Practical Algorithms in Pediatric Gastroenterology

116 Pages·2014·1.14 MB·English

by  Ron Shaoul

Practical
Algorithms in
Pediatric
Gastroenterology
Editor
Ron Shaoul, Haifa
51 graphs and 9 tables, 2014
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Contents
IV Contributors Gastroesophageal refl ux and vomiting 44 Chronic intestinal
II
pseudo-obstruction
22 Neonatal vomiting
VI Preface R. Shaoul; N.L. Jones T. Zangen; P.E. Hyman
Z. Hochberg 24 Nausea and vomiting 46 Irritable bowel syndrome
VII Introduction P.S. Lemos; R. Shaoul E. Chiou; S. Misra; S. Nurko
R. Shaoul
26 Recurrent vomiting and/or
regurgitation Stomach and intestine
Y. Vandenplas; R. Shaoul
Various gastrointestinal conditions 48 Protein-losing enteropathy
2 Abdominal pain 28 Typical and atypical refl ux syndrome B. Zeisler; F.A. Sylvester
Y. Vandenplas; R. Shaoul
R. Arnon; S. Misra 50 Celiac disease
4 Acute gastroenteritis 30 Recurrent vomiting and/or Y. Bujanover; R. Shaoul
regurgitation and poor weight gain
A. Lo Vecchio; D. Turck; A. Guarino 52 Helicobacter pylori
Y. Vandenplas; R. Shaoul
6 Food allergy N.L. Jones; B.D. Gold
32 Cyclic vomiting syndrome
B. Wershil; F.A. Sylvester 54 Gastrointestinal polyps
Y. Vandenplas; B.D. Gold
8 Failure to thrive B. Zeisler; F.A. Sylvester
A. Lahad; S. Reif 56 Intestinal malabsorption – Part 1:
Other motility disorders Pathogenesis and etiology
10 Chronic diarrhea
A. Guarino; E. Ruberto; Y. Finkel
Y. Finkel; A. Guarino 34 Achalasia
12 Upper gastrointestinal bleeding S. Nurko; Y. Vandenplas 58 Intestinal malabsorption – Part 2:
First diagnostic steps
C.G. Sauer; B.D. Gold 36 Constipation
A. Guarino; E. Ruberto; Y. Finkel
14 Lower gastrointestinal bleeding S. Misra; H.M. Van de Vroot
F.A. Sylvester; D. Turck 38 Dysphagia
16 Malnutrition P.E. Hyman; T. Zangen Infl ammatory bowel disease
P.S. Lemos; B. Wershil 40 Fecal incontinence 60 Infl ammatory bowel disease
18 Perianal disease A. Siddiqui; O. Eshach Adiv; S. Nurko D. Turner; A.S. Day
A.S. Day; N.L. Jones 42 Hirschsprung’s disease 62 Crohn’s disease
20 Gastrointestinal foreign bodies P.E. Hyman; T. Zangen D. Turner; A.S. Day
I. Rosen; R. Shaoul 64 UD. lTcuernraert;i vAe.S .c Doalyitis Downloaded by: Kainan University 203.64.11.45 - 1/25/2015 4:52:43 PM
Surgical conditions 80 Hepatitis C Pancreas
E. Granot
66 Abdominal mass 100 Acute pancreatitis
R. Udassin; A. Vromen; E. Gross 82 Elevated aminotransferases M. Wilschanski; R. Arnon
J. Garah; R. Shaoul
68 Right lower quadrant abdominal pain 102 Chronic pancreatitis
I. Sukhotnik; P.S. Lemos 84 Elevated alkaline phosphatase M. Wilschanski; R. Shaoul
R. Shaoul; J. Garah
70 Peritonitis
S. Peleg; R. Shaoul 86 Autoimmune liver disease
104 Index
G. Mieli-Vergani; M. Samyn
72 Short bowel syndrome
Y. Finkel; I. Sukhotnik 88 Sclerosing cholangitis 1 09 Abbreviations
G. Mieli-Vergani; M. Samyn
90 Acute liver failure
Liver
G. Mieli-Vergani; M. Samyn
74 Neonatal jaundice 92 Hepatomegaly
E. Fitzpatrick; A. Dhawan
E. Fitzpatrick; A. Dhawan
76 Acute hepatitis 94 Gallstones
Y. Bujanover; S. Reif
E. Broide; S. Reif
78 Hepatitis B 96 Portal hypertension
E. Granot
R. Arnon; A. Dhawan
98 Ascites
A. Ben Tov; S. Reif
Library of Congress Cataloging-in-Publication Data Disclaimer. The statements, options and data contained in this publi- All rights reserved. No part of this publication may be translated into
cation are solely those of the individual authors and contributors and other languages, reproduced or utilized in any form or by any means,
Practical algorithms in pediatric gastroenterology / editor Ron Shaoul. not of the publisher and the editor(s). The appearance of advertise- electronic or mechanical, including photocopying, recording, micro-
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Includes bibliographical references and index. products or services advertised or of their effectiveness, quality or permission in writing from the publisher.
