Pedia Prelims 2.4 Git Disorders II Trans

Top ic: PEDIA TRI CS – GAS TROIN TESTIN AL DIS ORDERS II
Lec turer: D r. Lib eriza M. O re no-‐ Ferrer
Date : D ecem ber 6, 2016
Trans cribe d by: Agu sti n| Bon ifacio |Da vid K .|D ela Cruz
P.| Dun gao |Go zu n| Lans ang
Up dat ed tra ns o f ba tch 2018

O UTLINE
1. Acute Gastroenteritis What is NOT diarrhea?
2. Current/ Reccurent Diarrhea • Frequent passing of formed stools
3. Probiotics • Loose, pasty stool on babies on exclusive breast
4. Malabsorption
milk
5. Short Bowel Syndrome
6. Acute Appendicitis Types of Diarrhea
7. Anorectal Malformations • Acute watery diarrhea (including cholera)
8. Anal Fissures o Cholera-‐ rice water stools
9. Rectal Prolapse -‐ very prone to cause an outbreak
10. Hemorrhoids
11. Hernia
• Acute bloody diarrhea (dysentery)
o Most common cause is Shigella

Case 1 o Request for fecalysis and give antibiotics
A mother brought her 4-‐month-‐old daughter Sofia to the • Persistent diarrhea (14 days or longer)
ER because of diarrhea of 3 days, described as watery o You may need to shift the type of milk
and non bloody. This was accompanied by low-‐grade being given because the child may be
fever with no vomiting. You look and found signs of having secondary lactose intolerance,
dehydration and noted the following, Sofia is alert, well wherein the villi that secretes lactase
child with sunken eye balls and moist tongue. She drinks are being eroded
eagerly and her skin pinch goes back quickly. • Diarrhea with severe malnutrition
Diagnosis-‐ Acute Gastroenteritis o There is usually superimposed infection
Describe the diarrhea-‐ watery or bloody (for o Slow rehydration
diagnosis)
Low grade fever with no vomiting-‐ for treatment Epidemiology
(could give paracetamol for fever) • In the Philippines, diarrheal disease is the 2nd
leading cause of morbidity for all ages
ACUTE GASTROENTERITIS o <5 years of age; safest: boiled water
• Gastroenteritis is a catch-‐all term for infection of especially in neonates (does not matter
irritation of the digestive tract, particularly the how long you boil the water)
stomach and intestine. • 6th leading cause of mortality for all ages
• Major symptoms include DIARRHEA, nausea, • It is the 3rd leading cause of infant deaths.
vomiting, and abdominal cramps. These
symptoms are sometimes also accompanied by Etiology
fever and overall weakness. • Most common cause is a viral infection
• Diarrhea is the passage of unusually loose or o ROTAVIRUS
watery stools, usually at least 3x in a 24hr period. o Adenovirus
However, it is the consistency of the stools rather o Calcivirus
than the frequency that is most important. o Astrovirus
• Breastfed babies have increase frequency of o Small round-‐structured viruses (SRSVs)
bowel movement and it doesn’t mean they have
diarrhea

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PEDIATRICS – Gastrointestinal Disorders II

