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IAP Specialty Series on Pediatric Gastroenterology
Ashish Bavdekar, John Matthai, Malathi Sathiyasekaran, SK Yachha
1:
Gastroesophageal Reflux
INTRODUCTION
PREVALENCE AND NATURAL HISTORY
PATHOPHYSIOLOGY OF REFLUX
PATHOGENESIS OF REFLUX DISEASE
SYMPTOMS AND MANIFESTATIONS
EVALUATION
Contrast Studies
Esophageal pH Studies
Nuclear Scintigraphy
Endoscopy and Biopsy
Empirical Acid Suppression as Diagnostic Test
Miscellaneous Techniques
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
Lifestyle Measures
Pharmacologic Therapy
Acid Lowering Agents
Barrier Agents
Prokinetic Agents
Surgical Treatment
Extraesophageal Manifestations
SUMMARY
ACKNOWLEDGMENT
2:
Helicobacter Pylori in Children
INTRODUCTION
EPIDEMIOLOGY
Prevalence of H. pylori Infection in Indian Children
Environmental Factors
Transmission of Infection
VIRULENCE FACTORS
CLINICAL FEATURES
Recurrent Abdominal Pain (RAP) and H. pylori
INVESTIGATIONS
How to Diagnose H. pylori?
Whom to investigate for H. pylori and how?
TREATMENT
Whom to treat and with what drugs?
H. pylori Infection in Children and Gastric Adenocarcinoma in Adults
Recommended Eradication Therapies for H. pylori Disease in Children
First Line Options
Triple Drug Regimen
Sequential Therapy
Second Line or Salvage Therapy (up to 14 days)
SUMMARY
3:
Recurrent (Chronic) Abdominal Pain in Children
INCIDENCE AND PREVALENCE
CLASSIFICATION
Diagnostic Criteria as per Rome III
H2a. Diagnostic Criteria* for Functional Dyspepsia
H2b. Diagnostic Criteria* for Irritable Bowel Syndrome
H2c. Diagnostic Criteria† for Abdominal Migraine10,11
H2d. Diagnostic Criteria* for Childhood Functional Abdominal Pain
H2d1. Diagnostic Criteria* for Childhood Functional Abdominal Pain Syndrome
H1c. Diagnostic Criteria* for Aerophagia
Approach to a Case of CAP
CAP with
Other Causes of RAP with Dyspepsia
Pathogenesis of Functional Abdominal Pain
Approach to Case of RAP
Complete and Diligent Physical Examination
Level I: Investigations
Level II: Investigations
Indications
Level III: Investigations
Management of Recurrent Abdominal Pain
Make a Positive Diagnosis
Goals of Therapy
Identify and Assuage Stress and Trigger Factors
Diet
Drug Therapy
Psychiatric Help
Prognosis
4:
Recent Trends in the Management of Acute Watery Diarrhea in Children
NEW REDUCED OSMOLARITY ORS
COMPOSITION OF REDUCED OSMOLARITY ORS
Why was there a Need for a New ORS Formulation?
Efficacy of the New Reduced Osmolarity ORS in non Cholera Diarrhea
Efficacy of the New Reduced Osmolarity ORS in Cholera Diarrhea
Is Reduced Osmolarity ORS Safe?
Zinc in Diarrheal Diseases
Should Zinc be Mixed with ORS?
WHO, IAP and Govt of India Recommendations for use of Zinc as an Adjunct to ORS in the Treatment of Diarrhea
Lack of Evidence to use Probiotics and Antisecretory Drugs in Treatment of Diarrhea Probiotics
Antisecretory Drugs in Diarrhea
5:
Persistent Diarrhea
DEFINITION
Prevention and Treatment of Dehydration
Recommendations for Dietary Management of Persistent Diarrhea (Fig. 5.3)
Older Infants and Young Children
Should Milk (Lactose) be Totally Eliminated or Only Restricted?
