OTHER CAUSES OF DIARRHEA

TRANSIENT LACTASE DEFIENCENCY

Occurs following AGE

Resolves in weeks to months

Use lactose free milk/formula But NOT on routine basis!

DIARRHEA

Toddler’s diarrhea Common and self-limited Most common cause of chronic

diarrhea in kids <3

Loose stools with undigested fibers No carbohydrates or fats

Treatment Dietary

Unrestricted fat Elimination of nonmilk fluids

(juice and soda)

QUESTION 6

A 5 yo patient presents with chronic diarrhea, abdominal distention, anemia and failure to thrive. Endoscopy with biopsy showed villous atrophy and crypt hyperplasia of the small bowel. What would be the most effective treatment for this patient?A. Triple drug therapy with 2 Abx and a PPIB. Systemic steroidsC. Pancreatic enzyme replacementD. Removal of lactose from the dietE. Removal of gluten from the diet

MALABSORPTION

Celiac Disease AKA gluten senstitive

enteropathy 1/133 Intolerance to dietary

gluten that results in malabsorption

Symptoms Chronic diarrhea Abdominal distention Weight loss/failure to thrive

Classic appearance Potbelly Wasted extremities and

buttocks

MALABSORPTION

Celiac Disease Other findings

Short stature Abdominal pain Constipation Arthritis Delayed puberty Anemia Osteoporosis

Diagnosis Gold standard

Small bowel biopsy Villous atrophy, crypt hyperplasia and abnormal surface

epthelium

MALABSORPTION

Celiac Disease Testing

Endoscopy Flattening of duodenal villi “scalloping”

Serologic tests Antigliadin or antiendomysial

antibodies Can be used to monitor

adherence Treatment

Complete removal of gluten Wheat Rye Barley Oats

DYSPHAGIA

DYSPHAGIA

Achalasia Incomplete relaxation of

the LES during swallowing Uncoordinated peristalsis

of esophageal smooth muscle

Diagnosis Esophagram Esophageal motility studies

Treatment Esophageal dilation Botox to LES Heller myotomy

DYSPHAGIA

Ingestion Caustic

Alkali

Low threshold for endoscopy

Injury heals with fibrosis Strictures Long-term dysphagia

Treatment Repeat dilations

QUESTION 7

A patient who has been treated for reflux with a PPI for the last 3 months returns to the clinic with worsening dysphagia, vomiting and abdominal pain. The endoscopy findings are pictured. The most appropriate treatment for this patient includes diet modification and _____?A. CorticosteriodsB. AntibioticsC. H2 blockerD. AntihistaminesE. An immune modulator

DYSPHAGIA

Eosinophilic Esophagitis Isolated intense eosinophilic

infiltration of the esophagus Symptoms

Similar to reflux Dysphagia Vomiting Feeding refusal Heartburn CP Abdominal pain

Does not completely respond to PPIs

DYSPHAGIA

Eosinophilic Esophagitis Diagnosis

Endoscopy with biopsy Linear furrowing of

esophagus Esophageal ring

formation Granularity Eosinophils

Treatment Diet modification Corticosteroids

TRAUMA

Duodenal hematoma Bicycle handlebar or

blunt trauma Partial or complete

obstruction Present with vomiting Usual slow resolution May be suspicious of

NAT

GI BLEEDING

QUESTION 8

A 14-year-old boy is brought to your clinic for evaluation of short stature. He complains of decreased appetite, but always feels full. He has had some bilateral hip and knee pain as well as low-grade fevers intermittently over the past year. Physical exam reveals apthoid lesions in the mouth and fleshy skin tags and fissures around the anus. Of the following, the MOST appropriate diagnostic test to obtain is a(n):A. Barium enemaB. CT scan of the abdomen to look for abscess formationC. Stool smear for WBCsD. US of the abdomenE. Endoscopy with biopsies

GI BLEEDING

Upper Melanotic stools Coffee ground emesis Frank hematemesis

Lower Bright red blood per

rectum

IBD

Crohn’s and UC

Symptoms Abdominal pain Weight loss Chronic diarrhea Rectal bleeding Fever Growth failure Delayed puberty

IBD

Crohn’s Severe perianal

disease Fistulas Fissures Perianal skin tags Abscesses

UC Rectal disease

IBD

Crohn’s Transmural

inflammation Granuloma Skip areas Mouth to anus

IBD

Crohn’s UGI

IBD

UC Crypt abscesses Mucosal inflammation Confined to large bowel Continuous

IBD

UC UGI

IBD Extraintestinal

manifestations Osteoarthopathy Rashes

Erythema nodosum Erythema multiforme Papulonecrotic lesions Ulcerative erythematous plaques Pyoderma gangrenosum

Arthritis Ankylosing spondylitis Sacroiliitis Apthous ulcers Uveitis Iritis Sclerosing cholangitis

