Pediatricians see patients for motility concerns every day and need efficient paths to making diagnoses and treatment decisions. In this talk, pediatric neurogastroenterologist Alice C. Huang, MD, MBA, offers case examples to differentiate similar conditions, such as gastroparesis and functional dyspepsia; describes essential physical exam and workup steps; lists red flags for referral; and breaks down the plethora of treatment options. Hear tips such as how to ensure a complete rectal exam and when to screen for an eating disorder.
All right. And Laura, do you see the um full screen? Ok. So today I'm gonna be presenting on pediatric motility conditions and like an update of what we do for them. Um So who am I? I ask myself this every day? So I'm Doctor Alice Wong. I'm one of the new pediatric G I attendings at uh U CS F uh Children Hospital of Oakland as well as Mission Bay. Um So I did my pediatric G I fellowship training nearby at Stanford. Um And then I did an additional year and a half uh specifically in motility disorders like constipation, achalasia, things like that um in neuro gastroenterology and motility training at Children's Hospital of Philadelphia. Um And I'm back in the Bay area at Children's Hospital of Oakland to re-establish the motility program here. And so I don't have any disclosures. And so today's agenda today, we're gonna go over first how motility conditions relate to you in the general pediatric uh practice. So you actually see a lot of motility in general pediatrics and I'll go into uh some of the statistics in that. Then we're gonna go through some common esophageal motility conditions that you might see in clinic first before you refer to me. So we'll go through a case, the differential diagnosis, the work up and then the treatment that we do, uh then we divide it into stomach motility conditions that you might see. And then our favorite which is the colon motility conditions like functional constipation. So, motility and general pediatrics is actually really common guys. And so motility encompasses a bunch of uh diagnosis. So I'll go into it later about what exactly do I specialize in. Uh But for example, constipation is under the umbrella of motility. Um and it makes up uh around like 3% of the general pediatric outpatient visits. Uh The prevalence of constipation, for example, range anywhere from 7.5 to 14.4% globally among Children. Um And the health care expenditure is for pediatric constipation alone, not even counting the disorders of the brain called axis and other motility disorders is $3.9 billion a year. Um And despite being so expensive to treat and being so prevalent, uh 50% of Children continue to be symptomatic despite the current standard of care. Um and so it is uh very common in our general pediatric practice and we do struggle with it both as a general pediatrician and as a a pediatric G I doctor. And so, motility conditions are separated into two umbrellas. So others primary mortality conditions like uh achalasia, gastroparesis, chrono, pseudo obstruction, and Hirsh brung disease. Um And then there's disorder of the brain gut uh access interaction. Um So this used to be functional G I disorders, but we're going more towards uh calling it disorder of the brain gut AIS interaction. Uh because like what exactly is functional G I disorder? You know what I mean? Like it's hard to explain to a patient what exactly what is functioning. Um And so we're going towards more this um uh nomenclature. And so things under this umbrella are like rumination, functional dyspepsia, cyclic vomiting I BS, functional constipation and more, however, I do want to remind people that they overlap a lot. And so it's like sometimes it's harder to differentiate between a primary motility disorder and disorder of the brain gut access. And so that's why I do both. And so first we're gonna go into a few cases that involve the esophageal mo Tilia that you might encounter in a primary G I setting. So first we have a five month old. Uh they born preterm at 36 weeks but otherwise healthy. Uh they're presenting with 6 to 7 episodes of the so called like vomiting per day for the past month. Uh The parents describe it as like an effortless kind of regurgitated regurgitation, whatever is in their stomach, like formula after feeding, followed by arching of the back and like periods of irritability. The baby starting to turn away from the bottle and not feed as well. Uh the baby is exclusively fed formula and they're on a cow's milk based formula. Uh The baby continues to be of appropriate weight and height and continues to gain weight. Well, the development is normal and the physical examination is unremarkable. So I'm sure we counter a lot of this in our general pediatric uh clinic. Um So the differential diagnosis for any baby that has regurgitation and possible vomiting, um the most serious being uh more anatomical ideology, metabolic disease, infection and neurological disease. Uh But once those are ruled out, um then you wanna think about infant regurgitation, which is the most common. Um and then things like cows mic protein allergy that's presenting like this reflux or gastroparesis. And so some of the red flags that would uh you would queue into during your uh general pediatrics clinic that would queue into more an atomic ideology or a neurological metabolic or infection is bili Emmis hands down to send to the emergency room. Um G I bleeding like blood in the vomit or blood in the poop. Um consistently what's described as forceful vomiting. So I asked the parents to like describe like how forceful is this vomit? Does it look like the exorcist movie? Um So that's like a bit of a red flag. Um onset of vomiting after six months is kind of strange because like if it's infant regurgitation, usually that be begins before six months. Um and then gets better around the six months to 12 month mark. Um fail to thrive is definitely a red flag, diarrhea, constipation, fever, lethargy, hepatomegaly on physical examination. Um neurological uh symptoms could be bulger Fontanel micro microcephaly seizures. A big red flag could be uh abdominal like tenderness um on exam and definitely distention. Um any and any suspected genetic and metabolic syndrome. So, in our case, however, the the baby did not have any of these red flags, right? So we can cross off like any concern for anatomical infection, neurological, metabolic disease. So then it focuses on could this just be like infant regurgitation? So what exactly is infant regurgitation? So, infant regurgitation is described as regurgitation that does not have irritability or arching of the back or development of oral version. Like there is no sequela of