Basis for the Initial Reduced Lactose Diet
The Second Diet B (Lactose-free Diet with Reduced Starch)
Basis for Diet B
The Third Diet C (Monosaccharide Based Diet)
Vitamin A
Monitoring the Response to Treatment in the Hospital
Criteria for Discharge from Hospital
Resumption of Regular Diet after Discharge
Recommendations for Antimicrobial Therapy in Persistent Diarrhea
Additional Drugs
Value of Laboratory Investigations
6:
Chronic Diarrhea and Malabsorption Syndrome
NORMAL PHYSIOLOGY OF DIGESTION
Etiology
APPROACH TO A PATIENT WITH CHRONIC DIARRHEA
History
Physical Examination
Investigations
MANAGEMENT
Supportive
Common Conditions Presenting with Chronic Diarrhea
Diagnosis
Treatment
Tropical Sprue (TS)
Diagnosis
Treatment
Bacterial Overgrowth
Diagnosis
Treatment
Immunodeficiency
Congenital Immunodeficiency
Acquired Immunodeficiency Syndrome (AIDS)
Diagnosis
Intestinal Lymphangiectasia
Diagnosis
Treatment
Abetalipoproteinemia
Diagnosis
Treatment
Endocrinopathies
Chronic Diarrhea of Neonatal Onset
Prognosis and Outcome
SUMMARY
7:
Celiac Disease
PREVALENCE
PATHOGENESIS
Clinical Presentation
Associated Conditions
Diagnosis
Celiac Serology
HLA Testing
Histology
Diagnostic Criteria
Treatment
Prevention
8:
Abdominal Tuberculosis
CLASSIFICATION OF ABDOMINAL TB
ETIOPATHOGENESIS
PATHOLOGY
Ulcerative (60%)
Hypertrophic (10%)
Ulcerohypertrophic (30%)
Peritoneal TB
Lymph nodal TB
CLINICAL FEATURES
Oral TB
Esophageal TB
Gastric and Duodenal TB
Small Bowel TB
TB of Vermiform Appendix
Segmental Colonic TB
Rectal and Anal TB
Tuberculous Peritonitis
Lymph Nodal TB
DIFFERENTIAL DIAGNOSIS
DIAGNOSIS AND INVESTIGATIONS
Paustian's Criteria25
RADIOLOGICAL STUDIES
Chest Radiograph
Plain Radiograph of Abdomen
Small Bowel Barium Meal
Barium Enema
Ultrasonography
CT Scan
Endoscopy
Immunological Tests
Ascitic Fluid Examination
Laparoscopic Findings
Laparotomy
MANAGEMENT
SUMMARY
9:
Inflammatory Bowel Disease in Children and Adolescents
INTRODUCTION
EPIDEMIOLOGY
Age
Sex
Other Diseases
Breastfeeding
ETIOPATHOGENESIS
Infections
Genetics
Immunologic Factors
Pathophysiology
PATHOLOGY AND DISTRIBUTION
Crohn's Disease
Ulcerative Colitis
CLINICAL PRESENTATION
Gastrointestinal Manifestation
Ulcerative Colitis
Crohn's Disease
Mild-Moderate Disease
Moderate-Severe Disease
Severe-Fulminant Disease
Gastrointestinal Complications
Extraintestinal manifestations
Malnutrition
Growth Failure
Bone Disease
DIAGNOSIS
Initial Evaluation
Ultrasound (US) of Abdomen
Endoscopic Evaluation
Radiological Investigations
Barium Meal Series
Contrast Enhanced Computerized Tomography (CECT)
Magnetic Resonance Imaging (MRI) Scan30
Other Investigations
Serological Markers
DIFFERENCES BETWEEN UC AND CD AND DIFFERENTIAL DIAGNOSIS
Difference Between UC and CD
THERAPY
Pharmacological Therapy
Nutritional Therapy
Psychological Therapy
Surgical Therapy
Multidisciplinary Approach
PROGNOSIS
SUMMARY
10:
Intestinal Parasites in Children
INTRODUCTION
EPIDEMIOLOGY
Classification of Intestinal Parasites
Characteristics of Intestinal Parasites
Protozoa
Entameba Histolytica
