Everybody poops. . . or not

Welcome to another episode of "Why Won't My Child Poop?" 

Today's cast of characters feature Ellie Bear, a distraught Mama Bear, clueless ER staff, members of the Comprehensive Care Clinic, and a jolly x-ray technician.

Want to know why this little Turkey is smiling?  This is outside Dell Children's Medical Center.
 She was there for her appt with Dr. Simon.  Elli is in luv with him. 

First, a little background:

I am unfortunately known among many parenting groups as "the poop guru" (seriously who wants that title as their claim to fame?) as I can pretty much get any child to poop. . . except my own.

Remember way back when Ellie went 22 days without defecating?  Well, by end of August we were back to that.  Okay, that is an over exaggeration as this go around it was more like 6 days, but given her surgical intervention from 2 years and 9 months ago, constipation shouldn't even be an issue.

Sadly, all of my experience as a former pediatric nurse practitioner and working closely with her gastroenterologist pretty much amounted to big amount of nothing in the Bear's land of excrement.  For those of you who have been following this blog for a while, then you are aware of such lengths we went to in the past to regulate Ellie's GI tract and we now know that she has what is called moderate-to-severe delayed colonic transit.  That's a fancy way of saying Ellie's colon doesn't move stool through it, but instead sits there getting harder and harder thus distending the colon.  If you really want to know the entire story as to what interventions, diagnostic tests, and whatnot that we have tried,  you can search this blog for "constipation" or "cecostomy" or click on the label on the right side bar or if you are feeling extra feisty, google "cecostomy" and this blog pops up.

Cecostomy

For those of you who are new to the Bear's adventures, Her Royal Stinker Butt had a cecostomy performed surgically back in December of 2016.  The purpose of this tube is that it allows for high volume enemas to be given directly into the top of the colon, thus flushing her out.  There are many types of enemas, but we were pretty much sticking with saline.  In theory, I know isn't everything great in theory?  Anyway, in theory, these enemas would keep her colon mostly empty and thus preventing her from getting constipated.  For the most part, it worked . . . until July when we were finding ourselves have to near daily enemas via the tube and even some rectal ones with minimal results.

Medications that cause constipation:

Do you ever read the side effects of medications?  Nearly every single of one of them go like this:

• Headache
• Diarrhea / Constipation
• Nausea
• Fatigue /Insomnia

So . . . Ellie Bear lost weight about 18 months ago.  Some of it was expected because we took her off of the Risperdal which caused excessive eating and excessive weight gain.  What we didn't expect was the amount of weight that she lost - over 7 lb.  Then that was it.  She just stopped growing for the most part.  She was still eating close to 1800 calories/day which is a lot of a child her age with Down syndrome (people with Ds have about 10-20% slower metabolism compared to the general population), but other than growing in height a little less than an inch, she hovers around 46 lb.  She is now 10 years-old.  She is not on the growth chart for weight while she is 18% for height on a Ds chart.

First vs. Last day of school last year

Where am I going with this failure-to-thrive nonsense?  Appetite stimulants!  That's right, GI has determined that she is 5-10 lb(!!!) underweight and she is probably a kiddo that just has a high metabolism and thus needs more calories. (E has a history of failure to thrive and again, there are several posts on this blog that address the FTT and determine what was the cause). Therefore, we started her on cyproheptadine (Periactin), which is a prescription antihistamine that works as an appetite stimulant (and along a migraine preventative FYI).  Again, where am I going with this?  One of the top side effects is. . . ding ding ding freaking constipation!!!

Mismatched shoes are in vogue right now - as per Fashionista Ellie

The point of this blog post:

Okay y'all.  Now that we've establish that my daughter was no longer excreting fecal matter on a regular basis thanks to a medication, she ended up in the ER.  After 2 months of never getting fully cleared out and then 6 days of nothing at all.  Absolutely nothing, I didn't know what else to do from home.  Saline, mineral oil, glycerin enemas.  Enema through the tube.  Rectal enemas.  We maxed out on what we could give her without causing phosphorus poisoning.  She looked pregnant and her stomach was hard.  The gas though. . . this child was tooting like her life depended on it.  The house and classroom smelled like cabbage and dead decaying squirrels.  Believe it or not, this was a good thing because it means there was no obstruction.

So there we were hanging out in the ER for fun and the resident walks in.  I start to relay what all I have shoved into this kid's colon (which would have been the equivalent of a colonoscopy bowel prep for at least 4 adults) and I am getting the whole skeptical "so this is all rectal?" and "are you sure she hasn't gone to the bathroom with all of that?"  Gah!  What part of tube in her colon or cecostomy tube were they not getting?!  After explaining it all yet again, I finally hear:

"So what is a cecostomy tube?"

Now granted, this was a resident and she was still learning and cecostomies are not common so I went with the:  "So a cecostomy is when  the appendix is brought to the surface of the abdomen and it is used for high volume enemas to essentially flush out the colon ..... and here are some pictures. . . "  For tips on preventing your child from pulling out tubes (i.e. g-tube and/or cecostomy tube), click here.

An x-ray was ordered to rule out bowel obstruction. Because the x-ray tech was a male, Ellie wanted to show off her awesomeness and be-bops over to the exam table for her x-ray and poses like she is a fashion model.