the regurgitation. Um The age of onset is between three weeks to 12 months old. The frequency has to be at least 2 to 3 times a day to be diagnosed with infant regurgitation and then must last for at least three weeks. And so the physiology behind infant regurgitation like why do they spit up? Uh compared to like adults eating? Well, that's because like infants actually ingest twice the volume per kilogram that they weigh than adults. And that leads to stomach getting distended more and then leads to more transient, lower esophageal sphincter relaxation which then causes the baby to spit up. Um 25% of the infants will present to your practice with severe enough regurgitation that the parent will ask for help. So you will see this a lot in the practice. Um The good thing to tell them is that if it's infant regurgitation, they improve after six months, especially when you start introducing like solid foods to them. And a good majority of them definitely resolve all the symptoms by 12 to 18 months. However, the baby that we saw in our case study did have irritability arching of back, like they started developing oral version and turning away from the bottle. And so then you start thinking like, ok, well, is this reflux, um could it be cosmic protein allergy or um the more rare cases, gastroparesis? And so here's a flow chart of like if you're suspecting, ok, like they're actually developing symptoms from this like regurgitation. First, of course, you do the history and physical exam and then you look for the red flags that we had talked about. Um, and then after there's no red flags and you get a better dietary history to see. Are they over feeding the child? Like as in there is a really large volume feed? Um So then you can like split them up for lower volume but more frequent feeds. Another common thing is that you can try to thicken the feeds and then if that improves everything you're good to go. However, if it doesn't improve anything, then you kind of treat it like almost like a cow milk protein allergy where you go for a partially hydrolyzed or a completely hydrolyzed diet or a maternal elimination diet. Uh for 2 to 4 weeks. Be aware though, when, if the mom goes on an elimination diet, you won't see the full effect of all of the uh so called like triggers and allergens out of her breast milk until two weeks later, 2 to 3 weeks later after she's been on the elimination diet. So you may not see the full effect until a few weeks after. Um And then if that still doesn't improve, definitely put in a referral to pediatric G I. But what do you do when you're waiting for that pediatric G I for this patient who might be like, you know, starting to lose weight a little bit and develop oral version. So at that time when they're waiting, you can consider a 4 to 8 week trial of acid suppression. Um And so for us, uh omeprazole is one of the most like PP I is the most effective compared to H two blocker. Um And then we can also then see them in clinic to see if they have improved or not and if they need further work up. So the work up that we can do for reflux is something called impedance probe. And the way that it differs from the regular Ph probe is that it detects non acidic reflux and acidic reflux. Whereas Ph probe only uh detects acidic reflux. Um We use the impedance probe to look at a patient if they're having reflux at baseline, like off any sort of medication, we use it to see if they're responding to PPIs and their uh anti reflux medication. We see of like their symptoms of um, systems such as like arching on the back or ability cough is associated with reflux episodes. Um And it, it can also guide who goes for Nissen Fund location or post pyloric feeds. Um Other things that we can do is upper G I upper endoscopy to look for things like eoe um and a gastric emptying scan. And yes, we can do gastric emptying scans for uh infants. Uh but it's just that it's a liquid gastric emptying scan and it's only one hour compared to the standard four hours. So the treatment for reflex when you're doing it at clinic while they're waiting for G I is definitely reassurance, uh dietary uh history to make sure they're not overfeeding. Um And the usual positional treatment. So, uh you do pace feeding where you burp the baby every one or two ounces of feeding, you keep them upright position for 30 minutes after um then you can try to thicken formula which have been shown to decrease regurgitation episodes and also improve waking. Um And then if that doesn't work, then you can try a more hydrolyzed uh partially hydrolyzed or completely hydrolysed formula as well. As a maternal elimination diet, like you're treating cow's milk protein allergy. And then if that doesn't work after a month or two, then you try A PP I so A PP I is better than an H two blocker. Some of the things that are being researched right now, that's like not uh officially recommended. But sometimes I do use it pro kinetics. Uh baclofen and Bethan target the transient, lower esophageal sphincter relaxation directly. So it's been used sometimes in reflex. Um And then if the really, really refractory cases of reflex, um then you refer for like a Nissan or to pay fund the application. Um However, there's more growing research that's kind of like going away from fund dation because there's post surgical complications like gas bloat syndrome or like dysphagia or like recurrence of reflex. So for some of the kids that already have a G two, then they consider more most p post pyloric feeds versus a nissan. So next, we're gonna go into a second case study. Um So then you have a seven year old male. He has a history of developmental delay and a recently diagnosed adrenal insufficiency. Weird, right. Um And he comes to your office complaining of difficulty swallowing solids, uh progressing to liquids with each meal, he's regurgitating undigested food with every meal. He has chest pain after eating. He has a nighttime cough and he has an unintentional weight loss of 10 kg in the past few months. So all these are like red flags that you should look out for. He recently immigrated here from the UAE. The parents are cousins. So weird. Um and he does not produce tears when crying. So this is a a weird case. So this is Al Grove syndrome and you this is like so rare but it might show up on the general pediatric boards and also the G I boards. Um and it's a try and what I'm hinting at at the whole scenario is red flags to look out for as a general pediatrician for Achalasia because that's an urgent referral. Um So in this case though, it's like a triad. Um so it's a triad of achalasia, they don't produce tears and they have adrenal insufficiency. Um A third of them