Much Ado about Poo - A paediatric gastroenterologist's blog

Your child is having a colonoscopy...here's what you need to know about bowel preparation

Tue, 05 May 2026 00:40:44 GMT

Bowel preparation plays a key role in your child having a successful paediatric colonoscopy

The days before a paediatric colonoscopy is when you and your child can really have a positive impact on optimising the appearance of the bowel lining during the colonoscopy.

Why does your child need a colonoscopy

First let's recap how we got to the point of your child needing a colonoscopy.

Your child has been having tummy troubles for some time. In some it may be prolonged diarrhoea (usually for longer than the usual 2-3 weeks that can happen with an infection) and can be accompanied by abdominal pain, weight loss and tiredness.

In some children there may be visible blood or mucus seen with the looser stools.

You may be concerned that there symptoms are similar to those of a close relative with a bowel condition.

Your doctor has performed some non-invasive investigations, such as blood tests and stool (faeces or poo) tests, including a faecal calprotectin . This is a protein released by white cells called neutrophils, that accumulate in areas of inflammation.

The results have come back and shown the possibility of significant gut inflammation. They don't make a diagnosis, for this the next step is that they need a paediatric colonoscopy to investigate things further.

You've seen a paediatric gastroenterologist about this. They have assessed your child and their situation, reviewed the tests performed so far. They recommend proceeding with endoscopy, in this case including a paediatric colonoscopy. They have booked your child in for the procedure.

What happens in the colon

You may recall that the digestive system is, in very simple terms, essentially a long tube that stretches from the mouth, through the oesophagus and stomach and into the small and then large intestines and empties via the rectum. Each area plays a different role in the digestive process.

Nutrients are absorbed throughout the small intestine. The colon (or large intestine) is where the leftover waste matter is processed and turned into what we recognise as poo (stool or faeces).

How much poo is in the colon, and what consistency it is, depends on the type of food we eat, how much we eat, how fast or slow your bowel moves the contents along, how much water is absorbed as the residue travels along the colon amongst other factors including any medications being used.

What happens during a colonoscopy

During any colonoscopy, whether in an adult or a child, the adult or paediatric gastroenterologist or endoscopist, inserts a long flexible floppy tube that contains intricate technology within it, and that has a light and video camera at one end, into the large intestine via the rectum (back passage). The camera's images are transmitted to a large high definition monitor that is directly opposite the endoscopist.

Any paediatric endsocopist or gastroenterologist hopes that the patient has good bowel preparation. They want to get as clear a view of the lining (also known as the mucosa) of the colon as possible. This is so that they can observe and document, with photographs, any areas that look abnormal. They can also take samples of tissue, known as biopsies, from those areas for more detailed analysis.

The picture here shows a very heavy amount of poo residue obscuring the view of the lining of the colon. This makes it very hard for the specialist to distinguish any areas of linng whether normal or abnormal at all.

This prolongs the procedure substantially. In children, who have endoscopy performed whilst they are under general anaesthetic, this means more time spent under the influence of general anaesthetic. It also adds another layer of risk should any complication, for example perforation, although rare, occur.

Can't the doctor just get rid of the poo?

Whilst it is possible to use a water jet wash to clear some of the residue away (hover over the image with your mouse to see what I mean), with such a heavy amount of poo about, it adds a lot of time of the procedure. Poo residue also increases the risk of missing any pathology and can also mean cutting the procedure short, so an incomplete procedure.

What can parents and children do ahead of any colonoscopy?

You have a vital role. The time spent on preparing one's child or teen for a colonoscopy is well worth it, in terms of:

safety
getting the most information out of the procedure as possible
minimising the time spent asleep with general anaesthetic.

The days before a colonoscopy are crucial as they are when you and your child can have a very positive impact on bowel preparation, that is, optimising the appearance of the bowel lining during the colonoscopy.

What is bowel preparation

This is the important act of getting the colon ready for procedures such as paediatric colonoscopy, so that the colon is effectively cleansed and has minimal poo residue within it during the procedure.

There are two phases to bowel preparation:

1st phase - Dietary changes

Your doctor and their team will give you specific instructions about modifying your child's diet in the 2-3 days before the procedure.

The advice is to:

avoid eating high fibre foods
then switch to diet that has only low residue foods.

This is all with the aim of having far less poo residue left in the colon before the procedure than one would have when on a normal fibre and normal residue diet.

Your team will provide you with a list of suitable foods so that you can prepare ahead of the procedure. It is important to prepare your child to understand that their diet will be different for a few days, to make it easier to see inside the colon properly.

2nd phase - Strong laxatives the day before colonoscopy

The day before a paediatric colonoscopy, your child or teen will need to drink some very strong laxatives. These aren't available over the counter. They are often prescribed by the doctor you met in a clinic, sent out by the endoscopy unit where the procedure will take place, or a prescription may be posted to you.

