Examination of child's gastrointestinal system

Gastrointestinal (GIT) diseases are very common in childhood.

The most common symptoms

Vomiting

• often accompanied by nauzea
• in young children it is difficult to distinguish regurgitation of gastric contents in gastroesophageal reflux (not accompanied by nausea, gastric contents return to the esophagus spontaneously, without active expulsion)
• vomiting + diarrhea – in acute gastroenteritis
• reactive vomiting – in acute pyelonephritis, in AA (acute abdomen)
• repeated vomiting without nausea + headaches + afebrilia – in intracranial hypertension
• bile admixture in vomit – ileus, duodenogastric reflux, long-term persistent vomiting
• in vomit leftover food ingested more than 12 hours ago – lined GIT motility
• blood admixture in vomit – in case of mucosal damage by persistent vomiting, bleeding from esophageal varices or from peptic ulcer
• vomiting of digested blood – after massive epistaxis with blood swallowing

Abdominal pain

• one of the most common symptoms for a child to see a doctor
• children often localize pain to the periumbilical area
• visceral (diffuse, dull pain of inaccurate localization)
• parietal (sharp, precisely localized pain)
• pain may come from the abdominal wall, or be vertebrogenic etiology or metabolic etiology (pseudoperitonitis diabetica in diabetic ketoacidosis; lead intoxication)
• psychogenic pain (diagnosis per exclusionem – exclusion of organic cause)
• we ask about the intensity of pain, the duration of the problem, the triggering factor and the accompanying symptoms

Constipation

• difficult bowel movements (low frequency, painful defecation)
• the frequency of bowel movements varies in children (infants have 1-7 stools per day; fully breastfed children can only have 1 stool in 10 days)
• functional x organic constipation– Hirschprung's disease, cystic fibrosis
• important information – pitch departure after childbirth
• accompanying difficulties: abdominal pain, meteorism, abdominal pain, vomiting
• functional constipation most often in toddlers – during the cleanliness training period
• spotting – the consequence of overflowing the anal canal and ampoule of the rectum with faeces and a reduction in the tone of the rectal sphincters with the consequent departure of a smaller amount of faeces; we palpate skybal during the large intestine, especially in the rectosigmoid
• in older children and adolescents, constipation is a frequency of 3 or fewer stools per week + difficult bowel movements in min. 25% of defecation

Diarrhea in children

• more frequent emptying of loose stools
• Loss of fluid in the stool can lead to dehydration
• according to the course: acute x chronic x recurrent
• according to the pathophys. mechanism: increased fluid secretion, decreased water absorption, exudation
• by etiology: viral x bacterial x parasitic x drug x non-specific intestinal inflammation
• may be a sign of malabsorption (celiac disease, brush border disaccharidase deficiency)

see also Diarrheal diseases in infancy

Physical examination

• we examine while lying on back with bent knees and arms along the body

View

• we monitor: size and shape of the abdomen, possible herniation in the inguinal canal area, distension (aerophagy, meteorism, hepatosplenomegaly, ascites, tumors), sunken abdomen (Congenital diaphragmatic hernia, spider nevi) and traumas

Palpation

• an essential part of the examination
• first surface palpation, then deep palpation
• we monitor the child's facial expression

Tap

• allows detection of enlargement of intra-abdominal organs, presence of free fluid, peritoneal irritation,…
• examination of the liver by tapping – we determine their upper and lower edge in the medioclavicular line – the total length of the liver in children is 6-10cm
  • in infants in the first half of life, the liver may extend the rib arch by 1-3 cm
  • the upper edge of the liver is usually in the 5th intercostal space in the medioclavicular line

Listening

• we detect the presence of peristalsis, its acceleration (e.g. in gastroenteritis) or disappearance (e.g. in ileus)

Per rectum

• we are looking for excoriations (roups), fistulas, perianal skin growths, .. (non-specific intestinal inflammations)
• we assess the tone of the sphincter, the content of the ampoule, the pain during the examination (during AA)

Special gastroenterological methods

Hydrogen test

• the amount of hydrogen in the exhaled air depends inversely on the breakdown of lactose by intestinal lactase

(reduced lactase activity –> higher hydrogen content in the intestinal lumen and in the exhaled air)

• method:
  • 20% ​​lactose solution after fasting (2g lactose/kg body weight, maximum 50g)
  • then the patient exhales air through the reduction valve into the syringe
  • we evaluate the last third of the tidal volume
  • we perform measurements at 30-minute intervals for a total of 180 minutes
• conclusion: pathological finding is a concentration of more than 10 ppm per basal value

24-hour esophageal pH measurement

• to detect reflux of gastric contents into the distal third of the esophagus
• method:
  • Insert a pH-metric probe with an antimony sensor into the distal third of the esophagus,
  • continuously monitor the pH for 4 sec. after 24 hours.

Enterobiopsy

• to take a sample of the intestinal mucosa for histological examination
• Crosby capsules attached to a probe that the patient swallows
  • the capsule is made of X-ray contrast material
• we perform on an empty stomach (6 hours of fasting), for infants and toddlers in premedication

Liver biopsy

• Mengini needle percutaneous liver biopsy
• in infants, toddlers and uncooperative children in general anesthesia in apnea pause
• in cooperating children under premedication and local anesthesia
• collection in the supine position with the right hand in the lining or behind the head, injection in the apnea pause (in the expiration)
• after the biopsy, the child lies on his right side for 24 hours.

Links

Related articles

• Examination of the child: Examination of the child's cardiovascular system ▪ Examination of the child's respiratory system ▪ Examination of the child's uropoietic system ▪ Examination of the child's endocrine system ▪ Examination of the child's musculoskeletal system ▪ Examination of child's skin and skin adnexa ▪ Examination of the child's sight and hearing
• Digestive system development
• Congenital malformations of digestive system

Literature

• LEBL, Jan – PROVAZNÍK, Kamil – HEJCMANOVÁ, Ludmila. Preklinická pediatrie. 2. edition. Praha : Galén, 2007. pp. 131-138. ISBN 978-80-7262-438-6.

Portal:Pediatrics Portal:Gastroenterology