Chapter 19 · Disorders of the Alimentary Tract & Liver

Gastroesophageal reflux · Malabsorption (coeliac, CF, IBD) · Necrotizing enterocolitis · Chronic liver disease · Biliary atresia · Hepatitis · Portal hypertension · Management
📌 Core principles: Recognize early signs of malabsorption (failure to thrive, chronic diarrhoea, anaemia). Biliary atresia requires Kasai portoenterostomy before 8 weeks. Coeliac disease: IgA tTG positive, duodenal biopsy; lifelong gluten-free diet. IBD: multidisciplinary, biologics for severe. Portal hypertension: variceal bleeding requires endoscopic banding/sclerotherapy.

📖 Alimentary & Liver Disorders – Key Concepts

🍼 Gastroesophageal reflux (GORD)
Physiological in infants; pathological if faltering growth, oesophagitis, aspiration. Management: positioning, thickened feeds, proton pump inhibitors (PPI), fundoplication if severe.
🌾 Malabsorption
Coeliac disease (IgA tTG, EMA, HLA-DQ2/DQ8, biopsy); cystic fibrosis (sweat test, immunoreactive trypsinogen, fecal elastase); chronic diarrhoea, failure to thrive, deficiencies.
🩺 Inflammatory bowel disease (IBD)
Crohn (skip lesions, perianal) & ulcerative colitis (continuous mucosal). Paediatric PIBD: endoscopy, MRI enterography, biologic therapy (anti-TNF).
🧸 Neonatal cholestasis
Biliary atresia (urgent Kasai procedure before 8 weeks; acholic stools, conjugated hyperbilirubinaemia); other: PFIC, Alagille, TPN cholestasis.
🍁 Chronic liver disease
Cirrhosis from BA, AIH, viral hepatitis, metabolic (Wilson, alpha-1 antitrypsin). Complications: ascites (spironolactone/furosemide), varices (non-selective β-blocker, banding), hepatic encephalopathy.

🔎 Symptom-based approach: Diarrhoea, jaundice, abdominal pain

1️⃣
Chronic diarrhoea + faltering growth – Coeliac disease, CF, post-enteritis lactose intolerance, food protein allergy. Measure tTG IgA, faecal elastase, sweat test.
2️⃣
Conjugated hyperbilirubinaemia in a neonate – Emergency! Exclude biliary atresia (acholic stools, hepatomegaly). Urgent ultrasound, hepatobiliary scintigraphy, liver biopsy. Kasai before 60 days.
3️⃣
Recurrent abdominal pain + weight loss + perianal lesions – Suspect Crohn disease. Faecal calprotectin, MR enterography, ileocolonoscopy with biopsies.
4️⃣
Hematemesis in a child with known liver disease – Variceal bleed. Immediate resuscitation, octreotide/terlipressin, endoscopic band ligation/sclerotherapy, non-selective β-blockers for secondary prophylaxis.
5️⃣
Abdominal distention + bilious vomiting in a newborn – Malrotation with volvulus (surgical emergency) vs NEC. Urgent upper GI contrast study, surgery.
⚠️ Red flags in paediatric gastroenterology: Bilious vomiting (obstruction until proven otherwise), palpable abdominal mass (Hirschsprung, Wilms), bloody diarrhoea + HUS (E. coli O157), ascites (portal hypertension, malignancy).

📋 Clinical management algorithms: GORD, IBD, Biliary atresia, Varices

🍝
Coeliac disease (diagnosed and managed)
▪️ Life-long strict gluten-free diet (GFD).
▪️ Nutritional deficiencies (iron, calcium, folate, B12, vit D) correction.
▪️ Monitor growth, tTG titres yearly, bone density, thyroid function (associated autoimmune).
🔥
Management of severe GORD in infants
▪️ Thickened feeds (alginate) + positioning (supine for SIDS prevention, but consider upright after feeds).
▪️ Trial of PPI (omeprazole 1-2 mg/kg/day) for 4–8 weeks if oesophagitis.
▪️ Fundoplication (Nissen) only in neurologically impaired or refractory aspiration.
🧬
Biliary atresia – diagnostic and surgical pathway
▪️ Any conjugated jaundice >14 days: urgent ultrasound (absent gallbladder, triangular cord sign).
▪️ Liver biopsy (ductular proliferation, bile plugs).
▪️ Kasai portoenterostomy before 60 days of life (better outcome).
▪️ Post-Kasai: UDCA, fat-soluble vitamins, monitor for cholangitis.
🩸
Acute variceal haemorrhage in portal hypertension
▪️ Airway, IV access, terlipressin/octreotide, broad-spectrum antibiotics (prophylaxis).
▪️ Endoscopic band ligation (preferred) or sclerotherapy.
▪️ Secondary prophylaxis: non-selective β-blocker (propranolol), repeat banding until obliteration.
▪️ Consider TIPS or surgical shunt if refractory.

💡 Reflex prompts – Alimentary & Liver disorders

🍞 A 2-year-old with chronic diarrhoea, abdominal distension, iron deficiency. Antibody test?
IgA tissue transglutaminase (tTG); if positive → duodenal biopsy (Marsh grade). Coeliac disease.
🟡 A 6-week-old with pale stools, conjugated bilirubinaemia. Next step?
Urgent abdominal ultrasound and referral to paediatric hepatology for possible biliary atresia.
🧂 A child with cystic fibrosis and steatorrhoea. Enzyme replacement?
Pancreatic enzyme replacement therapy (PERT; Creon) dosed per fat intake, with PPI to improve efficacy.
🩸 A 12-year-old with bloody diarrhoea, tenesmus, weight loss. Most likely diagnosis?
Ulcerative colitis – endoscopic continuous inflammation from rectum, confirm with colonoscopy + biopsies.
💊 First-line treatment for Crohn disease with moderate-severe ileocolitis?
Exclusive enteral nutrition (EEN) for 6–8 weeks; corticosteroids (prednisolone/budesonide) or anti-TNF (infliximab) in refractory.
⚠️ A neonate with bilious vomiting and abdominal distension. Most important next step?
Upper GI contrast study to exclude malrotation with volvulus – surgical emergency.
🧪 Most accurate non-invasive test to rule out coeliac disease in IgA-sufficient child?
IgA tTG (sensitivity >95%); if weak positive, confirm with EMA and HLA-DQ2/DQ8.
🩺 Treatment of hepatic encephalopathy in a child with cirrhosis?
Lactulose (oral/enema) to reduce ammonia; protein restriction avoided; manage precipitating factors (infection, bleeding, constipation).
🏥 A 14-year-old with dysphagia, food impaction, atopy. Suspected disorder?
Eosinophilic oesophagitis (EoE). Diagnosis by oesophageal biopsy (≥15 eosinophils/HPF). Treatment: PPI, swallowed topical steroids (budesonide/fluticasone).
🧫 A child with jaundice, hepatosplenomegaly, Kayser–Fleischer rings. Diagnostic test?
Serum ceruloplasmin, urinary copper, slit-lamp examination; Wilson disease – treat with zinc/chelators.