Paediatric gastroenterology is the speciality within paediatric medicine that deals with symptoms and conditions related to the digestive system of children. This includes the foodpipe, stomach, bowels, liver and pancreas.  Nutrition is another area of expertise covered by a paediatric gastroenterologist.

More details can be found at this Royal College of Paediatrics link.

There are a wide variety of symptoms related to the gastrointestinal tract.  Some of these may have an underlying cause or condition, others may not and will need symptom management.

Some of the more common digestive issues seen include

• abdominal pain or tummy ache - a very common symptom in children.  It can vary from mild occasional tummy ache to more severe regular pain that can significantly affect a child and in turn the whole family. Abdominal pain can be classified in various ways including according to the duration it has been present for example  Acute (short duration)  V  Chronic (long-standing).  In acute pain it is essential to rule out certain specific causes that need to be dealt with swiftly, for example appendicitis, intussusception, testicular torsion in boys and ovarian pathology such as cysts in girls to name just a few.  The list of causes is lengthy. In chronic abdominal pain ,Often despite multiple tests and investigations there is no obvious inflammatory, anatomical or metabolic disease process discovered yet the pain can be severe and interfere with day to day function. It can occur alone or in combination with other  symptoms such as a change in bowel habit,  for example in Irritable bowel syndrome.  This type of chronic pain is best dealt with in combination with other members of the team including dieticians and psychologists or therapists. Often a dietary change eg The FODMAPS diet or gut-directed hypnotherapy have been found to be more effective than medications.  The presence of so called 'alarm' symptoms or abnormal findings from test results point toward an underlying inflammatory, infective or anatomical cause that needs to be diagnosed and treated.
• bloating  - another common symptom that occurs in a variety of conditions including irritable bowel syndrome, lactose intolerance, coeliac disease and constipation to name a few.It is important to understand what is meant by bloating as for some it is a sensation of fullness, whilst in others there is a visible distension of their belly.  The causes can vary from lactose intolerance, to constipation to rarely in children an obstruction of the bowel.
• blood in poo -is often a scary sight. Most commonly it is due to a little tear in the skin around the bottom, an anal fissure, caused by  some difficulty passing poo with straining and constipation.  It may sometimes be due to other causes that need more investigations including colonoscopy. Particularly if it occurs repeatedly with no obvious features of constipation and straining.  The appearance of the blood, where it is found (on the poo, mixed in with loose poo, on the tissue paper when wiping, or if there is associated straining and pain can help determine the significance and need for investigations.  Other symptoms or concerns around reduced appetite, energy and weight loss or a family history of Crohn's disease or colitis would make me consider these early on and investigate appropriately with endoscopy.
• blood in vomit -this may be due to trauma to the upper gastrointestinal (GI) tract after repeated vomits during an illness ( a so-called Mallory-Weiss tear) or may be a sign of another more significant problem.  Blood tests are helpful to check for anaemia, liver and blood clotting disorders, poo tests may also be used to check for Helicobacter pylori infection.  An upper GI endoscopy or OGD is a useful test in such a scenario to try to find the source of any bleeding. You may find that your doctor has started your child on a medication that suppresses stomach acid production before they come to the clinic to help reduce any bleeding due to acid or helicobacter pylori infection-related causes such as ulcers.
• burping or belching -can be isolated and due to air being partially or fully swallowed then ejected, or can occur in association with other symptoms such as heartburn and reflux. Sometimes investigations such as a pH Impedance test may be useful to help distinguish between the various causes although simple modification of eating and breathing techniques may be all that are necessary when it is something that has become a habit behaviour that needs to be reversed.
• constipation - one of the most common symptoms seen in any gastroenterology clinic. In the vast majority of cases, there is no significant underlying medical or surgical condition.  It can come on at various points in childhood, often at times of feeds changing in an infant, weaning to solids, the time around potty training or in school age children when there is often an element of stool witholding and refusal to use school toilets.  It can be short-lived after a gastro illness and dehydration, or sometimes can evolve into a more chronic or long-standing condition that needs a combined approach to management using long-term laxatives and bowel retraining and adoption of good toileting routines.
• acute diarrhoea  is usually a  short lived problem for  1- 2 weeks. Often it is due to an infection with a virus or sometimes a bacteria.  There may be associated vomiting, and in some cases your child may have a temperature. It may have come on after contact with other affected people, after traveling or sometimes after food ingestion - food poisoning.  It is really important to keep well hydrated. Oral rehydration solutions such as Dioralyte can be carefully made up following the instructions. Aim to give small amounts often.  If you have concerns that your child is becoming too dehydrated then make sure to take them to a medical practitioner for an assessment. Stool testing  can sometimes be performed especially if a bacterial infection is suspected as occasionally antibiotics can be useful.
• chronic or prolonged diarrhoea - when diarrhoea lasts for longer than 2 weeks. This may be due to the consequences of an infection for example a temporary lactose intolerance, or may indicate an underlying condition that needs to be diagnosed such as coeliac disease or inflammatory bowel disease.
• feeding and swallowing problems - there are many reasons why a child may appear to have these.  More commonly it may be due to some fussy eating behaviour however sometimes an underlying condition such as gastro-oesophageal reflux can lead to problems because of the pain that comes on shortly after a feed or meal.  This can then lead to a baby or older child learning to avoid a feed or a meal in order to avoid the painful experience it brings on.  At other times there may be other causes of swallowing problems including allergy related inflammation of the oesophagus (foodpipe), or a narrowing of it brought on by the consequences of earlier undetected acid reflux.  Investigations carried out in a planned sequence can be useful to work out what's going on.
• reflux and vomiting - this is a very common symptom seen in all ages.  In babies it is usually due to reflux as they are more prone to it.  It can be quite a frequent occurrence, but often if there are no significant 'alarm' features present then simple modifications of milk or its consistency  can be tried first to reduce the symptoms before considering medications. Cows milk protein allergy can have a lot of overlap of symptoms with typical reflux.  Vomiting can be caused by multiple conditions including some that are not directly gut related and may be due to other body systems. For example a urine or kidney infection.  Taking a thorough history of the vomiting will help to work out the best way to approach investigating it further.