Then nothing.  I hear nothing!  The attending never comes in.  The resident doesn't come back in.  However, the nurse comes in with another enema which we could have done at home and I ask her for the x-ray results which to summarize involved a large volume of solid stool (no kidding, Sherlock). Let us not forget the 1cm x 1.5 cm foreign body that left me sighing and saying "again?"!  Twinkletoes has a history of this - see here.  Of course, they are all, "she'll poop it out." except my kid wasn't emptying her bowel at all!  After painfully pushing out the equivalent of 2 small meatballs, we were discharged without ever seeing the attending or resident.

The following morning, I informed GI that I would no longer be administering the cyproheptadine to Ellie.  The ER visit was August 26th and it wasn't until Sept 9th that things finally became regular.  It should be noted that while it appeared that Ellie gained 2 lb while on the appetite stimulant, she has lost those two pounds.  I am taking a survey on how many ounces you believe was stool.  Also of note, I never did find that foreign body.

~~~~~~~~~ 

*While this is a Down syndrome related blog, many of the health issues and psychiatric illnesses discussed here are unique to Ellie and not necessarily related to her having Ds.* Please see more information under the Disclaimers tab.

A quick update on Urology/GI procedure plan

When I last left off, I mentioned that both urologists confirmed that they could perform Ellie's cecostomy and tube placement for Monday Sept. 12, but they wanted to discuss the surgical approach.  Well. . . I was confused because at our long awaited urology pre-op appointment, we decided on a laparoscopic approach with the possibility of needing to open her abdomen up completely.

Of course, the other surgeon was out of town so they couldn't not discuss immediately.  I gave 2 weeks and left a message this past Monday with the nurse.  Tuesday, I get a phone call from Ellie's secondary GI specialist, the one who performed the colon manometry back in June. He tells me that the procedure will be done in interventional radiology [IR] where they just "pop" the button right in.  It is less invasive and the hospital stay is closer to 48 hour as opposed to 4 days.  Obviously, this is all good, except, at our urology appointment in July, GI relayed to urology to not do it through IR because her colon may be too floppy from being stretched out.  What?!  So do they bring her into IR and if it doesn't work we need to relocated to the OR?

Friday approached and as usual, I never heard back from the urology nurse.  Dr. McQ, the actual urologist calls me personally.  Her surgery on 9/12 was CANCELLED back on Tuesday since her procedure will be performed in interventional radiology and not the OR. She assumed that I knew this already.  Urology is no longer in charge.  GI put in the orders.  Radiology is taking over. If GI was going to put in the orders, why didn't he do so in June?!  I immediately called GI and then googled the number for radiology.  Radiology never calls back, but GI does. . . only it is the other GI's nurse.  According to her, IR is booking into late November, early December.  I may have lost it.  I spent the afternoon angry crying.

first day of 1st grade

Timeline:

June 16th - referred to pediatric surgery by GI, then Dr. C in urology
Dr. C out of town, then takes another week to look at her case
Referred to Dr. McQ in urology and she is out of town
July 24th - urology appointment, tentative surgery date because need to coordinate with Dr. S
Dr. S it out of town so more waiting to coordinate
Both urologist can do the 12th, but need to discuss approach, Dr. S out of town
August 30th - GI calls to change plan
Sept. 2nd - surgery cancelled
No new date yet.

She lost her front tooth!

This is ridiculous!  If she gets booked in December that is SIX months since the ordinal order was put in.  SIX MONTHS.  My daughter is in pain.  PAIN.  She is uncomfortable and only goes with a special enema that I have to constitute myself.  We can only give those enemas twice a week which is not enough to help her.  Her medications do nothing.  She spikes fevers because of this.  She had to have a urinary catheterization due to being unable to pee and screaming secondary to constipation.  This is unacceptable.  I will be rattling radiology's cage.  I will cry and beg for my daughter, but it isn't like I can personally create an opening in IR.  I will contact a patient advocate in hopes of filing a complaint.  Other than that, all I can do is scream and watch Ellie suffer for another 2.5 to 3 months while they all had their thumbs stuck up their *sses.  It seems they all forgot that a real human child is involved.






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Entourage, Little Thief, Oxygen, Urology

Hide the silverware!  My daughter is a thief.  She steals.  She is sly and crafty.  Ellie is obsessed with magnets.  Seriously, not metal object is safe around her.  She carries around her magnetic toys.  We were recently at a restaurant and when we returned home, she whipped out a fork from her backpack.  This was not a fork from our house.  No, girlfriend stole it from the eatery.  My goal is to nonchalantly return this eating implement to the restaurant. In the meantime, I will be searching her backpack before we leave any establishment.

I have been negligent on taking pictures and posting Ellie's entourage on Facebook.  That is not to say she isn't packing everything, but the kitchen since in her backpack.  Far from it.  She is MacGyver.  A boy scout of the "always be prepared" sort.  Some of the more entertaining items (aside from the fork):

Necklaces
Oven mit
Plug to the bathtub
Receipts (tons of receipts)
Napkins
Cups
Medical gloves
Sticks
Rock
Play dustpan
Safety googles
Spare shoes
Straws
Measuring spoons

Apparently, Ellie thinks she is going to be doing some cooking.

