Examination of digestive system. Semiotics of digestive system diseases in children

Vladyslava Maychuk

PhD, MD Ph.D., As DIGESTIVE SYSTEM

 Digestive system is a collection of organs carrying out mechanical and chemical processing of food, extracting from it of nutrients and their absorption and excretion. The gastrointestinal tract begins to function from 16-20 weeks of intrauterine development

By the time of birth, the baby's digestive tract is one of the most mature systems in the body, but adapted to the diet of exclusively breast milk Oral cavity

is relatively small the tongue is large and wide mass of the cheeks has the well developed fat pads (corpus adiposum buccae of Bitchat’s) Saliva deficiency up to 3-4 months Salivary gland development ends by 3-4 months the mucous membrane is gentle, dry and rich in blood vessels, very tender Increased salivation in 4-6 months (irritation of the trigeminal nerve with teething) Esophagus

 well expressed funnel-shaped form glands absence insufficient development of elastic and muscle tissues well developed blood vessels 3 parts of esophagus – cervical, thoracic and abdominal. 3 anatomical constrictions: in the initial part at the bifurcation of the trachea diaphragmatic Anatomical esophageal constrictions are expressed very bad in newborns and first-year babies.

regurgitation Located horizontally Stomach It has no definite shape The secretory apparatus is weak Motility slowed

The composition of gastric juice: •Hydrochloric acid •Lactic acid •Pepsin •The rennet enzyme •Lipase

The volume of the stomach: Newborn – 7 ml after birth and up to 80 ml on the 10th day 3 months − 100 ml 1 year − 200-250 ml 3 years − 500 ml 12 years − 1500 ml The liver in newborn is functionally undeveloped In children – relatively large: .the newborn liver constitutes 4,4 % of the body mass The liver is the largest gland in the organism of a person, .adultAgeliver − 2,8 % participating in: Normally the lower edge of the liver till 7 years of age is palpated below the edge of the right costal Till 6 months 2-3 cm lower  The process of digestion margin along on the right medioclavicularis line:  Metabolism 6 months – 2 years 1.5 cm lower  The system of blood circulation 3 – 7 years 0.5-1 cm lower  Realization of enzymatic functions >7 years Does not protrude from under the costal margin  Carrying out excretory functions The small intestine consists of: INTESTINE Peculiarities of intestine in  duodenum (7-10 cm after birth and 25-30 cm in a newborn: the adult person, i.e. the increases is relatively small)  jejunum (make 2/5 of the total length of small intestine) Circular muscles are better  ileum (make 3/5 of the total length of small expressed then longitudinal → intestine) spasms, colic Poor development of small and large omentum → rapid spread of the infectious process The products of absorption enter the bloodstream through the lymph, bypassing the liver → toxicosis Low secretory activity Insufficient barrier function Is relatively longer than that of an adult LARGE person The cecum is very INTESTINE mobile → difficulty in determining appendicitis Long sigmoid gut → tendency to The rectum is weakly fixed → tendency to fall The mesentery is long and weakly fixed→Intussusception

The structure of the large intestine corresponds to that of the adult person only at 3-4 years of age. Intestine

 In the first hours, the bowel is almost sterile  Natural feeding → Bifidobacteria predominate  Artificial feeding → Escherichia coli (decay processes)  The newborn secrete an earliest stool- meconium Functions of the digestive system

1. Motor function is carried out by the musculature of the digestive system and consists in chewing, swallowing, moving food along the digestive tract and removing undigested residues from the body. 2. The secretory function is to produce the glandular cells of the digestive juices: saliva, gastric, pancreatic, intestinal juices and bile. 3. The incretory function is associated with the formation in the digestive tract of a number of hormones that have a specific effect on the digestive process (insulin) 4. The excretory function - the secretion of the metabolic products by digestive glands into the gastrointestinal tract (eg urea, ammonia, bile pigments), water, heavy metal salts, medicinal substances, which are then removed from the body. 5. The absorption function is carried out by the mucous membrane of the stomach and intestines. The age features of feces in children External features Age The name Color The Smell consistency Dark Thick, – 1-3 day Meconium green homogenous Fragments Liquid, Graduall of different Transitional 3-5 day colors – watery, with y turns whitish, mucous and into sour yellowish, greenish lumps Usual Like liquid Acidic natural Golden- yoghurt (sour) Since 5-6 feeding yellow day till 6 months Artificial Light Porridge- Putrefac feeding yellow like (semi- tive, liquid= harsh doughy)

