Below are listed the common childhood gastrointestinal problems. If you click on any of the subjects, your browser will take you to the relevant section:
 

pH studies

This is the way to look at the amount of acid entering the lower part of the oesophagus which might cause problems due to reflux. It is a thin plastic tube placed usually at endoscopy so the insertion does not cause any discomfort and the tip lies about 3-4 cm above the junction of the oesophagus and the stomach. It is attached to a small box the size of a iPod type device and is usually left for 24 hours and the infant or child is encouraged to have as normal a day as possible. It records the amount of acid entering the oesophagus and this information can then be downloaded onto a computer and event markers such as sleeping, feeding and discomfort experienced can be recorded and then used in conjunction with the acid trace on the computer to determine the importance of any acid reflux causing problems and to determine the extent and severity of the gastro-oesophageal present.

• Technical Principle
  - gastric pH < 4
  - oesophageal pH 5 - 6.8
  - pH registration (0.25 Hz) and analysis
  - episodes of pH < 4 or > 7.5 in the oesophagus that fulfill the criteria of the standard algorithm are  considered GOR
• acid (< 4) and alkaline (> 7.5) GOR
• physiological oesophageal pH 5 - 6.8: concealed
• hypoacidic postprandial phase: concealed

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Oesophageal motility and manometry studies

These are a way at looking at the movement of the oesophagus and pressure waves set up by normal movement of the oesophagus and are quite unusual to be required. They are not particularly pleasant to undergo and therefore we do not use them very frequently in Paediatrics.

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Hydrogen breath tests

These will require your child to be present at the Outpatient Department for a period of 3 or more hours without having breakfast before arriving. This is because a drink involving an amount of the sugar to be tested for such as sucrose or lactose will be drunk and then if this is not absorbed properly into the gut it will be passed through into the large bowel where normal bacteria present will use the sugar for their growth and as a bi-product use hydrogen. This hydrogen will be absorbed via the gut lining and then it will leave the body in the child's breath. This can be detected by simply collecting one breath every 30 minutes or so and analysing it for the amount of hydrogen. This is a non-invasive way for looking for sugar malabsorption of various types.

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Common gut related blood tests

There are many different ways of looking at nutrition via blood tests such as iron levels, calcium levels and vitamin levels. There are many ways of testing for absorption problems such as Coeliac disease and there are many ways of looking for inflammation indirectly via blood tests. We can also look for anaemia and inflammation of the liver and the pancreas. Blood tests for allergies can also be used but these usually help in looking for the acute type of allergy such as that which occurs with rashes, asthma, hay fever rather than necessarily helping with the longer term delayed reactions associated with gut related food allergies. Although these tests if positive can be helpful, if they are negative they are less helpful.

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Liver biopsy

This is not usually needed unless there is a problem with the liver and in this circumstance it occurs usually with a general anaesthetic and a needle is passed into the right side of the abdomen just above the edge of a the rib cage and a small core of liver tissue, approximately 1-2cm in length and 1mm wide is removed. This will be in conjunction with a general anaesthetic and also installation of a local anaesthetic on the area so that when the child wakes up there is no significant discomfort experienced. It would be necessary to keep your child in hospital overnight in order to observe them as very occasionally a blood vessel can be punctured and this may cause bleeding. A blood count will be taken the next day to ensure that no significant blood less has occurred. Very, very occasionally the lung lining can be pierced causing what is called a pnuemo-thorax which is a recognised complication, albeit very rare, and this may cause breathing problems. Puncture of the gall bladder has been reported but is extremely rare.

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Pancreatic function studies

The easiest way to test for normal pancreatic function is by a sample of stool but more formal pancreatic function studies may occur via collection of the juice produced by the pancreas under direct vision by sucking this out by endoscopy and this may take up to an hour. This is an unusual test to be needed however.

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Faecal analysis

Faeces can be looked at for bacteria, viruses, the presence of parasites but all these are not particularly reliable. Faecal elastase is a test which can look for pancreatic function. There are other tests to look for blood loss and inflammation. In general, however, faecal analysis is not particularly helpful.

