Providing a high quality of evidence based care to children and their families
Conditions We Treat
At the Paediatric Gut Investigation Clinic, we treat a range of digestive disorders in children ranging from minor to life threatening and acute or chronic. Our experienced team are available at Spire Gatwick Park Hospital to give the best treatment and paediatric care to patients. We specialise in treating patients from birth until the age of 18.
Below is the list of conditions that we treat. If there is a particular condition or symptom that you are seeking help for and that is not listed, please feel free to contact a member of the team.
Irritable bowel syndrome (IBS)
It is a common functional gut condition. It is estimated about 1 in 6 of us suffers from IBS. IBS symptoms include abdominal discomfort and bloating, variable bowel habits between constipation and diarrhoea. The abdominal discomfort tends to get better after passing stool. The stools sometimes contain mucous. IBS sufferers often complain about the feeling of incomplete defaecation.
Although IBS is not a serious condition, the symptoms can be troublesome and can limit activities and affects their quality of life. It is more common in females than males.
Patients who are labelled with “IBS” may have underlying food intolerance such as sucrose or fructose or a small bowel bacterial overgrowth. It is therefore important to rule out these conditions before concluding a diagnosis of IBS.
The management of IBS is through lifestyle changes, avoidance of trigger foods, and managing stress. Low FODMAP (Fermentable Oligo Dimonosaccharides and Polyols) may be beneficial in some patient groups.
Constipation is a common problem in children. It is estimated 1 in 3 children will experience constipation during their childhood. The peak incidence is at the time of toilet training around 2-3 years of age. Children with constipation often have infrequent bowel movement (less than 3 times a week). The stools are either abnormally large or small in size like rabbit droppings and they tend to be hard and dry. These children often experience anorectal pain during defaecation, which leads to deliberate stool withholding. This prolonged period of stool retention increases the size and hardness of stools making them harder to pass. This eventually leads to development of megarectum, devoid of defaecation sensation and subsequent soiling. These children are often worried and quiet, have low self-esteem, experience bullying and being excluded from their peers. Lack of appetite, abdominal bloating and nausea are common findings.
Functional or idiopathic constipation (in the absence of an organic cause) is by far the commonest cause of constipation. There are organic causes for constipation such as hypothyroidism, Hirschsprung’s disease, coeliac disease, food allergy, connective tissue disorder (Ehler-Danlos Syndrome), reduced fluid intake, anorexia nervosa, narcotic usage and hypocalcaemia. These causes account for <10 % of all cases.
NICE has published a guideline for the management of constipation in childhood in 2010 and it was revised in June 2015 based on best evidence strategy for children with constipation in primary and secondary care settings. The goals of the treatment is for the child to be able to pass good amount of stools with relative frequency (3-5 stools per week) and normal consistency, without soiling and excessive straining. Children with simple constipation can be managed successfully with low dose osmotic laxatives, high fluid and fibrous diet. On the other hand, children with refractory constipation often need escalation of laxatives (combination of stool softeners and stimulants), managed by paediatricians and gastroenterologists. Faecal disimpaction by using Polyethylene Glycol (PEG) is often required. Rectal enema and surgical evacuation may be required in extreme cases. Parents should be warned that soiling may get worse during the initial phase of faecal disimpaction.
Parental and patient education is essential. Explanation of physiological basis constipation and soiling provides better understanding of process of constipation. Parents often have mistaken soiling for diarrhoea. They are often reluctant to give laxatives to their children for fear of them becoming dependent on laxatives. Reassurance of parents that laxatives are safe and adverse side effects are rare is important. They also need to be aware that non-punitive behaviour interventions and rewards are desirable for positive outcomes. Sudden cessation of laxative treatment should be avoided as if often leads to relapse of constipation.
Food allergy induced constipation (mainly cow’s milk and wheat allergy) is increasing recognised as a cause for constipation. Excluding these from their diet often leads to improvement of bowel movement and subsequent successful weaning of laxative.
Primary care physicians tend to undertreat children with constipation. Recent evidence has suggested that early adequate therapeutic intervention was more likely to be beneficial and contributed to successful outcome of constipation. In general 50% of children with chronic constipation will be cured after a year and 65-70% after 2 years, particularly in motivated, compliant families.
Crohn’s disease is a chronic idiopathic inflammatory disease that can affect any part of digestive tract from mouth to anus. Currently, there are at least 115,000 Crohn’s disease sufferers in the UK. Between 25-30% of Crohn’s disease patients are diagnosed before the age of 20. Children have a predisposition to have more severe disease (small bowel disease) at presentation and their diseases also have tendency to progress more rapidly compared to adult counterparts.
