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Other causes of diarrhea

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

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Other causes of diarrhea

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  1. Other causes of diarrhea

  2. Transient Lactase Defiencency • Occurs following AGE • Resolves in weeks to months • Use lactose free milk/formula • But NOT on routine basis!

  3. 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)

  4. 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 PPI B. Systemic steroids C. Pancreatic enzyme replacement D. Removal of lactose from the diet E. Removal of gluten from the diet

  5. Malabsorption • Celiac Disease • AKA gluten senstitiveenteropathy • 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

  6. 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

  7. 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

  8. Dysphagia

  9. 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

  10. Dysphagia • Ingestion • Caustic • Alkali • Low threshold for endoscopy • Injury heals with fibrosis • Strictures • Long-term dysphagia • Treatment • Repeat dilations

  11. 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. Corticosteriods B. Antibiotics C. H2 blocker D. Antihistamines E. An immune modulator

  12. dysphagia • EosinophilicEsophagitis • 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

  13. dysphagia • EosinophilicEsophagitis • Diagnosis • Endoscopy with biopsy • Linear furrowing of esophagus • Esophageal ring formation • Granularity • Eosinophils • Treatment • Diet modification • Corticosteroids

  14. Trauma • Duodenal hematoma • Bicycle handlebar or blunt trauma • Partial or complete obstruction • Present with vomiting • Usual slow resolution • May be suspicious of NAT

  15. GI Bleeding

  16. 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 enema B. CT scan of the abdomen to look for abscess formation C. Stool smear for WBCs D. US of the abdomen E. Endoscopy with biopsies

  17. GI Bleeding • Upper • Melanotic stools • Coffee ground emesis • Frank hematemesis • Lower • Bright red blood per rectum

  18. IBD • Crohn’s and UC • Symptoms • Abdominal pain • Weight loss • Chronic diarrhea • Rectal bleeding • Fever • Growth failure • Delayed puberty

  19. IBD • Crohn’s • Severe perianal disease • Fistulas • Fissures • Perianal skin tags • Abscesses • UC • Rectal disease

  20. IBD • Crohn’s • Transmural inflammation • Granuloma • Skip areas • Mouth to anus

  21. IBD • Crohn’s • UGI

  22. IBD • UC • Crypt abscesses • Mucosal inflammation • Confined to large bowel • Continuous

  23. IBD • UC • UGI

  24. IBD • Extraintestinal manifestations • Osteoarthopathy • Rashes • Erythemanodosum • Erythemamultiforme • Papulonecrotic lesions • Ulcerative erythematous plaques • Pyodermagangrenosum • Arthritis • Ankylosingspondylitis • Sacroiliitis • Apthous ulcers • Uveitis • Iritis • Sclerosingcholangitis

  25. 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

  26. Cystic Fibrosis

  27. 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. KUB B. Sweat test C. Barium enema D. Colonoscopy E. IBD serology

  28. Cystic Fibrosis • Most common inherited lethal disorder in whites • Neonates • Meconiumileus • Edema • Older • Pancreatic insufficiency • Steatorrhea • Failure to thrive • Recurrent pancreatitis • Rectal prolapse • 20%

  29. 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

  30. Jaundice

  31. Question 10 In older children, which is the most common cause of a conjugated hyperbilirubinemia? A. UTI B. Medications C. Viral D. Metabolic disease E. Biliary tract disorders

  32. Jaundice • Yellow discoloration of the skin and sclerae • Deposition of bilirubin • Unconjugated • Conjugated • >2mg/dL • ≥20% of total bili • Pathologic

  33. Jaundice in Infants • Unconjugatedbilirubin • 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

  34. Jaundice in Infants • Conjugated hyperbili • Pathologic • Causes • Biliaryatresia • Choledochal cyst • Hepatitis • TORCH • Congenital abnormalities or syndromes • Metabolic diseases

  35. Jaundice in Infants • BiliaryAtresia • +/- 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 • Situsinversus • Polysplenia • CHD • GI • Vascular

  36. 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

  37. Jaundice in Childhood • Unconjugatedhyperbili • 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

  38. 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

  39. 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

  40. Jaundice in Children • Autoimmune Hepatitis • Autoantibodies and hypergammaglobulinemia • Presentation • Adolescence • Usually female • Hepatitis • Asymptomatic jaundice • Liver failure • Treatment • Immunosuppressives • Corticosteroids • Azathioprine • Liver Transplant

  41. 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

  42. Miscellaneous

  43. 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

  44. 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

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