• Other common organisms include diarrhea, abdominal cramps, fever, overall
o ETEC (could be aggravated with weakness.
antibiotics) • Usually dehydrated
o Shigella
o Campylobacter Clinical Course
o Vibrio cholera • Gastroenteritis typically lasts about 3 days.
o Non typhoidal salmonella • Adults usually recover without problem, but
• Hospital and community based etiology studies children, the elderly and anyone with
in the Philippines showed the predominance of underlying disease are more vulnerable to
ROTAVIRUS and ETEC as cause of diarrhea in the complications such as diarrhea.
Philippines.
• Contrary to popular belief, E. histolytica was CHRONIC/ RECURRENT DIARHHEA
detected in <5% of cases. This data proves the • Chronic/persistent diarrhea: an episode that
relatively low prevalence of E. histolytica cysts starts acutely and lasts for at least 2 weeks
and trophozoites in the general population. o Rotavirus – 7 days duration
o Watery stool: Trophozoites, Formed stool: • Dysentery: diarrhea associates with blood and
cysts pus cells in the stools.
o If the child is less than 5 years of age, do not o Most commonly caused by Shigella
consider entamoeba histolytica as the
causative agent (5%, therefore unlikely). Epidemiology
− May be mistaken as macrophage, blood • These ‘types’ of diarrhea are important in that
cell, too small they are more likely to have severe
− To differentiate: nucleoli, macrophage consequences.
may ingest red blood cell • Studies have shown that one third to one half of
− Signs and symptoms: sick-‐looking with all diarrhea associated deaths among children
history of eating raw vegetables occurred following episodes of persistent
• Typically, children are more vulnerable to diarrhea, where dysentery accounts for 10%-‐
rotaviruses, the most significant cause of watery 15% of diarrheal episodes in children <5y/o, but
diarrhea. up to 25% of diarrheal deaths.
• Annually, worldwide, rotaviruses are estimated
to cause 800,000 deaths in children <5 y/o Etiology
• For this reason, an important vaccine has been • Less than half of all children with persistent
developed and is already in the market for diarrhea have a recognized enteric pathogen in
prevention of rotavirus infection (Rotarix and their feces.
Rotateq). Available in local health centers since • Enteropathogens that are isolated with greater
2011 for the indigent children. frequency from episodes of persistent diarrhea
o Rotarix – 3 doses include enteroadherent E. coli (EAEC),
o RotaTeq – 2 doses enteropathogenic E. coli (EPEC) and
− But of same efficacy Cryptosporidium.
• Shigella is the most common of dysentery (33%-‐
Transmission 62% of cases in 3 studies)
• Exposure typically occurs through the fecal-‐oral • The 2nd most common cause of dysentery,
route, such as consuming food contaminated by particularly in children <1y/o is Campylobacter
fecal material related to poor sanitation. • Other organisms which may cause dysentery
• Pacifier use-‐ increase risk for diarrhea and acute include: Invasive E. coli, P. shigelloides,
otitis media Salmonella and Aeromonas

Clinical Manifestation Pathophysiology
• The symptoms of gastroenteritis are usually • The mechanisms by which these agents cause
enough to identify the illness. persistent diarrhea are probably related to their
• Major symptoms: nausea and vomiting, capacity to adhere or invade the bowel mucosa.

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• Dysentery is cause primarily by bacteria, which o Empiric treatment with ciprofloxacin 15
invade the epithelial cells of the small intestines o mg/kg/dose BID for 3 days
and colon, produce a variety of toxins, disrupt • Consider differential diagnosis for bloody
the cells and cause an inflammatory response. diarrhea
• A number of organisms have been found in o Anal fissure
dysentery cases, and more than one pathogenic o Intussusception
organism is found in many cases o Allergic colitis
• Non-‐infectious causes: • Diagnosis made on clinical grounds (onset and
o Dietary factors (Cow’s milk intolerance) duration of diarrhea)
o Hepatobiliary disorders • Most of the cases (>60%) due to:
o Surgical disorders o Acute intestinal infection
o Endocrine causes o Dietary intolerance
o Pancreatic Exocrine Insufficiency − Protein-‐sensitive enteropathy
o Tumors (cow’s milk allergy)
o Miscellaneous (Antibiotic-‐related − Secondary disaccharide
diarrhea) malabsorption (lactose)