Andrew and I have been going on date nights lately!  We have this awesome respite care provider, but she left for college this week.  Arms crossed and foot stomp at this development.  Anyway, we have been trying out different restaurants and recently went swimming at Barton Springs.  It was so cold I couldn't even catch my breathe.  Of course, Andrew spent the evening telling me that the water felt great.

I would love to have a blog post without medical updates, but unfortunately, it will not be this post.

Today we had an appointment with Chest and Sleep Clinic.  A while back, we learned that Ellie had obstructive sleep apnea.  We did a lingual tonsillectomy and glossectomy (tongue surgery).  With a repeat sleep study, we learned that the surgery did indeed help alleviate some of the obstruction.  Unfortunately, she seemed to have developed central sleep apnea (basically the brain forgets to tell  you to breath).  A brain MRI revealed no organic cause for central apnea.  Because she refuses (actually is quite combative) the CPAP, we are now starting her on oxygen at night.  Fingers crossed she tolerates it.  I plan on putting on the nasal canula after she is asleep.

I made Belly Bands to cover up Ellie's C-tube so that she doesn't play with or pull at it.

Ellie's cecostomy surgery date is still tentatively for Sept. 12th.  Yes, it is still kind of sort of up in the air.  I am not happy.  I like things set in stone.  We have two urologists in the OR.  Both agreed that they were free for OR time on 9/12.  However, they are still deciding on how they are going to approach this surgery.  They may need a radiologist in the OR.  If that is the case, they may not be able to coordinate all 3 people which may mean a different surgery date.  Of course, the one urologist it out of town.  Seriously, they are always out of freaking town. She needs this surgery sooner rather than later.  Last week, Ellie had to be catheterized at the pediatrician due to a UTI and urinary retention.  Constipation can lead to urinary retention.  Ellie was doing so well until she well, wasn't.  She was crying and signing potty, but could not go.  Fortunately, the catheterization fixed the problem.  I do not want her to go through all of that again.

Hopefully, the next time I blog, I will have more exciting news to report.  No wait, boring.  I would love for life to be boring!




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July Update: The Fun Stuff and The Medical Stuff

Believe it or not, there is not much to report.  July has been relatively tame with the usual therapies, fun summer activities, and only 2 doctor's appointments.

The Fun Stuff:

At the very end of June and into July, my mom (Baba to Ellie) visited from St. Louis.  We had a full schedule trying to fit in everything we wanted to do.  With each visit, we make sure to get breakfast with awesome coffee and head to the mall to ride the train.  It is tradition, you know!  We went to a 4th of July BBQ at my friend's house - the friend I have known since I was 8 years-old, the one who introduced me to my husband.  We had a great time and Ellie was very well behaved.  You all know what a feat that is.

Ellie and Baba

Ellie is still trying to hard to talk.  She is saying new words such as arms, kick, and fast (sounds like *ss).  Girlfriend certainly has her curse words down. Her speech therapist had me write down 10 of her most favorite foods so that she can work on these words specifically.  At the very top of the list is "cake". Right now, she signs it incessantly while making the "k" sound only.

4th of July BBQ

At the beginning of July,  Ellie participated in a dance camp for the children who are a part of the 2dance2dream program.  The Bear had a great time and I had 2 hours for 3 days to myself.  It was wonderful.  I did grocery shopping and ran a few errands.

Enjoying dance camp

Last year, we started swim lessons with this woman who works solely with kids who have special needs and their siblings.  Ellie made great progress last year and I worried that she would have lost all her skills during the school year.  Not so, she remembered!  As a child who is petrified of water (aside from baths and a splash pad), she is doing great.  With some assistance, she can swim across the pool.  It isn't super wide, but it is amazing progress.  She knows to hold her breathe and come up for air and moves her arms to propel herself through the water.  She still has trouble coordinating kicking and arm movements together, but that will come with practice.  She is also able to pick up diving sticks from the bottom of the pool.

The Medical Stuff:

Weight Gain-- that's right, our girl finally gained weight!  Nearly 2 lbs.  The Bear is going to be a chunky chicken once again.  Well maybe not but her ribs don't hang out as much.  She is still eating the same amount of food, but we started Carafate for her ulcers.  I am thinking she is finally healing and is now able to absorb more nutrients from her food.  Fingers crossed she keeps the weight on.

Urology: Six weeks people.  Six weeks to get a pre-op appointment!!!  Apparently, GI does not do the cecostomy ostomy and button procedure [Malone procedure].  Urology does.  So on June 16th, we got referred to urology.  She already has a urologist for her chronic urinary retention (which has resolved!  Woooohooooo!), yet she was referred to a different doctor, Dr. C.  Dr. C was out of town.  Once he returned, he took an entire week to get to her chart before referring her to her primary Urologist, Dr. McQ.  At this point, Dr. McQ was out of town.  She was pretty quick to review Ellie's chart and set up phone conversations and emails with Ellie's gastroenterologist.  However, the GI doc wanted to meet with the urologist in person.  They were going to meet up in 2 weeks.  Both docs conversed this past Tuesday and Dr. McQ worked us into the schedule yesterday.  It is a good thing we had a pre-op appointment as GI told the urologist that we just wanted to catheterize and not have a button.  Um, no.  We want the button.  This is why it is good to confer with all people involved in your child's care.

