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Diseases of GIT

  1. Congenital hypertrophic pyloric stenosis:
    1. Commonest surgical disorder of the stomach during Infancy.
    2. More common in boys. (Specially first born)   M:F=5=1  
    3. Nonbilious vomitings Q is the initial symptom of pyloric stenosis.
    4. The vomiting may or may not be projectile initially but is usually progressive occurring immediately after a feeding.
    5. The vomiting usually starts after 3 wk of age.
    6. As vomiting continues, a progressive loss of fluid, hydrogen ion, and chloride leads to hypochloremic metabolic alkalosis.
    7. Serum potassium levels are usually maintained. Q
    8. Vigorous peristaltic waves moving from the left hypochondrii to umbilicus.
    9. Associated with TEF and hypoplasia of the inferior labial frenulum.
    10. H/O mother /father had Pyloric stenosis
    11. Hypochloremic metabolic alkalosis
    12. Jaundice associated with a decreased level of glucuronyl transferase is seen in =5% of affected infants. The indirect hyperbilirubinemia usually, resolves promptly after relief of the obstruction.
    13. The diagnosis has traditionally been established by palpating the pyloric mass. Q
    14. The mass is 6rm, movable, = 2 cm in length, olive shaped, hard, best palpated from the left side, and located above and to the right of the umbilicus in the mid epigastrium beneath rhe liver edge. In healthy infants, feeding can be an aid to the diagnosis.
    15. After feeding, there may be a visible gastric peristaltic wave that progresses across the abdomen.
    16. After rhe infant vomits, the abdominal musculature is more relaxed and the "olive" easier to palpate.
    17. Diagnosis –Ultrasound confirms
T/t: RAMSTEDT’S operation (pyloromyotomy) Q


2. Gastroesophageal Reflux-(GERD)

  1. GERD is the most common esophageal disorder in children of all ages. Gastroesophageal reflux (GER) signifies the retrograde movement of gastric contents across the lower esophageal sphincter (LES) into the esophagus.
  2. Spontaneous effortless regurgitation of gastric contents into the Esophagus
  3. GE reflux persisting after one year is pathological
  4. Recurrent regurgitation and vomiting is a common symptom. Q Recurrent lower respiratory infections, GI blood loss, anemia, failure to thrive are other features.
  5. Transient LES relaxation (TLESR) is the primary mechanism allowing reflux to occur. TLESRs occur independent of swallowing.
  6. Contrast (usually barium) radiographic study of the esophagus and upper gastrointestinal tract is performed in children with vomiting and dysphagia to evaluate for achalasia, esophageal strictures and stenosis, hiatal hernia, and gastric outlet or intestinal obstruction.
  7. Extended esophageal pH monitoring of Q the distal esophagus, now considered the sine qua non of a GERD diagnosis, provides quantitative and sensitive documentation of acidic reflux episodes, the most important type of reflux episodes for pathologic reflux.
  8. Endoscopy allows diagnosis of erosive esophagitis and complications such as strictures or Barrett esophagus; esophageal biopsies may diagnose histologic reflux esophagitis in the absence of erosions while simultaneously eliminating allergic and infectious causes. 


  1. Drugs- Antacids, H2 receptor antagonist, omeprazole cisapride
  2. Surgery-Nissen's fundal plication. 

3. Hirschsprung's disease:

  1. Hirschsprung disease, or congenital aganglionic megacolon, is caused by abnormal innervation of the bowel, beginning in the internal anal sphincter and extending proximally to involve a variable length of gut.
  2. most common cause of lower intestinal obstruction in neonates Q
  3. May be associated with other congenital defects including Down, Smith-Lemli-Opirz, Waardenburg, cartilage hair hypoplasia, and congenital hypoventilation ("Ondine curse") syndromes and urogenital or cardiovascular abnormalities.
  4. Also seen in association with microcephaly, mental retardation, and abnormal facies; with autism; or with cleft palate, hydrocephalus, and micrognathia.
  5. Males more affected
  6. C/F: usually' begin at birth with the delayed passage of meconium. Q
  7. In 98% of full-term infants, meconium is passed within 24 hr of birth.
  8. Should be suspected in any full-term infant (the disease is unusual in preterm infants) with delayed passage of stool. Q
  9. Some infants pass meconium normally but subsequently present with history of chronic constipation. Q
  10. Failure to thrive, with hypoproteinemia from a protein-losing, enteropathy Q is a less common presentation.
  11. Failure to pass stool leads to dilatation of the proximal bowel and abdominal distention.
  12. Stasis allows proliferation of bacteria, which can lead to enterocolitis (Clostridium difficile, Staphylococcus aureus, anaerobes, coliforms) with associated sepsis and signs of bowel obstruction.
  13. Diagnosis- Rectal manometry and rectal suction biopsy Q are the easiest and most reliable indicators of Hirschsprung disease.
  14. Rectal suction biopsies are the procedure of choice and should be performed no closer than 2 cm to the dentate line to avoid the normal area of hypoganglionosis at the anal verge. 