actually have autonomic dysfunction. So some people are like uh thinking of changing the name to quadruple A syndrome. Um but it's a mutation on the AAA S gene on chromosome 12 and it's an autosomal recessive pattern of inheritance and there's variable penetrance. So the same uh family can have different uh presentation of this uh syndrome. However, if you see those red flags uh um uh symptoms that I've just talked about such as uh regurgitation after uh food with every single meal um and weight loss and chest pain and there's a cough. Um This is really for achalasia and that's something to put in an urgent G I referral and while they're waiting for a G I referral. You might want to tell the patient to prioritize more of a liquid diet, like supplement with like pediasure or cape farms and things like that so that they can minimize the um the risk of aspiration uh because of the Alesia um and the impaction. Um So some of the work up that you'll see is that like if you order an upper G I there's that classic bird beak appearance where uh oh, I can't use the pointer. Uh but it's like the lower esophageal sphincter is not relaxing. So then the esopha uh the esophagus gets dilated uh before that obstruction point. So it looks like a bird beak and so that might appear on the pediatric G I board exam. Um Things that we see on scope sometimes we not, might not see anything because aguia is a functional obstruction of the lower esophageal sphincter. It's not a fixed obstruction, like an anatomical obstruction, you know. So like sometimes I can pass my scope through with no problem. Uh But some of the things I might see is, for example, it might be tight at the very exact moment that I'm putting down my scope. Uh But a lot of times I see like undigested food in the um in the distal esophagus, especially, they've been MP O for the whole surgery. So that's kind of weird. Um And inflammation in the distal esoph esophagus that looks almost like an eoe picture. Uh but it's actually from all the stagnant food material that's been building up in the distal esophagus. So some of the things that we can do when you refer to us for Eguia is definitely an expedited workout with an upper g upper endoscopy. And then afterwards, you can do an esophageal manometry to diagnose achalasia with a gold standard. So you see here that on the left hand side, it's a normal swallow study. So um blue is low pressure and green is high pressure. And so the top bar is the upper esophageal sphincter and the bottom bar is the lower esophageal sphincter. And so when it turns from green to blue, it's that sphincter opening up so that when the top bar turns from green to blue, it's opening up to let the bolus through in the upper esophageal sphincter, then you can kind of see the uh bullet kind of move through as a uh esophagus contracts it through in a peristaltic wave. Um And then you see the bottom bar which the lower es esophageal rin turned blue to open up to let the food through. However, in Achalasia, you can see that the bottom bar never turns blue, it always remains closed. And so that is uh Achalasia and there's different types. Um Now we're also doing Enzo flip that we're gonna be offering at Children's Hospital of Oakland where we can actually uh support the diagnosis of Eagles when the patient is sleeping. Um So a lot of patients uh can't really tolerate uh the esophageal manometry because number one, the catheter is pretty thick and it's stiff because it has electrodes in it. Um And so you like, usually like a teenager can tolerate it, but it's definitely not a pleasant study. It's inserted when they're awake and they have to co-operate during the study. So if there's like a kid that just really can't cooper, then the endo flip is a good option to support the diagnosis of achalasia. Uh because it can be done when the patient is sleeping. And during an upper endoscopy, basically, you put a balloon in to um put the middle of the balloon in the lower esophageal sphincter and you just blow up the balloon and see how distend this lower esophageal sphincter is. And so what you wanna see is how bad is that waste? That it's uh contracting again. So, some of the treatment options for Achalasia, um the old times was Botox injections, but we don't do that anymore. Uh The New Times, it's like there's a big um um uh uh discussion about, do we dilate beforehand with something called ezo flip balloon on pneumatic or like the balloons? Uh First to see if that improve the patient's symptoms or do we jump to something like Heller Myotomy and palm? Um Heller Myon has like a 90 to 95% curative rate. Um And it's sometimes paired up with the fund of location. That's not Nissan, it's like either the 180 or the 270 degree wrap because you can get a lot of reflux after Heller Myotomy. And so that um is sometimes paired up with like a partial wrap uh to minimize a reflex after the new trend is also poem where you actually um uh excise the tissue from the inside out. So from endoscopically, so it's not open surgery. Um And so, but there's no study that actually compares poem to Heller myotomy and which one's better? Um So that is the treatment for Achalasia. Now, we have a third one. This one, you might actually see a lot in a, a general pediatric uh clinic. So a 10 year old male with autism spectrum uh presents with these like episodes of like first he belches and then burps and then he followed by this like kind of like effortless regurgitation or whatever is in his stomach 5 to 20 minutes after eating the patient, then like either res res like chews it and then re swallows what was in his mouth or he spits it out. Um These episodes happen after a meal. Um the patient's been gaining weight well. And so like, usually you get that story in a general pediatric um uh population, but I'll give you more information to like try to um zone in what I'm trying to um talk about in terms of the diagnosis uh So the upper G I shows no esophageal anatomy. So we're not worried about like an anatomical uh uh reason for his regurgitation like a stricture, upper endoscopy was normal. So we're not worried about like things like Sinop esophagitis. Uh We even did an impedance probe to look for reflux and it was negative. Um and the gastric emptying scan was normal. So what is this, this rumination? Uh So rumination is a clinical diagnosis. So you don't actually need all of that work up. But uh in rumination, it's present in 3.1% of the global population, which is a lot higher than I thought. Um And the way that I like to explain it to patients is that it's like a mal adaptation of your burp reflex. So basically you contract the stomach down. And what that does is that opens up your