Pediatric Gastroenterology & Pediatric Gastroenterology & Hepatology Hepatology

For UndergraduateFor Undergraduate

Dr Hatem HusseinDr Hatem HusseinProfessor of PediatricsProfessor of Pediatrics

Associate member of Royal College Of Paed.&Child Associate member of Royal College Of Paed.&Child Health-UK Health-UK

Zagazig Faculty of Medicine-EgyptZagazig Faculty of Medicine-EgyptMar. 2008Mar. 2008

Hepatitis D Virus

•Associated exclusively with HBV infection •Incomplete virus that required HB surface

antigen for packaging •Infection with HDV

–Can occur simultaneously with HBV (coinfection)

–Can occur following HBV infections)superinfection(

•Superinfection of a HBV carrier with HDV increase the severity of chronic disease

DNA virusDNA virus

Uses HBsAg as an outsider coatUses HBsAg as an outsider coat..

Usually parenteral or perinatalUsually parenteral or perinatal

IP 3-10 wksIP 3-10 wks

Followed by hepatocellular Followed by hepatocellular damage,and hepatitis picturedamage,and hepatitis picture..

HBsAg clears up followed by the HBsAg clears up followed by the HDVHDV. .

Hepatitis C Virus Infection

•The most common cause of chronic hepatitis,cirrhosis and hepatocellular carcinoma

–HCV infection accounts for > 90% of non-A,non-B hepatitis secondary to blood transfusions

–The incidence of HCV infection due to bloodtransfusions has declined by >95% since 1989.

–>50% of all cases are community acquired with no known risk factors

•The cloned virus was used to develop theimmunoassay used to detect anti-HCV antibody

•At least 6 different genotypes have beenrecognized with type 1 being the most common

)72%.(

•Diagnosis is made by serology and PCR

RNA virusRNA virusRoutes of infection:Routes of infection:ParenteralParenteralSexualSexualVerticalVertical??????

Incubation 1-5 mo.Incubation 1-5 mo.Immune mediated hepatocellular Immune mediated hepatocellular necrosisnecrosis

C/PC/P

1-Prodroma Arthritis,Rash1-Prodroma Arthritis,RashHepatitis short preicteric stageHepatitis short preicteric stage(Fever,Abd. Pain,Tender (Fever,Abd. Pain,Tender heptomegaly,AH,M,Slpenomeg.)heptomegaly,AH,M,Slpenomeg.)

2- 1-2 wks icteric stage 2- 1-2 wks icteric stageMilder S.&S. than HAV and HBVMilder S.&S. than HAV and HBVMost patients are not jaundicedMost patients are not jaundiced

3- Hepatic compl.3- Hepatic compl.

A- A- Chronic persistent hepatitisChronic persistent hepatitis

Pathology involves the portal areas.mod. Pathology involves the portal areas.mod. Enzymopathy.may resolve or procceds toEnzymopathy.may resolve or procceds to

B- B- Chronic active hepatitisChronic active hepatitis

Rec. Jaundice and enzymopathy. May Rec. Jaundice and enzymopathy. May progress to progress to

C- C- Liver failureLiver failure , ,

either fulminant OR subacuteeither fulminant OR subacute

D- D- Hepatocellular carcinomaHepatocellular carcinoma

25 fold risk of norms.25 fold risk of norms.

InvestigationsInvestigations1- High ALT,which coincides with high 1- High ALT,which coincides with high direct bili.direct bili.2-AntiHCV abs appears after 1-8 2-AntiHCV abs appears after 1-8 monthsmonths3-Viral load. RNA can be detected after 3-Viral load. RNA can be detected after 2 wks of infection2 wks of infection

ManagementManagement!- supportive.!- supportive.2- Alpha interferonfor 6-12 mos.2- Alpha interferonfor 6-12 mos.Curative in 25%Curative in 25%

VOMITING IN VOMITING IN INFANTS&CHILDHOODINFANTS&CHILDHOOD

1- FEEDING RELATED:1- FEEDING RELATED:

OVER- ,Mechanical ,Formula intoler.OVER- ,Mechanical ,Formula intoler.

2-INFECTIONS:2-INFECTIONS:

OM,Pnum.,Pyelo.,Mening…etcOM,Pnum.,Pyelo.,Mening…etc

3- GASTROENTERITIS:3- GASTROENTERITIS:

Aetiolgy, electrolytes relatedAetiolgy, electrolytes related

4- Obstructive :4- Obstructive :

Volvolus, IntussceptionVolvolus, Intussception

5-DRUGS:5-DRUGS:

Aspirin,NSAID,Poison,AntibioticsAspirin,NSAID,Poison,Antibiotics

6- METABOLIC :6- METABOLIC :

Renal, DKA,Galactosemia,Urea Renal, DKA,Galactosemia,Urea cyc-cyc-

le,Fructosemia etcle,Fructosemia etc

7- Psychogenic7- Psychogenic

CONSTIPATIONCONSTIPATION::

1- UNDERFEEDING.1- UNDERFEEDING.2- ANAL FISSURES,HEMORROIDES.2- ANAL FISSURES,HEMORROIDES.3- INTESTINAL OBSTRUCTION.3- INTESTINAL OBSTRUCTION.4- HYPOTHYROIDISM4- HYPOTHYROIDISM5- NEUROLOGIAL e.g. 5- NEUROLOGIAL e.g.

