Textbook of Pediatric Gastroenterology, Hepatology and Nutrition Anupam Sibal, Sarath Gopalan, Akshay Kapoor, Vidyut Bhatia
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1Textbook of Pediatric Gastroenterology, Hepatology and Nutrition
2 3Textbook of Pediatric Gastroenterology, Hepatology and Nutrition
Anupam Sibal MD FIMSA FIAP FRCP (Glasg) FRCP (Lon) FRCPCH FAAP Group Medical Director, Apollo Hospitals Group Adjunct Professor, Department of Pediatrics School of Medicine, University of Queensland Brisbane, Australia Member, Institute Body Postgraduate Institute of Medical Education and Research Chandigarh, India Senior Consultant Pediatric Gastroenterologist and Hepatologist Indraprastha Apollo Hospitals New Delhi, India Sarath Gopalan MD (PGIMER, Chandigarh), Fellowship in Pediatric Gastroenterology and Clinical Nutrition (UK), MAMS Senior Consultant Pediatric Gastroenterologist and Hepatologist Indraprastha Apollo Hospitals Executive Director Centre for Research on Nutrition Support Systems New Delhi, India Akshay Kapoor MD Consultant Pediatric Gastroenterologist and Hepatologist Indraprastha Apollo Hospitals New Delhi, India Vidyut Bhatia MD Consultant Pediatric Gastroenterologist and Hepatologist Indraprastha Apollo Hospitals New Delhi, India John Walker-Smith
4
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Textbook of Pediatric Gastroenterology, Hepatology and Nutrition
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5CONTRIBUTORS
A Riyaz
MD DCH DNB DM (Gastroenterology)
Pediatric Gastroenterologist Professor and Head, Department of Pediatrics Goverment Medical College
Calicut, Kerala, India
AK Patwari
MD DCH MNAMS FIAP FAMS
Head, Department of Pediatrics
Hamdard Institute of Medical Sciences and Research
Associated HAH Centenary Hospital
Hamdard University
New Delhi, India
Akshay Kapoor
MD
Consultant Pediatric Gastroenterologist and Hepatologist
Indraprastha Apollo Hospitals
New Delhi, India
Amita Mahajan
MD MRCP (UK) CCST (Ped Oncol, UK)
Pediatric Hematology and Oncology Unit
Apollo Center for Advanced Pediatrics
Indraprastha Apollo Hospitals
New Delhi, India
Anupam Sibal
MD FIMSA FIAP FRCP (Glasg) FRCP (Lon) FRCPCH FAAP
Group Medical Director, Apollo Hospitals Group
Adjunct Professor, Department of Pediatrics
School of Medicine, University of Queensland
Brisbane, Australia
Member, Institute Body
Postgraduate Institute of Medical Education and Research
Chandigarh, India
Senior Consultant Pediatric Gastroenterologist and Hepatologist
Indraprastha Apollo Hospitals
New Delhi, India
B Sumathi
MD (Ped) DCH DM (Gastro)
Assistant Professor
Department of Pediatric Gastroenterology
Institute of Child Health
Chennai, Tamil Nadu, India
Bhupinder K Sandhu
OBE DSc MD FRCP FRCPCH
Consultant Pediatric Gastroenterologist
Bristol Royal Hospital for Children
Honorary Professor
Centre for Child and Adolescent Health
University of The West of England and
University of Bristol
United Kingdom
Boosba Vivatvakin
MD DTM&;H (Hon)
Consultant Pediatric Gastroenterologist
Pediatric Gastrointestinal Unit
Chulalongkorn University
Bangkok, Thailand
BR Thapa
MD
Professor and Head
Division of Pediatric Gastroenterology, Hepatology and Nutrition
Postgraduate Institute of Medical Education and Research
Chandigarh, India
Deepak Goyal
MD PDCC (Ped Gastro)
Associate Consultant
Department of Pediatric Gastroenterology, Hepatology and Liver Transplantation Medanta – The Medicity
Gurgaon, Haryana, India
Deirdre Kelly
MD
Professor
Department of Pediatric Hepatology, The Liver Unit
Birmingham Children’s Hospital HNS Trust and University of Birmingham
Steelhouse Lane
Birmingham
Past President