The cause of Crohn’s disease is unknown. Smoking and a genetic predisposition are thought to play an important role in the pathogenesis of the disease.
The diagnosis of Crohn’s disease is often delayed compared to Ulcerative Colitis, mainly due to the less prevalence of rectal bleeding. Children with Crohn’s disease may have insidious symptoms such as lethargy, intermittent bouts of diarrhoea, poor growth and generally being unwell. Only 25% of patients have the classical triad of abdominal pain, weight loss and diarrhoea, and 22% have rectal bleeding. When the abdominal pain coincides with eating, it may indicate small bowel stricture.
Blood tests often reveal raised inflammatory markers (CRP, ESR), low haemoglobin, low albumin (when there is extensive small bowel involvement), and markedly raised faecal calprotectin level. These laboratory tests may be normal if there is only limited disease, such as terminal ileum. It is important to obtain stool sample testing for infectious cause of diarrhoea including clostridium difficile.
Endoscopy is necessary to allow adequate mucosal survey and obtain a tissue sample diagnosis. The presences of epitheliod granuloma (less than 50% of bowel biopsies) and transmural inflammation with skip lesions in the bowel biopsy support diagnosis of Crohn’s disease. MRI of the small bowel is useful to detect small bowel involvement. When there is diagnostic difficulty, video capsule endoscopy can be deployed to obtain pictures of the small bowel.
The initial treatment of Crohn’s disease is either using exclusive enteral polymeric feed (modulen or Elemental E028), or corticosteroids. Enteral feed is preferable in children to promote better nutrition and growth. Corticosteroids are useful when such enteral therapy is not tolerated.
Patients with frequent relapses requiring repeated courses of steroid are likely to need long term immunosuppression medications such as Azathioprine, 6-mercaptopurine or methotrexate in order to keep disease in remission. Biologics such as infliximab and adalimumab are effective in inducing and maintaining remission in children who have advanced disease. 5-aminosalicylate acid can be useful in children with mild form of the disease. Up to 50-80% of people with Crohn’s disease will eventually need surgery due to a range of reason such as bowel stricture, fistula, abscess, and bowel perforation.
Patients are encouraged to join organisatons such as Crohn’s in Childhood Research Association (CICRA) and National Association of Crohn’s and Colitis (NACC) where they can obtain useful information about Crohn’s disease.
Ulcerative colitis (UC) is a chronic idiopathic inflammatory disease of the large bowel. The disease starts at the rectum and may extend proximally to other parts of the large bowel. The cause of UC is unknown, although genetic and environmental factors (hygiene, smoking) may play a part.
Patients with ulcerative colitis have tendency to have rectal bleeding associated with diarrhoea. Other common symptoms include lethargy and abdominal pain. Endoscopy is important to assess the integrity and extent of the large bowel involvement.
The treatment of UC is aim at reducing the bowel inflammation. 5-amino salicylate (5-ASA) is used to treat for mild disease. Corticosteroids may be needed for moderate to severe disease. Patients who has frequent relapses may need immunosuppressant Azathioprine to induce long term remission. In severe cases that are not responding to medical treatment, bowel surgery may be required to remove the inflamed bowel.
Patients are encouraged to join organization such as the National Association of Crohn’s and Colitis (NACC) where they can obtain useful information about Ulcerative Colitis.
Chronic abdominal pain
Abdominal pain is very common in children. Up to 10-25% of school-age children suffer from chronic abdominal pain. Abdominal pain can be mild and sometimes severe requiring high dose of pain killer. It is defined as 3 or more bouts of pain severe enough to limit activities, over a a period of 3 months. It implies no known cause has been identified. In other word, biochemical markers and imagings have failed to detect the abnormalities that would explain the cause of the abdominal pain. Hence the diagnosis is by exclusion of other known causes. The pain is usually generalised and lack of focal tenderness. Although it is not life threatening, the chronicity of pain can be troublesome to the patient affecting both physical and mental health. It has a big impact on patients’ daily activities and quality of health. Additionally, it also add on burden to the family members for example loss of work from parents and multiple clinic consultations.
Children who have long standing history of abdominal pain tend to be anxious and hypervigilant. Often they feel despondent and have low mood and easily fatigued.