Over 6 Thick (or Usual months Usual Brown formed =solid=shaped) (normal) Complaints

Diagnostic process usually starts with the patient’s complaints and anamnesis. All complaints which directly characterized diseases of gastrointestinal tract we can divide into 3 groups: Violation of appetite Dyspeptic disorder Pain in the Red Flags or “Alarm Findings” during the abdominal assessment • History - Involuntary weight loss - Deceleration of liner growth - Gastrointestinal blood loss - Significant - Chronic severe - Persistent right upper or lower quadrant pain - Unexplained fever - Family history of inflammatory bowel disease Disturbance in appetite can Appetite be conditionally divided into 4 kinds: 1. Reduced appetite 2. Anorexia 3. Increased appetite 4. Perverted appetite All this complaints can be a sign of appearance of diseases of gastrointestinal tract, and also a clinical feature of some diseases of another organs and systems. Increase of appetite (bulimia) occurs during diabetes mellitus, tumor of pancreas Appetite − insulinoma, brain tumor and dementia.

Bulimia also may be in the breast fed infants, in overfeeding with artificial formulas, when food flows easily from the bottle (big holes in the nipple).

The Perverted appetite is the condition in which the child willing eats uneatable substances like chalk, sand, soil, raw meat (lack of education of a child or lack of some substances in an organism (Ca) and in anemia). The Dyspeptic disorder

 Vomiting  Belching   The disorders of defecation:  Diarrhea  Constipation Defect of swallowing () is return of swallowed food or liquid through nose, fear of swallowing, and retrosternal pain during swallowing and aspiration of food.

Dysphagia is found in:  undeveloped hard palate  atresia or stenosis of esophagus  burn of esophagus  post operative stenosis of esophagus  narrowing of esophagus after esophagitis  collagenosis Cleft palate Vomiting (emesis) is the throwing out the contents of stomach and the upper part of the intestine through the mouth. It is a complex nervous reflux act. More often vomiting precedes nausea - unpleasant sensation in epigastrium, sometimes accompanied with vegetative vascular reaction − paleness, weakness, dizziness.

• Vomiting is the early sign of the different gastrointestinal diseases and diseases of another organs including meningitis, toxicosis, diabetic acidosis, etc. Reason of vomiting

Mechanical Central  Origin occurs often  origins of vomiting due to obstructive in children arises are process in digestive seen in tract. Brain edema brain tumor intracranial haemorrhage subdural haemotoma. Belching (eructation)

 is spontaneous involuntary movement of gastric content (food eructation) in very small amounts or gases (air eructation) back to oral cavity from the stomach.  In breast fed infants belching occurs during . Belching is seen in the 1st  During breast feeding air weeks of baby life. Step by may enter with milk in the step addition of solid food stomach. Accumulated air decreased frequency of in the stomach periodically comes from belching the stomach in the form of gas bubbles. With these gas bubbles food comes out. Vomiting

• Gastroesophageal Reflux Disease (GERD) – insufficient lower esophageal sphincter tone early in life • Clinical presentation: - Postprandial (after meal) regurgitation - Signs of esophagitis (arching, irritability, feeding aversion, failure to thrive) - Obstructive apnea, stridor, lower airway disease (cough, wheezing) The disorders of defecation

 Diarrhea is frequent defecation, at which the stool is liquid consistence. The liquidness of stool is caused by the allocation of water. There are many courses of diarrhea (enteric diarrhea, drug- induced, antibiotic- associated diarrhea, neurogenous diarrhea). The disorders of defecation