British Society of Paediatric Gastroenterology, Hepatology and Nutrition
European Society for Paediatric Gastroenterology, Hepatology and Nutrition
6Dhanasekhar Kesavelu
MBBS MRCPCH (UK) FRCPCH (UK) CCT (UK)
Consultant Pediatric Gastroenterologist
Apollo Children’s Hospital
Chennai, Tamil Nadu, India
Dinesh Banur
MBBS DCH MRCPCH (UK) FRCPCH (UK) CCT
Consultant Pediatric Gastroenterologist
Columbia Asia Hospital
Bengaluru, Karnataka, India
Efstratios Saliakellis
MD PhD
Clinical Fellow
Department of Pediatric Gastroenterology and Nutrition
4th Pediatric Department
Aristotle University of Thessaloniki
Greece
Division of Neurogastroenterology and Motility
Department of Gastroenterology
Great Ormond Street Hospital
London, United Kingdom
Garima Garg
MD
Junior Consultant
Pediatric Intensive Care Unit
Fortis Escorts Heart Institute
New Delhi, India
Hanifah Oswari
MD PhD
Gastrohepatology Division
Department of Child Health
University of Indonesia
Indonesia
Huma Cheema
MRCP (UK) DPGN (London University)
Professor Head
Department of Gastroenterology, Hepatology and Nutrition
The Children’s Hospital and The Institute of Child Health
Lahore, Pakistan
James Huang
MBBS (Hons, S’pore) MRCPCH (Paeds, UK)
Registrar
Division of Gastroenterology, Hepatology and Nutrition
Department of Pediatrics
KTP-National University Children’s Medical Institute
National University Hospital
Singapore
John Matthai
MD (Ped) DCH FAB (Ped Gastro) FIAP
Head, Neonatology Division
Professor, Department of Pediatrics
PSG Institute of Medical Sciences
Peelamedu, Coimbatore, Tamil Nadu, India
Juliet Sio Aguilar
MD MSc
Professor and Chair
Department of Pediatrics
Attending Pediatrician and Pediatric Gastroenterologist
University of the Philippines, Manila
College of Medicine–Philippine General Hospital
Philippines
K Vijayaraghavan
MD MSc (Community Health) MSc (Applied Nutrition)
Former Senior Deputy Director
National Institute of Nutrition
Hyderabad, Telangana, India
Kathleen B Schwarz
MD
Professor, Department of Pediatrics
Director, Pediatric Liver Center
President, Federation of International Societies of Pediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN)
Division of Pediatric Gastroenterology, Hepatology and Nutrition
Department of Pediatrics
Johns Hopkins University School of Medicine
Baltimore, USA
M Geetha
MD (Ped) DNB (Ped) DM
Gastroenterologist
Amrita Institute of Medical Sciences and Research Center
Kochi, Kerala, India
Malathi Sathiyasekaran
MBBS MD DCH DM
Senior Consultant Pediatric Gastroenterologist
Kanchi Kamakoti Childs Trust Hospital and
The Childs Trust Medical Research Foundation
Chennai, Tamil Nadu, India
Manas Kalra
MD DNB (Ped Hemato-oncology) FNB
Pediatric Hematology and Oncology Unit
Apollo Center for Advanced Pediatrics
Indraprastha Apollo Hospitals
New Delhi, India
7Manav Wadhawan
DM (Gastroenterology)
Senior Consultant Hepatologist
Indraprastha Apollo Hospitals
New Delhi, India
Marion M Aw
MBBS MMed (Ped) MRCP (UK) FRCPCH (UK) FAMS
Pediatric Gastroenterologist and Hepatologist
National University Children’s Medical Institute
Singapore
Md Iqbal Hossain
MBBS DCH PhD
Senior Scientist
Centre for Nutrition and Food Security, icddr, b
Clinical Lead, Nutrition Unit
Dhaka Hospital, icddr, b
Adjunct Associate Professor
School of Public Health, BRAC University
Bangladesh
Mohammad Nurul Akhtar Hasan
MD
Fellow
Pediatric Intensive Care Unit
Fortis Escorts Heart Institute
New Delhi, India
Neelam Mohan
DNB (Ped) FIAP FIMSA FACG
Director
Department of Pediatric Gastroenterology,
Hepatology and Liver Transplantation
Medanta – The Medicity
Gurgaon, Haryana, India
Neerav Goyal
DNB (GI Surgery)