Pathogenesis • In 30% of cases, no etiologies can be established
Risk Factors in the Pathogenesis of Persistent Diarrhea: despite extensive investigations
• Host factors (young age, malnutrition) • Complications include dehydration and life
• Previous infections (episodes of acute diarrhea) threatening arrhythmia (hypokalemia)
• Pre-‐illness feeding factors (recent introduction
of animal milk versus breastfeeding) Management
• Microbial isolates during the acute phase Gastroenteritis is a self-‐limiting illness, which resolves by
• Ineffective management during the acute phase itself. (manage complications of dehydration)
(food withholding, inadequate treatment of
shigellosis, use of antimotility drugs) WHO PROTOCOL FOR DIARRHEA
o NPO is before, nowadays we DO NOT NO SOME SEVERE
WITHHOLD FOOD. DEHYDRATION DEHYDRATION DEHYDRATION
o Do not give sweets because it causes Condition Well, alert Restless, Lethargic,
osmotic diarrhea. irritable unconsious
Eyes Normal Sunken Sunken
Diagnostic Investigation
Thirst Drinks Thirsty, drinks Drinks poorly
• Diagnosis for most cases of acute diarrhea: nomarlly, not eagerly or not able to
Clinical thirsty drink
o Based on the clinical syndromes:
Skin pinch Goes back Gies back Gies back very
− Acute watery diarrhea
quickly slowly slowly
− Bloody diarrhea
Treatment Plan A Plan B Plan C
− Persistent diarrhea
Fluid <5% of body 5-‐10% of body >10% of body
− Diarrhea with severe malnutrition
Deficit wt or wt or 50-‐ wt or
• Routine stool examination not necessary in most
<50ml/kg 100ml/kg >100ml/kg
cases of acute watery diarrhea
body wt body wt body wt
• Stool microscopy and culture indicated only

when patients do not respond to fluid
Management of acute diarrhea
replacement, continued feeding, and zinc
Objectives of the treatment
supplementation
• Prevent dehydration and treat if present
• Bloody Diarrhea
• Prevent malnutrition
o Ascertain if due to an infection
• Reduce duration and severity of diarrhea and
o 40-‐60% due to shigellosis
occurrence of future episodes by giving
o Stool exam to ascertain and document
supplemental zinc for 2 weeks
microorganism

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Mainstay for Diarrhea Management • Children who continue to have some
• One of the breakthroughs in Medicine: ORESOL dehydration even after 4 hours should receive
• BREAKTHROUGH-‐ they have an impact, they ORS by nasogastric tube or intravenously
change the mortality • If abdominal distention is present, then oral
• ORESOL – with the introduction of oresol, there rehydration should be withheld and only IV
is a decline in the mortality due to diarrhea. rehydration should be given.
o Problem with oresol is its bad taste, can • Amount of ORS to be given in the 1st 4 hours
induce vomiting (see appendix)
o Different flavors are now available and • *AGE should only be used if weight is not known
give it chilled. Example: Approximate weight of 2 year old:
• Zinc =(Age in years) x 2 +8
o Roles in Pneumonia and Diarrhea = 2x2 +8=12kg

WHO Plan A (no dehydration) WHO Plan C (severe dehydration)
Home therapy to prevent dehydration and malnutrition • Preferred treatment is rapid IV rehydration
(extra fluid and salt) • Give 100mL/kg Plain Lactated Ringer’s solution
FLUIDS to be given: or Plain NSS as follows
• ORS
• Salted drinks (salted rice water or salted yoghurt
drink)
• Vegetable or chicken soup with salt
• Home-‐based ORS:

o 3 grams table salt and 18 grams
common sugar in 1 liter of water • Repeat once if radial pulse is still very weak or
not detectable
• How much to give:
o Give as much fluid as the child wants • Reassess the child every 1-‐2 hours. If hydration
until diarrhea stops status is not improving, give the IV drip more
o Children <2 years of age: 50-‐100 ml of rapidly
fluid • After completion of IV fluids, reassess the
o Children 2-‐10 years: 100-‐200 ml patient and choose the appropriate treatment
o Older children and adults: as much as plan
they want • If IV therapy is not available, then ORS by
• Plain water should also be given nasogastric tube or orally at 20 ml/kg/hour for 6
• Commercial carbonated beverages, fruit juices, hours should be given
sweetened tea, coffee, medicinal tea should be • If abdomen becomes swollen or child vomits
avoided repeatedly, then ORS should be given more
• The infant’s usual diet should be continued slowly
during diarrhea and increased afterwards
Zinc Supplementation: Treatment
• Breastfeeding should always be continued
Acute Diarrhea
• Zinc supplement: 10-‐20 mg daily for 10-‐14 days
• Reduction in duration of -‐0.69 day (95% Cl: -‐0.97
should be given
to -‐0.40)

