Treatment

Until such time as the primary cause of achalasia can be reversed, namely the loss of esophageal innervation by inhibitory neurons, treatment of achalasia must address the relief of symptoms. Since the primary disorders are aperistalsis and abnormal LES relaxation, the goal of non-invasive and invasive treatments is relief of the obstruction and its associated dysphagia. Medical treatment focuses on promoting LES relaxation, whereas endoscopic and surgical treatments address disruption of the...

Clinical presentation

A child may present with either the primary or the secondary effects of the underlying disease. However, the clinical symptoms are variable and often non-specific. The location of the affected bowel, diffuse or regional, seems a more important determinant of the clinical presentation than the underlying disease. A child may be obstructed or complain of severe constipation depending upon whether the small intestine and colon or just the colon is affected. In addition, those with urinary tract...

Disorders of the enteric nervous system

The enteric nervous system is arranged in the form of two major plexuses the myenteric plexus, which is located between the longitudinal and circular muscle layers and primarily provides motor innervation to the muscle coats and the submucous plexus, which lies in the submucosa between the circular muscle layer and the muscu-laris mucosae.26 The submucous plexus is important in regulating secretion by the mucosa and providing sensory innervation of the mucosa. As a whole it is a collection of...

Testing for food allergies Food challenge testing

The essential criterion for diagnosis of food allergy is a response to an elimination diet, and other diagnostic tests are secondary to this. If there is allergy to a single food, exclusion should induce relief of all symptoms, and restore normal growth. For secure diagnosis, a positive response to challenge with the food antigen is strongly supportive of the diagnosis of food allergy. This is not always practicable in routine practice, if diagnostic tests were positive at diagnosis, and many...

Prognosis

The prognosis depends on underlying conditions that predispose to impaired sucking and swallowing. However, the early recognition of feeding problems, the diagnosis of underlying disorders and appropriate intervention improve outcomes for the child and the family. Table 15.4 Swallowing strategies for pediatric dysphagia Behavioral training Dietary modification thickened liquids thin liquids modification of feeding utensils and bolus presentation Swallowing exercises supraglottic swallow...

Genetic and environmental factors

It has been demonstrated that physiological reflux, heartburn, acid regurgitation and severe GERD are more frequent in men than in women. Barrett's esophagus is in part genetically determined.24 There is much information (in adults) demonstrating the aggravating effects of alcohol, smoking, drugs, dietary components, etc. on the incidence of GER. A detailed discussion on these environmental factors is beyond the scope of this chapter. Changes in lifestyle in men and women may result in the fact...

Conditions affecting the ileum and jejunum

The main congenital problems directly affecting the small intestine from the duodenojejunal flexure down to the cecum are atresia and stenosis. Jejunoileal atresia occurs more commonly than its duodenal counterpart, with an incidence varying from 1 in 330 to 1 in 3000 livebirths.11 Such lesions are one of the most common causes of neonatal intestinal obstruction. The major difference between atresias of the ileojejunum and those of the duodenum is in their etiology. It is postulated that...

Normal anatomy and physiology of anorectal function

The most distal part of the gastrointestinal tube is formed by the anal sphincter complex, and is responsible for maintaining fecal continence. This sphincter complex is embedded in the striated pelvic floor, where the puborectalis muscle joins the upper end of the external anal sphincter with a sling. The anal sphincter complex therefore consists of a smooth muscle component of the internal anal sphincter and a striated muscle component of the external anal sphincter and the puborectalis...

Congenital hepatic pancreatic and biliary abnormalities

Abnormalities of the hepaticopancreaticobiliary system are all extremely rare. They are included here as knowledge of their existence is important, as they form part of the differential diagnosis for infants with jaundice, malabsorption and hypo-glycemia. The most common lesions of the biliary tree are biliary atresia and congenital biliary dilatation. In biliary atresia the biliary tree is obliterated either completely or partially. Congenital biliary dilatation includes a variety of...

Gastropathies due to drugs toxins and other agents

Acetylsalicylic acid and other non-steroidal anti-inflammatory drugs It is well known that acetylsalicylic acid and other non-steroidal anti-inflammatory drugs (NSAIDs) can cause gastric injury including gastritis, gastric ulcers and gastrointestinal hemorrhage. Gastroduodenal damage can be seen at endoscopy in 20-40 of adults taking NSAIDs, and the overall risk for peptic complications (hemorrhage and perforation) in these patients is about three times greater than in controls.15 There are no...