Now, there will be two urologists involved in this 2-4 hours procedure.  The goal is to do this laparoscopically, only Ellie may have a super floppy colon due to the musculature issues and being stretched out.  If they are not able to do it laparoscopically, they will open her up.  I am quite apprehensive about this.  I do not want to do this if they have to make a big incision, but we also need to treat her issues.  We won't really know what will happen until they get into the OR. So coordination for surgery is tricky as both surgeons need to be available for 4 hours on the same day.  Fortunately, we have a tentative date for September 12th.  Ellie will be admitted the day before for a bowel prep and then surgery in the afternoon on the 12th.  After that, she has a 2-4 day post-op hospital stay.  How will I keep this child occupied for that long?! Fingers crossed and prayers that she can have surgery during this time or we are looking at a much later surgical date that may be affected by insurance changes. Fingers crossed that our primary insurance covers this procedure, the bowel prep, and hospital stay (recall they refused to cover Ellie's hospital stay and manometry last month).

Hanging out at the Dentist

Finally, Bear had a blast at the dentist.  I don't know why other than the toys and getting her own tube of toothpaste.  She was fabulous until it was time to floss.  It took two of use to hold her down, but she was great for the exam, brushing, and fluoride treatment.  If only she was that good at home!

As for me, my uterine ablation from last mont failed.  I am looking at a hysterectomy come November.  I am not looking forward to this.  It is a big decision and I flip flop back and forth between going through with it.  It is a 6 week recovery which should be interesting while caring for Ellie.  I will definitely need help.




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A bunch of updates: Miss Sassy Pants, Sleep surprise, GI/Urology, etc.

Ha!  I am going to spare you my usual spiel of "I am so sorry that I neglected the blog and I won't do it again".  However, I will promise you that this post isn't entirely about medical stuff. . . sort of.

The Sleep Study Results:
Why does it take so long to get results?  Three weeks to get the results.  Actually, it was 2 weeks, but the doctor neglected to call me because he was flabbergasted and needed to do a more comparative analysis of her previous sleep study.  Yeah, "flabbergasted" is never something you want to hear from a doctor.

To see her previous sleep study results (as in pre-surgery), click here.  Ellie Bear's hypoventilation (very low rate of breathing) has resolved!  As a result, her inhaled CO2 levels are near normal.  Her oxygen saturations for the majority of the night ranged from 92-94% (compared to 80% in the previous sleep study.  In more exciting news, she now has central sleep apnea.  Girlfriend can never doing anything half-*ssed and likes to keep us all guessing.  So. . . where did the central sleep apnea come from?  We do not know, which is why we are going to do an MRI of her brain just for sh*ts & giggles. . . can you all tell that I am just sick of this stuff.  Why the MRI, you ask?  Central sleep apnea tends to originate from the brainstem (or in some cases the heart).  Essentially, your brainstem forgets to tell your to breath.

Speaking of sleep apnea, I have it and so does Andrew.  A few months ago, Drew woke me up because I "wasn't breathing".  My allergies were horrible and he basically shoved Afrin up my nose and it cured me.  Last month, I was in Vegas with some friends.  Vegas, baby!  The cigarette smoke also mucked up my breathing and my friend informed me that I was obstructing.  Because I don't have enough doctors appointments before school lets out in 2 weeks (I have 5 and Bear has 2), I now have an appt. with my PCP.  I am wondering if this is why the past 3 month I have been averaging about 3.5 hours of sleep?  Very restless sleep.

My Fitness Best Friends (and texting buddies):
Michelle (my Ds blogging buddy and first time meeting her!)
Lindsey (former Canadian, former Austinite)
Lisa (fellow Canadian Beachbody coach!)

Motivation Fitness Takes Vegas:
Oh yes, my friends, I went on a girl's trip to Vegas.  That would be a trip without the child.  As in alone.  I am still a beachbody coach running my health and fitness group called Motivation Fitness.  Our Facebook group is full of amazing ladies.  We not only share our victories and support each other during health-related struggles, we have become friends.  Many of us had never met.  Last month, 10 of us took a 4 day trip to the Sin City.  From Vancouver, Canada, Montana, Florida, New York, Texas, Missouri, and Ohio, all of us had a wonderful time.  While we managed to clock in an average of 24,000 steps a day and while we also were a health group, it was our main mission to eat (and to pee -we are all moms with weak bladders) in every hotel room along the strip.

School: The IEP meeting
Nothing screams "welcome back from vacation" like an IEP meeting the morning after your flight lands.  The IEP meeting went well.  We have good goals in place.  Ellie will spend a majority of her time in a Functional Academic spec ed classroom [FAC], with appropriate push-ins for specials, lunch, and home work and other classes as tolerate.  The "as tolerated" = behavior is good.  On a sad note, Ellie will not be at the same school as next year.  Currently, Ellie goes to a school that is 30 minutes away.  While that is not ideal, her teacher and aides were/are amazing.  Next year, her home school that is just down the street from our house is going to have an FAC room.  Fingers crossed that we have an excellent teacher and aides next year.  Change is difficult.  Being shuffled around from different schools, different classmates, and different teachers can be tough on Ellie.