WHO Plan B (some dehydration) • Reduction in diarrhea risk lasting >7 days
RR=3.71 (95% Cl: 0.53-‐0.96)
• Can also use weight of the patient (kg) x 75
• No reduction in stool output
• Except for breast milk, food should not be given
during the initial 4-‐hour rehydration period. • Based on 18 RCTs (n=11.180 mainly from
developing countries)
• Can give food thereafter if treatment Plan B is

continued longer than 4 hours.
Persistent Diarrhea
• REASSESS the child after 4 hours and decide
• Zinc (with MV vs. MV alone, singly or with
what treatment to be given best as per grade of
vitamin A) significantly
dehydration.
o Reduced stool output

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o Prevented weight loss/ promoted of the intestinal mucosa
weight gain • Strategies for Diarrheal Disease Control
o Promoted earlier clinical recovery o Breast feeding (at least 6 months)
• Based on 2 RDBCTs in mod. Malnourished o Improved weaning practices
children 6-‐24 mos. (n=190 + 96) o Immunization against measles,
rotavirus, and cholera
Zinc Supplementation: Preventiom o Improved water supply and sanitation
1990s facilities
• Continuous trials (1-‐2 RDAs 5-‐7 times/week) o Promotion of personal and domestic
o OR = 0.82 [95% Cl: 0.72, 0.93] incidence hygiene
o OR = 0.75 [95% Cl: 0.63, 0.88]
prevalence Case 2
• Short-‐course trials (2-‐4 RDAs daily for 2 weeks) Aristotle is a 2-‐month-‐od baby boy who was brought to
o OR = 0.89 [95% Cl: 0.62, 1.28] incidence your clinic because of watery diarrhea with no fever and
o OR = 0.58 [95% Cl: 0.52, 0.83] vomiting.
prevalence Aristotle is fuzzy. This started when the mother him to
cow’s milk formula because she went back to work and
2000s cannot breastfeed anymore.
• 9% reduction in incidence of diarrhea
• 19% reduction in prevalence of diarrhea M ALABSORPTION
• 28% reduction in multiple (> 2) diarrheal Malabsorption is a state arising from abnormality in
episodes absorption of food nutrients across the gastrointestinal
• No statistically significant impact on persistent (GI) tract.
diarrhea, dysentery or mortality • Impairment can be of single or multiple
nutrients depending on the abnormality. This
Micronutrient Supplementation in Diarrheal Disease may lead to malnutrition and a variety of
• Malnutrition underlie 61% of diarrheal deaths anaemias.
globally • Some prefer to classify malabsorption clinically
• Micronutrient deficiencies into three basic categories:
o Diminish immune function o Selective, as seen in lactose
o Increase susceptibility to infections malabsorption
o Predispose to severe illnesses o Partial, as observed in
o Prolong duration of illness Abetalipoproteinaemia
o Total as in Celiac disease
Single vs. Multiple Nutrient Supplementation • Malabsorption constitutes the pathological
• Therapeutic strategy: zinc, vitamin A, folic acid interference with the normal physiological
• Preventive strategy: zinc, vitamin A, multiple sequence of digestion (intraluminal process),
micronutrients absorption (mucosal process) and transport
(postmucosal events) of nutrients.
PROBIOTICS
“Probiotics are live microorganisms which when Etiology
administered in adequate amounts confer a health • Mucosal damage (enteropathy)
benefit on the host.” (Expert Consultation at a meeting • Congenital or acquired reduction in absorptive
convened in FAO/WHO in October 2001) surface
• Use of Probiotics in prevention and treatment of • Defects of specific hydrolysis
diarrhea • Defects of ion transport
o Most common use • Pancreatic insufficiency
o The mechanism and the efficacy of a • Impaired enterohepatic circulation
probiotic effect often depend on • Due to infective agents
interactions with the specific microflora o Whipple's disease
of the host or immunocompetent cells o Intestinal tuberculosis