Edited by

University of Chicago Children's Hospital Director, University of Chicago Celiac Disease Program 2004 Taylor & Francis, an imprint of the Taylor & Francis Group First published in the United Kingdom in 2004 by Taylor & Francis, an imprint of the Taylor & Francis Group, 11 New Fetter Lane, London EC4P 4EE This edition published in the Taylor & Francis e-Library, 2005. To purchase your own copy of this or any of Taylor & Francis or Routledge's collection of thousands of eBooks...

Hirschsprungs disease

Hirschsprung's disease is the most common congenital malformation of the enteric nervous system with an incidence of approximately 1 in 5000 live births.24-26 Whilst most cases are sporadic a positive familial occurrence exists in 3.6-7.8 of cases27 and the presence of co-existing abnormalities including trisomy 21 suggests a genetic involvement (see also Chapter 17). This condition is characterized by the absence of enteric neurons and hypertrophy of nerve trunks in the distal bowel always...

Potential subtypes of cyclic vomiting syndrome and common associations

The vast majority (87 ) of patients with CVS have a migraine association either based most commonly on a family history of migraine or, less frequently, on the subsequent development of migraines in the affected child. Because these associated symptoms occurred less than half the time, we did not use headache, photophobia and phonophobia as specific criteria to determine who had migraine-associated CVS. When we examined the remainder with non-migraine-associated CVS (13 ), they appeared to have...

References

Jensen BL, Kreiborg S, Dahl E et al, Cleft lip and palate in Denmark, 1976-1981 epidemiology, variability, and early somatic development. Cleft Palate J 1988 25 258-269. 2. Womersley J, Stone DH. Epidemiology of facial clefts. Arch Dis Child 1987 62 717-720. 3. Shprintzen RJ, Siegel-Sadewitz VL, Amato J et al. Anomalies associated with cleft lip, cleft palate, or both. Am J Med Genet 1985 20 585-595. 4. Kyyronen P, Himminki K. Gastro-intestinal atresia in Finland in 1970-79, indicating...

Features of specific etiologies and virology

Reovirus-like particles were first identified in 1973 by electron microscopy in duodenal biopsies from children with acute diarrhea.40 This led to a cascade of clinical and laboratory studies that have established the rotavirus as the single most common agent causing diarrhea in childhood. Table 9.6 Etiological diagnosis of viral infections of the gastrointestinal tract Rotavirus EIA, latex agglutination ++++ RT-PCR EM, electron microscopy PCR, polymerase chain reaction EIA, enzyme immunoassay...

Diagnostic testing

In patients with no alarm symptoms, the Rome criteria have a positive predictive value of approximately 98 , with additional diagnostic tests providing a yield of 2 or less.105 When needed, the exclusion of an organic condition can be accomplished by utilizing inexpensive, non-invasive and easily available diagnostic tests such as complete blood cell count, erythrocyte sedimentation rate, chemistry panel, liver and thyroid function studies, urine analysis and stool examination for blood, ova...

Clinical patterns

CVS is distinguished by recurrent, severe, discrete episodes of vomiting. Episodes are stereotypical in regards to time of onset, duration and symptomatology. This disorder is also distinguished by an on-off pattern with intervals of returning to completely normal or baseline health between episodes.2 The duration of episodes is generally from hours to days, with a median duration of 27 h. The median frequency of episodes is 4 weeks. Because nearly 47 of all patients have regular intervals and...

Introduction

The parasites of humans are classified into five major divisions Protozoa amebae, flagellates, ciliates, sporozoans, coccidia, microsporidia Platyhelminths cestodes, trematodes , Acantho-cephela thorny headed worms Nematodes roundworms and Arthropods insects, spiders, mites, ticks . Geohelminths are a sub-group of soil-transmitted intestinal nematodes with similar epidemiological characteristics. They include Strongyloides, hookworm, Ascaris and Trichuris.1 In this chapter, we focus on the...

Patterns of food allergic responses Quickonset symptoms

Ige Mediated Responses

These often follow the ingestion of a single food, such as egg, peanut or sesame. Within minutes the sufferer may notice tingling of the tongue, and there may be the rapid development of skin rash, urticaria or wheezing. One localized variant, the oral allergy syndrome, is often seen in older pollen-sensitized individuals and is characterized by lip tingling and mouth swelling after ingestion of certain fruits and vegetables.24 More serious reactions, however, can occur at any age, and antigens...

Diagnosis

Sbbo Glucose Positive Result

Research to characterize the digestive tract microflora has developed mainly from the 1960s onward. The micro-organisms of the digestive tube flora, made up of aerobic and anaerobic bacteria, protozoa and even some viruses, form a complex ecosystem. The terms 'indigenous flora' and 'microbiota' are used as synonyms for normal flora and refer to micro-organisms that can be found in normal individuals. Therefore, in order to establish a diagnosis for SBBO, it is necessary to define the location,...