lower esophageal sphincter. And when that opens up, things come back up because like it's going from high pressure to low pressure. So things come back up all the way through and then your upper esophageal sphincter opens up to let the food come out. Of course, when you see someone that you're suspecting, oh, this is rumination. Uh You want to please rule out uh the other diagnosis which is gastroparesis, reflux. Uh sometimes coexists with rumination because a lot of the times why are they ruminating? Yes, rumination is a clinical diagnosis, but there is a subset that ruminates because they feel better after they ruminate because of gastroparesis or reflux. So you really want to rule out that it's a, it's a coexisting with the gastroparesis or reflux. You also wanna make sure there's no red flag symptoms like the previous case where they had weight loss, they had chest pain, they had nighttime cough. Um because that's concern for achalasia and you also want to make sure that it doesn't sound like an anatomical reason why they're regurgitating like things like baus emesis and things like that. So like an esophageal obstruction or a gastric outlet obstruction. Um Also for rumination, you need to screen for eating disorder because um 17% of bulimics have rumination. And so um please please please screen for an eating disorder if you're suspecting someone is having rumination. So once again, rumination is a clinical diagnosis. Um Yes, when you refer to us, we do do the basic work up of upper G I, right? To make sure there's nothing anatomical. We do a scope to make sure it's not eoe right? Like something that is causing the rumination. Um If I see um uh that there is a high suspicion for reflux, I might even do an impedance probe or if it sounds like gastroparesis and I might even do a gastric emptying scan. But rumination itself is a clinical diagnosis. So if you have a patient that's like, no, I need to know if this is for sure rumination or you're not sure if it's like rumination or Alesia or some sort of esophageal motility disorder, then you do esophageal manometry to confirm. And so in the old times, they had to do an ad manometry which is like a 7 to 8 hour study, it requires like sedation to place the probe, uh, to see the, uh, rumination events. Um, but we don't do that anymore because now we do esophageal manometry to catch the rumination. Um And so uh what I usually do is I, I ask the patient to bring in some triggering foods. Um And then, so I can see them what happens after they eat the triggering food and what happens when they regurgitate on the esophageal manometry. So basically, what is their esophagus doing when they're regurgitating? And so this is an example of a rumination event where it looks like almost like a uh like a uh a straight shot up uh from all the way from the bottom, which is the stomach and lower esophageal sphincter all the way up to the upper esophageal sphincter. And so when I see something like that, I know that that's definitely rumination. So the things that you can do in your office, right, while they're waiting for PHHG I referral, it's definitely education and reassurance saying that it is is not dangerous. This is not dangerous. OK. Um And you can teach them diaphragmatic breathing. So, like, for example, my virtual reality application teaches kids how to do diaphragmatic breathing. But you can also teach them diaphragmatic breathing because it actually resolves 30% of rumination cases. It's actually very effective and it improves regurgitation episodes and 56% of uh rumination. Uh If you have like the patients that continue to ruminate, you know what I mean? And you're like, what do I do because they are already doing diaphragmatic breathing. And so you will recommend it before meals, after meals, when they feel the sensation that things are going up. Um then you can uh try things like uh PP I, we definitely because remember there's a subset that coexists reflux with rumination. So it's like if you treat the reflux with the rumination get better. And so you can put them on A PP I trial and you can also have them on antiemetics like Zofran for example, to help with their symptomatic um uh relief. So those are definitely some of the things you can start with in the um general pediatric population. And then when they get referred to us, things that I use is sometimes like tr uh cyclic antidepressants though, those are kind of like falling on the wayside right now. Uh because it's not that effective uh Baclofen that targets the uh um uh transient, lower esophageal sphincter relaxation directly. Um We even use sometimes use like pro kinetics. Um If there is like Castro persis coexisting with the rumination. Um And if there's like really, really significant weight loss and we've done the work up and this is pure rumination. Um Then there is programs like motility programs that not here but like elsewhere, they put an NJ down uh to help with the weight loss that they see with the rumination. OK. So we're done with the esophagus and we're gonna go into the stomach. So this one, you might see, I, I feel like I see this a lot. So 17 year old female patient, she has migraines, she has pots, she has joint hypermobility and she's coming to your office with this like concern of like nausea. Uh She has like some epigastric belly pain, some fullness and bloating after 30 minutes to an hour after eating. She also complains that sometimes she like vomits up what she ate like an hour after she ate it. Um, symptoms began around six months prior. Her like bowel movements are daily and soft. So there's like no constipation involved. Um She had a COVID infection around the time of the symptoms starting and she also changed schools. And so like a lot of things were happening during that time when symptoms started. Um she has like a £5 weight loss because she feels full faster so she can't eat as much. Um And she hasn't been able to go to school as much reporting some anxiety and stress with school. And so like, uh usually that's the story you get in the general pediatric, um, uh, uh, office. Uh, you can start with sending some blood work, um, and some stool studies to just rule out things like celiac disease, inflammatory bowel disease. Right? H pylori because H pylori can actually lead to like things like reis. Um, so you've sent C BCE, SRCRP and calprotectin, those are all markers that you do for inflammatory bowel disease and they're all negative, right? And our H pylori stool is normal. He sent celiac screen and those are normal, right? Um And I'm gonna give you a bit more information. So, you know, like what am I trying to head for? Her upper jaw is normal? So we're not worried