Constipation  Constipation is the reduction of the frequency of defecation acts (it is quite often accompanied by difficulty) with the passage of thick stool mass. The sign of constipation in infants is the absence of excrement for more than 3 days (or daily, but with difficulty or bleeding). The reason of constipation at early age is the disorder of diet, in older age – disturbances in peristaltic of intestines, undevelopment of nervous-muscular system, psychogenic factor. Complaints

 Time, duration, periodicity  Connection with food intake and its type  Localization  Characteristics  Connection with physical, emotional stress and other factors Abdominal pain

 Abdominal pain is the most common complaint in children. In infants, abdominal pain is characterized by at least three episodes in a 3- months period in a child whose is normal. Abdominal pain

Fewer than 10% have organic disease. The incidence of organic disease increases in children under 3 years and in the presence of symptoms such as diarrhea, weight loss, dysuria, fever, or neurologic symptoms. The pain varies in intensity, duration and location. General Appearance

•Start with a general overview of the child’s appearance. •Take note of the child’s posture. The child that is unable to lie still is likely to suffer from colicky pain from acute cholangitis while the child that minimizes movement may have appendicitis or peritonitis. •Note any changes in colour – a patient with and scleral icterus is likely suffering from liver disease, while a pale patient may have anemia. General Appearance • Take note of a patients’ nutritional status. • Peripheral edema may suggest hypoalbuminemia. • Focus on the skin. There are some gastro-intestinal conditions that manifest skin lesions as part of the extra- intestinal symptoms of the disease such as dermatitis herpetiformis in Celiac Disease or erythema nodosum in Inflammatory Bowel Disease. • If inflammatory bowel disease (ulcerative colitis, Crohn’s disease) is suspected, evidence of other extra-intestinal manifestations should be thought, such as uveitis, aphtous ulcers, clubbing and arthritis. uveitis aphtous ulcers General Appearance

Stigmata of chronic liver disease: • muscle wasting, • asterixis, • palmar erythema, • whitening of the nails, • jaundice, • spider angiomas, • caput medusae • gynecomastia.

Dehydration

Severe dehydration a child has 2 of the following: Lethargic (V) / unconscious (P, U) Can't drink Sunken eyes The skin fold spreads very slowly - more than 2 seconds

Moderate dehydration a child has 2 of the following: Restless / annoying Drinking greedily Sunken eyes The skin fold spreads slowly

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? Desquamative glossitis ("geographical" tongue) Atrophic (Gunter) glossitis - diseases of the - deficiency of vitamin gastrointestinal tract, B12 and folic acid, diseases of the anemia associated with connective tissue impaired hematopoietic (collagenosis) processes

Macroglossia - hypothyroidism, Down syndrome, amyloidosis Abdominal Inspection • The patient should be supine with his or her hips slightly flexed. This relaxes the abdominal muscles, giving better access to deeper structures. • Always examine the patient from the right side. Abdominal Inspection • Abdominal distention which may indicate abnormal gas-filled loops of bowel, fecal retention, a mass lesion, or a ruptured viscus. • Scaphoid abdomen can be seen in a patient with upper gastrointestinal obstruction or as a result of starvation. • Peristaltic waves may be seen on occasion, but are especially prominent in pyloric stenosis. • Pulsations of large vessels should generally not be visible. Areas of abdomen

• 1 – right hypochondric area epigastrium 2 – exact epigastric area 3 – left hypochondric area

• 4 – right side area mesogastrium 5 – paraumbilical area 6 – left side area

• 7 – right inguinal (ileac) area hypogastrium 8 – suprapubic area 9 – left inguinal (ileac) area Abdominal Inspection • Abdominal wall protrusions. Umbilical frequently are present in the infant, toddler, and younger child. Most umbilical hernias are uncomplicated, require no surgery, and resolve spontaneously. Diastasis recti and small epigastric hernias can be elicited by having the patient raise his or her head off the examining table while lying supine or by having the child tense the abdominal muscles; these hernias also do not require surgical correction. The pathological changes of the abdomen

 Increase in the size of the abdomen can be in:

 Meteorism

 Ascites

 Hepatolienal syndrome

 Tumor

 Adiposity

 “Frog belly” – the abdomen is enlarged, however, its widening prevails on the sides, which is a feature of hypotonia of the abdominal muscles (the features of rickets). “Frog belly” ? ? Omphalitis The pathological changes of the abdomen

“Caput Meduasae” The pathological changes of the abdomen

The symptom of “sand watches” – in some minutes after stroking of epigastrium site with finger a ball-like swelling of the abdomen appears; it is a sign of pylorostenosis. Red Flags or “Alarm Findings” during the abdominal assessment • Examination - Localized right upper or lower quadrant tenderness - Localized fullness or mass effect - - - Costovertebral angle tenderness - Tenderness over the spine - Perianal abnormalities - Abnormal or unexplained physical findings

• Tympany is usually present in most of the abdomen caused by air in the gut (a higher pitch than the lungs). • Resonance is a lower-pitched and hollow sound (found in normal lungs). • Dullness is a flat sound without echoes; the liver, spleen, and fluid in the peritoneum (ascites) give a dull note, but an unusual dullness may be a clue to an underlying . • Percuss to determine if hepatomegaly is present. The transition between a tympanic and dull percussion tone marks the lower border of the liver. • A normal liver span in the midclavicular line for a child depends on gender and on age: -At one week of age the liver span should be less than 5 cm -At 12 years of age up to 8 cm in boys and up to 7cm in girls.

Percussion

• Percussion can also be used to determine the presence of ascites, using two different methods. 1. Test for “shifting dullness” is performed starting with the patient supine. Percuss from the flank towards the umbilicus in a plane perpendicular to the bed. At first dullness will be noted but as one approaches the umbilicus, the air-filled loops of intestine pushed centrally by peritoneal fluid will sound tympanic. Next ask the patient to role on their side. Repeat the maneuver. If ascites is present the fluid will redistribute into dependent areas and the line between tympany and dullness will be shifted accordingly.

Percussion 2. The second test for ascities tests for the presence of a “fluid wave”. Ask an assistant to place a hand vertically over the center of the abdomen with the patient supine. Then tap one flank with the tips of the fingers of one hand while feeling for a fluid wave over the contralateral flank. Costovertebral angle tenderness (CVAT), also known Pasternacki's sign, is a medical test in which pain is elicited by percussion of the area of the back overlying the kidney (the costovertebral angle, an angle made by the vertebral column and the costal margin). The test is positive in people with an infection around the kidney (perinephric abscess), pyelonephritis, hemorrhagic fever with renal syndrome or renal stone. Palpation

 Palpation is used to detect masses, and abdominal tenderness.  Knee-to-knee position.  For the obese child, a two-hand technique with the fingers of one hand applying pressure on top of the fingers of the other hand may be required. Palpation • Start with superficial palpation, progressing to deeper palpation. • When peritonitis is suspected, rebound tenderness may be elicited by pressing firmly and slowly on the abdomen and then quickly releasing pressure. Signs of pain upon withdrawal of pressure suggests peritoneal irritation. • Next palpate for organomegaly. The pathology of the gall bladder and liver

• Mussy symptom (phrenicus-symptom) – is considered to be positive if pain appears at pressing with a finger between the crus of the right sterno-cleido-mastoideus muscle. • Murphy's sign is tested for during an ; it is performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line Palpation

• In the newborn, the liver edge may be felt about 2 cm below the costal margin, • In older children the normal location of the liver edge is flush with or behind the inferior costal margin. • Also try to assess whether the liver edge is soft or hard, smooth or boggy. An inflamed liver edge may not only be enlarged but also feel boggy and irregular while a fibrotic liver may feel hard. Palpation • Several positive physical findings may help make the diagnosis if appendicitis is suspected. • The point of maximal pain and ternderness often progressed from peri-umbilical to a point 1/3 the distance between the iliac crease and the umbilicus in the right lower quadrant. • Light palpation over this location or McBurney’s point may elicit tenderness and guarding. • Deeper palpation and quick release of pressure may create rebound tenderness. • Tenderness over the right lower quadrant while palpating the contralateral side is often found (Rovsing’s sign).