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Meckel's diverticulum isotope scan

This involves injection of a radio-isotope into a vein which then collects in particular tissues containing gastric lining acid producing cells. In a Meckel's diverticulum which is a remnant of the embryological development which is an out-pouching of the small bowel and present in 2% of the population, this can have an ulcer present in it because of gastric tissue which is not normally there producing acid. This will be highlighted as a hot spot on a special type of x-ray after injection of this radio-isotope. It requires a morning being set aside but no anaesthetic is necessary and it is like a simple x-ray, albeit it with an injection.

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Barium swallow

Please refer to the Portland web page. www.theportlandhospital.com

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Barium meal and follow through

Please refer to the Portland web page. www.theportlandhospital.com

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Abdominal CT scan

Please refer to the Portland web page. www.theportlandhospital.com

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Abdominal MRI scan

Please refer to the Portland web page. www.theportlandhospital.com

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Cranial CT scan

Please refer to the Portland web page. www.theportlandhospital.com

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Cranial MRI scan

Please refer to the Portland web page. www.theportlandhospital.com

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Isotope white cell inflammatory scan

Please refer to the Portland web page. www.theportlandhospital.com

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Abdominal ultrasound

Please refer to the Portland web page. www.theportlandhospital.com

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Abdominal x-ray

Please refer to the Portland web page. www.theportlandhospital.com

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Upper GI endoscopy

This is a way of looking at the oesophagus, stomach and duodenum and first part of the small bowel, called the jejunum by using a video on a micro-chip relaying images to a screen. It is useful for diagnosing conditions such as gastro-oesophageal reflux, gastritis (inflammation of the stomach lining), gastric and duodenal ulcers, problems with absorption in the small bowel such as Coeliac disease or cow's milk protein absorption problems and certain distributions of inflammatory bowel disease, ie Crohn's disease. Under a short general anaesthetic, the procedure which will last approximately 5-10 minutes, will occur with pictures and video being taken.
 

Grade 2 Oesophagitis on Upper GI Endoscopy

Biopsies which measure 1-2mm in diameter will be taken in various points in the upper gut and will be looked at then under the microscope, the results of which are available within 5-7 days. It may be that the inflammation is at a microscopic level and is not therefore amenable to immediate diagnosis by looking with the naked eye but the endoscope allows us to have a relatively non-invasive way of looking at the gut for these pathologies.  The procedure itself does not cause any problems or health issues and the biopsy taking is not known to cause any significant problems, certainly no discomfort. As the biopsies are so small the chance of any breakage of the gut wall leading to perforation or any significant bleeding are very minimal indeed and although figures are not really available for this it is probably somewhere less than 1 in 5000.

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Ileo-colonoscopy

This is a way of using a video on a micro-chip relaying images to a screen to relay images by direct vision by an instrument which is manipulated by hand controls round the gut via the anus, via the colon to the area of interest. We will try to get round to the ileum which is the last part of the small bowel where it enters the large bowel or colon around about the area of the appendix. We would normally enter this area in 99% of people, except where there is a very narrow, scarred entrance point to the ileum. It is important to get to the terminal ileum because this is the area that is affected in 90% or more of patients with Crohn's disease.  It is also important that bowel preparation occur from the night before to allow a very clear view of the colon and this is dealt with in the bowel preparation section.
 

Terminal ileum - Crohn's Disease

Biopsies are taken which by themselves do not incur any discomfort and the risk of these causing any problems is virtually zero in the literature, probably a perforation risk of less than 1 in 5000. Without any bleeding problems the risk of any significant problem is virtually zero also. Therapeutic manoeuvres can occur such as removal of polyps that are present at the time and the risk of perforation in this circumstance is perhaps higher, anywhere between 1 in 100 to 1 in 500 but this is usually simply treated with conservative management, watching and waiting whilst the bowel repairs itself. A small wire is passed around the polyp which usually has a stalk like a bunch of grapes and this is slowly tightened as a very tiny electric current is passed through it in order to cauterise the polyp. The polyp would then be removed and analysed.