The Dysfunctional Voiding Clinic: NPs vs MDs and Gastroenterology + Urology
I love joint appointments.  It is so nice to kill 2 specialists with 1 stone.  As a follow up, Ellie is now peeing more.  As in 3-5 times a day now, compared to once every 18-29 hours.  Unfortunately, she likes to do things the opposite of "normal".  When she poops regularly, she doesn't pee.  When she doesn't poop, she pees more.  Go figure.

The Bear has lost weight again.  Not much, but this child should be gaining.  Like a ton.  She is on an appetite stimulant and she eats all the freaking time.  At first I figured "different scale", but after having 4 doctors appointments in 10 days and all 4 scales showing a similar weight, it could no longer be ignored.

Play-Doh Fun!
You can see that she lost a big of weight in her face.  We have also gone down a size in clothes.

This brings me to the awesomeness of Nurse Practitioners.  No, I am totally not biased given that I am also a NP.  I have battled with Ellie GI doc for a few years now.  Always dragging his heels on trying to figure WHY she has severe constipation and WHY she loses weight.

GI NP: She has had a colonoscopy, right?

Me: Nope.  She needs one and will get one next month with her testing

GI NP: She has had stool studies, right?

Me: Nope.

GI NP: How about an upper GI?

Me: Yes!  Just a few months ago after begging the doc for one for 2 years.  We ruled out celiac, h. pylori, and lactose intolerance and discovered esophageal gastritis instead.

So, we did a bunch of stool studies to look for malabsorption.  Good news!  The studies were normal.  Bear's poop is normal.  Yay!

Disney On Ice:  
Two weekends ago, we took Ellie to Disney on Ice.  I wasn't sure how she was going to do during the 2 hours show.  She was so excited!  Before it even started, she was clapping and grinning.  Her enthusiasm was priceless and infectious.  She did great. . . provide Mickey Mouse was on the ice.  When he wasn't, Ellie was telling us "truck, buh bye, Noble Pig".

This all brings me to next month: Surgeries and Hospitalization:

It is always great fun to kick of summer break with a 3 day hospital stay.  Right?!  Okay, this is gross, but we will be admitting Ellie to the hospital for a bowel cleanse.  Think dropping and NG tube from her nose to stomach and pumping her with a full gallon or two of GoLytely.  The following day, Ellie will have a colonscopy and the placement of a colon manometry tube.  Essentially this tube will remain in her colon and be taped to her butt or thigh until the following day when we will hook it up to this manometry machine.  While she is under anesthesia, she will also have her brain MRI with contrast and her yearly routine blood work.  The following day, is the colon manometry which will look at pressures throughout the colon - identifying if there is delayed colon transit and if so, if there is a specific part of the colon where this occurs.  Then, home!

The following week, I get to have surgery.  For the past 2 years, I have been battling woman's health issues.  A variety of treatments have been tried with no relief.  More drastic measures will be taken and I will essentially lose my fertility.  No more kids for us, so if one more person asks if we will have more. . . I feel like I am way too young for this nonsense, but at 35 years-old, I am apparently of
"advanced maternal age" even though I have quite a few older friends who are currently pregnant.

Haircut:
I cut the Bear's hair myself.  We keep it short for a few reasons: 1. She chews her hair; 2. It sticks to her messy Nutella face; 3. Drew loves it short; and 4. It gets scraggly when it is longer.  The reason I am the one to cut her hair is because she hates it.  It is like medieval torture to her.  She does okay with the back, but the sides freak her out.  Perhaps the sound of the scissors? Or maybe having a sharp object near her face?  Sensory issues?  The thing is, if I take her somewhere, she is still a wild banshee child and no amount of fun toys, movies, little riding things help the matter.  I end up paying for the haircut that looks just like my hack job and I feel the need to tip a ridiculous amount because the Bear is a tornado.

Tama Boo:
In sad news, our beloved, black cat, Tama, has been missing for a week now.  She is usually indoors by 9pm and comes when called.  There were storms last Tuesday night and Tama is petrified of thunder.  I have called/ searched for her, all the neighbors in a 1/2 mile radius are looking for her, and I have posted her picture on Next-door.

So even though it sounds like there is a ton of chaos over in the Theurer household, we are staying afloat.  Bear's new favorite word are "oops" and "buh bye".  Any time someone drops something "oose!" [oops].  Any time we leave a room, a toy, or someone leaves a room, it is "buh bye" with great drama and a princess wave.

School is almost over and I am really looking forward to July.  When all this medical stuff is behind us and when I can sleep past 5:45am. . . and instead wake at 6:45am.






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Upper Endoscopy - some answers and some questions

I wanted to give a quick little update as Bear had her upper endoscopy on Friday.  I hear you all snickering about the "quick" part because I am not exactly known for my brevity.

Upper GI or upper endoscopy or an esophagogastroduodenoscopy:  Whatever you want to call it involves inserting a lighted tube through the mouth, down the esophagus, and into the stomach and duodenum.  The duodenum is the upper 3rd of the small intestine.  This tube has camera that essentially allows the doc to see the insides of your upper gastrointestinal tract to look for reflux, ulcers, tumors, etc. and allows for biopsies.