about any sort of anatomical reason, like it's not gastric outlet obstruction, she doesn't have a mal rotation. Um and her upper endoscopy is normal, right? So there's no gastritis, there's no H pylori and there's no celiac disease. So, what is this a uh presentation of? So this is a presentation of gastroparesis versus functional dyspepsia. Um So functional dyspepsia is just a fancy word. I mean, there's uh exact criteria but it's a fancier word that they look like gastroparesis, but their gastric emptying scan is normal, but they have all the symptoms of gastroparesis. And the reason why I put them in like a Venn diagram is because there's so much overlap between gastroparesis and functional dyspepsia and that there is just a difference of the gastric emptying scan. But the patient doesn't feel different, they truly present with symptoms that look like gastroparesis. And so to truly differentiate between the two because there's actually different treatment that you focus on when um they are gastric persis versus functional dyspepsia um is a gastric emptying scan. Um And so a gold standard would be a four hour test. And so that would be uh where they have to eat solid, so they have to eat eggs and toast. And so we offer that at Children's Hospital of Oakland. Um This test, please do it after um, you've done like an upper G and a scope and that they come back to you and they're like, oh, I'm still symptomatic. So this is a good next step to do uh once you ruled out like anatomical and mucosal causes of their symptoms. Um And so this test will allow you to differentiate between true gastroparesis and functional dyspepsia. And so, um a lot of my patients actually can't tolerate this test. So for example, if you get a test back and it's positive, you make sure that they actually ate the whole meal because if they didn't complete the whole meal, the stomach doesn't get the cue to empty if it's not full enough. And so then it's a false positive. So like you have to be careful and just read that, did they consume the meal or not? Um And then second of all, you have to find a place and we do it for four hours, but some places only do it for two hours, which is shown that it's less sensitive and does pick up gastro Preis as well as a four hour test. So if you have to get a gastric emptying scan, make sure that they eat the full meal and that they it's like conducted over four hours and not two hours. So our hour institution, we do a standard of four hours to catch like gastroparesis. Um We can also do an ad manometry as a motility specialist to truly for the really refractory cases of gastric reis and sometimes actually functional dyspepsia um to make sure their pylori and their small intestine is um uh working well uh in response to some motility agents. So, the treatment of gastroparesis is that a lot of reassurance because um unlike adults, a lot of c like pediatric gastroparesis is idiopathic and post viral and temporary at um the time spans anywhere from a few weeks, a few months to two years of having gastroparesis. Um More um more rare things that you might wanna look out for as risk factors for gastro Preis is like surgeries, uh certain medications if they have thyroid issues. Hypo P Addison's and autoimmune disorders. Um And also you might also see it in uh your uh Children that have like really bad constipation and poorly controlled constipation. And they'll tell you that like when, when, while they're having like heart P like consistently stool and literally symptomatic from constipation. They also get nauseous when they eat and that's actually secondary to like this um normal reflex that we have called clog gastric break. Um And so what that means is I explain it to patients that if your colon is full of poop, your stomach's not gonna say I'm gonna add more poop to you. And so then you don't feel as hungry. So like gastro Preis is linked with constipation just because of this like normal existing break. Um So it's not abnormal for me to see a patient with constipation, also complain of nausea after eating. Um It's also associated in things like uh eating disorders. So like if you do gastric emptying scans on patients that have anorexia, um then they do have a lot of them have gastroparesis. However, in those cases, we don't put a tube down or like uh try to do that. Um gastroparesis is seen in like malnutrition. So I tell patients like that, that we focus on the nutritional aspect to improve the motility of your stomach. So if you address the anorexia, you address the gastroparesis. And so what you can do at your general pediatric um clinic is first, you can do a more of a gastroparesis diet because a lot of these are like post viral and temporary, right? So like you may not even need to do full blown medication. Um And so you'll say like, oh during this time, you wanna do like small low fat, right? Meals. Um more frequent five times a day versus three times a day. Low fat because like fat uh slows down the stomach. Um You could also emphasize more liquid like formula like Kate farms or pediasure during that time because the stomach empties, liquid better uh than solids. Other alternative therapies you can think of is like acupuncture, ginger can help with the nausea. Peppermint oil can help with the spasms of the ST um of the muscle. And if you're really, really, really suspecting gastroparesis and they're waiting for a G I referral, then you can try to use Erythromycin to see if that would improve some of their symptoms. Um Things that when Erythromycin doesn't work is that you can see if they develop tolerance to Erythromycin like. So usually I hear that patients say like, oh, when I first started Erythromycin, it helped a lot, but then it kind of lost its efficacy. So people sometimes can toler um develop tolerance to it. So what you wanna do is like, do a drug holiday of a week and then put them back on Erythromycin and it works much better that way. So it's like three weeks on one week off. Um Other options that you can also try is Azithromycin. But like this is like when they see me, I try like Azithromycin, I try Reglan sometimes and even the new medication that's on the market motegrity. Um and then when they come see me, if they're really refractory, we can do things like Pyloric Botox, which has improved symptoms in two thirds of patients. And they're really severe cases, you can just bypass the stomach altogether and just put down an NJ tube. And then in the very, very, very severe cases, you can refer to like nationwide, for example, that does gastric pacemakers. But however, if it's functional dyspepsia, so for example, you have your patient, they're presenting like almost