In the UK there are a variety of laxatives used. In children we commonly use laxatives that increase the water content of the stools making them a lot looser. They also cause the bowel to contract to push the poo out. Different brands exist such as Picolax, Moviprep etc. Sometimes combinations of common laxatives are used.

They may be specially adapted to lower doses for smaller children.

It is important to closely follow the instructions sent to you including the amount to give your child and also the timing of when to give the laxatives.

Often 2 doses are given several hours apart on the day before the colonoscopy.

Over the course of the 24 hours before the procedure your child will experience the need to urgently get to the toilet, and the stools may become very watery, to the point where it can be difficult to keep control of the bowels. Sometimes accidents or leaks can happen. This is not your child's fault.

To make the experience as comfortable as possible, it is best to stay off school, nursery or college the day before the colonoscopy whilst taking these laxatives.

Top tips for bowel preparation in children having a colonoscopy

Prepare your child ahead of any procedures - talk them through what is going to happen using age appropriate terms. Your doctor will often have done this in clinic and can provide age appropriate resources to read through or links to videos to watch.

Plenty are also available on the web.

Knowing what is ahead is usually better than springing a surprise and not being prepped.

Shop ahead for fun low residue foods

Have a good look at the list of allowed low residue foods sent to you by your doctor. Discuss these with your child and see what they would like from them. Have them all ready so that you're all set for the days before the procedure.

Let school and your work know

Tell your child's school that they will miss school the day before and the day of the colonoscopy procedure. Let your family and work colleagues know that you will be needed by your child on those days.

The day before the colonoscopy and taking the Bowel prep laxatives

Make sure your prescription is available at your local pharmacy and picked up well ahead of the procedure - avoid any last minute panic hunting for a pharmacy that supplies the medicine. Have this all ready at home days before the procedure.

Stay at home the day before procedure - so much more comfortable for all involved

Follow the instructions on how to make the prep medicine and use these tips when using it

Let it get cold - the colder the better. Often these medicines generate heat when made up
Flavour it with an allowable and child-friendly taste - a cordial for example
Use a straw
Drink plenty of water - especially in younger children, but in all ages it is important to keep your child hydrated
Plan to be close to a toilet . Few things are more distressing than getting caught short when out and about. Having a familiar bathroom and toilet nearby makes for a far more pleasant experience. One of the benefits of being at home for this if age allows.
You or your child should have a good look at what consistency of poo is coming out - the nurses or doctors will want to know if the bowel preparation has worked well enough. Ideally the poo should be very watery (almost like wee -or type 7 on the Bristol stool chart) with just bits in it. If it hasn't turned that watery or there is a doubt, the team may prescribe a rectal laxative called an enema to get a final clear out of any residue so that the colon is cleansed thoroughly ahead of any colonoscopy
Follow the fasting instructions that your team has sent you. It is important when having an anaesthetic that these are followed closely to minimise any risk of stomach contents coming up and then going down the windpipe whilst asleep (known as aspiration)

If you're in any doubt or have any questions about any of this process ahead of your child's colonoscopy, then please ask your doctor or the endoscopy team.

Remember that we all want to get the most information, in the safest possible way, from any paediatric colonoscopy. So getting bowel preparation right is a crucial role that you and your child have.

For more information about tests including paediatric endoscopy click here .

If you are concerned about tummy troubles that your child has, and you think they need an evaluation with an experienced paediatric gastroenterologist, then please do be in touch by emailing us

Wishing you and your child all the best with getting ready for their colonoscopy.

Dr Crespi

Constipation in children and poo accidents

dancrespi1976@gmail.com (Daniel Crespi) — Sun, 01 Mar 2020 02:48:44 GMT

Constipation in children - A guide to the most common reason for poo accidents

Constipation in children is a very common situation that I come across in my Kids Gastro Care clinics.

The research literature often quotes a stat that up to 25 % of visits to a paediatric gastroenterologist are about constipation. Here I will discuss in some more detail, just one particular aspect of constipation in children, that of faecal incontinence or poo accidents. It is commonly associated with faecal impaction.

For more on the diagnosis and management of constipation in children please click here.

Being a 'poo doctor' I have become very used to talking about all aspects of bowel function and poo every day - just ask my kids!

This isn't always the case for many others. There is still a great deal of stigma attached to poo problems in children and adults of all ages. One such area is around Poo accidents in children. Also called soiling, encopresis and faecal incontinence, it is not often the first thing that families talk about when I meet them in my clinics. In fact it may only come up when I directly ask about them.

Poo accidents can be a tremendous source of upset, embarrassment, as well as social awkwardness, isolation and shame. They can leave parents frustrated at times as it is difficult to understand how their child can not seem to control their bowel motions. Sometimes children are told that they're being lazy and it can be easy to blame the child for the situation.