ISBN 978-3-318-02509-5 (alk. paper) -- ISBN 978-3-318-02510-1 safety. The publisher and the editor(s) disclaim responsibility for any
(e-ISBN) injury to persons or property resulting from any ideas, methods, in- © Copyright 2014 by S. Karger AG, P.O. Box, CH–4009 Basel
I. Shaoul, Ron, editor of compilation. II. Series: Practical algorithms in structions or products referred to in the content or advertisements. (Switzerland)
pediatrics. Printed in Switzerland on acid-free and non-aging paper (ISO 9706)
[DNLM: 1. Gastrointestinal Diseases--Handbooks. 2. Adolescent. 3. Drug Dosage. The authors and the publisher have exerted every effort by Werner Druck, Basel
III Child. 4. Decision Trees--Handbooks. 5. Infant. 6. Liver to ensure that drug selection and dosage set forth in this text are in ISBN 978–3–318–02509–5
Diseases--Handbooks. 7. Pancreatic Diseases--Handbooks. WS 39] accord with current recommendations and practice at the time of pub- e-ISBN 978–3–318–02510–1
RJ446 lication. However, in view of ongoing research, changes in government
618.92’33--dc23 regulations, and the constant fl ow of information relating to drug ther-
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Contributors
Orly Eshach Adiv, MD Emer Fitzpatrick Avishay Lahad, MD
IV Pediatric Gastroenterology and Nutrition Unit Consultant Paediatric Hepatologist Pediatric Gastroenerology and Nutrition Unit
Rambam Medical Center Paediatric Liver GI and Nutrition Center Pediatric B North Department
Haifa, Israel King’s College Hospital Edmond and Lili Safra Children’s Hospital
London, UK Sheba Medical Center
Ronen Arnon, MD, MHA Tel Hashomer, Israel
Associate Professor of Pediatrics and Surgery Jamal Garah, MD
Medical Director of Pediatric Hepatology and Pediatric Gastroenterology and Nutrition Unit Piedade Sande Lemos, MD, PhD
Liver Transplantation Rambam Medical Center Pediatric Gastroenterology Consultant
Recanati-Miller Transplant Institute Haifa, Israel Hospital Fernando Fonseca
Mount Sinai School of Medicine Director, Clinica CUF Cascais
New York, NY, USA Benjamin D. Gold, MD, FACG Cascais, Portugal
Pediatric Gastroenterology, Hepatology and
Efrat Broide, MD Nutrition Andrea Lo Vecchio, MD
Head of Pediatric Gastroenterology Children’s Center for Digestive Healthcare Section of Pediatrics
Institute of Gastroenterology Atlanta, GA, USA Department of Translational Medical Science
Assaf Harofeh Medical Center University of Naples Federico II
Zerifin, Israel Esther Granot, MD Naples, Italy
Kaplan Medical Center
Prof. Yoram Bujanover Rehovot and Hebrew University-Hadassah Giorgina Mieli-Vergani
Pediatric Gastroenterology Unit Medical School Professor of Paediatric Hepatology
Edmond and Lili Safra Children’s Hospital Jerusalem, Israel Consultant Paediatric Hepatologist
Sheba Medical Center Paediatric Liver, GI and Nutrition Centre
Tel Hashomer, Israel Eitan Gross, MD King’s College London School of Medicine
Pediatric Surgery Department King’s College Hospital
Eric Chiou, MD The Hebrew University Medical School London, UK
Pediatric Gastroenterology, Hepatology and Hadassah
Nutrition Jerusalem, Israel Sudipta Misra, MBBS, MD, DM
Texas Children’s Clinical Care Center Clinical Professor of Pediatrics and Chief
Houston, TX, USA Alfredo Guarino, MD Division of Pediatric Gastroenterology,