Bear actually had one back in August of 2011 because she was Little Miss Spits A Lot with her reflux projectile vomiting.  Funny thing, is that after she got the endoscopy, she stopped spitting up.  It was as though the test cured the reflux.  We couldn't completely 100% rule out celiac based off of this upper GI because she has barely started to consume gluten after testing out of an oat allergy (yes, a random oat anaphylactic allergy).  Oats are often grown next to wheat or manufactured in the same plants as wheat, which is why we pretty much stuck to rice.

There are two main differences between the endoscopy results from 2011 and this past Friday.  The one from 2011 showed a beautifully pink and normal upper GI tract.  The one from Friday did not.

Bear's esophagus was beautiful. No signs of reflux or anything exciting like that.  Her stomach, however, is quite angry.  Red.  Inflamed.  Basically, she has gastritis.  The GI doc did a rapid test for H pylori, which is a type of bacteria that causes ulcers.  It was negative.  He will send a sample to the lab to do a more conclusive test.  There is also the possibility that one or some of her medications are causing the gastritis.  Or it may be something else.  The upper part of her duodenum is also not very happy with marked pockets of inflammation aka duodenitis.  This could be from leaking stomach acid into the small intestine, an autoimmune disorder such as celiac disease, lactose intolerance, or some other inflammatory process. The lower portion of the duodenum appears normal.

Upper GI of esophagus through duodenum (upper part of small intestine):
all areas pale pink with no signs of ulceration or inflammation.

Upper GI: Abnormal (I apologize for poor quality)
Note the redness in the 2 views of the stomach as well as a small ulceration in the upper duodenum.
The yellow is bile , which is a normal finding.

Seven tissue biopsies were taken and have been sent to the lab.  It will be 1-2 weeks before we know the results.  Based off those results, we will have a clearer idea as to what is causing the inflammation, what other tests need to be run, and a treatment plan.  Interestingly, it may have nothing to do with her constipation issues, but probably has had a significant impact on her poor appetite and her poor weight gain even with the appetites stimulant..  It is a lot of wait and see.  In the meantime, we are going to start her on Protonix, a proton pump inhibitor similar to prilosec ,which well help decrease stomach acid production and allow her stomach to heal.

To say that I am stressed out is an understatement.  I really thought everything was going to come back normal. How long has this been going on?  Why didn't the GI doc agree do the scope earlier?  How could I not know that my daughter was/is in pain?!  Oh how I wish Ellie was able to communicate and tell me what hurts and bothers her!

Ellie Bear vs. the OR:
We were fortunate that Ellie was able to have her procedure at the outpatient day surgery center rather than in the hospital OR.  It was a much more pleasant experience for the most part.  Well, as pleasant as a surgical center can be. She did great in the waiting room, but then lost it when we got pulled back into pre-op.  She saw those hospital beds and knew what was coming.  This was  her 3rd time under anesthesia in the past 5 months so she remembered how cruddy she feels afterwards.  She calmed down with the help of her iPad, a fresh coloring book with color wonder markers, and a new book . . .  until the surgeon, charge nurse, and anesthesiologist showed up, which is when she displayed her super human Bearity Bear strength and shenanigans.  Ellie gave us a little trouble coming out of anesthesia.  Probably because she wanted some beauty sleep, but as soon as she was up, she was wild!  Girlfriend is a cranky pants, combative little toot post-surgery.  She screamed the entire way home and continued to be agitated even after she ate 3 chocolate frosted donuts.  A few hours later, she was back to her usual perky, spunky self.




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GI Situation, Foreign Body, Failure to Thrive

*Part 1: written on 12/27/2015

While several children with Down syndrome are more likely to have some constipation due to their low muscle tone, Ellie's extreme gastroinstestinal issues are not related to her sporting an extra 21st chromosome.

Ellie has something called moderate - severe delayed colonic transit.  Something that was confirmed last year via Sitzmaker study.  What this means is that the stool moves very very slowly through her small and large intestines.  Due to the sluggish nature, this allows for more and more water to be pulled out of the stool and reabsorbed into the intestinal walls.  What this means is her poop becomes hard a rock moves even slower.  This is something that cannot be measured by dietary measures along such a increased fiber, prune juice, increase in fluids, coconut oil, or diet high in magnesium  Diet is a part of her bowel regime, but she also on 2 daily osmotic laxatives (these are laxatives that push water into the stool).  She is on a stimulant laxative (Senna) two weeks on and two weeks off and that helps with intestinal movement.  She cannot take the Senna Lax all the time because as a stimulant laxative, the bowel can become dependent on it.  For the past few months, we have increased our use of enemas.  I am not pleased.  Andrew and I refuse to get into a situation where it is 9-10 days without pooping and necessitating a hospitalization.  For that reason, if she doesn't go within 5 days or we see her stop eating/drinking,  she gets 3 enemas - one for 3 consecutive days.  The reason for this is because the first day nothing happens.  The saline just comes out 20 minutes later.  The second day may produce something or it may not.  Day 3 works!

