Gastroenterology and Hepatology

Starship's Gastroenterology/ Hepatology service provides assessment, diagnosis, treatment and long term follow-up for children and adolescents with a wide range of gastrointestinal and liver conditions. The service is part of the New Zealand Liver Transplant Unit, providing a nationally based service for children requiring transplant.

Our team currently is made up of five consultant gastroenterologists & hepatologists, three nurse specialists as well as many other staff including junior doctors, dietitians, pharmacists, psychologists, social workers, cultural support workers and play specialists.


What is Gastroenterology?

Gastroenterology is the branch of medicine concerned with the diagnosis and treatment of disorders of the stomach, small and large bowel and the pancreas.
Such disorders include:

  • Inflammatory bowel disease (Crohn’s disease, ulcerative colitis and IBD unclassified)
  • Intestinal failure & intravenous nutrition (IVN) dependence (sometimes called TPN dependence)
  • Coeliac disease
  • Complicated gastro-oesophageal reflux
  • Gastrointestinal bleeding
  • Children with a risk of familial bowel cancer (eg. polyposis syndromes)


What is Hepatology (liver disease)?
Hepatology is the branch of medicine that is concerned with diseases of the liver.
Such disorders include:

  • Liver transplantation
  • Biliary atresia
  • Autoimmune hepatitis and sclerosing cholangitis
  • Intestinal failure-associated liver disease
  • Viral hepatitis (B and C)
  • Fatty liver disease & NASH
  • Alagille syndrome
  • Metabolic liver disease
     

Consultants

  • Dr Stephen Mouat Paediatric Gastroenterologist & Hepatologist
  • Dr Helen Evans Head of Department & Consultant Paediatric Hepatologist & Gastroenterologist
  • Dr Jonathan Bishop Paediatric Gastroenterologist & Hepatologist
  • Dr Amin Roberts Paediatric Gastroenterologist & Hepatologist
  • Dr Robert N Lopez Paediatric Gastroenterologist & Hepatologist

Referral Expectations

Many common childhood gastrointestinal problems such as uncomplicated gastro-oesophageal reflux, abdominal pain and constipation can be managed well by general paediatricians and GPs without needing input by the Paediatric Gastroenterology & Hepatology Service. Our service primarily manages serious, long-term gastroenterology and hepatology conditions such as inflammatory bowel disease, liver disease and intestinal failure.

We have updated our referral criteria in 2014 for GPs and paediatricians.

REFERRAL OUTCOMES

Urgent assessment
If your child has an urgent problem, they will be assessed in the Children's Emergency Department at Starship Hospital. Based on your child’s condition they may be admitted to Starship Hospital for ongoing care or follow-up arranged at the outpatient clinics.

Patients from outside of Auckland will be assessed by their local paediatrician who will discuss with the on call paediatric gastroenterologist & hepatologist at Starship. Appropriate arrangements for transfer to Starship can then be made if required.

Other assessment
If your child has a less urgent problem, a letter of referral will be sent to our department. A senior doctor will look at the letter and a decision will be made based on the information provided in the letter. We are not able to see all children referred to us and many conditions can be looked after by general paediatricians. Possible outcomes from referral include:

  • Outpatient clinic appointment:

An appointment will be offered. For most referrals this will be within a month. All children will be seen within 4 months. If your child's symptoms are getting worse while waiting, please see your General Practitioner or paediatrician again.

  • More investigations are needed:

Sometimes, when we read the referral letter, we feel it would be useful for your child to have more tests, either to decide whether we need to see your child or to provide valuable information for when we see your child. These tests may be blood, urine or faecal (stool) tests or radiological tests (eg. X-rays or ultrasound scans).  In this case we will write to your referring doctor asking them to arrange these tests, then refer your child when the tests have been done.