gastroparesis, like, but their gastric emptying scan is normal. So then they fall into the category of functional dyspepsia. And so in this one, you want to focus more on the bops psychological model. Um So there's a lot of reassurance telling them like, ok, this is not dangerous, right? And you wanna focus targeting directly on the brain gut access. So the one of the ways to target that connection directly is cognitive behavioral therapy. And I tell patients like this is one of the most effective ways to target that brain gut access. So you do have to refer to a therapist that would do cognitive behavioral therapy. We also provide our Children Hospital of Oakland got directed hypnotherapy as well. Um Like it, it goes by the only name hypnosis uh for like the nausea and it does help a lot of the patients. Um other things you can consider are yoga, biofeedback, assisted relaxation therapy. And then if you're really, really struggling. We do do a trial of PP I for functional dyspepsia to see if that improves. That's actually one of the first interventions that we do for functional dyspepsia uh to see if that would improve the um symptoms and if that doesn't work, then uh functional dyspepsia is focused on uh increasing the volume that your stomach can hold versus gastroparesis, which is focused on treating um speeding up the motility of the stomach itself. So for functional dyspepsia, we focus on medications like for example, periactin, you can start at your pediatrician clinic uh to help increase the volume of their stomach. So it really helps with nausea. Um And then if they see me, I can try BuSpar, BuSpar is also known to increase the volume of your stomach and also indirectly treat anxiety. And so that's really good for kids that have this and anxiety. Um And then you can also give Zofran for just symptomatic relief when they get like nauseous. Um for the visceral hypersensitivity component. You might see the gastric emptying scan being rapid that actually signals the patient has like more visceral hypersensitivity. You can try things like peppermint oil, IB guard. Um and then antispasmatic Pr Ns like Bentyl and Lepin, and then you can refer to us and when they see us, there's um things in our um arsenal that we sometimes use for function dyspepsia such as Triglycerin antidepressants like amitriptyline. That's the answer on the G I like the pediatric boards. Uh But that's kind of like falling into the wayside because it does require EKG monitoring every time you go up on a dose. Um The more growing trend is like remin it really helps with uh nausea and increasing appetite and increasing weight gain. Uh However, remar is not a candidate for someone that's obese. Um and then adults, they're using more and more ssris to treat uh functional uh G I disorders. And another thing that we offer at Children Hospital of Oakland is neuromodulation with IV stem. So basically, it's literally a device that we like ins install on your ear. Temporary, don't worry, it's not permanent. Um And it just literally zaps you and stimulates the vagus nerve and just continues zaps you. Um And so then um it's like a weekly treatment for several weeks and it does help with a lot of the nausea component in the functional dyspepsia. So another thing is that when you see someone for any disorder of the brain, gut functional dyspepsia, I BS any of those things like functional abdominal pain, um there is things that can contribute to making their condition worse than what they uh could be. So like, I usually tell patients like these are what I call augmenting factors. So they make your symptoms worse than what it is at baseline. So like you need to optimize these conditions so that they are at their best operating state I also tell them that I don't have a magic pill that will cure them of their disorder of the brain gut axis. But my job as a doctor is to minimize their symptoms so that they can go and function in their lives and live their lives, go to school, hang out with their friends, do sports. Um And so like, I don't promise them a cure, but I do promise them I will do my best to help quiet down the noise of your disorder of the brain to access so that you can function in life. So I focus more on the quality of life and functioning. But I also make sure that things that are the what I call augmenting factors are addressed. So things like make sure they don't have small bacterial overgrowth and things like small bacterial over will be like a lot of bloating, a lot of distention, loose stool sometimes. And like as a general pediatrician, you don't have access to like our breath test, right? Like lateral breath test, glucose, breath test that can like confirm CB. So like if they're waiting for an appointment, you can trial like AC B um medication of course to see if that improves their symptoms because actually a lot of them improve after AC plus, especially rifAXIMin for I BS. Um So you can try a rifAXIMin alone or rifAXIMin neomycin if they have constipation for a 10 or 14 day course to see if that improves their symptoms, then you also wanna look at like, is there any like certain food triggers, especially lactose intolerant? Uh because that can manifest as a like augmenting that functional G I component. And so you wanna eliminate lactose and use lactate pills as needed to see if that would help with the G I symptoms. And then they have co anxiety and depression. They need to have it addressed with either psychiatry or psychology. A lot of the patients come to me and be like, oh, like I was told it's all in my brain. Um And I don't tell them that because not everyone that has anxiety and depression has functional G I disorder. So like uh but I do tell them that it definitely can worsen your symptoms from baseline. So it needs to be addressed. So the anxiety and depression needs to be a um sleep hygiene is super important for the functional G I disorders. Um And then if there's a clear link between a flare of the G I symptoms and menstruation, then I also think like, well, do they need a referral to adolescent for like birth control pills? Um So you try to minimize and like um all of these augmenting factors that can be contributing to making everything worse so that they're at their best possible operating state. Um And then in the case study, what I was hinting at was I've noticed that she had multisystem involvement So she had migraine headaches, she had pots or like orthostatic hypotension. Usually they will come to you and be like, I faint when I change positions a lot. Um sometimes they have joint hyper flexibility. Um that doesn't meet the full criteria for Elis Danlos, but they do are hyper flexible and they get injured more