There is no universal effective treatment of children with recurrent abdominal pain. Education, reassurance, cognitive behavioural therapy may be useful in alleviating the pain, Anti spasmodic medications are sometimes helpful in alleviating the pain.
Coeliac disease is an autoimmune condition of the small bowel caused by a reaction to gluten. Gluten is found in wheat, rye and barley. It is a common condition occurring in about 1 in every 100 people in UK. It is more common in Caucasian population.
Coeliac disease comes in different forms; typical, atypical, silent, latent and refractory. Typical coeliac disease has classical abdominal symptoms such as bloating, abdominal cramps, diarrhoea and constipation when ingesting gluten. Atypical coeliac disease is when a patient does not have gastrointestinal symptoms, instead they have extra intestinal symptoms such as migraine, ataxia and joint pains. Latent coeliac disease is when a patient tested negative for coeliac disease but later develop the disease. Refractory coeliac disease is when a patient continues to be clinical symptomatic despite being on a gluten free diet. Cross contamination of gluten free food with gluten containing food is often the cause of “refractory” coeliac disease
Patients with coeliac disease may have other extra intestinal features such as dermatitis herpetiformis, dental enamel hypoplasia, iron deficiency anaemia, low vitamin D, short statue, delayed puberty, arthritis, osteopenia or osteoporosis, ataxia, psychiatric disorder.
Coeliac disease patients have raised anti-tissue tranglutaminase antibody and positive endomysial antibody. Patients often undergo gastroscopy to obtain a histological diagnosis of coeliac disese which show the presence of villous atrophy.
Coeliac disease is a lifelong condition. Patients need to be on gluten free diet indefinitely. The patient and family are encouraged to join the Coeliac UK Society for information and support.
Gastroesophageal Reflux (GOR) is a condition where the food contents from the stomach go back up to the oesophagus. It is very common in infants. It is estimated up to 50% of infants less than 3 months of age have reflux. Only 1% of these infants will still be experiencing reflux by the age of one.
Gastroesophageal reflux can presents in many ways such as regurgitation, distressed behaviour or irritability, back arching, disturbed feeding, recurrent cough, faltering growth and apnoea.
There are many ways to diagnose gastroesophageal reflux. A good detailed history is important. Barium swallow and abdominal ultrasound can detect reflux in real time. 24 hour pH study can detect acid reflux. New study pH impedance study can detect acid, non-acid and alkaline reflux. Gastroscopy helps to detect oesophagitis and oesophageal stricture (narrowing).
A simple non-complicating reflux need not require medicinal treatment. Reassurance and practical advice such as frequent winding, avoidance of over feeding, 30 degree head elevation, frequent smaller feeds are often suffice. Feed thickeners such as carobel, SMA Stay Down, Cow and Gate Anti-Reflux and Aptamil Anti-Reflux milk can be trialed before considering gaviscon. For infants whose reflux are not controlled with the above measures, antihistamine H2 receptor antagonist and proton pump inhibitors may be considered.
Food protein hypersensitivity (milk, soya, egg, wheat) can also cause reflux and should be considered if there is no relief from antihistamine H2 receptor antagonist or proton pump inhibitors. In these cases, reflux symptoms will improve only after eliminating these foods from their diet.
Peptic ulcer disease
Peptic Ulcer Disease (PUD) commonly involves the stomach and first part of the small bowel which is the duodenum. Most peptic ulcer disease is caused by the use of nonsteroidal anti-inflammatory drug and helicobacter pylori. Smoking and alcohol can predispose to PUD. Patient may experience heart burn, epigastric pain (pain just below breast bone), left hypochondrium (below left rib cage), nausea and bloating. In severe cases, it can cause black tarry stools (melaena) and hametemesis (vomiting blood). Patients with duodenal ulcers tend to have pain at night whereas gastric ulcers sufferers tend to have pain triggered by food.
Helicobacter pylori gastritis is more common in the adult population. Treatment with proton pump inhibitors coupled with 2 antibiotics for 1 week is usually effective in eliminating the bacteria. NSAIDs induced ulcers is common. Patients should be refrained from using NSAIDs (aspirin, ibuprofen) if there is a clear history that NSAIDs causing the ulcer. Anti-secretory agents including anti histamine H2 receptor antagonist (ranitidine) or proton pump inhibitors (omeprazole, lansoprazole and esopmeprazole) for 4 weeks is usually required.
Gastroscopy is indicated for patients who do not response to medical treatment. It allows detailed mucosal assessment checking for erosive oesophagitis, gastric ulcer, duodenal ulcers.