Giardia
Cryptosporidium
Balantidium
Isospora
Cyclospora
Diagnosis of Intestinal Parasites
Treatment of Intestinal Parasitic Infections
Prevention of Intestinal Parasites
SUMMARY
11:
Constipation in Children
INTRODUCTION
DEFINITIONS
Constipation
Encopresis
Fecal Soiling
Fecal Incontinence
CLASSIFICATION
Pathophysiology of Constipation
Normal Bowel Habits
Physiology of Defecation
Bowel Training
Pathogenesis of Constipation
Infancy
Toddlers/Preschool Children
School Children
Association of Chronic Constipation
Clinical Presentation
Approach to Constipation
Treatment
Acute Simple Constipation
Chronic Constipation
Initial Education and Counseling
Mild Chronic Constipation
Chronic Constipation with Impaction and Encopresis
Bowel Disimpaction/Evacuation
Oral Route
Rectal Route
Enemas
Suppository
Purgation
Surgery
Maintenance Therapy
Dietary Modification
Retraining/Toilet Training
Biofeedback
Follow-up
Outcome and Prognosis
Prevention
SUMMARY
12:
Childhood Pancreatitis
ANATOMY
PHYSIOLOGY
PANCREATITIS
ACUTE PANCREATITIS
Classification
Pathogenesis (Fig. 12.1)
Etiologies
Clinical Spectrum
Complications of Acute Pancreatitis
Systemic Complications
Organ System Complications
Diagnosis
Laboratory Investigations
Nonspecific Laboratory Tests
Specific Laboratory Tests
Serum Amylase
Amylase Isoenzymes
Amylase Creatinine Clearance Ratio
Serum Lipase
Serum Immunoreactive Trypsin
Ribonulcease
Imaging Procedures
Conventional Radiology
Ultrasonography
Abdominal Computed Tomography
Degree of Confidence
False Positives/Negatives
Endoscopic Retrograde Cholangiopancreatography
Clinical Course and Complications
Complications
Local Complications
Systemic Complication
Treatment
Medical Therapy
Surgical Management of Acute Pancreatitis
CHRONIC PANCREATITIS
Categories of Chronic Pancreatitis
Etiology of Chronic Pancreatitis
Diagnosis
Pancreatic Function Tests
Imaging Studies
Endoscopic Ultrasonography Criteria for Chronic Pancreatitis
Ductal
Parenchymal
Management
Abdominal Pain
Maldigestion
Management of Complications
13:
Symptoms and Signs of Liver Disease in Childhood
INTRODUCTION
SYMPTOMS OF LIVER DISEASE
General Ill Health
Gastrointestinal Symptoms
Jaundice (Fig. 13.2)
Hematologic and Circulatory Symptoms
Nervous System Manifestations
Endocrine Problems
History of Past Illness in Liver Disease
Family History
Social History
POSITIVE PHYSICAL EXAMINATION SIGNS IN CHILDREN WITH LIVER DISEASE
Physical Signs in Liver Disease—General Examination
Abdominal Examination in Liver Disease
Inspection
Palpation
Clinical Significance of Liver Span
Percussion
Auscultation
Examination for Endocrinologic Abnormalities in Liver Disease
Neurologic Findings in Liver Disease
Summary
14:
Liver Function Tests
INTRODUCTION
PATTERNS OF LIVER INJURY
TESTS OF LIVER CELL INJURY
Aminotransferases
AST: ALT Ratio
Role of Serial Monitoring
Lactate Dehydrogenase
TESTS THAT DETECT IMPAIRED BILE FLOW OR CHOLESTASIS
Alkaline Phosphatase (ALP)
Gamma-Glutamyl Transpeptidase (GGT)
5'nucleotidase
TESTS OF SYNTHETIC FUNCTION
Albumin
Prothrombin Time (PT)