• Coeliac disease - is an autoimmune disease where the body's immune system is activated against one's own organs, in this case, the small intestine. It develops when those with a genetically susceptible background, eat gluten, found in wheat, barley and rye. Now thought to affect as many as 1 in 100 people. Abdominal pain, bloating and diarrhoea were the more classic combination of symptoms seen years ago.  The pattern of symptoms now is more varied and can include anaemia from iron deficiency, weight and growth issues, teeth problems, or occasionally there may be no symptoms at all and it is picked up incidentally during investigations.  It can be associated with other so-called autoimmune conditions including Type 1 Diabetes and thyroid problems.  If suspected it is best to keep on a normal diet containing gluten until all investigations have been completed and the diagnosis is confirmed.  The way we diagnose this condition in children differs somewhat from how our adult gastroenterology colleagues diagnose this in those over the age of 18. Recently the newest guidelines for paediatric coeliac disease have had some significant changes. See my post in the Much Ado About Poo Blog about these new guidelines here
• constipation - is one of the most common symptoms seen in any gastroenterology clinic. In the vast majority of cases, there is no underlying medical or surgical condition.  It can come on at various points in childhood, often at times of feed changes in an infant, weaning to solids, the time around potty training or in school-age children when there is often an element of stool withholding and refusal to use school toilets. It can develop into a vicious cycle that can make it last a very long time and needs to be treated carefully in the best possible way using a combination of laxatives alongside healthy habits around eating and toilet routines.
• Eosinophilic oesophagitis - an allergic condition affecting the food pipe (oesophagus) and how it functions.  It is a relatively recently recognised condition.  Allergy cells or Eosinophils, are found in the lining of the food pipe when usually they should not be present there.  When they release their contents they can cause troublesome symptoms such as swallowing problems and a feeling of food getting stuck, or can sometimes produce similar symptoms to gastro-oesophageal reflux yet not respond fully to standard reflux treatment.  An upper GI endoscopy or OGD is an essential test to diagnose and then monitor progress in this condition as biopsies are necessary to make the diagnosis.  
• food allergy - occurs when the immune system reacts to foods.  There are different types of food allergies with immediate (IgE) type food allergy with a rapid onset reaction to contact with a food eg peanut.  The other type of reaction is a slower non-IgE mediated reaction with a delay of several hours or more before symptoms start  
• Helicobacter Pylori - is a bacteria that is often acquired during childhood.  The bacteria can live in the stomach despite the harsh acidic conditions there. It can be found incidentally during testing such as endoscopy and may not always be the cause of symptoms.  However, it can also lead to symptoms such as abdominal pain, nausea and vomiting (sometimes with blood) as it is a major cause of stomach and intestinal ulcers. Treatment is with a combination of antibiotics and acid suppression medication.  
• Inflammatory bowel disease - there are two main types of IBD. Crohn's disease and Ulcerative colitis. They are both chronic (long term) conditions that affect the bowel.  In children, they can be more severe and extensive than in adults and require expert treatment ideally within a multidisciplinary team setting. Crohn's disease can affect anywhere from the mouth throughout the entire digestive symptom to the anus and surrounding area. It can cause a variety of GI symptoms including abdominal and perianal pain, diarrhoea, and weight loss. Ulcerative colitis predominantly affects the colon or large intestine only and to differing degrees of severity and length of colon involved.  

