General: For each of the following signs and symptoms of the digestive tract disorders, know the following:

Pathophysiology/pathogenesis Age-related differences Distinction between functional and organic causes Importance of non-digestive tract causes of some GI symptoms in children Management: general and specific Recognize the disorders that will need pediatric surgical referral

 Vomiting Know the common causes in the different age groups Be aware of the entity of cyclic vomiting

 VOMITING. regurgitation relatively frequent symptom during the neonatal period. In the 1st few hours after birth, infants may vomit mucus, occasionally blood streaked rarely persists after the 1st few feedings it may be due to irritation of the gastric mucosa by material swallowed during delivery If vomiting is protracted, gastric lavage with physiologic saline solution may relieve it.

 When vomiting occurs shortly after birth and is persistent:

intestinal obstruction metabolic disorders increased intracranial pressure

A history of maternal polyhydramnios suggests upper gastrointestinal (esophageal, duodenal, ileal) atresia

Bile-stained emesis suggests intestinal obstruction beyond the duodenum, but may also be idiopathic Abdominal x-rays (kidney-ureter-bladder [KUB] and cross-table lateral views) should be performed in neonates with persistent emesis and in all infants with bile-stained emesis patterns of obstruction
double bubble: duodenal atresia Pneumoperitoneum: intestinal perforation

A contrast swallow roentgenogram with small bowel followthrough is indicated in the presence of bilious emesis.

 Obstructive lesions of the digestive tract are the most frequent gastrointestinal anomalies esophageal obstruction= vomiting within the 1st feeding. The diagnosis of esophageal atresia can be suspected if :
unusual drooling from the mouth is observed and if resistance is encountered during an attempt to pass a catheter into the stomach diagnosis should be made before the infant has trouble with oral feedings and develops aspiration pneumonia.

 Infantile achalasia (cardiospasm), a rare cause of vomiting in newborn infants, is demonstrable roentgenographically by obstruction at the cardiac end of the esophagus without organic stenosis

 Regurgitation of feedings because of continuous relaxation of the esophagealgastric sphincter, or chalasia, is a cause of vomiting Management:
Keeping the infant in a semi-upright position, thickening the feeding, or administering prokinetic drugs

 Obstruction of the small intestine

usually begins on the 1st day of life frequent, persistent, usually non-projectile, copious, and, unless the obstruction is above the ampulla of Vater, bile stained

associated with:
abdominal distention visible deep peristaltic waves reduced or absent bowel movements

 Malrotation with obstruction from midgut volvulus

an acute emergency upper gastrointestinal contrast series X-rays of the abdomen show the distribution of air in the intestine, which may point to the anatomic location of an obstruction malrotation can be identified only by contrast studies.

 Normally, air can be demonstrated by x-ray:

jejunum by 1560 min ileum by 23 hr colon by 3 hr after birth Absence of rectal gas at 24 hr is abnormal.

 Persistent vomiting may occur with congenital diaphragmatic hernia. The vomiting associated with pyloric stenosis may begin any time after birth but does not assume its characteristic pattern before the 2nd3rd wk.

 Vomiting with obstipation is a common early sign of Hirschsprung disease Vomiting may occur with many other disturbances that do not obstruct the digestive tract
milk allergy Galactosemia organic acidemias Septicemia UTI
- adrenal hyperplasia of the salt-losing variety

- hyperammonemias - inc. ICP - meningitis

 In many infants, it is simply regurgitation from overfeeding or from failure to permit the infant to eructate swallowed air