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o HIV related malabsorption irritation from unabsorbed fatty acid.
o Tropical sprue • The latter also results in bloating, flatulence and
o Traveler's diarrhea (ETEC) abdominal discomfort. Cramping pain usually
o Parasites e.g. Giardia lamblia, fish suggests obstructive intestinal segment e.g. in
tapeworm (B12 malabsorption); Crohn's disease, especially if it persists after
roundworm, hookworm (Ancylostoma defecation.
duodenale and Necator americanus) • Weight loss can be significant despite increased
• Due to structural defects oral intake of nutrients.
o Inflammatory bowel diseases commonly • Growth retardation, failure to thrive, delayed
in Crohn's Disease puberty in children
o Fistulae, diverticulae and strictures • Swelling or edema from loss of protein
o Infiltrative conditions such as • Anemias, commonly from vitamin B12, folic acid
amyloidosis, lymphoma, Eosinophilic and iron deficiency presenting as fatigue and
gastroenteritis weakness.
o Radiation enteritis • Muscle cramp from decreased vitamin D,
o Systemic sclerosis and collagen vascular calcium absorption. Also lead to osteomalacia
diseases and osteoporosis
o Short bowel syndrome • Bleeding tendencies from vitamin K and other
• Due to surgical structural changes coagulation factor deficiencies.
o Gastrectomy; Vagotomy
o Bariatric surgery (Weight loss surgery) Diagnosis
• Due to mucosal abnormality • There is no specific test for malabsorption. As
o Celiac disease for most medical conditions, investigation is
o Cows' milk intolerance guided by symptoms and signs. A range of
o Soya milk intolerance different conditions can produce malabsorption
o Fructose malabsorption and it is necessary to look for each of these
• Due to enzyme deficiencies specifically.
o Lactase deficiency including lactose • Many tests have been advocated and some are
intolerance (constitutional, secondary or complex, vary between centers and have not
rarely congenital been widely adopted. However, better tests
o Sucrose intolerance have become available with greater ease of use,
o Intestinal disaccharidase deficiency better sensitivity and specificity for the causative
o Intestinal enteropeptidase deficiency conditions. Tests are also needed to detect the
• Due to other systemic diseases affecting GI tract systemic effects of deficiency of the
o Celiac disease malabsorbed nutrients (such as anemia with
o Hypothyroidism and hyperthyroidism vitamin B12 malabsorption).
o Addison’s disease
o Diabetes mellitus Laboratory Tests
o Hyperparathyroidism and Routine blood tests may reveal
hypothyroidism o Anemia, high CRP or low albumin; which shows a
o Carcinoid syndrome high correlation for the presence of an organic
o Malnutrition disease.
o Fiber deficiency o Microcytic anemia usually implies iron deficiency
o Abetalipoproteinemia and macrocytosis can be caused by impaired
folic acid or B12 absorption or both.
Clinical Manifestations o Low cholesterol or triglyceride may give a clue
• Diarrhea, often steatorrhea is the most common toward fat malabsorption.
feature. Watery, diurnal and nocturnal, bulky, o Low calcium and phosphate may give a clue
frequent stools are the clinical hallmark of overt toward osteomalacia from low vitamin D.
malabsorption. It is due to impaired water, o Specific vitamins like vitamin D or micronutrient
carbohydrate and electrolyte absorption or like zinc levels can be checked.

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o Fat-‐soluble vitamins (A, D, E & K) are affected in Common in the Phils-‐ intestinal parasitism of
fat malabsorption. Prolonged prothrombin time ascariasis
can be caused by vitamin K deficiency. Don’t use Diphenhydramine anymore in deworming
Worm burden: 1 adult ascaris lays 40,000 eggs
Serological Studies 40,000 X 30 (1month) then multiply by 3 (3
o Specific tests are carried out to determine months) = 360,000 eggs—worm burdern
the underlying cause IgA Anti-‐ Ascaris bolus can cause partial gut obstruction
transglutaminase antibodies or IgA
Antiendomysial antibodies for Celiac disease Patients na lumunok ng buto ng Santol and patient an
(gluten sensitive enteropathy). nagka ascariasis-‐ watch out for short bowel syndrome