I have seen children who needed upward of 8 changes of underwear and clothes a day because of poo accidents. Schools often send children home when these accidents occur. What should be fun childhood social activities such as swimming and sleep overs are limited or even stopped all together for fear of the dreaded accident happening.

In the majority of children with poo accidents, the most common reason for this to occur is constipation.

In some there is no significant constipation. I won't go into detail about that situation here in this post, as other aspects of care, often with a psychological emphasis, need to be addressed in greater detail.

When there is a significant build up of poo within the large intestine (colon) or 'poo factory' as I call it, this is known as faecal impaction . Often the build up occurs in the very last section of the colon called the rectum - a sort of holding area for poo before it is passed out of the body. The impacted faeces sits in the colon and builds up gradually over time becoming more and more firm. Newer poo can sometimes slide past this mass of older poo, and slip out unannounced, as an accident. Sometimes this can be mistaken for diarrhoea.

The rectum becomes more and more stretched over time. The usually sensitive rectum, loses its ability to sense being filled up with new poo as it has been stretched beyond its usual dimensions. Accidents can occur at any time, often seemingly without the child even noticing.

To add to an already difficult situation, and because of the close location of the stretched rectum to the bladder, wee accidents can also become a part of the problem.

Often this situation isn't recognised for what it is until late in the journey. A crucial early step is understanding what has happened and explaining how it has developed, using a non-judgemental, no blame approach. This combined with the right type of laxative treatment then aims to clear out - or disimpact - the old mass of poo that's been sitting there probably for some time.

Occasionally, a special type of x ray of the tummy, a so called shape study (colonic transit study) may be used to help clarify the situation and visually demonstrate the build up of poo. The X ray picture at the top of this blog post, shows an accumulation of shapes in a mass of faeces in the pelvis,. This is in the last part of the colon with a stretched rectum. Other parts of the colon are also loaded with poo. The sensation of needing to go is weakened by this stretch of the rectum and so accidents occur regularly.

The good news is that often dramatic improvements can be made when the situation is recognised and then managed appropriately with disimpaction . I have seen children go from having multiple accidents each day to none overnight, with a simple intervention using laxatives to clear out the impacted rectum .

Disimpaction can either involve taking several days of oral laxatives in increasing amounts , or as an alternative more direct way, using 2 or 3 days of laxatives administered rectally - using enemas. Occasionally a combined approach is useful. Once this crucial first step has taken place, then a regular schedule of laxatives is needed to keep the colon clear and prevent a further build up.

I really feel it's time to break down these taboos around poo and get this issue more widely recognised and then treated properly. Talking about poo with a fun down to earth approach is a start. It is only poo after all...

If you think your child may be experiencing issues similar to those I have mentioned in this post, please do have a look at the Kids Gastro Care website for more information about constipation in children . If they're having troubles with their bowel control and you'd like to discuss things in more detail in an appointment with me, then please don't hesitate to be in touch and give us a call .

The ERIC website , run by ERIC -the Childrens Bowel and bladder charity- is a fantastic resource for families affected by these issues. Please do help support their amazing work if you can by making a donation. I recently posted about this on our Facebook page with a request for donations for ERIC.

Paediatric endoscopy - the view from the inside and a moment to reflect

dancrespi1976@gmail.com (Daniel Crespi) — Wed, 05 Feb 2020 02:30:52 GMT

The small bowel, digestion, and a moment to reflect

Every so often during my weekly paediatric endoscopy list, a striking image comes up on the screen, that makes me stop and reflect on the wonders of the human body.

Here you can see a healthy-looking duodenum, from a recent paediatric endoscopy of the upper Gastrointestinal (GI) tract. This type of diagnostic endoscopy is also known as an Oesophago-gastro-duodenoscopy (OGD for short) or Gastroscopy.

The duodenum, the first, and shortest part of the small intestine, derives its name from the Latin word duodeni. This refers to its length being approximately 12 finger-breadths.

Partially digested stomach contents, in an acidic semi-fluid mass known as chyme, leave the stomach via the pylorus and enter the duodenum. Here further digestive processes take place.

To help get your bearings with the image here, I'll explain a little more about some of the terminology and jargon used by an endoscopist. The central cavity of any hollow tube within the body is knows as its lumen. Having a good clear view of the lumen is essential during endoscopic procedures such as an OGD or colonoscopy. When trying to describe where a specific or noticeable feature or point of interest is during a procedure, and for ease of reference, endoscopists tend to compare the lumen of the bowel to a clock face.

The protrusion visible at the 9 o'clock position, is the duodenal papilla. This is an important landmark seen during endoscopic procedures involving the upper gastrointestinal tract such as an OGD or ERCP. The latter is a specialised type of endoscopy used to look at the gall bladder, pancreas and their associated pipework (or ducts to be more formal).