IBD

Treatment First line

5-ASA Second line

Corticosteroids 6-MP, azathoprine or methotrexate Cyclosporine or tacrolimus

Infection Antibiotics

Flagyl and cipro Surgery

Try to avoid in Crohn’s patients Colectomy

UC

CYSTIC FIBROSIS

QUESTION 9

A mother brings in her 2 year old child who she is currently potty training. The mother is concerned because she noticed today that the child’s “insides were coming out” while she was having a bowel movement. What is the most appropriate test to order for the patient?A. KUBB. Sweat testC. Barium enemaD. ColonoscopyE. IBD serology

CYSTIC FIBROSIS

Most common inherited lethal disorder in whites

Neonates Meconium ileus Edema

Older Pancreatic insufficiency

Steatorrhea Failure to thrive

Recurrent pancreatitis Rectal prolapse

20%

CYSTIC FIBROSIS

Distal intestinal obstruction syndrome Fecal impaction in the terminal

ileum and cecum Recurrent abdominal pain Palpable mass in RLQ Signs of bowel obstruction

Liver disease Elevated transaminases Hepatic steatosis

Poor nutrition Hepatic fibrosis

Focal biliary cirrhosis

JAUNDICE

QUESTION 10

In older children, which is the most common cause of a conjugated hyperbilirubinemia?

A. UTIB. MedicationsC. ViralD. Metabolic diseaseE. Biliary tract disorders

JAUNDICE

Yellow discoloration of the skin and sclerae Deposition of bilirubin

Unconjugated

Conjugated >2mg/dL ≥20% of total bili Pathologic

JAUNDICE IN INFANTS

Unconjugated bilirubin Most common “physiologic” Increased bili production Inadequate bili excretion Causes

ABO or Rh incompatibility Breastfeeding Breast milk Hemolysis

G6PD or hereditary spherocytosis Extravascular increased bili

Bruising Sepsis Congenital hypothyroidism

JAUNDICE IN INFANTS

Conjugated hyperbili Pathologic Causes

Biliary atresia Choledochal cyst Hepatitis

TORCH Congenital

abnormalities or syndromes

Metabolic diseases

JAUNDICE IN INFANTS

Biliary Atresia +/- history of acholic stools 1/8,000-15,000 Most common indication for liver

transplant in children Early diagnosis is important

US followed by HIDA then biopsy Kasai procedure <2mo

Other anomalies Situs inversus Polysplenia CHD GI Vascular

JAUNDICE IN INFANTS

Alagille Syndrome Facies

Deeply set eyes Narrow chin

Pulmonary artery anomalies

Butterfly vertebrae Xanthomas Pruritis Chromosome 20 Liver Bx

Paucity of interlobular bile ducts

JAUNDICE IN CHILDHOOD

Unconjugated hyperbili Hereditary hyperbilirubinemia syndrome

Gilbert During times of illness, stress or fasting

Dubin-Johnson and Rotor AR Mild elevations with normal liver enzymes and function

Conjugated hyperbili Uncommon Viral

Hepatitis Medication

Acetaminophen or anticonvulsants Reye’s

JAUNDICE IN CHILDHOOD

Conjugated hyperbili Chronic liver disease and/or

cirrhosis Firm, enlarged and irregular

liver early Splenomegaly

Portal HTN Portosystemic venous

anastomoses Caput medusae Varices Hemorrhoids

Ascites Spider nevi

JAUNDICE IN CHILDHOOD

Wilson’s Disease Presentation

Hepatitis Neuropsychiatric

disturbances Hemolytic anemia Cirrhosis Kayser-Fleisher rings

Labs Decreased ceruloplasmin Elevated 24h copper

excretion Elevated hepatic copper

Treatment D-Penicillamine Transplantation

JAUNDICE IN CHILDREN

Autoimmune Hepatitis Autoantibodies and hypergammaglobulinemia Presentation

Adolescence Usually female Hepatitis Asymptomatic jaundice Liver failure

Treatment Immunosuppressives

Corticosteroids Azathioprine

Liver Transplant

JAUNDICE IN CHILDREN

Congenital Hepatic Fibrosis Presentation

Massive splenomegaly Large, firm left lobe of liver GI hemorrhage

Associated with Polycystic kidney disease

Treatment Shunting procedures Liver function may remain

normally

MISCELLANEOUS

IRRITABLE BOWEL SYNDROME

Functional disorder Abdominal pain for at least 12wks 2 out of 3 criteria

Abdominal pain relieved by defication Pain associated with change in stool frequency Pain associated with change in stool form

Others: bloating, urgency, incomplete evacuation

Treatment: High fiber diet, address emotional factors

FAMILIAL POLYP DISORDERS Gardner’s

Polyps of small and large bowel: premalignant

Extra teeth Osteomas AD inheritance Surgical resection

Peutz-Jeghers Hamartomatous polyps:

premalignant Pigments of lips and gums AD inheritance Surgical resection