  • Endoscopy:

For some conditions your child may be booked directly to endoscopy without being seen in clinic first. The reason for this is to decrease delay prior to treatment. Both you and the referring doctor will be sent a letter explaining this. If you have any concerns or questions please contact the team via our secretary (extension 22292 at Starship Hospital) as we can see you in clinic to discuss things more fully, if necessary. Endoscopy waiting times are currently 8-12 weeks.

  • Referral to another service:

Straightforward cases may be referred back to your referring doctor (as explained above) with written advice or we may suggest a more suitable service to see your child.

  • Referral return:

Sometimes your child may already be receiving appropriate management from their general practitioner or general paediatrician and we will not need to see them. In this case, an appointment is not made and we write back to the referrer. Should symptoms change, a re-referral to our service can be made.

 


 

Common Conditions / Procedures / Treatments

Gastroscopy/Upper Endoscopy

This is a camera test which allows the doctor to see inside the oesophagus, stomach, and the first part of the small intestine (duodenum). 
 
What to expect
Your child will have a general anaesthetic (be completely asleep) for the procedure.  The gastroscope is a flexible plastic-coated tube about the width of a ballpoint pen which has a tiny camera attached that sends images to a viewing screen.  It is passed down through your child's mouth into the oesophagus (food pipe), then onwards into the stomach and duodenum (first part of small intestine).  During the gastroscopy, the doctor may take a biopsy (a small piece of tissue) to send to the laboratory for testing. This is not a painful procedure. The gastroscopy will be performed as a day case procedure so you child will go home the same day.  It takes around 20 minutes but your child will be away from you for around 1 hour to allow them to recover from the anaesthetic.
 
Before the procedure
You will be sent instructions as your child will need to fast for several hours before the endoscopy.

After the procedure
Your child will stay in the Day Stay Unit until they are ready to go home.  If biopsies are taken these will be sent for analysis and results will be available within 2-3 weeks.  A report and copies of these will be sent to the doctor who referred your child. We do not telephone results.

Colonoscopy

This is a procedure which allows the doctor to see inside your child's large bowel and examine the surface directly and take biopsies (samples of tissue) if needed.  Treatment of conditions can also be undertaken.
 
What to expect
Your child will have a general anaesthetic (be completely asleep) for the procedure.  The colonoscope is a flexible plastic-coated tube a little thicker than a ballpoint pen which has a tiny camera attached that sends images to a viewing screen. Once your child is asleep the colonoscope is passed into the rectum (bottom) and gently moved through the large bowel.  This is not a painful procedure. The colonoscopy will be performed as a day case procedure so your child will go home the same day.  The procedure takes between 20 minutes and 1 hour, but your child will be away from you for around 1 to 1½ hours to allow them to recover from anaesthetic.
 
Risks of a colonoscopy are rare but include:-
  • bleeding if a biopsy is performed
  • perforation (tearing) of the bowel wall.
 
Before the procedure
Your child will need to follow a special diet and take some laxatives (medicine to make them go to the toilet) over the days leading up to the test.
 
After the procedure
Your child will stay in the Day Stay Unit until they are ready to go home.  If biopsies are taken these will be sent for analysis and results will be available within 2-3 weeks.  A report and copies of these will be sent to the doctor who referred your child.  We do not telephone results.
 

 

Liver Biopsy

The best way to establish what type of liver disease is present and the extent of the disease, is a biopsy.  Your child will have a general anaesthetic (be completely asleep) for the procedure.  The biopsy is usually performed by inserting a needle into the liver through the skin and taking a small sample of liver tissue. Examination of the sample under the microscope can demonstrate what damage or what type of disease is present. Before the doctor does this procedure, they will check whether or not your child is at increased risk of bleeding by doing blood tests. Following the procedure, children are monitored for a minimum of 6 hours in hospital and may require an overnight admission.

Barium Meal

This is an x-ray test of the small intestine. Your child will have to drink some special liquid (barium). If they are unable to drink the liquid, a soft flexible tube (naso-gastric tube) may be placed through one of their nostrils and then down into their stomach. The barium liquid can be seen on x-ray.  It coats the lining of the intestine and x-rays are then taken which may identify an abnormality of the intestine.