Section of Pediatrics Hepatology and Nutrition
Prof. Andrew S. Day Department of Translational Medical Science Brody School of Medicine, East Carolina University
Paediatric Gastroenterologist University of Naples Federico II Vidant Medical Center
Department of Paediatrics Naples, Italy Greenville, NC, USA
University of Otago
Christchurch, New Zealand Paul E. Hyman, MD Samuel Nurko, MD
Professor of Pediatrics, Louisiana State University Director
Anil Dhawan Chief, Gastroenterology Center for Motility and
Professor of Paediatric Hepatology Children’s Hospital Functional Gastrointestinal Disorders
Director Paediatric Liver GI and Nutrition Centre New Orleans, LA, USA Boston Children’s’ Hospital
King’s College Hospital Boston, MA, USA
London, UK Nicola L. Jones, ND, FRCPC, PhD
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Shimon Reif, MD Anees Siddiqui, MD Prof. Dr. Yvan Vandenplas
Director Pediatric Gastroenterology Pediatric Gastroenterology
Department of Pediatrics Specially for Children/Dell Children’s UZ Brussel, Vrije Universiteit Brussel
Hadassah Medical Center Medical Center Brussels, Belgium
Jerusalem, Israel Austin, TX, USA
Holly M. Van de Voort, MD
Irit Rosen, MD Igor Sukhotnik, MD Centennial Pediatrics Murfreesboro
Pediatric Gastroenterology and Nutrition Unit Pediatric Surgery Unit Murfreesboro, TN, USA
Rambam Medical Center Bnai Zion Medical Center
Haifa, Israel Haifa, Israel Amos Vromen, MD
Pediatric Surgery Department
Eliana Ruberto, MD Francisco A. Sylvester, MD The Hebrew University Medical School
Section of Pediatrics Professor of Pediatrics and Immunology Hadassah
Department of Translational Medical Science University of Connecticut School of Medicine Jerusalem, Israel
University of Naples Federico II Attending Pediatric Gastroenterologist
Naples, Italy Connecticut Children’s Medical Center Barry Wershil, MD
Hartford, CT, USA Professor of Pediatrics
Marianne Samyn Feinberg School of Medicine at
Paediatric Liver, GI and Nutrition Centre Amir Ben Tov, MD Northwestern University
King’s College London School of Medicine Gastroenterology Unit Chief, Division of Pediatric Gastroenterology,
King’s College Hospital Dana-Dwek Children’s Hospital Hepatology, and Nutrition
London, UK Tel Aviv Sourasky Medical Center Ann and Robert H. Lurie Children’s
Sackler Faculty of Medicine, Tel Aviv University Hospital of Chicago
Cary G. Sauer, MD, MSc Tel Aviv, Israel Chicago, IL, USA
Assistant Professor of Pediatrics
Emory School of Medicine Dominique Turck, MD Prof. Michael Wilschanski
Endoscopy Director Professor of Pediatrics Director, Pediatric Gastroenterology
Children’s Healthcare of Atlanta University of Lille Hadassah University Hospital
Training Program Director, Pediatric GI Fellowship Lille, France Jerusalem, Israel
Emory Children’s Center
Atlanta, GA, USA Dan Turner, MD, PhD Tsili Zangen, MD
Head, Pediatric Gastroenterology and Pediatric Motility Service
Ron Shaoul, MD Nutrition Unit Pediatric Gastroenterology and Nutrition Unit
Associate Clinical Professor of Pediatrics Shaare Zedek Medical Center Wolfson Medical Center
Director, Pediatric Gastroenterology and The Hebrew University of Jerusalem Holon, Israel
Nutrition Unit Jerusalem, Israel
Rambam Medical Center Bella Zeisler, MD
Haifa, Israel Raphael Uddasin, MD Connecticut Children’s Medical Center