Epidemiology

Chronic abdominal pain is one of the most common pediatric complaints,3 accounting for 2-4 all of pediatric office visits.4 Symptoms consistent with irritable bowel syndrome IBS , one of the most common functional bowel disorders, occur in 14 of all high-school students and 6 of all middle-school students.5 IBS is more prevalent than other medical conditions such as hypertension, asthma and diabetes that tend to receive greater medical attention.6 As many patients with IBS do not seek medical...

Diagnosis and differential

Coliti Plesiomonas

Table 25.3 Differential diagnosis of colitis HIV and HIV-related opportunistic infections Other Ulcerative colitis Crohn's disease Henoch-Sch nlein purpura Hemolytic uremic syndrome Intestinal ischemia Intussusception Allergic colitis primarily in infancy Hirschsprung's enterocolitis primarily in infancy The diagnosis of ulcerative colitis is established by the information gathered from a detailed symptom and family history, physical examination, and a combination of laboratory, radiological,...

Prognosis and followup

Whether children with ulcerative colitis are treated medically or surgically, they have an excellent long-term prognosis and good quality of life. The majority of children with ulcerative colitis respond to medical therapy. In one American retrospective study of 171 children ranging in age from 1.5 to 17.7 years, diagnosed with ulcerative colitis between 1967 and 1994, 43 had mild disease at presentation and 57 had moderate or severe ulcerative colitis. With treatment, 70 of all the children...

Conclusion

GER and GERD are frequent conditions in infants, children and adolescents. Symptomatology differs with age, although the main pathophysiological mechanism, transient relaxations of the LES associated with reflux, is identical at all ages. Although infant regurgitation is likely to disappear with age, little is known about reflux. The majority of symptomatic reflux episodes are acid, but non-acid and gas reflux can also cause symptoms. Complications of reflux disease may be severe and even life...

Principles of management of persistent diarrhea

In general the management of persistent diarrhea in malnourished children represents a blend of the principles of management of diarrhea and malnutrition. Associated malnutrition may be quite severe in affected children, necessitating rapid nutritional rehabilitation, often in hospital. Given This is the preferred mode of rehydration and replacement of on-going losses. While in general the standard WHO oral rehydration solution ORS is adequate, recent evidence indicates that hypo-osmolar...

Contents

1 Microvillus inclusion disease and 1 epithelial dysplasia 2 Congenital problems of the 13 gastrointestinal tract Nigel Hall and Agostino Pierro II Diseases of the Esophagus and Stomach 3 Infectious esophagitis 29 Salvatore Cucchiara and Osvaldo Borrelli 4 Gastroesophageal reflux disease 39 Yvan Vandenplas, Silvia Salvatore and Bruno Hauser 5 Achalasia 61 Carl-Christian A Jackson and Donald C Liu 6 Helicobacter pylori gastritis and 73 peptic ulcer disease Costantino De Giacomo 7 Other...

Chronic granulomatous disease

Chronic granulomatous disease is a rare group of inherited disorders characterized by impaired phagocyte oxidative metabolism caused by missing components or subunits of the NADPH oxidative complex, resulting in defective intracel-lular killing of catalase-positive micro-organisms. The most common form of chronic granulomatous disease is inherited as an X-linked recessive trait, although autosomal-type mutations have been described. The disease usually appears during the first two years of life...

The basic mechanisms of immune response to dietary antigen

The intestine is an organ that shows the traces of evolutionary longevity, and indeed Cambrian period fossils from over 600 million years ago show a recognizable gastrointestinal tract.118 There is much current interest on the links between innate and adaptive immune responses, in particular pattern receptor molecules such as toll-like receptors and nod proteins that induce an immune response within innate cells, such as dendritic cells, that polarize subsequent T-cell responses.119,120...

Constipation in mentally handicapped children

The incidence of constipation was around 61 in a large cohort of mentally handicapped children in Dutch and Belgian institutions. Constipation was defined as bowel movements less than 3 times a week. Eighty-eight per cent of the constipated, mentally handicapped, children used laxatives, in comparison to 40 of constipated controls whose constipation was easily controlled. A significant correlation was found between non-ambulancy, cerebral palsy, use of anticonvulsive medication or...