Digestive juices from the gallbladder and the pancreas are transported downstream via these sophisticated pipes (ducts) to just behind or upstream of the papilla. They are mixed together, then squirted through the papilla, into the lumen of the duodenum, to mix with the chyme and help with digestion. These digestive juices contain:

- Bile salts that help emulsify fat

- Pancreas enzymes to help digest food

- Bicarbonate to neutralise the acidity of the chyme and protect the lining of the small intestine from acid damage.

Anyone who has experienced the pain brought on by a gallstone lodged in some of the ducts draining the gallbladder or pancreas, can testify to the fact that it is almost impossible to stand during such an episode. Although less common in children, gallstones can occur and are associated with bowel conditions such as Crohn's disease.

I couldn't help but think how fitting are the words of the blessing for good health "Asher Yatzar". "Blessed... who has formed man with wisdom and created within him many openings and hollow spaces. It is obvious and known before Your Seat of Honor, that if even one of them would be opened, or one of them would be sealed, it would be impossible [to survive and] to stand before You.”

This is recited at times most of us take for granted, after going to the loo for a wee or a poo for example. There was just something about this image that made me recognise the importance of being grateful for simple things, such as all our pipes and tubes being in good working order.

For more about common topics related to paediatric gastroenterology, digestion and endoscopy click here .

And if you would like to meet to discuss a digestive problem your child has, please don't hesitate to be in touch by calling us or sending us an email .

Poo in children and babies: A simple guide for parents to normal and abnormal poo patterns in kids

Sun, 03 Nov 2019 04:28:46 GMT

What's in a stool sample?

Poo...it comes out of all of our kids and us (and if it doesn't you should come and see me!) but it can vary so much in its consistency and appearance.

What is normal, what gives it its colour (or colours) and what do the different consistencies mean?

As a paediatric gastroenterologist it has become so normal for me to openly discuss poo with my patients and families, that I can sometimes forget (until my kids remind me!) that for some it is still an awkward topic to discuss.

When I asked some parent's recently what topics they would like to know more about with regard to their children's digestive health, some of the replies were about poo and its consistency and colour.

So I've put together a simple guide about what is and what isn't normal poo in babies and children for parents. It covers the basics and is not exhaustive in its approach. Always remember though that if you have concerns about your child, you should seek medical attention regardless of what you read below, as this is only meant to be a helpful basic guide to this topic.

WARNING!!:

Be prepared for a few food related references when it comes to descriptions...seems to be the way with us medics.

Poo frequency -How often should my child poo?

In the beginning...

Most babies born at term will pass their first poo or Meconium (a thick dark tar like) poo within the first 48 hours of life. Delays greater than 48 hours may be a sign of a problem such as Hirschsprung's disease where the bowel's nervous system hasn't developed fully leading to a bowel obstruction. There may be other symptoms including a swollen or distended belly, green/bile stained vomiting and even blood-stained diarrhoea. Feeding may be off and there may also be concerns about growth. Occasionally it presents later in life with really difficult to treat constipation in an older child.

As a rough guide....

Breast fed babies can poo as often as with every breast feed or just once a week! The consistency and colour is often described as mustard-like with seeds.

Formula fed infants generally poo less often than their breast fed compatriots and the consistency is a little firmer, more peanut-butter like ( I did warn you...!)

As children get older, their bowel habits and frequency of pooing is similar to adults. Even we (adults) can vary widely with our bowel habits, from 3 times a week to 3 times a day! This often comes as a surprise to families when I mention this in clinic.

An important point to note is that constipation is not defined only by the frequency or infrequency of bowel movements. Other symptoms such as pain, straining, accidental leakage, signs of stool witholding all need to be considered as well. The bowel habits of your child will change over time and in the first year of life may change in the first few months, with milk changes or when moving over to solid foods.

The whole picture of your child and their health, including growth patterns, needs to be considered rather than just one aspect when assessing bowel function.

Poo colour - What colour should my child's Poo be ?

The colour of poo is influenced by what we eat but is mostly derived from pigments. These organic pigments (bilins) come from the breakdown of the haem protein found within red blood cells as they get recycled towards the end of their lifespan. The pigments include biliverdin and bilirubin (the pigment that causes jaundice) and eventually end up as stercobilin. Now from the distant memory of a non-linguist verde means green and sterco refers to droppings or dung!

What are normal poo colours?

Generally anything green and various shades of brown are normal.

Just a note about Yellow poo - if poo appears excessively fatty, is difficult to flush away and quite stinky, then this may indicate a problem with fat maldigestion/absorption and should be evaluated.

Colours to be concerned about include :

Red or black

These colours may indicate bleeding from the gastrointestinal tract.

Bright red blood usually indicates fresh bleeding from a source closer to the exit or even just around the exit - a small fissure or tear in the skin around the bottom after a hard poo has been passed for example is a common cause.