Stool Studies SHORT BOW EL SYNDROM E
o Microscopy is particularly useful in diarrhea, SBS, also short gut syndrome or simply short gut) is a
may show protozoa like Giardia, ova, cyst and malabsorption disorder caused by the surgical removal
other infective agents. of the small intestine, or rarely due to the complete
o Fecal fat study to diagnose steatorrhea is rarely dysfunction of a large segment of bowel. Most cases are
performed nowadays. acquired, although some children are born with a
o Low fecal pancreatic elastase is indicative of congenital short bowel.
pancreatic insufficiency. Chymotrypsin and
pancreolauryl can be assessed as well. Signs and Symptoms
Radiologic Studies • Abdominal pain, diarrhea and steatorrhea (oily
o Barium follow through is useful in delineating or sticky stool, which can be malodorous)
small intestinal anatomy. Barium enema may be • Fluid depletion
undertaken to see colonic or ileal lesions. • Weight loss and malnutrition
o CT abdomen is useful in ruling out structural • Fatigue
abnormality, done in pancreatic protocol when
visualizing pancreas. Complications
o Magnetic resonance cholangiopancreatography • Patients with short bowel syndrome may have
(MRCP) to complement or as an alternative to complications caused by malabsorption of
ERCP vitamins and minerals, such as deficiencies in
vitamins A, D, E, K, and B12, calcium,
Treatment magnesium, iron, folic acid, and zinc. These may
• Treatment is directed largely towards appear as anemia, hyperkeratosis (scaling of the
management of underlying cause: skin), easy bruising, muscle spasms, poor blood
o Replacement of nutrients, electrolytes clotting, and bone pain.
and fluid may be necessary.
o In severe deficiency, hospital admission Etiology (usually caused by surgery for)
may be required for parenteral • Volvulus, a spontaneous twisting of the small
administration; often advice from intestine that cuts off the blood supply and leads
dietitian is sought. People whose to tissue death
absorptive surface is severely limited • Tumors of the small intestine
from disease or surgery may need long-‐ • Injury or trauma to the small intestine
term total parenteral nutrition. • Necrotizing enterocolitis (premature newborn)

Abdominal Pain
Case 3 • A common symptom during childhood
Marcus us a 2-‐year-‐old boy who came in because of on • May be regarded with little significance and
and off abdominal pain especially at night. The pain is dismissed as simple “colic” or it can be a cause
not related to food intake or defecation. There was one of alarm for parents and physicians alike.
episode of vomiting with 1 adult worm 2 days ago. There • Evaluation in children is challenging because it’s
is no diarrhea. hard for them to describe the pain