This test is done in the x-ray (radiology) department at Starship Hospital.

It is done to see if there are any problems with the small intestine (like Crohn’s disease or vomiting).

MR Abdomen (magnetic resonance scan)

This is a test where the abdomen is examined using an MR scanner. Children lie on a special table which moves in and out of a donut shaped scanner. Pictures of their small intestine and liver can be taken. There are no x-rays with this scan. The scan may take up to 45 minutes. It is noisy but completely painless.  Younger children may require a general anaesthetic to help them keep still during the scan.

pH/Impedance Study

A pH/Impedance study is a test designed to see if your child has reflux [the contents of the stomach coming back out the stomach into the oesophagus (food pipe)]. A pH/Impedance probe is a long, fine, flexible tube which is inserted through the nose and down the back of the throat. One end of the probe is taped to the side of the face and the other end sits at the bottom of the oesophagus. The probe is usually placed under sedation or general anaesthetic.

A small box is attached to the tube. This records the results of the test which usually last 24 hours.

A diary is kept by the parents of any food, sleep or symptoms that occur while the test is being carried out.

Endoscopic Retrograde Cholangio Pancreatography (ERCP)

This test is relatively rarely performed in children, so the Paediatric gastroenterology team usually seek support from colleagues in Adult gastroenterology who are very experienced in doing this test. Your child will have a general anaesthetic (be completely asleep) for the procedure.  A flexible tube with a tiny video camera attached (endoscope) is inserted through the mouth into the stomach and small intestine.  A smaller tube is then moved through the first tube into the bile duct (the tube that connects your child's gallbladder to the intestines).  Dye is then injected through this tube and into the bile duct.  This dye shows up on x-ray, so x-rays are then taken to look at the duct.  This procedure also enables dilatation (stretching) of narrowed ducts, placement of stents (tubes to keep narrowed ducts open) or removal of gallstones from the ducts without the need for surgery.

Oesophageal Manometry

This is a test to see how effective the oesophagus (swallowing tube) is at moving food and liquid from the mouth to the stomach. It is particularly useful in children who are getting food "stuck" in the oesophagus after swallowing.

A slender flexible tube is placed into the nose and down to the stomach.  The tube is usually placed with your child under sedation (medicine is given to make the child relaxed but not completely out to sleep).  Your child will then sip a small amount of liquid or eat a small amount of food.  The manometer measures how the oesophagus muscles are able to push liquid or food down.

It takes 10-20 minutes to complete the test, although the child will need to stay longer to allow the sedation to wear off before going home.

Intestinal Failure

Children who have intestinal failure are unable to take food normally either because their bowel is not working properly or because they do not have enough bowel because they have had some removed (short bowel syndrome). Most of these children can take some food by mouth, but are unable to absorb enough food and nutrients to allow them to grow and thrive. When this happens artificial nutrition may be given into a vein. We call this intravenous nutrition or IVN. Some other places call it total parenteral nutrition (TPN or PN). Children with intestinal failure are seen at Starship for assessment and to create a treatment plan to maximise the rehabilitation of the remaining bowel, with the aim that they will eventually be able to feed normally. Some children are born with problems in the way their intestine absorbs food or in the way the food is moved along the intestine. These children may require IVN for their whole life and will therefore be managed mainly by the Paediatric Gastroenterology and Hepatology Service at Starship Hospital.

Biliary Atresia

Biliary atresia is a disease that affects children in the first weeks of life. The tubes which connect the liver to the intestine become damaged and blocked. Babies with biliary atresia will have jaundice (yellow eyes and skin) and pale stool (poo). Babies usually look otherwise well.  It is common for babies to be mildly jaundiced in the first week of life. However, if your baby is  deeply jaundiced  (very yellow eyes and skin)  and is still jaundiced after 2 weeks of age and/or has pale stool they need an urgent blood test.  If the blood tests suggest they may have biliary atresia they will be admitted to hospital urgently for further testing and possible surgery.