Black stools can indicate blood that has had time to be digested by gut enzymes, so usually the source of bleeding is higher up the digestive tract. The poo passed is known as melaena and often has a tar-like appearance with a characteristic smell. It should always be evaluated thoroughly by a specialist.

This is unless of course you've recently had red food colouring / beetroot or are taking iron tablets (cause poo to turn black) etc. If your bowel habit is a little on the infrequent side, it can come as quite a surprise to see red/purple coloured toilet water/poo a couple of days after eating beetroot !

White or Clay

The other colour or lack of colour I should say, to cause concern, is when the stools are very pale and have a white or clay like appearance -this can indicate that the bile pigments produced in the liver aren't passing through the bile pipework easily. They can't reach the gut so the stool produced has no colour.

An example of this may be in a newborn infant who develops jaundice after a few days and that doesn't fade away. Prolonged jaundice in a newborn (for two weeks in a term baby or 3 weeks in a baby born prematurely) and in whom the poo is very pale...needs to be evaluated thoroughly as this may indicate a condition known as biliary atresia . This needs to be promptly diagnosed and treated.

That's why part of the clinical examination of a jaundiced baby should ALWAYS include having a look at a poo sample.

Poo consistency - How hard or soft should my child's poo be ?

Poo consistency reflects the time spent travelling through the large intestine or colon. One of the main functions of this organ is to reabsorb water from faeces, so that the final poo passed is solid and smooth.

Poo researchers have studied the effect of bowel transit time on the consistency of poo and have produced charts such as the Bristol stool chart. This has 7 different stool consistencies 1 to 7. I even walk around with one in my clinic !! I find that it is sometimes a lot easier to use a chart when asking for a description of poo, than relying on words. It can also often make for a light hearted-moment in clinic.

The longer a poo resides in the bowel before exit, the more water is absorbed from it leaving harder type 1, 2 or 3 stool consistency. Poo that leaves the bowel in a hurry is more type 6 or 7.

Ideally we should see type 4 (a smooth slippery sausage like poo) being passed.

Bowel diary and poo charts

As a busy parent, I can't accurately know all of my family's bowel habits! I imagine this may be the case with a fair few other parents as well. Collecting this type of information along with stool consistency can be really useful to look at together in clinic, and so I will often recommend this 'homework' exercise be used. There are various bowel diaries available but one really fun one is here.

For more information about poo please have a look at this excellent poo-torial from Guts UK , a charity that funds research into all things Gastrointestinal including the pancreas.

I f you have worries or concerns about your child's poo or other tummy troubles :

Please don't hesitate to be in touch. If you're looking to discuss things further or want to arrange to have a thorough paediatric gastroenterology assessment then please have a look at the main website for more information regarding Kids Gastro Care clinics and how to book an appointment with me.

Feedback about this post or other KGC output (for want of a better word!)

Feel free to leave a comment here, or via the Kids Gastro Care Facebook page or send me an email here .

As a newbie at this (blogging not paeds gastro!) I would love to have your feedback about this article or other posts on the blog, the website or Facebook page.

How to diagnose coeliac disease in children by a paediatric gastroenterologist

Wed, 25 Sep 2019 02:46:30 GMT

How to diagnose coeliac disease in children

Hot off the press, in fact just published online ahead of print, are the latest European guidelines on how to diagnose coeliac disease in children - to see a draft version click here .

Now you may have already known from my previous posts here in the Much Ado about Poo Blog , and on the Kids Gastro Care F acebook page that Coeliac disease is fairly common and thought to affect 1 in 100 people. The mainstay of treatment remains total and life-long exclusion of gluten from the diet.

When and how does Coeliac disease present ?

Coeliac disease can affect anyone of any age provided that gluten has already been introduced into the diet. However, despite it being so common, it is still under diagnosed, possibly because of the many different ways it can show manifest.

From being asymptomatic (no symptoms to speak of) to a variety of gastro-related symptoms including

tummy ache
change in bowel habits (constipation or more often loose stools)
abdominal bloating
loss of appetite
vomiting
weight loss
A negative effect on growth, children may not be growing as tall as expected for parental heights
or they may not pass through the stages of puberty as expected.

It can also affect other bodily systems including

the skin with dermatitis herpetiformis
the bones with relatively easily sustained fractures
the blood system with difficult to treat anaemia.
The liver may show changes (on liver related blood tests)
very rarely the brain can be involved
In women of childbearing age it can also be a cause of fertility related issues.

How does a paediatric gastroenterologist diagnose coeliac disease

The way coeliac disease is diagnosed in adults involves a combination of clinical history and examination, blood tests and endoscopy with biopsy samples from the small bowel. It is imperative to remain on gluten throughout the diagnostic process until it is complete as otherwise these tests are not accurate and there can be diagnostic confusion. See the brilliant Coeliac UK website for more details about this here.