often. They say they have fatigue, they have pain disorder. Um and they also have G I disorders. And so this falls in the umbrella of this autonomia in general. Um So like, that's when the whole autonomic nervous system is effective. And the reason why I'm uh touching on this more is because we're seeing an increasing um uh rates of dis a anomia, especially after the COVID pandemic. And they don't know, is it because of long COVID? You know what I mean? Or is it because of like, like people were like sheltered and like, you know, now they're resuming school. So there's like more pressure and then at least the more diss aon Noia we're not sure, but we're seeing a, a huge increase in dis Aon Noia in Children. And so the mainstay of treatment while you're waiting to see a specialist, right? Like what do you do for your patient when you see this constellation of symptoms? And they're waiting forever to get into this autonomia clinic or see a specialist. Number one is definitely education and reassurance, telling them that nothing dangerous is happening. And then for dis autonomia, it's mainly fluid and salt. So you focus on fluid repletion of 2 to 3 L a day. And this seems a lot for someone that has a lot of nausea, right? And a lot of belly pain after eating, but that is really the mainstay of treatment is to increase that fluid. Um And then you also wanna do salt supplementation if you don't feel. So, cardiology does like the exact salt, how much salt someone needs um for an adult it's 10 to 12 g a day for a anomia treatment. Um But if you don't feel comfortable with that, you can always encourage them to eat more saltier foods, you know, like potato chips and like chess, uh things like that to increase their salt intake, you can also refer to PT uh because a lot of these kids get deconditioned, right? Because they don't want to leave their rooms, they don't wanna go to a school, things like that. Um And also if they have joint hyperflex, they might not meet the um uh criteria for E Los Del, but they really should strengthen their muscles so that they don't sub lex. And so uh dislocate. Um So you're addressing that component as well if they have like the fainting episodes and like the orthostatic hypertension that you wanted to send for cardiology to do a tilt table test if they have pots to do a holter or a ZAC to see if it could be arrhythmia and then if it is truly possible and start them on floor and f is a really uh common option. I see them start on for their migraine headaches and they should go to neurology. Uh Sometimes we use amatine for both migraine headaches and for uh functional abdominal pain. So sometimes we talk uh with the neurologist so that they're on one medication that addresses both. Um And then these kids really do need multidisciplinary care. So like at Mission Bay, we actually have a disorder nomia clinic for these patients that has a neurologist, a cardiologist and then a double boarded G I doctor that has psychiatry and G I. Um and then I follow these kids um for their G I uh concerns uh as an outpatient like um because I can provide them more frequent appointments than this autonomia clinic. So that concludes the stomach. And so we're gonna go into the colon. That is my favorite topic guys. Um So this is a seven year old female patient. She comes to your office. Um And she's saying that she sees like shrieks of uh bowel movement in her underwear every day. Uh She reports that she has hard palate like consistency two times a week. So she only poops two times a week. Um when she does have the bowel movement, it's so large that it clogs the toilet for the mom. She says she does strain. She does have sometimes pain with defecation and she feels like she's not completely emptying after she has a bowel movement. Uh, she does sometimes report that she holds in her poop at school because like school, she doesn't want to poop at school and it's like not the most private bathroom. Um And the parents said that they did notice that she was starting to have constipation around, she was like three years old around toilet training time. And so they were using like prune juice and like mirror lashes as needed. Uh So a little bit about her history is that she did pass meconium within 48 hours with no reflex, there's no blood in her poop. Um She doesn't have any sort of urinary accidents with the pooping accidents or UTIs and her lower extremity does not feel weak, she's not falling all over the place and she's not weak on physical exam. Um So you do a physical examination on her and it's normal, you do a digital rectal examination on her yay. Um And it was normal. Um And her growth parameters are normal. Some of the things you can do if you're struggling with constipation with a patient is definitely do the digital rectal exam in the general pediatric office. Um And some of the work up you can send while they're waiting to see G I is definitely the following. So her C BCE SRCRP electrolytes, thyroid function CIA actually, and calprotectin. Um So those are all normal. So what this screens for is associated conditions that can um look like poorly controlled constipation, like thyroid dysfunction, celiac disease. And believe it or not IBD can look like constipation. So you wanna just screen them out while they're waiting for the G I referral and definitely do the digital rectal exam. So what is this our favorite functional constipation? Uh So, functional constipation is two or more of the following. So they do have to have like training lumpy hard stools. Um This is a really common one, incomplete evacuation, uh anal rectal obstructions, they need manual maneuvers to help them poop. So I've heard patients say like, oh, I need to stick a finger up my uh kid's butt to make them poop or I use a rectal thermometer and those are manual maneuvers to make someone poop. Um And they don't fulfill a criteria for I BS. So like I BS has belly pain that's alleviated by bowel movements. Um So, um that's like a even though there's treatments that we use for both, um It's important to differentiate between the two. So some of the red flags you want to look out for if someone's coming you for constipation in the general pediatric office, it's definitely if the constipation starts really early in life, that's a huge red flag as in they're on a liquid diet, they really shouldn't be constipated. So, um, if they're saying that they were constipated straight out of the gate that, so that's a red flag passage of meconium in more than 48 hours is definitely a red flag. The majority like 90% pass it within 24 hours and then of those 50% pass it at 48 hour mark. So when it's more than 48 hours, you should definitely do