Senior Consultant GI and Liver Transplant Surgeon
Indraprastha Apollo Hospitals
New Delhi, India
Nikhil Thapar
BM MRCPCH PhD
Senior Lecturer and Honorary Consultant
Division of Neurogastroenterology and Motility
Department of Gastroenterology
Great Ormond Street Hospital
London, United Kingdom
Stem Cells and Regenerative Medicine
UCL Institute of Child Health
London, United Kingdom
Nkem Onyeador
MBBS MRCPCH Specialist
Registrar in Pediatric Gastroenterology
Bristol Royal Hospital for Children
United Kingdom
Olivier Goulet
MD PhD
Professor Department of Pediatrics
Head, Department of Pediatric Gastroenterology,
Hepatology and Nutrition
Chair, National Reference Center for Rare Digestive Diseases
Necker-Enfants Malades Hospital
University of Paris-Descartes
Paris, France
Osvaldo Borrelli
MD PhD
Consultant and Honorary Senior Lecturer
Division of Neurogastroenterology and Motility
Department of Gastroenterology
Great Ormond Street Hospital
London, United Kingdom
Palittiya Sintusek
MD
Consultant Pediatric Gastroenterologist and Hepatologist
Chulalongkorn University
Bangkok, Thailand
Paolo Quitadamo
MD
Endoscopy and Digestive Motility Unit
University of Naples “Federico II”, Italy
Clinical Fellow
Division of Neurogastroenterology and Motility
Department of Gastroenterology
Great Ormond Street Hospital
London, United Kingdom
Parag Karkera
MCh (Pediatric Surgery) MS (General Surgery)
Assistant Professor
Department of Pediatric Surgery BJ Wadia Hospital for Children
Mumbai, Maharashtra, India
Parvathi U Iyer
MBBS MD
Associate Director
Pediatric Cardiothoracic Surgeon
Fortis Escorts Heart Institute
New Delhi, India
8Rajeev Redkar
MCh (Pediatric Surgery) MS (General surgery) FRCS (Ped)
FRCS (Ed) FRCS (G) FCPS DNB IAS
Consultant Pediatric Surgeon
Lilavati Hospital and Research Centre
Shushrusha Citezen’s Co-operative Hospital
BJ Wadia Hospital for Children
Mumbai, Maharashtra, India
Ramaswamy Ganesh
MBBS DNB MNAMS
Consultant Pediatrician
Kanchi Kamakoti Childs Trust Hospital and
The Childs Trust Medical Research Foundation
Chennai, Tamil Nadu, India
Ravinder Goyal
MD DM
Assistant Professor
Division of Pediatric Gastroenterology, Hepatology and Nutrition
Postgraduate Institute of Medical Education and
Research
Chandigarh, India
Rimjhim Shrivastava
MD
Short Term Trainee
Division of Pediatric Gastroenterology, Hepatology and Nutrition
Postgraduate Institute of Medical Education and Research
Chandigarh, India
Sandipan Sarkar
MD
Senior Resident
Pediatric Intensive Care Unit
Fortis Escorts Heart Institute
New Delhi, India
Sanjiv Verma
MD
Senior Resident
Department of Pediatric Hepatology
Institute of Liver and Biliary Sciences
New Delhi, India
Sankaranarayanan VS
MD (Ped) DM (Gastro)
Professor and Head
Department of Pediatric Gastroenterology
Madras Medical College
Retd Professor and Head
Institute of Child Health and Hospital for Children
Consultant Gastroenterologist
Kanchi Kamakoti Childs Trust Hospital
Chennai, Tamil Nadu, India
Sarah Paul
DCH MD
Head, Neonatology Division
Professor, Department of Pediatrics
PSG Institute of Medical Sciences
Coimbatore, Tamil Nadu, India
Sarath Gopalan
MD (PGIMER, Chandigarh), Fellowship in Pediatric Gastroenterology and Clinical Nutrition (UK), MAMS
Senior Consultant Pediatric Gastroenterologist and Hepatologist
Indraprastha Apollo Hospitals
Executive Director
Centre for Research on Nutrition Support Systems
New Delhi, India
Seema Alam
MD
Additional Professor
Department of Pediatric Hepatology
Institute of Liver and Biliary Sciences
New Delhi, India
Siham Al Sinani
MD FAAP FRCPC
Senior Consultant
Department of Pediatric Gastroenterology, Hepatology and Nutrition