Until recently coeliac disease was diagnosed in a very similar fashion in children as well, that is to say a combination of symptoms, positive blood tests and gut biopsies obtained during an upper GI endoscopy.

In children it is important to remember that all endoscopy should ideally be carried out by paediatric gastroenterologists and the procedure is performed under general anaesthetic rather than the sedation used in adults. This has become the accepted standard of care for paediatric endoscopy and is how I do things at Kids Gastro Care . For more about children's endoscopy please have a look at the useful resources page on the Kids Gastro Care (KGC) website where you can find a child friendly video discussing this.

Blood tests

The blood tests involved measure an IgA antibody to an enzyme called Tissue Transglutaminase or tTG-IgA test for short. Alongside this test one should also always test for a blood protein called Immunoglobulin A (IgA) as deficiency in this protein can lead to so called false negative results when measuring tTG. Other blood tests are also used to confirm a diagnosis including endomyseal antibody (EMA) and in the last few years a genetic marker test that looks at specific markers known as Human leucocyte antigens or HLA DQ2 and DQ8 has also been used.

Now the TTG blood test is a highly specific and sensitive test, so that when negative it is pretty good at ruling out coeliac disease. If there is also IgA deficiency as well, the test is much harder to interpret accurately. When positive it is a pretty good indicator that something is up in the small bowel, the most likely cause being coeliac disease.

The gut biopsies

The biopsies are small samples of tissue taken from the innermost layer or lining (mucosa) of the small intestine. The first part of the small intestine or duodenum is where most biopsies are taken from.

Now if I can take you back to Biology lessons of distant memory, the small intestine is the major site of absorbtion of nutrients in the body. Damage to this highly specialised absorbtive area leads to loss of the villi or finger like projections where absorbtion takes place and throws the body into a state of malabsorbtion and development of symptoms of pain, diarrhoea, weight loss etc.

To reach the small bowel to obtain these biopsies, an upper GI endoscopy or camera test is necessary

( see here for more detail )

How was coeliac disease diagnosed in children before the tTG blood test was available...

Pre-dating the development of the blood test that measures the levels of antibody to Tissue transglutaminase (tTG) in those children in whom coeliac disease was suspected biopsies were essential. So going back to the 1970s, children would undergo a series of 3 endoscopic procedures with accompanying gut biopsies.

- the first would be to demonstrate the damage and changes in the small bowel associated with coeliac disease whilst on a normal (gluten containing diet),

- the second to show the recovery of the small intestinal mucosa or lining once placed on a gluten free diet for period of time

- and then the third to show the damage sustained when the child was challenged again with gluten to 'prove' the offending trigger was gluten. OUCH! or OUCH X 3!!!

So whats new Doc?

Since the introduction of the TTG blood test, the process for the diagnosis of coeliac disease changed dramatically.

If a child was suspected of having coeliac disease because of symptoms, a family history, or other blood test findings such as persistent iron deficiency anaemia, they would have a blood test to screen for it. The test would measure tTG and if they had a positive result they would then always go on to have an upper GI endoscopy and a set of biopsies whilst on a gluten containing diet, to show the damage sustained by the small bowel to confirm the diagnosis.

2012... a move away from blood tests and biopsy for all

In children, until 2012 the same methods as described above, were used to diagnose coeliac disease in all children. That is to say in all children, blood tests and biopsies from the small bowel collected during upper GI endoscopy were needed. For more information about these procedures see the Useful resources page on the Kids Gastro Care website here

In 2012, this all changed. Given that the tTG test is such a good test for coeliac disease, in select cases it was deemed possible to diagnose the condition without need to resort to endoscopy and biopsy. The higher the result of the tTG test, the greater the certainty of coeliac disease changes to be found at upper GI endoscopy.

The no-biopsy approach from 2012 for some not all

The criteria to fall into this group of patients included a child with symptoms consistent with coeliac disease alongside a strongly positive tTG result, more precisely if it was more than ten times the upper limit of normal for the laboratory in which it was being measured. So in the Lab at the Royal Free Hospital London where I have my clinics and endoscopy lists, if it was more than 60, in combination with compatible symptoms and as well as the 2 other blood tests mentioned earlier (EMA and HLA tests) being positive, then that combination would be enough to diagnose coeliac disease.

This approach, a non-biopsy approach, was suggested only in this specific subset of paediatric patients fulfilling these criteria and also if the family are happy to go along with it. In all other cases, for example, no convincing symptoms, an associated condition such as Type 1 diabetes and a high tTG, a weakly positive tTG result, or at family request, then all those children would still need a biopsy.

In adult gastroenterology, this no biopsy approach has not been adopted (yet ?? ) and is a controversial area.