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Types of Abdominal Pain • If the pain persists for more than 3 hours, this
Visceral pain should be regarded as an abdominal emergency
o Generally felt in the dermatome from which the until proven otherwise.
organ derives its innervations o Vomiting that PRECEDES a colicky type
o Localized in the epigastric area: liver, pancreas, of abdominal pain suggests the problem
biliary tree or upper GI tract of gastroenteritis while vomiting that
o Localized in the periumbilical area: distal small occurs AFTER the onset of pain is
intestine, and proximal colon suggestive of a surgical condition. The
o Localized in the suprapubic region: distal colon, suspicion is strengthened if the vomitus
urinary tract and pelvic organs is bilous.
• An intestinal obstruction is suspected if the
Parietal pain vomiting is frequent and copius.
o Transmitted through the C fibers of nerves
corresponding to the dermatomes T6-‐L1 Casuses of Abdominal Pain
o Pain is usually more localized and severe Early Infancy
compared to visceral pain o Abdominal colic (baby is crying because of
bloating)
Referred pain o Usually 10-‐12 weeks of age occurring in 10-‐15%
o Relates to the distribution of segmental nerves of babies
o Typical example is pain from then inflammation o Unexplained intermittent crying, with relief of
of the diaphragm which is referred to the upper symptoms by 3 months of age
back and lower neck areas o Feeling of being gassy and being relieved with
o Periumbilical pain radiating and localizing to the passage of flatus
right iliac fossa is almost diagnostic of acute o Consider: viral gastroenteritis, cow’s milk protein
appendicitis intolerance, overfeeding, incarcerated inguinal
hernia, torsion of the testicle or missed trauma
Chronic or recurrent abdominal pain
o At least 3 episodes of pain extending over a Older healthy infant
period of more than 3 months, severe enough to o Sudden onset of severe abdominal pain
restrict activities o Passage of currant-‐jelly stools
o Consider: Intussusceptions
Diagnosis
• Good history and careful physical examination Preschool child 2-‐5years
are mandatory and very important although o Common causes: age, mesenteric lymphadenitis,
limited because children would not be able to acute appendicitis, intestinal parasitism
accurately describe their abdominal pains. (recurrent abdominal pain)
• The time, mode of onset, character, localization, o Non-‐digestive causes: lobar pneumonia,
duration, and radiation of the pain are helpful pyelonephritis, hydronephrosis
clues in the analysis of the nature of pain.
• Associated symptoms are equally important in School age and teen age
the diagnosis of abdominal pain o Other than those found in the preschool age
• Symptoms include: include: Mittelsmerz phenomenon (menstrual
o Fever cycle), peptic disease (chronic, recurrent
o Vomiting epigastric pain), recurrent intussusception from
o Diarrhea Meckel’s diverticulum or intestinal polyp, renal
o Respiratory difficulty (tonsillitis-‐ stones
presented with abdominal pain)
o Relationship with defecation and Abdominal migraine
urination o Characterized by recurrent episodes of
o Previous abdominal surgery stereotyped paroxysmal abdominal pain
• Persistence of pain suggests persistence of the associated with nausea and vomiting with in-‐
cause. between periods of general wellness

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o In many cases, a family history of migraine can • Presence of tenderness at McBurney’s point
be elicited among the first-‐degree relatives • Pararectal tenderness
(Worawattanaku et al, 1999)
Classsical signs
• Rovsing’s sign: pain in right lower quadrant on
Acute Surgical Abdomen palpation of left side
o Always need to rule out • Obturator sign: Pain on internal rotation of right
o Clinical manifestations: hip present when inflamed appendix lies in the
− Very sick or toxic appearance pelvis
− Hypo/hyperthermia • Iliopsoas sign: pain on extension of the right hip,
− Generalized continuous abdominal pain present in retrocecal appendicitis
− Retching, vomiting
− Peritoneal signs ANORECTAL M ALFORMATIONS
• Group of malformations, congenital conditions
Common Causes comprising a spectrum in severity from
imperforate anal membrane to complete caudal
formation
• Incidence is 1 in every 5000 newborns
• Are medical problems affecting the structure of
the anus and rectum
• A person with an anorectal problem would have
some sort of deformative feature of the anus or
rectum, collectively known as an anorectal
malformation.
Case 4 • Examples of anorectal anomalies include:
Jenny is a grade 1 pupil who was brought to the ER o Anal stenosis
because of abdominal pain associated with vomiting of o Imperforate anus
two days duration. Further PE, the pain is located at the o Proctitis
right lower quadrant. o Anal bleeding
Diagnosis: Acute appendicitis o Anal fistula
o Anal cancer
ACUTE APPENDICITIS o Anal itching
Age specific findings o Hemorrhoid (Piles)

VACTERL association is a disorder that affects many body
systems. VACTERL stands for vertebral defects, anal
atresia, cardiac defects, tracheo-‐esophageal fistula, renal
anomalies, and limb abnormalities.

