteropathyandan%bodiesspecificforcoeliacdisease:
•  %ssuetransglutaminasean%bodies–tTGA
•  endomysialan%bodies–EMA
•  deamidatedgliadinpep%de–DGP
•  histocompa%bilityan%gensHLA-DQ2orDQ8
Coeliac disease- classificaJon
1.  Theclassicformofthedisease
2.  Hidden
refractoryanemiaandrecurrent
shortstature
delayedpubertyandinfer%lity
enamelhypoplasia
recurrentaphthousinmouth
3.  Latent
4.  Thepoten%al(onlyHLA)
Coeliac disease – classical form
 Arich,smelling,fa{ystools
 Inhibi%onofweightgainordecrease
 Growthretarda%on
 Childsad,apathe%c,irritable
 Lipoatrophy
 Alargeprotrudingbelly,thinlegs
Toddler’s diarrhoea
 Themostcommoncauseofchronicdiarrhoea!
 Painlesspassingthreeormoreunformedstoolsforatleast4weeks
 Onsetbetween6a36m.ż.
 Stoolsonlyduringtheday%me
 Nodisturbancesofweightgain(ifsufficientcaloricintake)
 Children
◦  treatmentisnotnecessary
◦  increasingthedoseoffatandreducedamountsofjuices
 Parents
◦  explainthenatureofthedisease
◦  persuadingparentsaboutthebenignnatureofthedisease
ConsJpaJon
Defeca%onoccursless1per3daysand/orthebigeffortsisnecceserybecause
hard,thoughstoolconsistencyinchildrenaTerinfancy.
Func%onalcons%pa%onaccordingtoRomeIIICriteria:
*≤2stools/week
*≥1episodeoffecalinconinenec/week
*fecalmassesinrectalampulla
*ininterview:reten%onbehaviours,hard,toughstools,largediameterofthe
stools
*Diagnosis-2ormoresymptomsoccursatleastfor2months
Organic causes of the consJpaJon
q Surgical:
•  Hirschsprungdisease
•  Anusandrectaldiseases
•  Acuteabdomen
q Metabological
• 
• 
• 
• 
dehydrata%on
Cys%cfibrosis(meconiumobstruc%on)
Hipothyroidism,adrenalinsufficiency
Hipercalcemia
q neuromuscular
• 
• 
• 
• 
hypotensionabdominalmuscles(Downsyndrome,MPD)
musculardystrophy
spinalinjury(tumors,spinabifida)
Congenitalmuscularlimpness
q ATerdrugsintake
• 
• 
• 
• 
narco%cs
an%depressants
psychotropmedicines
vincris%ne
q Psychiatric:anorexianervosa,depression
q Inolderinfantsexclusivelybreas~ed
ConsJpaJon
INTERVIEW
 Physicalexamina%on
q Childage
q assessmentofnutri%onalstatus
q Dura%on%meofilness
q abdominaldistension
q Frequencyofbowelmovement,stools
consistency,effortduringdefeca%on,bloodin
stools,fecalincon%nence
q palpa%onassessmentoffaecalimpac%oninthe
leTandsome%mesrightiliacfossa%me
q TimeaTerbirthwhenmeconiumappears
q drugs
q VitD3supplementa%on
q diet
q Otherdiseases
q rectalexamina%on-evalua%onvoltageof
sphincter,thepresenceoffecalmassesina
rectum
AddiJonal tests
q Ultrasoundofabdominalcavityandthyroid
q electrolytes
q Thyroidhormones
q Sweatchloridetest
q Vitamin25OHD3
q Anorectalmanometry
q enema
q rectoscopy
q transit%me
q Rectalbiopsy:histologicalexamina%onandhistochemical
Treatment q Coloncleansingfromdefaul%ngfecalmasses
q Drugs:laxa%ves,drugsaffec%nggastrointes%nalmo%lity
q High-fiberdiet
q Increasedphysicalac%vity
q Psychologicalexamina%on
q Surgicaltreatment
Literature
Ø  Pediatria,Kawalec,Grenda,PZWL,Warszawa2013
Ø  IllustratedtextbookofPediatrics,4thEdi%on
Ø  EuropeanSocietyforPediatricGastroenterology,Hepatology,andNutri%onGuidelinesfor
theDiagnosisofCoeliacDisease.JPGNVolume54,Number1,January2012
Ø  DrossmanDA.Thefunc%onalgastrointes%naldisordersandtheRomeIIIprocess.
Gastroenterology.2006;130:1377-90.
Ø  SummaryandRecommenda%ons:Classifica%onofGastrointes%nalManifesta%onsDueto
ImmunologicReac%onstoFoodsinInfantsandYoungChildrenSampson,HughA.;
Anderson,JohnA.JPGN,2000,30,S87-S94
Ø  Google.com
Ø  Slideshare.net