Fast forward to 2019..more changes ahead

And now we are entering another new era in the diagnostic pathway for coeliac disease in children. This latest guideline from ESPGHAN, is now advocating a Biopsy avoidance approach in a much wider group of children.

The inclusion criteria has expanded greatly. So from now on, this would apply not only for children with obvious symptoms and strongly positive tTG blood test results but even in those with no symptoms at all and a strongly positive tTG result. The guidelines also remove the need for testing for HLA DQ2 or HLA DQ 8 markers.

So to summarise these latest developments:

if a child is suspected of having coeliac disease for whatever reason (symptoms or no symptoms etc) then they may be able to avoid having an upper GI endoscopy and small bowel biopsies if they have a combination of a strongly positive blood test result for tTG along with a positive EMA result on a second blood test sample.

Pitfalls in diagnosis of coeliac disease

I can not emphasise these points enough as from my experience of hundreds of cases they are still not always considered when referrals are made.

1) Prematurely removing or significantly reducing gluten intake before a confirmed diagnosis

When gluten is removed from the diet prematurely before the diagnostic process is complete it can often lead to confusion around a diagnosis. The child is then subjected to a gluten challenge or reintroduction of gluten in order to complete the diagnostic process more accurately.

It is essential that there has been enough gluten in the diet and for a sufficient length of time prior to testing so that the blood tests can be reliably interpreted. If in doubt a paediatric dietician can help review your child's diet to ascertain if sufficient gluten has been ingested.

2) Forgetting to measure Total IgA at time of other tests

Other causes of confusion include having IgA deficiency. This is a fairly common from of immune system deficiency especially in the Caucasian population. Approximately 1 in 600 people generally are affected and it is even more common in those with coeliac disease.

See the information leafle t from the primary immunodeficiency UK charity here for more information about selective IgA deficiency. In such a situation the standard tTG test becomes unreliable as it depends on there being enough IgA around.

What does a paediatric gastroenterologist do ? Specialist involvement in diagnosing coeliac disease

Being a specialist in the field I'm aware of these latest guideline developments at an early stage.

As with previous changes to disease specific and specialty guidelines, awareness of this new route to diagnosis will gradually increase over time among family doctors and my colleagues in general paediatrics. The guidelines suggest that diagnosis is made by a paediatric gastroenterologist. All of these points will be covered during a consultation with a specialist in paediatric gastroenterology , and as with all my consultations, shared decision making conversations are held with you and your child to work out the best next steps around managing the situation.

Should you find yourself in a scenario where coeliac disease is being suspected please make your doctor aware of these new guidelines and also ask for a referral to a paediatric gastroenterologist.

Into the depths of the bowel

dancrespi1976@gmail.com (Daniel Crespi) — Tue, 30 Jul 2019 00:01:50 GMT

Into the depths with Double Balloon Enteroscopy

Every so often, I feel a sense of awe whilst at work. I came across this view during a specialised type of endoscopy (Double Balloon Enteroscopy or DBE) performed by a colleague, and I had that feeling again. Seeing a moving carpet of villi, the tiny finger like projections that coat the inner lining or mucosa of the small intestine in such detail, brought home to me the incredible workings of the human body, and how fortunate I am to be able to see this on a regular basis. Thousands upon thousands of these amazing structures help to hugely increase the surface area available for absorption of essential nutrients. including iron and vitamins.

The small bowel can be affected by a variety of conditions that inflict damage to the villi. This impairs their ability to function so that one is at risk of malabsorption. Examples include Coeliac disease and Crohn's disease. Sometimes suspicion of the likely nature of the disease and it's involvement of the small intestine isn't enough. This is especially true when considering the use of potent medications that suppress the immune system, with the aim of healing the damaged areas. Having actual visual and biopsy proven evidence of involvement of this section of the GI tract can be crucial in deciding on the next steps in managing a condition.

With most of its length, aside from the first and last few centimetres, being beyond the reach of standard upper and lower Gastrointestinal (GI) endoscopy, the small bowel has always been harder to investigate. Imaging using Barium with x rays is now rarely if ever used as other radiological techniques are available and also to avoid excessive radiation exposure especially in children. MRI of the small intestine gives a huge amount of information not only about the small bowel but also surrounding areas and organs. It is used in both children and adults. Ultrasound of the small intestine, in the right hands, can also give very useful information about the state of the small bowel particularly with regard to whether it is affected by inflammation in Crohn's disease. It is particularly useful in children as it avoids the sometimes claustrophobic feeling some can feel when in an MRI scanner as well as being faster and cheaper.

Using Double Balloon Enteroscopy or DBE, it is possible to inspect the entire length of the lining of the small intestine. It allows the endoscopist to reach a lot further than a standard upper GI endoscopy or OGD does. The same is true of video capsule endoscopy (VCE), the miniaturised video camera within a swallowed pill, that takes thousands of images of the small intestine as it moves along it.