Pathogenesis

Pathogenesis Acid Secretion

Role of acid and pepsinogen secretion The bulk of our knowledge on acid secretion is derived from studies in adults. Gastric acid secretion begins in the newborn from the first day of life it is not sensitive to gastrin, but rather to pentagastrin stimulation, which is the best way to evaluate it. Serum gastrin is usually elevated in the newborn period.35,36 Maximal acid output after pentagastrin stimulation increases from 0.031 mEq kg per h at 1 month to 0.122 mEq kg per h at 3 months, and up...

Trichuriasis

Worms Damp Soil

Trichuris trichiuria, meaning 'hairy tail', is actually a misnomer, since it is the proximal end that is hairlike. The popular name is whipworm, with the whip as the long thin pharynx stichostome and the whip handle as the posterior end with reproductive organs and intestine Figure 11.3 . A mature female worm produces up to 20 000 eggs day, which are 50 im long and not infectious until the larval stage develops in the soil over 2-4 weeks. Warm damp soil is ideal for embryonation, Figure 11.3...

Meconium ileus

Meconium ileus is a common cause of neonatal intestinal obstruction and the most common cause of antenatal intestinal perforation.19 It should be included in the differential diagnosis of infants presenting with GI tract obstruction. In approximately 80 of cases it is associated with cystic fibrosis.20-22 The underlying defect in cystic fibro-sis, an abnormality in a transmembrane chloride channel, results in the production of abnormally viscid and sticky meconium. This meconium sticks to the...

Shigella

Kiyoshi Shiga first isolated Shigella dysenteriae type 1 during a severe dysentery epidemic in Japan in 1896, when more than 90000 cases were described with a mortality rate approaching 30 .18 Shigellae are Gram-negative, non-lactose fermenting, non-motile bacilli, with S. sonnei the main type found in industrialized countries, and S. flexneri and S. dysenteriae predominating in underdeveloped countries. Humans are the only natural hosts and transmission occurs by fecal-oral contact. The low...

Portal hypertensive gastropathy

Involvement of the gastric mucosa is common in children with intrahepatic or extrahepatic causes of portal hypertension.33 Endoscopic findings vary from mild involvement, including a snake-skin mosaic pattern of the mucosa, a fine pink speckling and superficial erythema scarlatina-type rash , to a severe gastropathy, defined by cherry red spots with a diffuse confluence of reddened areas and a hemorrhagic appearance. These patterns seem to be specific for portal hypertensive gastropathy and...

Classification

Picture Type Tef

A number of classification systems have been proposed over the years. The abbreviated list in Table 2.1 describes the most commonly encountered anatomical variants Figure 2.1 . The Table 2.1 Classification of esophageal atresia EA tracheoesophageal fistula TEF anomalies and frequency6 Figure 2.1 Common anatomical variants of esophageal atresia EA tracheoesophageal fistula TEF anomalies. a EA with distal TEF b isolated EA with no TEF c H-type TEF d proximal and distal TEF e EA with proximal TEF....

Pathophysiology and mode of transmission

A defect in the membrane trafficking of immature and or differentiating enterocytes has been discussed as an etiopathogenic mechanism in MVID.20,21 This membrane defect results, as a Figure 1.2 Microvillus inclusion disease CD-10 immunostaining. a Normal mucosa, normal CD-10, brush-border immunostaining b abnormal accumulation of positive material in the apical cytoplasm of epithelial cells in microvillus inclusion disease. direct functional consequence, in complete intestinal failure. It has...

Other parasites Hymenolepiasis

Hymenolepis nana is the dwarf tapeworm and the only human tapeworm that does not require an intermediate host. Nevertheless, rodent strains for H. nana are infectious for humans including pet rodents such as rats, mice and hamsters. It occurs worldwide, with high childhood prevalences gt 10 reported from Argentina, Peru, Brazil, Egypt, Pakistan and Zimbabwe.41 Transmission is mostly fecal-oral, either from person to person or in food and water, with high rates in children from orphanages.139...

Nonpharmacological and nonsurgical therapies for gastroesophageal reflux

Non-pharmacological and non-surgical therapies for reflux do not have any proven efficacy on reflux, although some may decrease the incidence of regurgitation. Lifestyle changes in adults are rarely beneficial.96 No significant difference was shown between the flat and head-elevated prone position. Despite gravity, the upright seated position leads to significantly more and larger reflux episodes than the simple prone and 30 elevated prone position, when the infant is awake or asleep.97 This is...

Histological features

Features Epithelial Dysplasia

Villus atrophy of variable severity is present. In the typical form, abnormalities are localized mainly in the epithelium and include a disorganization of surface enterocytes with focal crowding, resembling tufts Figure 1.5 . These characteristic 'tufts' of extruding epithelium first described by Reifen et al36 are seen towards the villus tip, and may affect up to 70 of villi. The tufting process is not limited to the small intestine but also involves the colonic mucosa.11 This picture can also...