Most anorectal malformations are identified at birth but
a sigmificant number of milder symptoms are not
identified until later

ANAL FISSURES

• Are common and usually occur in preschool
Diagnosis children. An anal fissure is caused by the
• Young children with appendicitis invariably passage of hard feces, which tears the delicate
present late, and perforation at time of anal lining. The tear means that defecation
presentation, common in children <5 years old becomes very painful, the child may scream and
• Abdominal signs can be subtle blood may be seen on the feces or toilet paper.
• Abdominal distention is common • (For children who are not yet toilet-‐trained,

9


passing of stool should be very pleasant.) developing world-‐ trichuris), neuromuscular
• A cycle can easily develop as follows: passage of disorders, pelvic nerve disorders,
hard, dry lump of poo -‐> tear of anal lining -‐> myelomeningocele, bladder and cloacal
anal fissure exstrophy, Hirschsprung’s disease, high
o To break this cycle, it is important to make anorectal malformations, cystic fibrosis, chronic
the feces soft and ensure defecation is respiratory infections and coughing, lymphoid
regular hyperplasia, rectal polyps, and shigellosis.
o Regular, soft feces usually allow healing of
the fissure Epidemiology
o Despite healing, the memory of the pain and • Pediatric rectal prolapse is more common in
anticipation of it last much longer. It is tropical and underdeveloped countries, where
therefore critical that treatment is not diarrhea and parasitic infection play much
stopped, but gradually weaned down greater roles.

Treatment HEM ORRHOIDS
• The aim of treatment is to ensure that soft feces • The most common cause of hemorrhoids among
are passed regularly with minimal straining, this children is constipation, due to all the urging and
can be achieved by: straining that kids will do to try to move their
o Ensuring a good fluid intake bowels. Often, kids may complain of not being
o Encouraging a balanced nutritional diet able to defecate, or feeling full even after they
which contains plenty of fruit have a bowel movement.
o Use of lactulose and/or senakot (“senna”) • In the pediatric population, rectal prolapse is
which have separate but complimentary most common in patients younger than 4 years;
functions the highest incidence is in the first year of life.
Incidence is evenly distributed between males
RECTAL PROLAPSE and females in the pediatric population. This is
• Pediatric rectal prolapse is uncommon in in contrast to the adult population, in whom
Western societies. rectal prolapse is 6 times more common in
• Most cases are self-‐limiting, characterized by women. No racial predilection is noted in the
prompt resolution with institution of pediatric population.
conservative measures aimed at correcting • Treatment:
associated underlying problems. o Treat the underlying cause
• Rectal prolapse in children is thought to begin as o If it is due to parasitic infection, institute
mucosal prolapse starting at the mucocutaneous regular deworming
junction, which may eventually progress to full o If it is due to constipation, give high fiber
thickness prolapse. diet or stool softener
• In the pediatric population, rectal prolapse • Prognosis: Most prolapses spontaneously
should always be considered as a presenting reduce. Failure to reduce may lead to venous
sign of an underlying condition and not a stasis, edema, and possibly ulceration. Long-‐
discrete disease entity unto itself. standing or frequent recurrent prolapse may
lead to proctitis.
Etiology • Approximately 10% of patients who experience
• The exact etiology of rectal prolapse in children rectal prolapse as children continue to
is unknown. However, several predisposing experience it in their adult lives. Approximately
factors have been identified. The most common 90% of children aged 9 months to 3 years who
underlying condition is chronic constipation and experience rectal prolapse respond to
straining (52%). conservative management by age 6 years.
Spontaneous resolution is much less likely in
Other causes children who first experience prolapse when
• Diarrhea (15%), rectal parasites (the most they are older than 4 years.
common cause of rectal prolapse in the

10


HERNIA
• Is the protrusion of an organ or the fascia of an
organ through the wall of the cavity that
normally contains it.
• By far the most common hernias (up to 75% of
all abdominal hernias) are the so-‐called inguinal
hernias
o Indirect inguinal hernia (2/3 of cases), in
which the inguinal canal is entered via a
congenital weakness at its entrance (the
internal inguinal ring)
o Direct inguinal hernia type (1/3 of
cases), where the hernia contents push
through a weak spot in the back wall of
the inguinal canal.
• Inguinal hernias are the most common type of
hernia in both men and women.
• Femoral hernias occur more often in women
than men, but women still get more inguinal
hernias than femoral hernias.

11

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