Treatment: Once the diagnosis is established, the definitive treatment is operative intervention.

  1. Abdominal pain:

“Chronic or recurrent abd pain is defined as recurrent or persistent bouts of abd pain that occurs monthly for a minimum of 3 months, with severity that interrupts routine function”


Commonest cause of Chronic or recurrent abd pain in older children (>2 yrs) is functional. Functional pain is that which can not be explained by any cause usually around umbilicus , non radiating, can be severe enough to interfere routine function. 


Table: Recurrent or chronic Abdominal pain Children





Recurrent abdominal pain syndrome

(functional abdominal pain)

Nonspecific pain, often periumbilical

Irritable bowel syndrome

Intermittent cramps diarrhea, and constipation

Nonulcer dyspepsia

Peptic ulcer – like symptoms without abnormalities on evaluation of the upper gastrointestinal tract

Gastrontestinal Tract

Chromic constipation

Hx of stool retention, evidence of constipation on examination

Lactose intolerance

Symptoms may be associated with lactose ingestion, bloating gas craps and diarrhea

Parasite infection (especially Giardia)

Bloating, gas gramps, and diarrhea

Excess fructose or sorbitol ingestion

Nonspecific abdominal pain, bloating gas and diarrhea

Crohn disease

See chapter 333

Peptic ulcer

Burning or gnawing epigastric pain worse in awakening or before meals relieved with antacids


Epigastric pain with substernal burning

Meckel’s diverticulum’s

Periumbilical or lower abdominal pain ,blood may be present in stool with episode

Recurrent intussusceptions

Paroxysmal severe cramping abdominal pain, blood may be present in stool with episode

Internal ,inguinal, or abdominal wall hernia

Dull abdomen or abdominal wall pain

Chronic appendicitis or appendicle mucocele

Recurrent RLQ pain, often incorrectly diagnosed, may be rare cause of abdominal pain

Galibladder And Pancraes


RUQ pain, may worsen with meals

Choledochal cyst

RUQ pain, mass elevated bilirubin

Recurrent pancreatitis

Persistent boring pain, may radiate to back, vomiting

Genitourinary Tract

Urinary tract infection

Dull suprapubic pain flank pain


Unilateral abdominal or flank pain


Progressive , severe pain, flank to inguinal region to testicle

Other genitourinary disorders

Suprapubic or lower abdominal pain genitourinary symptoms

Miscellaneous Causes

Abdominal migraine

See text ;nausea, family HX MIGRAINE

Abdominal epilepsy

May have seizure prodrome

Gilbert syndrome

Mild abdominal pain (causal or coincidental? )slightly elevated un conjugated bilirubin

Familial Mediterranean fever

paroxysmal episodes of fever severe abdominal pain and tenderness with other evidence of polyserositis

Sickle cell crisis


Lead poisoning

Vague abdominal pain constipation

Henoch- Schönlein purpura

Recurrent ,severe crampy abdominal pain occult blood in stool characteristic rash arthritis

Angioneurotic edema

Swelling of face or airway crampy pain

Acute intermittent porphyry

Severe pain precipitated by drugs, fasting or infections


Abd, abdominal ; EEG, electroencephalogram :Hx history ;IVP intravenous pyelography O&P ova and parasites PE physical exam RLO right lower quadrant RUQ right lower ;RUQ Right upper quadrant


Table : Causes of Constipation

Nonorganic (Functional – Retentive




Anal stenosis

Chemotherapeutic agents (vincristine)