Gastrointestinal duplications

Duplication cysts of the GI tract are rare congenital abnormalities. They can occur at any point in the GI tract from mouth to anus, although they are most commonly found around the ileocecal region. Duplication cysts are defined according to strict criteria, as devised by Ladd and Gross they are closely attached to some part of the GI tract, have a smooth muscle coat and have an epithelial lining that resembles some part of the alimentary canal.43 Duplications may be spherical or tubular in...

Domperidone

The studies supporting efficacy of domperidone in improving GER in infants are limited.104 The ability of oral domperidone to increase the pressure of the LES or to promote healing of reflux esophagitis has not been demonstrated in placebo-controlled trials. Most studies have been performed in older children, or investigate the effects of domperidone co-administered with other anti-reflux agents.104 Comparing domperidone to metoclopramide, elicited adverse effects on the central nervous system...

Amebiasis

Recent molecular and immunological techniques have demonstrated two distinct species of Entamoeba that are morphologically identical. E. histolytica is pathogenic, causing symptomatic disease in 10 of infections whereas E. dispar causes only asymptomatic colonization. In addition to the E. histolytica strain, other risk factors for invasive disease are interaction with bacterial flora, host genetic susceptibility, malnutrition, male sex, young age and immunodeficiency. Entamoeba coli and E....

Muscular dystrophy

Gastrointestinal involvement may occur in a number of forms of muscular dystrophy including myotome muscular dystrophy and the dystro-phinopathies Duchenne and Becker muscular dystrophy. Involvement of the smooth muscle of the gastrointestinal tract and bladder is well described in myotonic muscular dystrophy, and seemingly motor abnormalities can be found throughout the whole gastrointestinal tract.23 Duchenne and the milder variety Becker muscular dystrophy are due to abnormalities of...

Etiology

The disease processes, which result in CIP, affect the control mechanisms of intestinal motility. The disorders and disease may primarily be of the intrinsic enteric nerves with or without involvement of the extrinsic autonomic nerves, the smooth muscle cells themselves or of the tumoral and endocrine environment. Good examples of the effect of disturbance of the endocrine environment are the ileus associated with vasoactive intestinal polypeptide-secreting tumors such as ganglioneuromas, and...

Menetriers disease

Menetrier's disease, a rare disorder of unknown etiology, is characterized by enlarged gastric folds due to mucosal thickening in the gastric body. To date, fewer than 100 pediatric cases have been described. Significant differences between adult and pediatric disease in terms of onset, presentation, course and prognosis have been observed.25,26 In children, the disease often begins abruptly and is usually self-limited, with resolution of clinical features within weeks or months. In contrast,...

Signs and symptoms

Because the incidence of achalasia in children is so low, the majority of information regarding the diagnosis comes from adults. The earliest, and most common, symptom of achalasia is dysphagia. This dysphagia initially is for solids, but frequently progresses to dysphagia for liquids by the time treatment is sought.65-67 The next most common symptom in adults is regurgitation, which is non-acidic and non-bilious, owing to the contracted LES, and most often occurs right after eating or during...

Fungal infections

Esophageal Burns With Alkaline

Candida species are the most common agents of infectious esophagitis. Candida albicans is the most common pathogen, but C. tropicalis, C. parapsilosis and C. glabrata have occasionally been reported. These organisms are usually Table 3.1 Causes of esophageal disease in HIV infection and AIDS present in the normal oral flora, where their growth is controlled by commensal organisms. Conditions predisposing to esophageal candidiasis in immunocompetent subjects are inhaled or ingested...

Cholera

Zonula Occludens Toxin

Of all enteric pathogens, Vibrio cholerae is responsible for the most rapidly fatal diarrheal disease in humans.1 Although cholera is rare in developed countries, it remains a major cause of diarrheal morbidity and mortality in many parts of the developing world.2 However, with the occurrence of both natural e.g. earthquakes and human-generated calamities such as ethnic wars , the spreading of cholera infection in refugee camps, where sanitary conditions resemble those in cholera endemic areas,...

Laboratory and instrumental investigations

Bird Beak Barium

For patients in whom a diagnosis is uncertain, a plain chest radiograph may be the first available study. The classically described finding on upright chest X-ray is an absent gastric air-bubble. This finding, present in nearly all normal individuals, is absent in approximately half of patients with acha-lasia.73,74 Additional findings include a widened mediastinum from esophageal dilatation, a posterior mediastinal air-fluid level from retained food secretions and lung parenchymal...

