Understanding gastrointestinal motility studies in pediatrics.

Motility of the gut is affected by the nervous system, the endocrine system, smooth muscle cells, interstitial cells of Cajal, secretory mucosal cells, the immune system, and gut flora. Abnormal gastrointestinal motility can generate nonspecific symptom complaints that are refractory to standard treatment approaches. It is important to exclude anatomical obstruction or other causes for patients' symptoms prior to proceeding with motility evaluation. Motility studies that help to evaluate children with suspected motility problems include combined multichannel intraluminal impedance (MII) and pH recording, esophageal manometry, gastric emptying scinitigraphy, antroduodenal manometry, colonic manometry, and anorectal manometry. Many pediatric gastrointestinal motility evaluations should be completed in a pediatric motility center where specialized training is completed by physicians in this field. Indications for pediatric gastrointestinal motility studies and how the procedures are performed are addressed in this paper.

Assessment and management of pediatric constipation for the primary care clinician.

Constipation is a common problem in pediatrics and accounts for 3-5% of all pediatric office visits and 10-25% of all pediatric gastroenterology referrals. Functional constipation accounts for about 95% of constipation cases, but "red flag" symptoms that suggest organic causes need to be considered. A diagnosis of functional constipation can be made in absence of "red flag" symptoms and a normal physical assessment. Physical assessment should focus on growth, abdominal exam, inspection of the perianal region, and examination of the lumbosacral region. Abdominal x-rays are generally not useful to differentiate between functional and organic causes of constipation. Treatment of constipation includes dietary changes, medication use, and behavioral modification. Osmotic laxatives are used as first-line treatment, and stimulant laxatives can be added if there is no improvement with osmotic laxatives. Despite improvement with laxatives, 40-50% of children with constipation experience at least 1 relapse in 5 years. Quality improvement opportunities exist for improving care of children with functional constipation by specialists partnering with primary care.

Reducing hospital admissions of healthy children with functional constipation: a quality initiative.

Functional constipation (FC) is a common medical problem in children, with minimal risk of long-term complications. We determined that a large number of children were being admitted to our children's hospital for FC in which there was no neurological or anatomical cause. Our hospital experienced a patient complication in which a patient died after inpatient treatment of FC. Subsequently, we developed a standardised approach to determine when paediatric patients needed hospitalisation for FC, as well as to develop a regimented outpatient therapeutic approach for such children to prevent hospitalisation. Our quality improvement initiative resulted in a large decrease in the number of children with FC admitted into the hospital as well as a decrease in the number of children needing faecal disimpaction in the operating room. Our quality improvement process can be used to decrease hospitalisations, decrease healthcare costs and improve patient care for paediatric FC.

Limited granulomatosis with polyangiitis in an adolescent with Crohn's disease on infliximab therapy: cause or coincidence?

Pulmonary involvement in Crohn's disease (CD) may precede the development of intestinal inflammation, but in most cases occurs during the course of treatment, either as an extra-intestinal manifestation, because of secondary infections, or as a side effect of the therapy itself. This case highlights the differential diagnosis and work up for multiple pulmonary nodules that developed in a patient with CD who had been in remission on infliximab therapy. Even though infectious causes, such as Mycobacteria and Fungi, account for majority of these cases, the possibility of non-infectious conditions such as autoimmune disorders should also be considered.