I often get asked about the different types of endoscopic procedures that can be used.  Here I'll explain them in a little more detail, as they can have several names that may add to any confusion. 

I'd also recommend that you have a look at how the digestive system works via the DK website about digestion.

The lining layers of each of the different areas of the digestive system appear very distinct during an endoscopy.

It is the characteristic innermost layers that an endoscopist must recognise during the procedure and know when abnormalities are present. 

What is endoscopy?

Simply put, an endoscopy is a medical test that lets an endoscopist have a  look inside the body.

An endoscope is a long thin floppy tube that has a camera at one end.  The camera sends pictures/video images to a High Definition monitor.

Ear nose and throat doctors may use nasendoscopy to look at the lining of the nose and areas of the throat. Lung specialists use special endoscopes called bronchoscopes to look inside the windpipe and some of its branches in the lungs.

Gastrointestinal (GI) Endoscopy is the general name given to camera tests that allow a thorough visual inspection of the stomach and intestines or bowel.  

During the procedure, it is possible to take samples of tissue known as biopsies from the innermost lining or 'mucosa' of the gut.  These are processed and then analysed under a microscope by a specially trained pathologist.

Other tests may be used to look at the remaining outer layers of the bowel wall, for example, X-rays and more recently, ultrasound or MRI scans are regularly used when looking for inflammatory changes in the wall of the small intestine or colon in those suspected or known to have Crohn's disease.

Paediatric endoscopy usually takes place under general anaesthetic, administered by a Consultant Paediatric Anaesthetist. This is one of several ways in which it differs from adult endoscopy.  In most cases, an adult gastroenterologist will administer sedation and local anaesthetic throat spray.

For more information about General Anaesthetics and Children,  please click here to take you to the Royal College of Anaesthetists website and resources related to this topic for parents, children and families. Other more general resources on anaesthesia are available here.

Another more obvious difference is that the equipment used for paediatric endoscopy although similar to that used in adult endoscopy, is smaller and adapted to the various sizes of infants and younger children.

Endosocopy can be divided into upper and lower GI endoscopy. In most cases it is performed for diagnostic purposes to aid in making a diagnosis of gastrointestinal conditions such as coeliac disease, or inflammatory bowel disease - this is so-called Diagnostic endoscopy.

Interventional or therapeutic endoscopy occurs when a treatment or therapy is used during the procedure, for example the removal of a polyp during a colonoscopy.

An Oesophago-gastro-duodenoscopy or 'OGD',  is also known an upper GI endoscopy or gastroscopy and  is used to look at the upper GI tract. This area of the digestive system  consists of the Oesophagus  (food-pipe), Gastric  (stomach) region and  Duodenum ( first part of the small intestine)

A colonoscopy is used when an investigation of the lower GI tract (colon) lining is necessary.  This may be useful in a variety of situations including chronic diarrhoea, rectal bleeding that is not thought to be due to constipation and straining, as well as suspected inflammatory bowel disease. Remember that the major functions of the colon are the recycling/reabsorption of water to produce a formed poo, whilst also transporting this poo towards the anorectal or exit region.

During the procedure if present, visible changes can be described and documented with high resolution pictures. For example, areas showing ulceration that may be due to infection or inflammation.  Normal appearances should also be noted as this helps to rule out certain conditions.  Any biopsies taken are processed and analysed, and usually the results become available within 1-2 weeks.

To see more of the small intestine  in detail, other types of small bowel endoscopy techniques may be used occasionally.