Crohns disease

Crohn Disease Children

Although Crohn's disease CD most commonly affects the terminal ileum and or the colon, involvement of the upper gastrointestinal tract is frequently found in both adults and children. Symptoms such as epigastric pain, early satiety, nausea, vomiting, weight loss and, less frequently, hematemesis and melena are commonly reported in these patients and have previously been related to reflex inhibition of foregut motility secondary to inflammation and partial obstruction of the distal small bowel....

Histological examination

Microvillus Inclusion Disease

Histological analysis of small bowel biopsies shows a variable degree of villus atrophy without any inflammatory infiltrate. Highly characteristic for this disorder is the accumulation of periodic acid Schiff PAS -positive secretory granules within the apical cytoplasm of enterocytes.18-20 On the ultrastructural level, rare or absent microvilli on intestinal epithelial cells along with inclusions of microvilli in the cytoplasm of enterocytes are seen, which define this entity.21 Diagnosis may...

Collagenous gastritis

Collagenous gastritis is an extremely rare disorder of unknown etiology, To date, fewer than ten cases have been reported in the literature. The condition is characterized by deposition of a subepithelial collagen band greater than 10 im in thickness. The disorder was originally described by Colletti and Trainer in a 15-year-old girl with refractory H. pylori-negative chronic gastritis.55 It has been reported either as an isolated entity or with synchronous collagenous colitis, collagenous...

Complications

Colonic Dilatation

Complications of ulcerative colitis include massive hemorrhage, toxic megacolon, perforation of the bowel, strictures and colon cancer. Massive hemorrhage can occur with severe ulcerative colitis and is managed with blood transfusions and treatment of the underlying ulcerative colitis urgent colectomy may be required. One consensus group suggested that an individual with ulcerative colitis who requires more than 6-8 units of blood in the first 48h and is still actively bleeding should undergo a...

Ascariasis

Ascaris lumbricoides is a large, 15-35 cm long white roundworm that is specific to humans. Ascaris is one of 63 species of nematode infecting humans, and the adult roundworm has a biologically inert surface, so the main antigenic stimuli to the host are excretory and secretory antigens from the orifices. A. suum is the related pig species which may migrate through human tissues in the larval stage,36 but cannot complete its life cycle in man. The female Ascaris worm produces about 200 000 eggs...

Pathophysiology

The pathophysiology of GER is complex and diverse, as it is influenced by factors that are genetic, environmental e.g. diet and smoking , anatomic, hormonal and neurogenic Figure 4.1 and Table 4.1 . We have recently reviewed the Gastric distension gastric mechanoreceptors near cardia Vagally mediated abnormal neural control of LES by CNS Defective LES motility Increased TLESRs - lt Low basal LES tone - lt - Gastric acid Hiatal hernia, obtuse angle of His Delayed acid clearance Delayed volume...

Risk factors for persistent diarrhea

Risk Factors For Acute Diarrhea

It is important to recognize the major risk factors for development of persistent diarrhea, as appropriate case management of acute diarrhea is key to the prevention of prolonged episodes. The association of specific bacterial and viral infections with persistent diarrhea has been the subject of considerable debate.30,31 Evidence from Risk factors for persistent diarrhea 195 Figure 12.2 Mechanisms and effects of enteropathy of malnutrition and prolonged diarrhea. Figure 12.2 Mechanisms and...

Strongyloidiasis

Disseminated Strongyloidiasis

Although not a major cause of morbidity worldwide, the nematode Strongyloides stercoralis is unique in its ability to persist indefinitely within the host through autoinfection, and cause disseminated disease with the prolonged use of cortico-steroids or other causes of immunosuppression. Adult females are about 2.5 mm in length and are attached to the lamina propria of the duodenum or proximal jejunum Figure 11.4 . Their eggs, which hatch into rhabditiform larvae 250 im long and pass via feces...

Diagnosis with differential

Hirschsprung

For the diagnosis of Hirschsprung's disease, the subject's history is very important. The crucial elements to obtain are the age of the appearance of symptoms whether the passage of meconium has been normal or delayed and whether the child presented with episodes of functional intestinal obstruction. In addition, a functional idiopathic megacolon must be ruled out. A clinical comparison between functional and congenital megacolon is shown in Table 17.1. When the history early onset of...

