Other causes of diarrhea
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Transcript 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
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 PPI
B. Systemic steroids
C. Pancreatic enzyme replacement
D. Removal of lactose from the diet
E. 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. Corticosteriods
B. Antibiotics
C. H2 blocker
D. Antihistamines
E. 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 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
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. KUB
B. Sweat test
C. Barium enema
D. Colonoscopy
E. 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.
B.
C.
D.
E.
UTI
Medications
Viral
Metabolic disease
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