Autoimmune Hepatitis and Sclerosing Cholangitis

Autoimmune hepatitis and sclerosing cholangitis are a group of uncommon liver conditions where the body’s own immune system begins to attack the liver and the bile ducts which drain bile into the intestine. Symptoms of autoimmune hepatitis or sclerosing cholangitis include jaundice (yellow eyes or skin), itchy skin and tiredness. Diagnosis can be suspected based on blood test results but requires a liver biopsy for confirmation and usually a specialised Xray called an MRCP or MR cholangiogram.

Hepatitis B and C

Hepatitis B and C are viruses that cause long-term damage to the liver. Most children with Hepatitis B and C are very well and don't have any particular signs or symptoms of the virus. Usually the virus is transmitted from mother to baby. It is important for us to see and monitor your child regularly to make sure their liver is staying healthy and that no complications are developing. Children usually have blood tests and a scan every year. Often treatment for the virus can occur when your child is older. For more information about Hepatitis B and C see www.hepfoundation.org.nz

Liver Transplant

Although severe liver disease is relatively rare in childhood, a small number of children in New Zealand will need a liver transplant each year.  The Department of Paediatric Gastroenterology and Hepatology at Starship Children’s Hospital is part of the New Zealand Liver Transplant Unit. The service provides liver transplant assessment, surgery and long-term follow-up for all children in New Zealand who require a liver transplant.

Inflammatory Bowel Disease

Inflammatory bowel diseases (IBD) are a group of conditions that cause long-term inflammation of the intestines (bowel). These conditions can affect only the large bowel (ulcerative colitis) or may affect any part of the entire digestive tract, from the mouth to the anus (Crohn's disease).
Symptoms of inflammatory bowel disease may include: frequent bowel motions which may contain blood or mucous, abdominal pain, fever, weight loss, pallor and fatigue. The inflammation can also affect other parts of the body, such as the eyes, joints or liver.
Inflammatory bowel disease is treated with medicines and sometimes with a change in diet. In some cases, surgery may be needed.

Coeliac Disease

Coeliac disease is an illness in which there is a permanent intestinal intolerance of gluten. Gluten is a protein found in wheat and other cereals, which is present in a lot of foods including bread and pasta.  Coeliac disease is common, occurring in about 1 in 100 people.  Symptoms include diarrhoea (loose poo), poor growth or stomach bloating. A proportion of people with coeliac disease have mild or no symptoms. This diagnosis is a common reason for referral.  The diagnosis may sometimes be made on the basis of blood tests, but a number of children require an intestinal biopsy to confirm the diagnosis.  This needs to be performed before any dietary change is commenced. The biopsy is taken at gastroscopy and is a day stay procedure.

The treatment is to stop eating all foods with gluten in them, like bread and pasta. Sometimes the blood test may be only mildly abnormal and in this case, a repeat test may be necessary before referral to our service for endoscopy. Most children who have confirmed coeliac disease can be followed up by their general paediatrician or general practitioner once they have adjusted to the new diet.

Gastrointestinal Bleeding

The presence of blood in vomit or in the stool (poo) is a common reason for children to be referred to the Paediatric Gastroenterology and Hepatology service.  The blood may be red or sometimes may cause tarry black stools. The cause will depend on the age of the child and may include oesophageal varices, (abnormal blood vessels at the bottom of the food pipe), stomach or duodenal ulcers, gastro-oesophageal reflux, Helicobacter pylori infection, inflammatory bowel disease, allergic colitis (allergic inflammation affecting the large intestine) or colonic polyps (non-cancerous growths) affecting the lining of the large intestine. The best way to find out the cause is a gastroscopy or colonoscopy (see above).  The urgency of this procedure will depend on the amount of blood passed and how unwell your child is due to the bleeding. 

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