Associate Professor of Pediatric Surgery Hartford, CT, USA
Head of Pediatric Surgery Department
The Hebrew University Medical School
Hadassah
Jerusalem, Israel
V
Contributors Downloaded by: Kainan University 203.64.11.45 - 1/25/2015 4:52:43 PM
Preface
VI
This is the fourth volume of the se- troenterologists and nutritionists in given problem. In the process of
ries Practical Algorithms in Pediat- the world and edited by my friend writing this book I served as the
rics. The previous volumes – Practi- Dr. Ron Shaoul, it is obvious that non-specialist lay reader. Thirty-
cal Algorithms in Pediatric Endocri- the spirit of the algorismus has five years after having completed
nology (now in its 2nd edition), been utilized to its best. my pediatric residency, I discov-
Practical Algorithms in Pediatric Practical Algorithms in Pediatric ered that pediatric gastroenterolo-
Hematology-Oncology and Practi- Gastroenterology is meant as a gy has become a sophisticated spe-
cal Algorithms in Pediatric Nephrol- pragmatic text to be used at the pa- cialty with a solid scientific back-
ogy – have become working tools tient’s bedside. The experienced ground of which I know so little. I
for many general pediatricians and practitioner applies step-by-step would still refer my patients to a
trainees in the respective pediatric logical problem-solving techniques specialist with many of the diagno-
subspecialties. for each patient individually. Deci- ses, symptoms and signs discussed
The term ‘algorithm’ is derived sion trees prepared in advance here. But, with the help of this out-
from the name of the ninth century have the disadvantage of unac- standing book, I would refer them
Arabic mathematician Algawrismi, quaintedness with the individual after an educated initial workup,
who also gave his name to ‘alge- patient. Yet, for the physician who and would be better equipped to
bra’. His ‘algorismus’ indicated a is less experienced with a given follow the specialist’s manage-
step-by-step logical approach to problem, a prepared algorithm pro- ment.
mathematical problem-solving. In vides a logical, concise, cost-effec-
reading the final product, written tive approach prepared by a spe- Ze’ev Hochberg, MD, PhD
by some of the finest pediatric gas- cialist who is experienced with the Series Editor
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Introduction
The field of pediatric gastroenterol- gists. There is an increasing need well as a very enriching and gratify-
ogy is rapidly expanding, and the from both trainees in pediatric gas- ing experience to interact and work
approach to diagnosis and man- troenterology and general pediatri- with everybody. I would like to
agement of the various conditions cians for simple, bedside algo- thank the series editor Professor
is continuously changing. A better rithms. Practical Algorithms in Pe- Hochberg for his guidance and sup-
understanding of the pathogenesis diatric Gastroenterology is meant port and am especially grateful to
of many gastrointestinal disorders to be a pragmatic text which classi- Freddy Brian from Karger Publish-
has led to a more physiologic ap- fies common clinical symptoms, ers for his patience and his under-
proach and the development of bet- signs, laboratory abnormalities and standing in this long process.