• In advanced cases of appendicitis, significant abdominal muscular rigidity can develop, making palpation difficult. • The involves pain on internal rotation at the hip, a maneuver which stretches the obturator muscle which may be irritated when the appendix is located inferiorly. • The elicits pain on right hip flexion tested against resistance, present when the inflamed appendix is located in the retroperitoneum and is irritating the psoas muscle.

Additional methods of GI system investigation Abdominal US exam

Ultrasound imaging of the abdomen uses sound waves to produce pictures of the structures within the upper abdomen. It is used to help diagnose pain or distention (enlargement) and Камни в желчном пузыре evaluate the kidneys, liver, gallbladder, bile ducts, pancreas, spleen and abdominal aorta. Ultrasound is safe, noninvasive and does not use ionizing radiation. Esophagogastroduodenoscopy (EGD)

Diagnostic endoscopic pro cedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure CT scan Computed tomography (CT) of the abdomen and pelvis is a diagnostic imaging test used to help detect diseases of the small bowel, colon and other internal organs and is often used to determine the cause of unexplained pain. CT scanning is fast, painless, noninvasive and accurate. In emergency cases, it can reveal internal injuries and bleeding quickly enough to help save lives. Colic

Baby colic, also known as infantile colic, is defined as episodes of crying: for more than 3 hours a day, for more than 3 days a week, For 3 weeks in an otherwise healthy child. The cause of colic is unknown Fewer than 5% of infants with excess crying have an underlying organic disease

Pyloric stenosis

Pyloric stenosis is a narrowing of the opening from the stomach to the first part of the small intestine (the pylorus).

Signs of pyloric stenosis usually appear within three to five weeks after birth. Pyloric stenosis is rare in babies older than 3 months. Pyloric stenosis Vomiting after feeding. The baby may vomit forcefully, ejecting breast milk or formula up to several feet away (projectile vomiting).

Persistent hunger.

Stomach contractions. You may notice wave- like contractions (peristalsis) that ripple across baby's upper abdomen soon after feeding but before vomiting.

Dehydration

Changes in bowel movements. Since pyloric stenosis prevents food from reaching the intestines, babies with this condition might be constipated.

Weight problems. Pyloric stenosis can keep a baby from gaining weight, and sometimes can cause weight loss. The differential diagnosis of pylorospasm and pylorostenosis Clinical signs Pylorospasm Pylorostenosis Volume of urine and Can be reduced 1.5-2 times Considerably reduced frequency of urinations (3-4 times) Often cries, restless, shouts Mostly quiet, sometimes Condition of the child before and during vomiting may get excitated before vomiting

Symptom of Absent Is present “sand watches” barium remains in the barium remains in it for about The results of X-ray stomach for about 24 hours and more 6-8 hours Normal Pyloric part: The result of ultrasound .Hypertrophy of the wall > 4 mm .Increase in length > 20 mm .On the cross-section – symptom of “cockarde” Efficiency of treatment with Positive result after some No effect cholinolytics days Hematochezia (fresh, red blood in stool)

Intussusception – bowel drags mesentery with it and produces arterial and venous obstruction and mucosal necrosis – classic “black currant jelly” stool Clinical presentation: - Sudden onset of severe paroxysmal colicky abdominal pain; straining, legs flexed - Progressive weakness - Lethargy, shock with fever -Vomiting in most (early on, it is bile-stained) - Decreased stooling - Blood in most patient in first 12 hours - Sausage-shaped mass on right in cephalocaudal axis

Inflammatory bowel disease Onset usually during adolescence Have remissions Specific etiology (autoimmune?) Crohn’s disease Ulcerative colitis  Extraintestinal findings  Affects colon only (uveitis, aphtous  a long-term condition ulcers, clubbing and  inflammation and ulcer arthritis) s of colon  May occur  abdominal pain everywhere along the  diarrhea mixed GI tract with blood Inflammatory bowel disease Diagnosis-endoscopy with biopsy Inflammatory bowel disease What is syndrome? What is syndrome? What is syndrome? What is syndrome? Thank you for attention!