Why am I telling you all of this?  Well just before Christmas, we narrowly avoided a hospitalization.  Doesn't everyone want to spend Christmas week in the hospital?  After Ellie's surgery around Thanksgiving, we knew there would be trouble.  Narcotic pain meds actually cause constipation.  Ellie was on them for 4 days.  I had the unrealistic hope that her antibiotic would counteract the GI side effects or Lortab, but we were wrong.  Since then, we have not been able to get a handle on things.  The enemas were only producing small amounts of poop and she was bloated.  I finally put the call into GI.  They wanted to obtain an abdominal x-ray to determine her fecal load.  Okay, I think that is funny "fecal load".  Sorry, it is juvenile of me, but one has to have a bit of humor in times like these!

The x-ray was interesting. . .

x-ray tech: Did Ellie ever have some kind of GI surgery?
Me: no
x-ray tech: Like something with clips or clamps?
Me: no
x-ray tech: what about bladder or ureter surgery?
Me: No.  Better let me take a look.

Now, not that I am exactly an expert at reading X-rays or anything, but I can tell a foreign body when I see one. . . and tons of POOP!

This x-ray is a bit reversed in that sold objects and bone should appear white while air /gas should appear black.
Note all the gas and large amount of fecal content throughout the entire colon pushing up on her diaphragm.
Red Arrow = foreign body in the pelvic region

As it turns out, the GI specialist didn't give a flying rat's patootie about the foreign body.  "Oh that will just be pooped out" only, my child doesn't poop!  That is the problem here.

Here was his big plan: an at home, 3 day cleanse.  If she didn't expel a substantial amount of stool by that Monday, she would be admitted to the hospital.  The cleanse was going to involve continuing the above medications while adding in 3 days of Milk of Magnesia, 3 days of fleets enemas, and a Magnesium Citrate.

Magnesium Citrate is nasty as all get out.  It is fizzy, but not like soda fizz.  Think more along the lines of pouring vinegar on baking soda fizz.  Only it tastes like liquid fizzy chalk with some flavoring - citrus, cherry, or grape.  Now they will go on about serving it very cold and adding in crystal lite or Mio drops and what not.  They are delusional.  I gag and vomit with just a few sips so imagine my developmentally delayed 6 year old having to drink 1/2 bottle.  Riiiigggghhhhttt.

Needless today I busted out laughing on the phone and told them that it wasn't going to happen, but I would add in the MOM and do the enemas.

--------

Well, I needed to eat my words. She did poop is out.  The next day.  It was one of those erasers that you put on top of a pencil.  My guess is she used her teeth to pull it off the pencil and swallowed it by accident.

She had a yellow one of these bad boys.
How she didn't choke when it went down surprised me.
It happened at school.  She is an eraser thief.

That cleanse seemed to work because she wouldn't stop pooping.  . .  until she reverted back to her old ways.  We had to repeat an enema on New Years Eve (we totally know how to ring in the New Year) and start this new medication called Amitiza.  It seems to be working!  We are continuing with the Miralax and have cut the lactulose down to once a day.  She is eating a bit more than usual too. This is exciting!

--------

*Update: 1/21/2016
I spoke too soon.  She hasn't gone in over 4 days.  I know 4 days doesn't sound like a huge deal, but this is kind of how things go.  She does great for 3-7 days and then suddenly nothing. Nada. Zip.  Her appetite isn't horrible, but it is less than it was last week.  We saw her GI doctor today.  Apparently, she may be one of those kids what will require weekly enemas for life.  I am not accepting this.

A few things from today's visit:
1. Ellie has gained 2 lbs!!!!  She has also gotten a bit taller which I knew about last month when some of her pants got too short.  TWO POUNDS!!!  She is slowly getting back to wear she was ~ 2 years ago.  Soon to be a Chunky Chicken again!
2. I convinced the doctor that Magnesium Citrate is nasty.  That he needs to go and try it himself so he can realize just how much he is asking of his patients.
3. The doc finally realizes that her constipation is out of control and that it is time to do more tests.  If she has something like Celiac's, her gut will be inflamed and damaged.
4. Next Friday, Ellie Bear is getting an upper endoscopy to rule out celiacs once an for all.  This is where they take a small noodle-like scope through the nose - esophagus- stomach- duodenum (upper portion of small intestine).  It allows the doc to look at all the mucosa to see if there are ulcers, reflux, inflammation, polyps, etc and to also take biopsies.
5.  If she has celiacs disease, she will be going gluten free.  If not, then she is going to see her other GI doc who specializes in motility disorders and will have a colonic manometry.  I'll spare you the details for now, but it is similar to the anorectal manonmetry she had 18 months ago to rule out Hirschsprung's Disease.

Photo: ramsayhealth.co.uk

All in all, I am glad that we are finally trying to get to the bottom of the GI issues.  For so long, I have felt like the GI specialists were focused more on treating the constipation rather than trying to discover the reason behind it.  Hopefully, I won't take forever to give you all an update after next week's procedure.  I have been dealing with some health issues these past several months, which sadly means the blog has taken a back seat. I have a Christmas post that I still need to publish!





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Urology, Oliguria and Happy 6th Birthday, Ellie!