Lipids and Lipoproteins
TESTS THAT ASSESS METABOLIC AND EXCRETORY FUNCTION OF LIVER
Bilirubin
Bile Acids
Ammonia
TESTS THAT ASSESS LIVER FIBROSIS
TESTS IN SPECIFIC SITUATIONS
Ceruloplasmin
α1-antitrypsin
α-fetoprotein
15:
Acute Hepatitis
INTRODUCTION
VIRAL HEPATITIS
HEPATITIS A
Epidemiology
Clinical Features
Diagnosis
Management
Prevention
VIRAL HEPATITIS B
Hepatitis B Virus
Natural Course of HBV Infection
Clinical Features
Serology of Acute Hepatitis B Infection (Fig. 15.2)
Management of Acute Hepatitis B
HEPATITIS E
Clinical Features
Diagnosis
Management
OTHER VIRUSES
DRUG-INDUCED HEPATITIS
Clinical Presentation
Diagnosis
Specific Drug Hepatotoxicity
Paracetamol
Valproic Acid
Phenytoin
Carbamazepine
Phenobarbitone
Lamotrigine
Antituberculous Drugs
Antibiotics
Management
SUMMARY
16:
Acute Liver Failure in Children
INTRODUCTION
DEFINITIONS
Limitations of these Definitions in Relation to Pediatric Patients
Hepatic Encephalopathy
Etiology
Risk Factors
Precipitating Factors
Clinical Presentation
Management
Immediate Intensive Care
Initial Workup
Fluid and Metabolic Disturbances (Table 16.4)
Infections
Cerebral Edema (Table 16.5)
Hepatic Encephalopathy (Table 16.6)
Coagulopathy (Table 16.7)
Renal Failure and Hepatorenal Syndrome (HRS) (Table 16.8)
Liver Transplantation
Liver Support Mechanisms
Monitoring Protocols (Tables 16.9 to 16.11)
Mortality/Morbidity in ALF
SUMMARY
17:
Neonatal Cholestatic Jaundice
ETIOLOGY
BILIARY ATRESIA
IDIOPATHIC NEONATAL HEPATITIS (GIANT CELL HEPATITIS)
GALACTOSEMIA
PROGRESSIVE FAMILIAL INTRAHEPATIC CHOLESTASIS (PFIC)
ALAGILLE SYNDROME
HEREDITARY TYROSINEMIA
NEONATAL HEMOCHROMATOSIS
MANAGEMENT
CHOLESTASIS IN PREMATURE BABIES
EFFORTS TO IMPROVE REFERRAL
18:
Chronic Liver Disorders in Children
CONCEPT OF CHRONIC LIVER DISEASE1–3
SPECTRUM AND PREVALENCE OF CLD IN INDIA3,4
MANIFESTATIONS OF CHRONIC LIVER DISEASE5–7
Clinical Manifestations
Presentation
Biochemical Features Suggesting Chronicity
Histological Manifestations
INVESTIGATIONS OF PATIENTS WITH SUSPECTED CHRONIC LIVER DISEASE 5,7,8
General
Etiological Investigations in Selected Patients
MANAGEMENT OF CLD AND ITS COMPLICATIONS6,9
INDIAN CHILDHOOD CIRRHOSIS (ICC)4,10,11
ICC: Epidemiological and Clinical Features (Fig. 18.1)
Histopathology (Figs 18.2A and B)
Differential Diagnosis
Copper and Indian Childhood Cirrhosis
Prevention of ICC
Treatment of ICC
ICC Like Disorders: Cu Associated Childhood Cirrhosis
VENOUS OUTFLOW OBSTRUCTION DISORDERS12–14
Veno-occlusive Disease of Liver (VOD)
Budd-Chiari Syndrome (BCS)
Chronic Constrictive Pericarditis and Chronic CCF
Treatment
NONALCOHOLIC STEATOHEPATITIS (NASH)15,16
CONCLUSION
19:
Portal Hypertension
DEFINITION
CLASSIFICATION OF PH
Etiology
Infections
Hypercoagulable States
Trauma
Invasion and Compression
Intrahepatic Causes of PH
Idiopathic
Intrahepatic Causes of PH
Noncirrhotic Portal Fibrosis
Chronic Liver Disease
CLINICAL FEATURES OF PH
Factors Predicting Rupture
INVESTIGATIVE APPROACH TO PH
IMAGING
Noninvasive Investigations
Ultrasound Doppler