ter diagnosis and treatment modal- issues of management as present-
ities. Pediatric gastroenterology is ed in daily practice. I am honored Ron Shaoul, MD
quite unique compared to adult that many of the algorithms in this
gastroenterology. We are dealing book have been written by the lead-
with developmental disorders, ing experts in the area of pediatric
some of which start in utero. The gastroenterology and the surround- I would like to thank my family,
issue of growth and development is ing fields. I would like to take this my wife Ety and my children
unique for pediatrics, and therefore opportunity to thank all those who Dolev and Shaked for their
the approach to the same disease agreed to take part in this book and continuous understanding and
condition may be different between contributed their priceless experi- support.
adult and pediatric gastroenterolo- ence. It has been my privilege as
VII
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Various gastrointestinal conditions R. Arnon · S. Misra Abdominal pain
Abdominal pain
2
History and complete physical examination (cid:3) – (cid:4)
Presence of alarm symptoms and signs (cid:2)
Yes No
Directed laboratory studies and imaging (cid:5) Periumbilical abdominal pain
Normal limited screening (cid:9)
Referral and consultation as indicated (cid:8) No Yes
Functional abdominal pain
Specific directed treatment (cid:6) Biopsychological treatment (cid:7)
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Chronic abdominal pain, defined as long-lasting intermittent or (cid:10) (cid:5) — In case of alarming symptoms and suspected IBD, direct- Selected reading
constant abdominal pain, is a common pediatric problem. It is ed imaging studies include upper GI series and small intestinal
Chiou E, Nurko S: Management of functional abdominal pain
usually functional, without objective evidence of an underlying follow-through, US or CT of the abdomen.
and irritable bowel syndrome in children and adolescents.
organic disorder. The exact prevalence of chronic abdominal
pain in children is not known. It appears to account for 2–4% of (cid:10) (cid:9) — Clinical evaluation: in functional abdominal pain, a lim- Expert Rev Gastroenterol Hepatol 2010; 4: 293–304.
Di Lorenzo C, Colletti RB, Lehmann HP, Boyle JT, Gerson WT,
all pediatric office visits. ited and reasonable screening includes a complete blood cell
Hyams JS, Squires RH Jr, Walker LS, Kanda PT: Chronic ab-
count, erythrocyte sedimentation rate or CRP measurement,
(cid:10) (cid:3) — The required duration of symptoms to define chronicity is urinalysis and urine culture. Other biochemical profiles (liver dominal pain in children: a technical report of the American
Academy of Pediatrics and the North American Society for
2 months, and the symptoms should occur at least once a week. and kidney) and diagnostic tests (stool culture and examination
Pediatric Gastroenterology, Hepatology and Nutrition. J Pedi-
for ova and parasites, serology for celiac disease and breath
(cid:10) (cid:11) — Patients with chronic abdominal pain commonly com- hydrogen testing for sugar malabsorption) can be performed at atr Gastroenterol Nutr 2005; 40: 249–261.
Di Lorenzo C, Colletti RB, Lehmann HP, Boyle JT, Gerson WT,
plain of pain in the periumbilical area. the discretion of the clinician, based on the child’s predominant
Hyams JS, Squires RH Jr, Walker LS, Kanda PT: Chronic ab-
symptoms and degree of functional impairment and parental
(cid:10) (cid:12) — Constipation can be a cause of chronic periumbilical ab- anxiety. dominal pain in children: a clinical report of the American
Academy of Pediatrics and the North American Society for
dominal pain. Functional constipation according to the Rome III
committee describes all children with a developmental age of at (cid:10) (cid:8) — Referral to and consultation of a pediatric gastroenterolo- Pediatric Gastroenterology, Hepatology and Nutrition. J Pedi-
atr Gastroenterol Nutr 2005; 40: 245–248.
least 4 years in whom constipation does not have an organic gist for further evaluation may be indicated.
Huertas-Ceballos A, Logan S, Bennett C, Macarthur C: Pharma-
etiology and who have insufficient criteria for IBS.