MENINGOCELE,TETHERED SPINAL MENINGOCELE,TETHERED SPINAL CORDCORD

6-HABITUAL??? FEEDING,LIFE 6-HABITUAL??? FEEDING,LIFE STYLE,STRESSESSTYLE,STRESSES

CONGENITAL MEGACOLONCONGENITAL MEGACOLON( HIRSCHSPRUNG’S DISEASE)( HIRSCHSPRUNG’S DISEASE)Functional intestinal obstructionFunctional intestinal obstruction

Can affect any part of the colon.Can affect any part of the colon.

1/50001/5000

High incidence in trisomy 21High incidence in trisomy 21

AetiologyAetiology: :

Failure of segmental relaxation due to Failure of segmental relaxation due to defective innervations. Leads to proximal defective innervations. Leads to proximal empty segment, hypertonic segment and empty segment, hypertonic segment and distally hugely dilated segment.distally hugely dilated segment.

Clinically:Clinically: Failure to pass meconium up to 24h.Failure to pass meconium up to 24h. Progressive constipation Progressive constipation Huge distensionHuge distension Complicated by Diarrhea, Malnutrition, ent-Complicated by Diarrhea, Malnutrition, ent- erocolitis, anaemiaerocolitis, anaemiaInvestigations:Investigations: P/RP/R Ba enema (cone shaped)Ba enema (cone shaped) Rectal biopsyRectal biopsy Treatment:Treatment: 1- manual evac.1- manual evac. 2- supportive care2- supportive care 3- surgical management3- surgical management

Chronic Abdominal Pain in Childhood: Diagnosis and

Management

Affects more than third of the childrenAffects more than third of the children..

Becomes chronic if it lasts more than 2 Becomes chronic if it lasts more than 2 weeksweeks..

Needs simple approach before rushing Needs simple approach before rushing to sophosticated investigationsto sophosticated investigations..

Needs a 5 steps approach based on Needs a 5 steps approach based on history,cl. exam.,investig.,individual history,cl. exam.,investig.,individual imagings and interventionsimagings and interventions..

DIFF. DIAG. OF PAEDIATRIC AGE DIFF. DIAG. OF PAEDIATRIC AGE ABDOMINAL PAINABDOMINAL PAIN

ACUTE CAUSES:ACUTE CAUSES:1-INFECTIONS1-INFECTIONS

URTI.,GE,Pancreatitis,PyeloURTI.,GE,Pancreatitis,Pyelo.,Appendicitis,Hepatitis..,Appendicitis,Hepatitis.

2- ACUTE OBSTRUCT.2- ACUTE OBSTRUCT.3- AUTE DISEASES:3- AUTE DISEASES: e.g. HSP, e.g. HSP,

DKA,RHEUMATIC ,PNUMONIDKA,RHEUMATIC ,PNUMONIAA

RECURRENT RECURRENT CAUSES:CAUSES:

1-Irritable bowel1-Irritable bowel2-Parasitic e.g. Giardia2-Parasitic e.g. Giardia3-Chronic constipation3-Chronic constipation4- Chronic pancreatitis4- Chronic pancreatitis5-Malabsorption5-Malabsorption6-Chronic hepatitis6-Chronic hepatitis7-Acid peptic disorders7-Acid peptic disorders8-H.pylori8-H.pylori9-IBD9-IBD10-Renal stones10-Renal stones11-Gynecological11-Gynecological

History

Location, intensity, character and duration of pain, time of day or night.

Appetite, diet, satiety, nausea, reflux, emesis Stool pattern, consistency, completeness of evacuationReview of systems: weight loss, growth or pubertal delay, fever, rash Medications and nutritional interventions Family history, travel Interference with school, play, peer relations and family dynamics

Physical examinationPhysical examination

Weight, height, growth velocity, Weight, height, growth velocity, pubertal stage, blood pressurepubertal stage, blood pressure Complete physical examination Complete physical examination Objective abdominal findings: location, Objective abdominal findings: location, rebound, mass, psoas signrebound, mass, psoas sign Liver, spleen and renal size, ascites, Liver, spleen and renal size, ascites, flank painflank pain Perianal findings: rectal and pelvic Perianal findings: rectal and pelvic examinations, stool testing for occult examinations, stool testing for occult

bloodblood

Laboratory tests

Complete blood count with differential, erythrocytesedimentation rate

Urinalysis and urine culture

Laboratory tests --Stool testing and culture for parasites, Giardia

antigen Serum chemistry profile, amylase level --Pregnancy test, cultures for sexually transmitted

Diseases, Breath hydrogen test: lactose, fructose-Serologic testing for amebae, Helicobacter pylori

Imaging studies individualized Imaging studies individualized according to indicationaccording to indication

Abdominal and pelvic sonographyAbdominal and pelvic sonography Upper gastrointestinal contrast study Upper gastrointestinal contrast study with small bowel testing,with small bowel testing,

abdominal computed tomographyabdominal computed tomography Upper endoscopy, colonoscopy, Upper endoscopy, colonoscopy, laparoscopy laparoscopy

Empiric interventionsEmpiric interventions

Patient and parent educationPatient and parent education Symptom diary of pain, bowel pattern, diet Symptom diary of pain, bowel pattern, diet and associated features, response to and associated features, response to interventionintervention

Constipation investigated as a factorConstipation investigated as a factor Dietary interventions, including adjusted Dietary interventions, including adjusted fiber intake, reduced lactose intake, fiber intake, reduced lactose intake, reduced juice intakereduced juice intake Trial of peptic management Trial of peptic management