Download 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