(cid:10) (cid:6) — Specific directed treatment for IBD, celiac disease or cological interventions for recurrent abdominal pain (RAP) and
(cid:10) (cid:13) — IBS is abdominal discomfort or pain, which improves PUD may be indicated according to the laboratory, imaging or irritable bowel syndrome (IBS) in childhood. Cochrane Data-
base Syst Rev 2008; 1:CD003017.
with defecation and is associated with a change in the frequen- endoscopic and pathological findings.
Rasquin A, Di Lorenzo C, Forbes D, Guiraldes E, Hyams JS,
cy and form of the stool without evidence of an inflammatory,
anatomic, metabolic or neoplastic process that could explain (cid:10) (cid:7) — A biopsychosocial approach to children with functional Staiano A, Walker LS: Childhood functional gastrointestinal
disorders: child/adolescent. Gastroenterology 2006; 130: 1527–
these symptoms. abdominal pain is recommended, including cognitive therapy
1537.
and hypnosis. Reassurance and explanation of possible mecha-
(cid:10) (cid:14) — The clinical history in children with chronic abdominal nisms involving the brain-gut interaction should be given to Shulman RJ, Eakin MN, Jarrett M, Czyzewski DI, Zeltzer LK:
Characteristics of pain and stooling in children with recurrent
pain should include: family history of abdominal pain, IBS or the child and parents. The possible role of psychosocial factors,
abdominal pain. J Pediatr Gastroenterol Nutr 2007; 44: 203–208.
IBD, dietary history (excessive sugar intake, lactose intolerance) including triggering events, should be explained. It is often
Weydert JA, Ball TM, Davis MF: Systematic review of treat-
of the patient and evidence of constipation, diarrhea or growth helpful to summarize the child’s symptoms and explain that,
ments for recurrent abdominal pain. Pediatrics 2003; 111:e1–
failure. although the pain is real, there is most likely no underlying
e11.
serious or chronic disease.
(cid:10) (cid:4) — The physical examination, including rectal examination,
should be complete. A recent Cochrane Database review of the pharmacological in-
terventions for RAP and IBS in childhood revealed only weak
(cid:10) (cid:2) — Alarm symptoms, signs and features in children and ado- evidence for the efficacy of any pharmacological agent in chil-
lescents with nonfunctional abdominal pain include: persistent dren with RAP and recommended the use of drugs only in clini-
right upper or right lower quadrant pain, pain that wakes the cal trials.
child from sleep, dysphagia, persistent vomiting, arthritis, peri-
rectal disease, GI blood loss, involuntary weight loss, nocturnal
diarrhea, deceleration of linear growth, unexplained fever or
family history of IBD or celiac disease.
3
Various gastrointestinal conditions R. Arnon · S. Misra Abdominal pain Downloaded by: Kainan University 203.64.11.45 - 1/29/2015 7:20:12 PM
Various gastrointestinal conditions A. Lo Vecchio · D. Turck · A. Guarino Acute gastroenteritis
Acute gastroenteritis(cid:2)
4
Initial assessment Neonates
Exclude etiologies other than intestinal infections
Food poisoning
Surgical conditions
Antibiotic toxicity
Urinary infection
Assessment of dehydration (cid:3)
<5% 5–10% >10%
None/minimal Mild/moderate Severe
Offer ORS ad libitum; encourage normal feeding with no restriction (cid:5)
Reassess dehydration
after 3–4 h
Improved/stable Impaired Hospitalization (cid:7)
(cid:129) Weigh child and start fluid balance chart
(cid:129) Assessment of electrolytes, bicarbonate,
urea and creatinine
Consider: blood count, CRP/ESR, stool culture,
parasites, urinalysis and urine culture, blood
gasses analysis (cid:4)
CoPRSnramsoicdbeeecicortai tttdiehcoset rfiolllowing in addition to rehydration (cid:6) Ctoo cnasried efro rfa tmheil ych ailbdilities Strongly consider NG tube ORS (preferred) or i.v. fluids Downloaded by: Kainan University 203.64.11.45 - 1/29/2015 7:20:12 PM