About 3 weeks ago I left off with the results of Ellies MRIs, Renal ultrasound, and blood work results - all to look at why she isn't regaining weight even with the appetite stimulant, why she isn't peeing, why she isn't pooping, and why she doesn't breath at night  -  ah, basic life functions going haywire.

Funny thing here, when Ellie was born and we learned that she had Down syndrome, I immediately worried about her heart.  After all, it is said that up to 50% of kiddos with Ds can have a heart condition.  Well, Ellie did have a hole in her heart.  A small one.  Not real exciting.  Closed at a year old.  That was that.  Never did it cross my mind that Bear would have a whole slew of health issues completely unrelated to sporting an extra chromosome (well, aside from the sleep apnea which tends to be more common in people with Ds).

These two turkeys crack me up!

So. . . not peeing.  I would LOVE to tell you how Bear's urology appointment went only she hasn't been seen!

Brief history:

Ellie is not potty trained.  She is not purposefully holding onto urine and refusing to void.  She is not secretly peeing in the toilet without us knowing.  She isn't leaking small amounts of urine into her diaper.  She never acts like she has to go, but will occasionally have to "push" to pee, usually after 20+ hours.  She is peeing once every 21 - 24.5 hours.  She is peeing at an average rate of 0.7 cc/kg/hr.  Normal urinary volume for a child her age/size is 1-2 cc/kg/hr.  So, she has decreased voiding frequency and decreased urinary output (oliguria).  Not horrendous, but not normal.  Failure to void on a regular basis can lead to urinary tract infections [UTI] and can also cause urine to back up into the kidneys and cause damage.  So not peeing for 24 hours is sort of a problem.  Not to mention uncomfortable.  I am doing the potty dance right now just thinking about it.

Her renal ultrasound was performed under sedation on 9/4 after 20 hours of not peeing.  Her bladder was moderately full.  Her kidney anatomy was normal.  Her right kidney is 1.1cm larger than the left.  It isn't uncommon for one kidney to be larger than the other - usually the left one, but the right can be normal too.  Now the size differential may be statistically significant since it is >1 cm size difference. Also, the good news is that her kidneys have grown since a previous ultrasound.

"Hi everyone!"

Ellie's BUN  and Creatinine levels were normal - blood work that measures kidney function.  Her spinal MRI, ordered by her GI specialist, was also normal.  This ruled out tethered cord as a cause for her constipation and urinary issues. We were referred to urology on 9/9/15.  Austin is and has been having a huge growth in population.  Lots of young adults and young families are flocking to the Live  Music Capital of the World or Silicon Dessert.  Unfortunately, the number of pediatric urologists have not caught caught up to this population boom.  There is 1 pediatric urology clinic in the Austin area.  This clinic has 4 doctors.  Two of them work with voiding issues.  When I call, just to talk to a scheduler "you are caller # 1" is 17 minutes average on-hold time.  SEVENTEEN!

Anyway, I finally talk to a real live person and I kind of flabbergasted her when she asked what we needed the appointment for.  I know a lot of key words - see early paragraph about "brief history".  Spouting off kidney sizes, history of Ds, failure to thrive, GI issues, urinary output kind of startled her.   She connects me to a nurse.  The nurse then goes "let me see if one of our urologist can access Ellie's ultrasound because we are booking in November and I don't think she should wait that long".  I was told I would get a call back.  I never did so I followed up myself.  They created a chart for Ellie and in her chart it says that the urologist wants to see her in 2-3 weeks.  I am told that they will call with an appointment.  They never did.  Notice a theme?  As it turns out, when they say they want her seen in 2-3 weeks and that she shouldn't wait, it means that they are NOT squeezing her in but rather adding her to a rather long wait list that anyone can be added to.  It also means that nearly 3 weeks have passed and she has still not been seen.  Her current appointment is for November 30th.  Over 2.5 months from the time of my first phone call.

Ellie was so excited about the cake. . . until Andrew took away the remainder of the cake.  Apparently, Chunky Chicken though that she would get to eat the ENTIRE cake and not just one piece.

To say I am peeved is a bit of an understatement.  What kind of practice is this???  I am not ignorant of how things work in the medical field.  I used to work as a pediatric ENT nurse practitioner in Philadelphia where our first available was over 4 months out.  I was the one who would work certain new patients with complex medical issues into the schedule.  Overbook appointments because some of these kiddos couldn't wait the 4 months.  Discuss with the doctor and make sure the patient was seen.  Being a squeaky wheel doesn't see to be working either.

Again, these two crack me up.

So what now?  We wait and wait and wait.  She finally gets seen at the end of November only for the doc to order tests.  Like a VCUG or something along those lines.  Then we wait to get scheduled for that and then wait some more for the follow up.  At this rate, the poor kid will have damaged kidneys.  Right now, I am trying to come up with a plan of action which will involve enlisting the help of Ellie's pediatrician.  I just feel so helpless.

Okay, I am done complaining.  Nothing is accomplished by ranting other than me feeling a bit more sane!  The pictures in this post are from from a small birthday celebration that included Bear's best friend and a few family members and close family friends.  It was a great deal of fun and I know that Bear got a kick out of the Mickey Mouse cake.

Happy 6th Birthday, Ellie Bear!

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