In very simple terms, I think of the VCE as a reconnaissance of the area, scouting for anything abnormal. A form of window shopping, when I can only see the area of interest, however I can't sample what I see.

With DBE one can both see and sample the lining with a biopsy and in some cases therapeutic techniques can be used. The VCE is often used as a screening investigation and then if needed, one can literally examine the depths of the small bowel with the DBE to obtain samples of tissue for examination under a microscope.

The two techniques complement one another and along with other investigations, when put together like a jigsaw, help build up the bigger picture. Both techniques have their pros and cons of course and these are always discussed in detail before they are used. Carefully selecting the right test for the right patient is part of the challenge so as not to lead to any harm that could have been avoided. For more information and child friendly videos on endoscopy, have a look at the Useful resources page of the website.

Launch of the Latest IBD Standards of care by IBD UK

Mon, 24 Jun 2019 22:01:02 GMT

The latest Standards for care for those with IBD

Crohn's disease and ulcerative colitis - the main Inflammatory bowel diseases are chronic illnesses that affect the gut. They have a waxing and waning natural history with periods of remission punctuated by flare episodes when the inflammatory process cascades into a relapse of the illness. An often quoted stat is that up to 25% of IBD affects young people and children. Whilst there is some overlap between adult and paediatric IBD, there are also some significant differences. Generally paediatric IBD is more extensive and more severe.

National audits of care for those with IBD showed significant variation in care. This led to the publication of the original IBD standards in 2009. The recently updated IBD standards have recently been published. They are the product of collaboration between 17 patient and professional organisations that deal with inflammatory bowel disease. Much has improved since the original standards were published, and this updated version of the standards aims to continue that improvement.

They set out to ensure that "those with IBD receive safe, consistent, high quality personalised care"

Included within the standards are sections for every part of the journey for someone with IBD . They highlight what an IBD team and service should consist of. They give advice on referral pathways and timelines for action to help reduce unnecessary delays in reaching a diagnosis. Management of the condition is also covered both for inpatients as well as outpatients. There are sections on disease flare management with a strong emphasis to encourage self-management by the patient as part of the initial stage. Good, clear and timely communication between primary, secondary and tertiary care is another essential. Areas where further improvement are needed include increasing the availability of psychological support and the speed of response to a disease flare up.

It's bound to be another step forward to achieving the aims of consistent high quality care whatever the age and wherever the patient is. Copy the link below to have a look.

https://ibduk.org/ibd-standards

Constipation in the news..people talking about poo

dancrespi1976@gmail.com (Daniel Crespi) — Thu, 06 Jun 2019 08:05:56 GMT

Breaking the poo taboo down

Good article on the BBC website discussing some research from King's College London. We talk about constipation in the paediatric gastro and nurse -led constipation clinics but are we actually talking about the same thing that patients are when we discuss it. Patients and their doctors and nurses should all be on the same page when it comes to defining what constipation is.

As a 'poo' doctor I make no apologies for getting into the nitty gritty detail about bowel habits in consultations to make sure I get a good understanding of the situation from the patient perspective. It's only poo after all. Breaking down the taboo further. A good read for all of us.

https://www.bbc.co.uk/news/health-48528058

You gotta start somewhere...go with your gut feeling

dancrespi1976@gmail.com (Daniel Crespi) — Thu, 30 May 2019 21:28:51 GMT

Mind Gut connections - Going with your gut feeling

It's a phrase one often hears.. 'follow your gut feeling' but what is that all about? Intuition or 'gut feeling' is something we all feel at different times. Some researchers from Florida State University have found that gut feelings are part of a protective system helping us to avoid running into trouble. Powerful gut to brain signals have a significant effect on our emotions and decisions. This is something I often talk about with patients...how the gut and brain are hard wired to one another and constantly communicating. It's a fascinating area with lots of research going on. This so called gut-brain axis has a significant role to play in many symptoms and conditions that are commonly seen in a gastroenterology clinic and offers another angle when it comes to formulating a treatment strategy.

You can read more about it in the article published in the journal Physiology in 2018 authors L Rinaman and J Maniscalco. More on this in future posts.

Neurogastroenterology in London April 2019

dancrespi1976@gmail.com (Daniel Crespi) — Thu, 30 May 2019 21:27:39 GMT

Neurogastroenterology...our guts and our brains are hardwired to 'talk' to one another

A fantastic 2 day course run by the team at the Royal London Hospital. It covered all aspects of Neurogastroenterology. Studies show that a large number of GI outpatient consultations revolve around conditions within this subspecialty of gastroenterology. Understanding the mechanisms behind the development of these conditions allows for a more personalised treatment plan incorporating a biopsychosocial approach. (Image from D.A Drossman, Rome III (3) process , Rome Foundation).