Imperforate anus

Pancreatic enzymes (fibrosing colonopathy)

Anteriorly displaced anus


International stricture (post necrotizing enterocolitis)

Vitamin D intoxication

Abnormal Musculature

Metabolic Disorders

Prune belly syndrome Gastroschisis


Down syndrome


Intestinal Nerve or Muscle Abnormalities


Hirschsprung disease

Diabetes mellitus

Pseudo obstruction (visceral myopathy or neuropathy)

Intestinal Disorders

Intestinal neuronal dysplasia

Celiac disease

Spinal cord Defects

Cow’s milk protein intolerance

Tethered cord

Cystic fibrosis (meconium ileus equivalent)

Spinal cord trauma

Inflammatory bowel disease (stricture)

Spina bifida



Connective Tissue Disorders


Systemic lupus erythematosus



Psychiatric Diagnosis

Anorexia nervosa

  1. Intussusception in Infants:
    1. It is the most common cause of intestinal obstruction between 3 mo and 6 yr old age.
    2. Sixty percent of patients are younger than 1 yr, and 80% of the cases occur before 24mo; it is rare in neonates.
    3. Etiology And Epidemiology: The cause of most intussusceptions is unknown.
    4. Correlation with prior or concurrent respiratory adenovirus Q (type C) infection has been noted, and the condition may complicate otitis media, gastroenteritis, Henoch-Schönlein purpura, or upper respiratory tract infections.
    5. In 2-8% of patients, recognizable lead points for the intussusception are found, such as a Meckel diverticulum, intestinal polyp, Q intestinal duplication, hemangioma, Q or malignant conditions such as lymphoma. Intussusception can complicate mucosal hemorrhage, as in Henoch-Schönlein purpura or hemophilia.
    6. Cystic fibrosis Q is another risk factor Postoperative intussusception is ileoileal.
    7. Child around the age of 1 yr presents with severe, colicky abdominal pain manifesting as episodic crying.
    8. Vomiting and current jelly like stools Q ***
    9. A sausage shaped mass in the Right quadrant of the abdomen. Q
    10. Rt iliac fossa is empty
    11. Investigation Ultrasound
    12. Intussusception is a surgical emergency 



  1. Diarrhea

Diarrhoea is the passage of three or more liquid or watery stools in a day. However it is the recent change in consistency and character of the stool rather than the number of stools that is more important.

[Diarrhea is also defined as an increase in daily stool weight above 200gm (older children/adult) or > 10 gm/kg/day (up to 3 yr) when patient also complains abnormal increase in stool liquidity 'and frequency].

Dysentery -It is characterized by the presence of blood and pus in the stool abdominal cramps and fever.

Acute diarrhea →
 It refers to diarrhea that begin acutely but lasts less than 14 days. The most common causes of acute diarrhoea are infectious agents. Acute diarrhea also caused by ingested drugs of toxins.

Persistent diarrhea
 It begins as acute diarrhoea but persists for more than 14 days


Chronic diarrhea  Diarrhea of long duration (more than 2 wk) mainly non-infectious and generally associated with


Infectious Diarrhoea, Pathophysiologic Mechanisms and Causes

Pathophysiologic Mechanism


Toxin production preformed toxin

Bacillus cereus

Clostridium perfringens

Staphylococcus aureus


Aeromonas sp.

Enterotoxigenic E. coli

Vibrio cholerae

Clostridium difficile



E. coli 0157: H7

Entero adherence


Cyclospora sp.

Enteroadherent and enteropathogenic E. coli



Mucosal invasion Minimal

Norwalk virus


Other viruses (e.g. adenovirus, astrovirus, calvci virus, coronavirus cytomegalovirus, herpes simplex virus)


Aeromonas sp.

Campylobacter sp.

Salmonella sp.

Vibrio parahaemolyticus


Entamoeba histolytica

Enteroinvasive E. coli

Shigella sp.

Systemic infection





Rocky Mountain spotted fever

Toxic shock syndrome

Viral hepatitis


Assessment of child with diarrhea


Assess during examination

  1. Physical signs of dehydration
  2. Nutritional status of the child weight is the best parameter
  3. Presence of other associated infection

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