Pathophysiology of viral diarrhea

Pathophysiology Diarrhea

In the classic and simple view, the pathogenesis of diarrhea may be divided into osmotic and secretory Figure 9.1 . Viral diarrhea was originally believed to be caused by cell invasion and epithelial destruction by enteropathogenic agents, therefore being the result of endoluminal fluid accumulation osmotically driven by non-absorbed nutrients. It is now known that several mechanisms are responsible for diarrhea, depending on the specific agents and the host features. In addition, selected...

Intestinal malrotation

The incidence of intestinal malrotation is difficult to establish as not all affected patients develop symptoms, but autopsy studies estimate the incidence at approximately 1 in 500. The traditional embryological basis for disorders of intestinal rotation is that of abnormal position ing of the intestinal loops in relation to one another as they return to the abdominal cavity from the yolk sac. During normal development the midgut rotates through 270 so that the duodenum lies posterior to the...

Pathophysiology of functional constipation

The pathophysiology underlying functional constipation might be multifactorial and is certainly not well understood. Functional constipation results from abnormal function of the colon, rectum and sphincter complex, and conscious and subconscious factors in the child. Two main subgroups are described slow-transit constipation and outlet obstruction, leading to retention of feces in the rectum and extending to the whole colon. It is unclear whether different pathophysiological mechanisms are...

Management of diarrhea and nutritional support

HIV infection in children is often thought to be a rapidly and uniformly lethal disease. In Rwanda, however, 40 of children with perinatal infection survive for 5 years without antiretroviral treatment, and there are many children in sub-Saharan Africa with vertically acquired HIV infection attending schools and growing into adoles-cence.112 Optimizing the quality of life for these children is a necessary challenge, especially when the option of effective antiretroviral therapy is absent. The...

Bile reflux gastropathy

This is also known as alkaline gastritis and describes an ongoing, chronic condition in which bile-containing intestinal contents reflux into the stomach. In animal studies it has been shown that bile salts and other intestinal contents, such as lysolecitin, break down the gastric mucosal barrier, leading to back-diffusion of H ions and histological injury. Bile acid salts are also potent releasers of histamine and other mediators from mast cells and induce non-specific cytotoxicity.30...

Development and normal swallowing function

Newborn Phases Swallowing

The newborn infant is reflex bound and automatically makes certain oral motor movements. For example, the newborn's automatic-phasic bite Figure 15.1 a The adult oropharynx. The phases of swallowing are labeled. 1, preparatory phase 2, oral phase 3, pharyngeal phase 4, esophageal phase. b The infant oropharynx. Note that the infant oral cavity providing little space for manipulation of the food bolus. The larynx is elevated so that the epiglottis almost touches the soft palate. The tongue is...

Viral infections

Hsv Esophageal Ulcers

HSV and CMV are the most common viral agents involved in infectious esophagitis, although some cases have been ascribed to HIV infection of the esophagus. HSV HSV I or, rarely, HSV II esophagitis causes a self-limited disease in normal subjects, but it can be severe and prolonged in the compromised patients. Table 3.3 Drugs for esophageal candidiasis Liver disorders can occur during therapy. The occurrence of liver disorders while on ketoconazole could be fatal unless properly recognized. Liver...

Intestinal epithelial dysplasia or tufting enteropathy

In 1994, three cases of neonatal severe diarrhea with abnormal epithelial pictures were reported by Reifen et al under the name of 'tufting enteropa thy'.36 In our own series at Necker-Enfants Malades, we identified nine cases of severe neonatal diarrhea that were clearly different from MVID.12 Further studies in these patients confirmed that intestinal epithelial dysplasia IED is a constitutive epithelial disorder involving both small intestine and colon.37 In our experience, IED seems to be...

Eosinophilic gastritis

Eosinophilic gastritis is a component of eosinophilic gastroenteropathy, a rare disease characterized by prominent eosinophilic infiltration of the gastrointestinal tract. The cause is unknown and the mechanisms responsible for gastrointestinal infiltration by eosinophils remain poorly understood. Recently, it has been shown that the production of eotaxin, a protein with 73 amino acid residues and a member of the chekines family, at the site of inflammation promotes recruitment and aggregation...

Intestinal neuronal dysplasia

Intestinal neuronal dysplasia IND or hypergan-glionosis, a condition that clinically resembles Hirschsprung's disease, was first described by Meier-Ruge in 1971.7 It is often associated with Hirschsprung's disease and may cause failure of clinical improvement after resectional pull-through surgery. In 1983, Fadda et al classified IND into two clinically and histologically distinguished subtypes, called types A and B. Type A occurs in less than 5 of cases and is characterized by congenital...