MEDICAL AND ENDOSCOPIC MANAGEMENT OF PH IN CHILDREN
Steps of Management of Acute Bleeding
MANAGEMENT OF VARICEAL BLEEDING
Management of Acute Variceal Bleeding
Pharmacotherapy
Hemodynamics of PH
Vasoconstrictors
Vasodilators
Vasopressin (VP)
Nitrovasodilators
Terlipressin
Somatostatin
Use of Antibiotics
Prevention of Hepatic Encephalopathy
ENDOTHERAPY
Endoscopic Sclerotherapy
Preparation
Instruments
Sedation
Technique
Sclerosant
Complications
Balloon Tamponade
Surgical Management of EHPVO
Prevention of Variceal Bleeding
Pharmacologic Therapy for Primary Prophylaxis105
Endoscopic Treatment
Secondary Prophylaxis or Prevention of Recurrent Hemorrhage
20:
Metabolic Liver Diseases
WILSON'S DISEASE
DIAGNOSTIC CHALLENGES
Variable Clinical Features
No Single Diagnostic Test
ROLE OF GENETIC STUDIES
Mutational Analysis
Haplotype Analysis
What is the Diagnostic Approach?
THERAPEUTIC CHALLENGES
Diet
Drugs
D-Penicillamine (DP)
Trientine
Zinc (Zn)
Ammonium Tetrathiomolybdate (TM)
Liver Transplant
Management of Sibs of WD
Outcome of Wilson's Disease
Glycogen Storage Disease
GSD Type I
GSD Type III
GSD Type IV
GSD Types VI and IX
Management of GSD
Galactosemia
GALT Deficiency
Pathogenesis
Investigations
Treatment
Long-term Management
Prenatal Diagnosis
Galactokinase Deficiency
Epimerase Deficiency
21:
Ascites in Children
INTRODUCTION
ETIOLOGY
FETAL ASCITES
NEONATAL ASCITES
Biliary Ascites
Chylous Ascites
Management
TUBERCULOUS ASCITES
Diagnosis of Tuberculous Ascites
Clinical Features of Ascites
Symptoms
Signs
Physical Examination Findings in Ascites
Secondary Effects
Diagnosis of Ascites
Naked Eye Examination of the Ascitic Fluid
Serum Ascites Albumin Gradient (SAAG)22
Radiology and Imaging Studies in Ascites
Plain X-ray of the abdomen9
Abdominal Ultrasound in Ascites
CT Scan of Abdomen11
Management of Ascites
Management of High SAAG Ascites23,24
Principles of Treatment of Cirrhotic Ascites
Diuretic Therapy
Furosemide
Evaluation of Diuretic Treatment Response and Complications
Refractory Ascites28
Large Volume Paracentesis (LVP)
Peritoneovenous (Le Veen) Shunt (PVS)
Liver Transplantation (LT) in Refractory Ascites31
Prognosis
22:
Liver Transplantation in Children
INTRODUCTION
Indications
Acute Liver Failure (ALF)
End Stage Chronic Liver Failure
The Pediatric End Stage Liver Disease (PELD) Scoring System
LT for Metabolic Disorders
PRE-TRANSPLANT EVALUATION
Pre-transplant Assessment Guidelines for Recipient
Pre-transplant Medical Management
Nutritional Rehabilitation
Immunization
Management of Complications of ESLD
Counseling
Transplant Surgery
TECHNICAL VARIANTS
Split-Liver Transplantation
Living Related Liver Transplantation
Monosegmental Liver Transplantation
Auxiliary Partial Liver Transplantation
The Postoperative Course
Retransplantation
Immunosuppression
NOVEL THERAPIES
Looking Beyond Immunosuppression: Tolerance
Hepatocyte Transplantation
Liver Assist Devices
Life After Transplantation
Registries and Databases
Liver Transplantation in India
SUMMARY
INDEX
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