Child Health Department Sultan Qaboos University Hospital
Muscat Oman
SK Mittal
MD (Ped) FIAP
Pediatric Gastroenterologist
Chairman
Centre for Comprehensive Child Health
Ghaziabad, Uttar Pradesh, India
Visiting Professor
Chacha Nehru Bal Chikisalya
New Delhi, India
Srikanth KP
MD
Senior Resident
Division of Pediatric Gastroenterology, Hepatology and Nutrition
Postgraduate Institute of Medical Education and Research
Chandigarh, India
S Srinivas
MD DM
Consultant Pediatric Gastroenterologist and
Hepatologist
Apollo Children’s Hospital
Chennai, Tamil Nadu, India
9Subash Gupta
MS FRCSEd
Chief Liver Transplant Surgeon
Indraprastha Apollo Hospitals
New Delhi, India
Sujit Chowdhary
MBBS MCh FRCS FACS
Senior Consultant
Department of Pediatric Urology and Pediatric Surgery
Indraprastha Apollo Hospitals New Delhi, India
Suresh Vijay
MD RCPCH
Consultant
Inherited Metabolic Disease (IMD)
Birmingham Children’s Hospital
United Kingdom
Tahmeed Ahmed
MBBS PhD
Director
Centre for Nutrition and Food Security, icddr, b
Professor, Public Health Nutrition
James P Grant School of Public Health
BRAC University
Dhaka, Bangladesh
Vidyut Bhatia
MD
Consultant Pediatric Gastroenterologist and
Hepatologist
Indraprastha Apollo Hospitals
New Delhi, India
Wafa’a Al-Qabandi
BM BCh DCH MRCP
Department of Pediatrics
Faculty of Medicine
Kuwait University
Kuwait
Wikrom Karnsakul
MD
Assistant Professor
Department of Pediatrics
Johns Hopkins University School of Medicine
Baltimore, USA
Yogesh Waikar
MBBS MD DNB Fellow in Pediatric Gastroenterology and Liver
Transplant MNAMS PGCC
Consultant Pediatric Gastroenterologist and Hepatologist
Care Hospital
Nagpur, Maharashtra, India
10 11FOREWORD
This textbook is a landmark in the history of pediatric gastroenterology and hepatology. It demonstrates the coming of age of this discipline in much of the developing world. The authors are a talented group of leaders in their fields of interest. The technological advances in recent years within this field are quite remarkable. Perhaps, the most dramatic and complex in practice, is the development of pediatric liver transplantation with immense advantages for children who would otherwise have died, in past years. At another level, it is important to appreciate that much simpler therapeutic techniques, also based upon scientific research, such as the development of oral rehydration therapy (ORT), have had dramatic beneficial effects for much larger numbers of sick children with dehydrating diarrhea due to infection. Across the world, there has been a dramatic fall in diarrheal disease mortality, especially in infancy, chiefly related to development (public health measures of particular importance) but in part, especially in developing communities to the use of ORT. Whilst the contents of this book may have the greatest appeal in the countries of the contributors, it has international appeal as a state-of-the-art text across the world.
I have visited relevant centers in Asia since the 1980s up to Sri Lanka in 2013. The changes have been dramatic. Outside help and advice from experts in the United States and Commonwealth countries, especially Australia, Canada and the United Kingdom have played an important role. However, great success has come from the “home teams”. This has been assisted by the provision of training opportunities in the nations mentioned, with very positive outcomes. The Commonwealth Association of Paediatric Gastroenterology, Hepatology and Nutrition (CAPGAN) has contributed. This began in Asia in 1991 with a conference in New Delhi on Diarrhea and Malnutrition in Children and most recently in 2013 in Colombo.