Video capsule endoscopy - when a pill containing a specialised camera  is either swallowed or inserted into the small bowel during an upper GI endoscopy in younger children unable to swallow the capsule - and a video of the small bowel is recorded. Thousands of images can be captured for later specialised analysis.  The lining can be inspected thoroughly and analysed  but no biospies  can be collected during this particular investigation. In some situations, a dummy run is performed first, to make sure the bowel is patent , with no significant narrowed areas that could lead to retention or hold up of the capsule. I think of it as window shopping - I can see the lining of the small bowel but can not take a sample or biospy for more detailed analysis.

This type of endoscopy can help to decide upon a diagnosis as certain characteristic changes can be   identified.  It may be used to decide that  another detailed endoscopic examination of the small bowel with the ability to take biopsies, using a specialised  double balloon enteroscope (a specific small bowel endocope),  may be necessary. Please have a look at this blog post for a beautiful image of the small bowel and the multiple villi that line its surface.

You may find watching the child friendly video about endoscopy together with your child useful in the run up to any procedures.

It is important to know from the outset that not all symptoms involving the digestive system need an endoscopy in children.  A common example is that of constipation, as this is thought to have no underlying inflammatory, mechanical or other cause in the vast majority of patients.

However, when certain symptoms arise and are thought to be due to a problem involving the lining layer of the digestive system, then an endoscopy becomes necessary. These are known as indications for endoscopy.

For example problems with swallowing, repeated vomiting, blood-stained vomiting, or concerns about growth, anaemia or abdominal pain due to a possible ulcer, would all be strong indications for performing an upper GI endoscopy. 

Some indications for colonoscopy (a lower GI endoscopy) include some cases of chronic diarrhoea, blood in poo on a regular basis and not thought to be due to constipation, suspicion of polyps or inflammatory bowel disease.

There is a recent European Guideline published on paediatric endoscopy and can be accessed here. 

As I deal with the bowel and its function on a daily basis, I'll happily explain how it all works when we meet in a clinic appointment and in the sections below.

However I realise that for many of us, myself included, Biology wasn't always a favourite subject at school, so I have been on the lookout for really handy websites and videos that explain it all in a clear and fun way.  

I'm a big fan of the DK books and this website about how the Digestive system works for children, by DK,  is really great.  

 Click here for the DK Digestion website.

Another website about the digestive system and problems that occur, aimed at older children and adults is here.

Hope you enjoy it!

Basic structure of the digestive system 

From the mouth all the way through the digestive system to the anus, there are  4 layers in the wall of the digestive system.  

They vary somewhat according to the region as different areas serve different purposes. The structure influences the function. 

For example the innermost lining layer or mucosa of the oesophagus or food pipe is very different to the lining of the stomach. 

The oesophagus needs to be able to withstand the transport of substances  of  various consistencies from liquid to solid, and of varying temperatures, during movement from the mouth to the stomach. 

The stomach on the other hand, acts a receiving and temporary storage organ.  It needs to be able to relax whilst receiving the food bolus from the oesophagus and then it needs to get to work on the food contents.  

It acts to churn or grind the food down into minute particles as well as pump out strong hydrochloric acid to aid and kickstart  the digestive process. At the same time, it must fight off and neutralise harmful bacteria or other bugs that may have entered the digestive system.  All of this whilst also being able to protect itself from the harsh acidic conditions.

The small intestine  has a huge surface area, as it is the major site of digestive processes and absorbtion of nutrients such as vitamins, minerals and fat, protein and carbohydrates.

The colon  is different again as it functions to transport waste material along it's length to the rectum, as well as acting to salvage and recycle water and some nutrients, so that the poo eventually passed is a firm rather than watery consistency.  

Without wishing to sound odd,  looking at a poo sample can tell me quite a lot about your digestive health and bowel function. 

What does your poo colour and consistency mean?

Have a look at my  Much Ado About Poo Blog Post on this topic for information about poo in babies and children. Also have a look at this excellent Poo-torial from Guts UK - a charity that funds research into all things Gastrointestinal and pancreas related. 

Feeling ready for a short challenge?  

Can you remember what you've already read about the digestive system and want to test yourself?  

Then try this short quiz by DK via this link

For those of you who want to know even more... where your digestive system is housed and what else is in your abdomen, then this is a great video for you.   

Be prepared it is a busy place!