work up, see what's going on. Uh, family history of Hirsh Bung disease is also a huge red flag because there's certain genes that are associated with Hersh Bung disease like red or Fox two B. Uh Other things are like blood in the poo and there's no cut, no anal fissure theo or thrive is a really big one, a bilious emesis, like they're getting so constipated, they literally vomit. That's a red flag. Um in the older kids, like if they feel like a weird thyroid or severe abdominal distension uh during your phys, your physical exam, you should really look at the um when you're doing the digital rectal exam, what are you looking for? Right. Like, first you want to look for like where exactly is the anus? Because if it's too an interior, then you're like, oh, look at that. It might be interiorly place um anus. And then you also wanna check the tone when you place the finger in like, is it a good tone or is a really low tone where you're like, oh, is this like um uh spinal pathology? Like a tether cord. Um And then you also want to check if it's like you're hitting, uh what are you hitting? Right. Are you hitting hard poop? Where um a oral Miralax clean out will be difficult to clean up this hard poop and you're not, you're gonna need enemas or are you hitting soft poop where you could clean them out with Miralax or you hitting no poop? Right? Um And then in the infants you wanna see if you can uh uh simulate like a squirt sign for hirsh brung disease. Um Other than you should also look at the back because like what you're looking for is like um any sort of spinal pathology. So like a tuft of hair or a sacred dimple or glu cleft deviation. So those are like all alarm symptoms that you're like, mm I should do further work up for this constipation. So for this patient though, she didn't have any of these ref lax, right? Um So like what you do at the general pediatric clinic is definitely do a diet history. If it's infant, you wanna ask a little bit more about what they're getting in, in terms of formula because cow's milk protein allergy can present as constipation. Um And then you also want if they're older, right? And they're taking in like cow's milk, for example, then you wanna see how much dairy intake are you taking in because like I have had babies like literally drink five bottles of cow's milk and that's like too much that's constipating. Um And so you definitely want to cut down on the dairy. Um If you wanna like because it's constipating. Um then you wanna also ask like, is there like certain behaviors around toiling? So like are they scared of the toilet? Do they not wanna sit on the toilet? Was toilet training? Really? Um uh traumatizing for them? Do they like when they feel the sensation to poop? Do they like run to the corner and hide there to poop? Um So things like that. Um And then the most important thing you can do as a general pediatrician is to do a digital rectal exam. It can provide so much information like number one it can uh is this like look, you look at the location of the anus, right? Is the anterior place? Is it a weird anus like as in like I've seen that before where you can't even stick a finger in? And we need to worry about Impey anus and we have to worry about anal rectal malformation. Uh You also wanna look at like, is it a good tone? Do I need to get an MRI of the spine? Is it like the lower extremity is a strong? Um And then you also wanna look at the spine and make sure like, oh, do I need to worry about the spine? Like for infants, you can do an ultrasound spine for the older people, you can do an MRI of the lumbar spine. Um If um if you're doing, if you're really struggling with constipation, so I don't recommend initial work up for everyone that has constipation in the general pediatric clinic. But if you're truly struggling, right, you can do some initial work up while they're waiting to be seen by uh A pediatric G I so definitely check the thyroid, right? Like low thyroid can cause constipation, electrolytes for sure. Uh Celiac screen um to make sure it's not undiagnosed celiac disease. Fun fact, even though the kids that have constipation from celiac disease, the constipation sometimes don't improve when they go on a gluten free diet, just like a fun fact. Um You also want to screen for inflammatory bowel disease where they're starting to lose weight uh because sometimes inflammatory bowel disease can present as constipation and not always like this nima and diarrhea and blood in the poop. Um And also calcium levels. And so that's like on the right hand side is all the differential diagnosis uh associated with constipation. Um You can do an X ray to guide the clean out and to assess how much poop burden is in there on the X ray. You can actually also see if there's like a mega rectum because like um how do you tell if the rectum is big? Right? Like, so what I use as like a um a uh uh rule of thumb is that if it's bigger than the spinal process and that's a mega rectum. And so what does that mean? Right. So once I see a mega rectum, I'm like, ok, this kid definitely needs a clean out. I think he's withholding or and then it also needs um might benefit from enemas if the kid is amenable to that, but a lot of kids are not amenable to enemas. Um And then you also wanna like this kid might need stimulant laxatives instead of just mere lax. Um So those are some things to look for. Ok. Sometimes we can do cyst markers to differentiate between the types of constipation like slow transit and outlet dysfunction, which is withholding. Uh We can also do an erectum manometry and balloon explosion test to look for things like Hershman disease and pelvic floor dysynergia. Uh We can also do colonic Monet to test the whole mortality of the colon to see if they're a candidate for psychos toy or ostomy for the really refractory constipation. Um And then for you, you can increase fluids, fibr supplements, prebiotics and probiotics and increase physical activity. Um Those don't really work though according to literature, but the number one thing is that you have to dis impact them, you have to do a clean up first and then start them on a maintenance regimen with a goal of daily peanut butter consistency stool. If there are anything less, they should be more maintenance regimen, you could also do behavioral interventions. Sorry guys, these are all the laxatives um and these are the new ones on the market uh for um constipation. Um And that's it. This is what we can do now, this is what we can do in the future in terms of motility. Um And then this is a referral line. And then if you have any uh questions about like uh you need help with like something motility. You can always email me.