Pediatric Gastrointestinal Health and Clinical Procedures

Preparation for Large Intestine Examination

Pediatric Constipation and Evacuation

Symptoms of Constipation

The Mechanism of Evacuation

1. External sphincter and puborectal muscle relax.
2. The rectoanal angle becomes flat.
3. Abdominal muscles and the diaphragm contract.
4. Pressure inside the rectum becomes higher than in the anal canal, and evacuation occurs.

Indications for Special Examination

• Constipation in newborns and infants.
• Constipation in older children with specific risk factors.
• Constipation associated with Down syndrome.
• Ineffective treatment lasting over 6 months.

Treatment Protocols for Constipation

I. Primary Counseling: Adjustment of diet, increased water intake, and added fiber.

II. Emptying the Bowel: Required if fecaloma formation or overflow soiling occurs. Use large enemas for 1–3 days and confirm evacuation. Avoid long-term enema regimens.

III. Toileting Routines: Use stimulant laxatives (bisacodyl, senna, picosulfate). Start with high doses and taper slowly based on response.

IV. Maintenance: Use bulk laxatives. Start when the stimulant laxative dose is reduced to approximately one-third of the starting dose.

Hirschsprung Disease (Congenital Megacolon)

Definition: Aganglionosis of the bowel, equivalent to megacolon in adults. It is caused by the absence of ganglion cells in the rectum and colon (typically the rectosigmoid area). It is genetically acquired due to failure of formation in utero.

Pathophysiology: The aganglionic bowel is unable to relax. Morphologically, there are no parasympathetic ganglia plexuses in the submucosa and hyperplasia of the neuronal plexus in the mucosa.

Clinical Features and Symptoms

• Failure to pass meconium within 24-48 hours.
• Distended abdomen and bilious vomiting.
• Symptoms of enterocolitis (inflammation, distention, sepsis).
• Chronic constipation and ribbon-like, foul-smelling stool.
• Empty rectal ampulla upon examination.
• Clinical and radiological signs of bowel perforation.

Diagnosis and Treatment

Treatment: Surgical resection of the aganglionic portion and restoration of intestinal continuity (anastomosis).

Incontinentia Alvi and Encopresis

Rectal Prolapse in Children

Diagnosis: Inspection, Digital Rectal Examination (DRE), Anorectal Manometry, and Rectoromanoscopy.

Treatment: Manual reduction with lubricant, non-operative management, circumferential injection procedures, Thiersch’s operation (perianal sling), or abdominal rectopexy.

Anorectal Malformations (ARM)

Diagnosis: Clinical features, urine tests, invertogram (at 12 hours), and colostogram.

Anatomy of the Infant Gastrointestinal System

• Meconium: Should pass within the first 24 hours as a sign of GI health.
• Peristalsis: Greater in infants than adults.
• Sphincters: Relaxed cardiac sphincter; pyloric sphincter is well-developed.
• Enzymes: Deficient until 4-6 months (reason for breastfeeding).
• Liver: Immature at birth.
• Stomach: Smaller capacity; vertical position.
• Hydration: Children need more water and dehydrate quickly due to immature kidneys.

Oral Cavity and Pharynx

• Small size with a short, wide, and thick tongue.
• Well-developed lip and cheek muscles for sucking; fat pads atrophy by year 4.
• Infants can breathe and eat simultaneously due to the high location of the laryngotracheal groove.
• Teeth: Milk teeth start at 6-8 months. Formula: Number of teeth = Age in months - 4. All 20 milk teeth should appear by age 2. Permanent teeth (32 total) include 3rd molars emerging at 17-21 years.

Esophagus and Intestines

• Esophagus: Short (10 cm) and narrow with thin walls and high blood supply.
• Small Intestine: Villi are not as developed as in adults.
• Large Intestine: Haustra appear at 6 months; topography completes by age 2-4. The rectum is not yet mature.
• Pancreas: Very small (2-3g); increases 4x by year one. Islets of Langerhans are dominant.

Oral Candidiasis (Stomatitis Candidosa)

Symptoms: Hyperemia of the oral mucosa and white semolina-like spots.

• Light Form: White dotted spots on hyperemic mucosa; easily removed.
• Intermediate Form: Membrane-like plaques; harder to remove with possible bleeding.
• Hard Form: Extensive plaques covering the palate, uvula, and pharynx. Burning sensation and enlarged submaxillary lymph nodes. Risk of Candida sepsis.

Diagnosis: Culture showing large colonies, microscopic smear (blastospores and pseudomycelium), and skin tests.

Treatment: Avoid sour substances, use antifungal medications, maintain mouth hygiene, and use 2-3% soda solution washes 5-6 times a day. Stop antibiotics or hormones if applicable.

Acute and Chronic Gastritis

Acute Gastritis

Treatment: Liquid diet (sugarless tea) for the first 3 hours. Day 1: Rice porridge (no butter). Day 2: Grains and pasta. Day 3: Broth and meat. Restrict spicy/fried foods for 20-30 days.

Chronic Gastritis

• Infectious: H. pylori (epigastric pain, fullness, nausea, flatulence). Diagnosis via endoscopy and biopsy. Treatment: Triple therapy (Metronidazole, Tetracycline, Bismuth).
• Non-Infectious: Autoimmune or NSAID-induced.

Infantile Colic

Rule of 3: Crying for >3 hours/day, >3 days/week, for >3 weeks. Causes include cow's milk protein sensitivity, high motilin, psychosocial stress, or an immature nervous system.

Clinical Features: Crying, distended abdomen, pained facial expression, drawing legs up, and increased rectal gas.

Treatment: Massage, swinging, dietary changes, parental education, and occasionally sedatives or antispasmodics.

Peptic Ulcer Disease

• Duodenal Ulcers: Pain occurs hours after meals or at night (nocturnal pain); relieved by eating.
• Gastric Ulcers: Pain aggravated by eating; leads to weight loss.

Diagnosis: CBC, amylase/lipase, abdominal Ultrasound, X-ray, and Esophagogastroduodenoscopy.

Treatment: H2 antagonists, PPIs (Omeprazole for 4 weeks), and H. pylori eradication (Omeprazole + Clarithromycin + Metronidazole for 7-14 days).

Gastroesophageal Reflux Disease (GERD)

Definition: Reflux of gastric content into the esophagus causing tissue damage. Often physiological in infants due to lying position and lower esophageal sphincter (LOS) relaxation.

Symptoms: Poor weight gain, esophagitis, neurobehavioral changes due to pain, and persistent respiratory syndromes (aspiration pneumonitis).

Diagnosis: History, physical exam, endoscopy, 24-hour pH study, and empirical PPI trials.

Treatment: Small frequent meals, weight control, elevating the head during sleep, and medications like PPIs (Prilosec) or H2 inhibitors.