Paediatrics: Intestinal disorders

Intestinal disorders

Gastritis and peptic ulcer disease

This disease is rare in children. It most commonly affects the duodenum.

Causes

•   Helicobactor pylori infection (strong familial link, associated with increased risk of adult gastric cancer).

•   Stress ulcers, e.g. post-trauma, HIE.

•   Drug-related, e.g. NSAIDs.

•   Increased acid secretion (Zollinger–Ellison syndrome, multiple endocrine neoplasia type I, hyperparathyroidism).

•   Crohn’s disease.

•   Eosinophilic gastroenteritis.

•   Hypertrophic gastritis.

•   Autoimmune gastritis.

Presentation

•   Often asymptomatic.

•   Chronic abdominal and epigastric pain.

•   Nausea +/– vomiting.

•   GI haemorrhage.

•   FTT +/– anorexia.

•   Iron deficiency anaemia.

•   Perforation (very rare).

Investigation

•   C¹⁴ urea breath test (H. pylori).

•   Upper GI endoscopy and biopsy (H. pylori histology and culture).

Treatment

•   Treat underlying cause, e.g. eradicate H. pylori with 7–10 days oral amoxycillin (clarithromycin), bismuth, metronidazole +/– omeprazole (quadruple therapy).

•   ‘fall’ gastric acid production, e.g. proton pump inhibitors (PPI), H₂ antagonists; sucralfate (cytoprotective).

•   Antacids, e.g. aluminium hydroxide.

Protein-losing enteropathy

This disorder is characterized by chronic intestinal protein loss.

Causes

•   GI infection, e.g. giardiasis.

•   Severe food hypersensitivity.

•   Coeliac disease or IBD.

•   Severe cardiac failure.

•   SLE; graft vs. host disease.

•   Polyposis or lymphatic obstruction.

Presentation 

There is hypoalbuminaemia +/– diarrhoea or abdominal pain.

Increased faecal A₁-antitrypsin confirms the condition.

Treatment 

Treat the underlying disease; give nutritonal support and albu-min infusions as required.

Short bowel syndrome

Is due to severe intestinal disease or the surgical removal of a large por-tion of the small intestine. The condition manifests as malabsorption, fluid and electrolyte loss, and malnutrition.

Presentation

• Diarrhoea, steatorrhoea.

• FTT.

• Dehydration, electrolyte loss (Na, K, Mg, Ca).

• Cholestasis (bile salt loss).

• Peptic ulcer disease (due to increased gastrin).

• Specific (e.g. vitamin B₁₂) +/– generalized malnutritional disorders.

• Renal stones (oxalate).

Treatment

• Correct fluid and electrolyte disturbance.

• Specific nutritional supplements; hydrolysed protein/elemental diets.

• PN.

• Gastric acid reducing drugs, e.g. PPI or H₂ antagonists.

• Anti-diarrhoeal drugs, e.g. loperamide.

• Cholestyramine (chelates bile salts).

• Parenteral somatostatin.

• Oral antibiotics to reduce bacterial overgrowth.

• Surgery to reduce GI motility or small bowel transplant.

Prognosis 

Prognosis is improving, with 90% 5yr survival. Retention of ileo-caecal valve significantly improves prognosis.

Intestinal polyps

Most juvenile polyps are hamartomas, single, and located in the distal colon. Polyposis (multiple polyps) syndromes include:

• Peutz–Jegher’s syndrome (mucocutaneous pigmentation).

• Familial polyposis coli.

• Gardner’s syndrome (GI polyps, osteomas and soft tissue tumours).

Presentation

• Often asymptomatic.

• Haematochezia.

• Rectal polyp prolapse.

• Protein-losing enteropathy.

• Intussusception.

• Mucoid diarrhoea.

Investigation 

Gastroscopy and ileo-colonoscopy, barium radiology.

Treatment

• Endoscopic or surgical removal.

• Periodic colonoscopy surveillance is required in polyposis syndromes because of significant risk of neoplasia.