The field of medicine described in this text is one where immense benefits occur by multiple interactions between a wide range of medical disciplines and contact between countries, developed and developing. Clinical problems evolve and change over the years, in part related to development per se. In my own professional experience from the 1960s till now, within developed communities in Australia and the United Kingdom, I have seen a remarkable decline in infection- related disorders, especially in infants and young children and a remarkable rise in inflammatory bowel disease in older children, in recent years. This continuing change in the pattern of disease provides a great challenge and also opportunity to those concerned with the clinical care of children with this group of disorders and to scientists investigating these disorders. These disciplines are fields where research and improved service go hand in hand, for the benefit of individual children. Much more research is required across the world, with international collaboration of key importance.
It must always be remembered that all these endeavors are directed towards improving the care of children with gastrointestinal and liver problems and indeed to prevent these disorders, in the long term. Huge advances have been made during my own clinical experience over the past 50 years, but there are still fearsome challenges ahead.
John Walker-Smith
MD BS (Sydney) FRCP (London & Edinburgh)
FRACP FRCPCH MA (King’s College, London)
Emeritus Professor
Department of Pediatric Gastroenterology
University College London
United Kingdom
12 13PREFACE
The last few decades have witnessed an exponential growth of knowledge in pediatric gastroenterology, hepatology and nutrition. The understanding of the pathophysiology of several disorders has improved while newer disorders have been described. Newer genetic, metabolic and biochemical tests have become available.
Novel therapies for treatment of diseases, such as tyrosinemia and neonatal hemochromatosis, have evolved over the last decade. Treatment for hepatitis B and C has improved. Especially impressive has been the transfer of liver transplantation from the realms of fantasy to becoming a routine procedure for many centers across the world. Techniques such as gene transfer and hepatocyte transplantation are likely to see the end of the tunnel in the coming years.
Advancements in the field of luminal gastroenterology have been no less remarkable. Newer modalities in endoscopy, such as endoscopic ultrasound and capsule endoscopy, have revolutionized assessment of gastrointestinal disorders. We now have newer therapy in the form of biologicals for management of inflammatory bowel disease. The field of enteral and parenteral nutrition continues to evolve. Fecal microbiota transplantation is being explored as therapy for several conditions. Intestinal transplantation is now established therapy.
This book specifically looks at disorders of the gut and liver from a developing country’s perspective. This book is meant to be used by postgraduates, pediatric gastroenterologists as well as pediatricians with an interest in gastroenterology. While this book features topics that are relevant and necessary for postgraduate teaching, updates on latest developments have also been included. The authors have been chosen carefully based on their expertise. Many contributors are internationally recognized experts. We would like to thank all the contributors, for their contribution. We hope that this book will serve as a valuable clinical resource.
Anupam Sibal
Sarath Gopalan
Akshay Kapoor
Vidyut Bhatia
14 15ACKNOWLEDGMENTS
We would like to express our gratitude to Dr Prathap C Reddy (Founder Chairman), Apollo Hospitals Group, for his guidance and encouragement. We would also like to thank Dr Preetha Reddy (Executive Vice-Chairperson), Ms Suneeta Reddy (Managing Director), Ms Shobana Kamineni (Executive Vice-Chairperson) and Ms Sangita Reddy (Joint Managing Director), Apollo Hospitals Group, for their constant support.
A big thank to Mr Jaideep Gupta, Mr P Shivakumar, Mr AK Singhal, Gen LR Sharma, Ms Anjali Kapoor, Ms Usha Banerjee, Ms Raji Chandru, Mr Rohit Kapur, Mr CP Tyagi, Dr Ritu Rawat, Mr Raj Raina and Mr Sachin Patidar, for providing an environment that encourages academics and research.
No words will suffice to acknowledge the untiring efforts of Ms Neha Kapoor, Ms Harsimran, Dr Smita Malhotra, Dr Rajesh Kumar, Dr Karunesh Kumar and Dr Hasnain Hussain, in getting this textbook published.
We thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and Mr Tarun Duneja (Director–Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for undertaking the task of publishing this book. A special word of praise for Ms Shivangi Pramanik from the publishing house, for her efficient coordination.