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Wireless capsule endoscopy

This is a new and exciting technique to look at the area between the beginning of the jejunum, small bowel and the beginning of the terminal ileum which is the majority of the small bowel and accounts for anywhere between 1 and 3 metres depending on the age of the child. It is a small capsule, approximately 23mm by 11mm which is swallowed and then transmits images via radio frequency, which is perfectly safe, to a harness which is worn for a period of 8 hours. It is useful for looking for inflammation in the mid-small bowel or for any polyps that have not been seen before or for any areas of bleeding which may be occurring causing anaemia or blood loss from the gut. We have pioneered the paediatric use of this technique at the Portland Hospital and Sheffield Children's Hospital and it has proven extremely useful in diagnosis. The capsules are disposable and are simply passed normally with faeces and are not usually retrieved. This may indeed be the future for diagnostic purposes although biopsies as yet cannot be taken with this technique.
 

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ERCP

The full name of this is endoscopic retrograde cholangio pancreaticography which is a way of looking at the drainage of the liver and the pancreas for any abnormalities such as gall stones impacted in the biliary tree which is the drainage system of the liver or any evidence to suggest inflammation in the pancreas due to congenital anatomical abnormalities for instance. It is like a normal endoscopy but includes x-rays and a dye passed by a small tube into these drainage systems which drain in to the second part of the small bowel called the duodenum. There is a 5% chance of initiating inflammation of the pancreas by this technique and hence this is the technique which usually involves an overnight stay after the procedure. Increasingly MRCP, which is an x-ray technique without endoscopy, is being used in adults to look for abnormalities involving these two drainage systems but as yet the sensitivity and detail allowed by these techniques in children is probably not superior to ERCP. If stones are found in the biliary tract they can be removed during this technique. The patient is usually covered by antibiotics during the procedure.

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Per-cutaneous gastrostomy

This is a technique by which a small tube is passed via endoscopy straight through the abdominal wall into the stomach cavity and a plastic tube is left there in order that feeds can be administered to promote good nutrition. This is particularly helpful for children with very bad feeding problems or an inability to use the normal routes of feeding to promote good nutrition. This happens in children such as those with cerebral palsy or those who have a requirement for calories which is much greater that their normal capacity to provide them, eg cystic fibrosis or significant feeding disturbances. The tube is usually 4-5mm in diameter and is made of an inert plastic. It has a flange on the inside which keeps it in place and usually some fixation device at the skin level. After a 3-4 month period it can be changed for a balloon device where a balloon inside can be inflated with water and this is flush on the outside of the abdomen with the skin. These devices can stay for a long period of time or they can be removed after a short period of time and when they are removed within 24 hours the small hole clears up. This is only 4-5mm in diameter and there is no other visible scarring.
 

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Endoscopic fundoplication

This is a new technique which Dr Thomson has been performing and is reserved for children with significant reflux which has not responded to high dose medical treatment with medicines or in whom the child has been dependant on high dose medical treatment and the parents and the child after a period of a year or more have decided that they do not want to be on long term treatment. It has been shown to be effective, reversible, safe and efficacious in 90% of the children down to the age of 6 in whom it has been performed to date. The time that this has been now shown to be effective is up to 18 months in this age group. At the present moment this is a technique offered by only 2-3 centres worldwide and Dr Thomson is pioneering this.  We have recently described a 3 year experience of 17 children with good efficacy in 11-12 of the 17 sustained for 3 years and we have now described a 1 year experience for over 60 children with a very good success rate.It has the extra advantage of not preventing a formal operation from occurring subsequently and the benefit that it is not a permanent anatomical change as occurs with the surgical fundoplication. Problems are associated with the surgical fundoplication in up to 60% of children such as an inability to burp, an inability to vomit, an inability to swallow properly and 20% of children require this to be repeated within 5 years. 20% also have a failure of this form of procedure to control their symptoms. With the endoscopic fundoplication the endoscopy takes approximately just over an hour and from the child's point of view at least it is simply like having an endoscopy. What actually happens is 3 pairs of stitches are placed just below where the oesophagus meets the stomach and have the effect like a purse string. After this anti-vomiting medicines are given for 24 hours just as a precaution and a pureed diet occurs for a 4 week period. After the procedure, probably 6 weeks later, a pH study will occur off treatment to ensure improvement in the amount of acid reaching the bottom of the oesophagus from the stomach. This technique has great promise in being a relatively non-invasive, safe, effective and reversible technique for the control of these longer term reflux problems in this specific population in children.