Lymphocytic gastritis

Lymphocytic gastritis is characterized by an increase of intraepithelial lymphocytes in surface and foveolar epithelium, together with a variable amount of inflammation in the lamina propria of the gastric mucosa, which ranges from a predominantly lymphocytic pattern to a mixed chronic active pattern. The generally accepted criterion for the diagnosis of lymphocytic gastritis is the finding of 25 or more lymphocytes per 100 epithelial cells.39 Lymphocytic gastritis is thought to be a histologic...

Etiology and pathophysiology

Pancreatitis Ultrasound

The clinical characteristics of acute pancreatitis follow a similar pattern, despite its varied causes. Damage occurs to the pancreatic acinar cell by an inciting event, leading to premature activation of the digestive enzymes while still within the cell. This inciting event may be infectious, traumatic, metabolic, drug-associated or related to an underlying anatomic anomaly. An inflammatory response occurs to these damaged cells, activating platelets and the complement system. Pro-inflammatory...

Conditions affecting the duodenum

Duodenal atresia, duodenal stenosis and annular pancreas are the most common congenital condi- tions to affect the duodenum. All are capable of giving rise to duodenal obstruction. The incidence is reported to be between 1 in 5000 and 1 in 10 000 live births.8 Explanations of the etiology of duodenal atresias are not universally accepted. Unlike atresias of the ileum, they are not thought to be due to vascular accidents and the most widely accepted explanation is that of failure of...

Epidemiology and etiology

While infectious gastroenteritides are the second most common diseases in childhood worldwide, viruses are the most frequent agents of infectious diarrhea. Viral infections of the gastrointestinal tract cause 2 billion cases of diarrhea in children per year, resulting in 18 million hospitalizations and as many as 3 million deaths.1 Acute diarrhea is thus an enormous problem both in developing and in industrialized countries, but with two distinct consequences. In the former, enteric infections...

Other viral pathogens

Varicella zoster virus VZV is a relatively uncommon agent of infectious esophagitis in immunologically normal subjects, but it causes a severe esophagitis in immunocompromised patients, usually accompanied by other signs of systemic dissemination e.g. pneumonitis, hepatitis, encephalitis .37 The endoscopic appearance ranges from vesicles to necrotic ulcerations. Definite diagnosis requires biopsies both for routine histology ballooning degeneration, multinucleated giant cells, intranuclear...

Drug treatment

The drugs recommended by WHO for soil-transmitted helminthiasis are albendazole, mebenda-zole, levamisole, pyrantel and ivermectin and for schistosomiasis they are praziquantel and oxam-niquine for S. mansoni Table 11.3 .2 The benzimidazoles, albendazole and mebenda-zole, have broad-spectrum activity against round-worm, whipworm, hookworm, pinworm and wire-worm species. The action of albendazole on the parasite is to bind to tubulin, inhibit microtubule assembly, decrease glucose absorption and...

Functional nonretentive fecal soiling

The Rome II group defined functional non-retentive fecal soiling as follows once a week, or more, for the preceding 12 weeks, in a child older than 4 years who failed to be toilet trained , a history of defecation into places and at times inappropriate to the social contacts in the absence of structural or inflammatory disease and in the absence of signs of fecal retention. Many studies performed in encopretic children assumed that these children were constipated. Therefore, the new definition...

General guidelines for treatment of diarrheal diseases

As outlined in the various sections of this chapter see also Chapter 37 , the treatment of the majority of infectious diarrheal episodes is supportive, with ORS representing the cardinal intervention to minimize life-threatening dehydration, particularly in young children.105 Breast feeding should be continued, as it may confer protection. Intravenous rehydration should be reserved for high-risk patients who are unable to tolerate enter-als due to recurrent vomiting or diminished mental status....

Definition of protracted and intractable diarrhea of infancy

Originally, the syndrome of IDI was described by Avery et al in 1968, based on the following features diarrhea occurring in a newborn younger than 3 months of age, lasting more than 2 weeks, with three or more negative stool cultures for bacterial pathogens.1 Most cases were managed in hospital, using intravenous fluids while the diarrhea was persistent and intractable, with a high mortality rate from infection or malnutrition.2 Recently, the term 'severe diarrhea requiring parenteral...

Future challenges and opportunities in food allergy

There have been substantial recent advances in the basic science of food allergies. There has been a broadening of the concepts of food allergy, away from simple focus on IgE and towards a consideration of overall mucosal tolerance. Could a genetic tendency to high IgE responses simply make adverse immunological reactions to foods more noticeable As many practitioners are uncomfortable without supporting diagnostic tests, non-IgE-mediated allergy may remain a difficult and controversial...