1. O THER CAUSES OF DIARRHEA

2. T RANSIENT L ACTASE D EFIENCENCY Occurs following AGE Resolves in weeks to months Use lactose free milk/formula But NOT on routine basis!

3. DIARRHEA Toddlers 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. Q UESTION 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. M ALABSORPTION 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

6. M ALABSORPTION 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. M ALABSORPTION 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. D YSPHAGIA

9. 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. D YSPHAGIA Ingestion Caustic Alkali Low threshold for endoscopy Injury heals with fibrosis Strictures Long-term dysphagia Treatment Repeat dilations

11. Q UESTION 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 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

13. DYSPHAGIA Eosinophilic Esophagitis Diagnosis Endoscopy with biopsy Linear furrowing of esophagus Esophageal ring formation Granularity Eosinophils Treatment Diet modification Corticosteroids

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

15. GI B LEEDING

16. Q UESTION 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 B LEEDING Upper Melanotic stools Coffee ground emesis Frank hematemesis Lower Bright red blood per rectum

18. IBD Crohns and UC Symptoms Abdominal pain Weight loss Chronic diarrhea Rectal bleeding Fever Growth failure Delayed puberty

19. IBD Crohns Severe perianal disease Fistulas Fissures Perianal skin tags Abscesses UC Rectal disease

20. IBD Crohns Transmural inflammation Granuloma Skip areas Mouth to anus

21. IBD Crohns UGI

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

23. IBD UC UGI

24. 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

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 Crohns patients Colectomy UC

26. C YSTIC F IBROSIS

27. Q UESTION 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 childs 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. C YSTIC F IBROSIS Most common inherited lethal disorder in whites Neonates Meconium ileus Edema Older Pancreatic insufficiency Steatorrhea Failure to thrive Recurrent pancreatitis Rectal prolapse 20%

29. C YSTIC F IBROSIS 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. J AUNDICE

31. Q UESTION 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. J AUNDICE Yellow discoloration of the skin and sclerae Deposition of bilirubin Unconjugated Conjugated >2mg/dL 20% of total bili Pathologic

33. J AUNDICE IN I NFANTS 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

34. J AUNDICE IN I NFANTS Conjugated hyperbili Pathologic Causes Biliary atresia Choledochal cyst Hepatitis TORCH Congenital abnormalities or syndromes Metabolic diseases

35. J AUNDICE IN I NFANTS 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

36. J AUNDICE IN I NFANTS 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. J AUNDICE IN C HILDHOOD 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 Reyes

38. J AUNDICE IN C HILDHOOD 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. J AUNDICE IN C HILDHOOD Wilsons 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. J AUNDICE IN C HILDREN Autoimmune Hepatitis Autoantibodies and hypergammaglobulinemia Presentation Adolescence Usually female Hepatitis Asymptomatic jaundice Liver failure Treatment Immunosuppressives Corticosteroids Azathioprine Liver Transplant

41. J AUNDICE IN C HILDREN 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. M ISCELLANEOUS

43. I RRITABLE B OWEL S YNDROME 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. F AMILIAL P OLYP D ISORDERS Gardners 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