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Practical Issues

Bowel Prep

This is the term used to encompass the technique to clean the large bowel of faeces prior to doing a colonoscopy. It will require that your child comes into hospital with you in the late afternoon prior to the colonoscopy and at that junction the nurses will give two types of medicines which work as strong laxatives to clear the bowel. This will usually be given at 6pm and then again early in the morning prior to the procedure. This will result in diarrhoea which unfortunately is necessary to clear the bowel out properly. If your child's bowel motions are not clear approximately 1 hour before the procedure then an enema will be administered in order to clear the rectum out effectively.

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What happens during admission

You will come in either the night before the procedure for colonoscopy and more complicated endoscopic procedures or on the morning of the procedure and you will have had an opportunity to talk to Kate King, Practice Manager, and Dr Thomson prior to coming in to the hospital regarding what this will involve. In essence no solid food will be given if you come in the night before for bowel preparation for colonoscopy and no foods or milk should be given after 2.30am on the morning of the procedure before an endoscopy. For an endoscopy you will be expected to be in the hospital by no later than 7.30am and clear fluids may be given up until 6.30am.

When you come to the hospital you will be directed to the appropriate floor where the nursing staff will be expecting you and will go through a nursing clerking procedure. You may see one of the junior doctors who come in the night before who will do a medial clerking procedure which is just a formality to ensure that your child is well. On the morning of the procedure you will see Dr Thomson who will go through any questions you might have and a long consent document will be explained with complication rates of the procedure and any other matters that might be needed by you to be explained will be addressed at that time. You will be expected to sign a consent form and will be given a copy of this. By this time your child will have been changed into a theatre gown and you will also have seen the Anaesthetist, usually Dr Lloyd-Thomas (www.AL-T.dial.pipex.com) who is a very experienced Paediatric Anaesthetist and one of the best in the country at his job and your child will therefore be in extraordinarily safe hands. He will explain the whole anaesthetic procedure and details of this and the pre-anaesthetic arrangements are available on his web page. You and your child will go down to the endoscopy theatre and you will be able to stay with him/her until they go to sleep and then you will be escorted back to the ward. When the procedure is finished which usually takes 10 minutes for endoscopy or 20 minutes (maximum 30 minutes) for the colonoscopy you will be invited to come down the recovery area which your child will be waiting. The whole time you are away from your child may take longer because of the waking up time in the recovery area and there will be a recovery nurse there to explain what has happened. At this time Dr Thomson will come through and explain the findings if there are any which were seen by the naked eye, give you a video of the procedure, and with the aid of a diagram and photographs show you what was found, if anything. It is important to remember that the biopsies that are taken may actually be able to provide a lot more information when they are looked at under the microscope than the naked eye appearances at endoscopy. You will have the opportunity at this point again to ask any questions that arise. If any immediate medical treatment is needed this will be prescribed and you will return to your room with your child for a period of time until the nursing staff and yourselves are happy that your child has drunk and eaten and is able to go home. If a pH probe is placed at the time of endoscopy it may be that you elect to stay in the hospital overnight with your child and then the probe would be removed simply by gentle withdrawal the next morning. Dr Thomson will be available to the nursing staff during the time your child is an inpatient should any problems occur or questions arise that you may have. Blood tests are usually taken whilst your child is asleep rather than when they are awake in order to minimise any discomfort or bad experiences.


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