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Recording from Gastroenterology Teaching by Dr Sahil Kakar



Join the interactive on-demand teaching session with medical experts Doc and Dr. Sahil. In this session, the focus will be on pediatrics with a particular emphasis on gastroenterology. The doctors will provide valuable insights into conditions like appendicitis and celiac disease, their pathophysiology, symptoms, diagnosis, and management. There will also be discussions on appendectomy, use of prophylactic antibiotics, and the role of different diets. This session is specially designed for 3rd, 4th, and final year medical students preparing for their finals. Attendees can actively engage in the session and raise their questions and concerns for a dynamic learning experience.
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Learning objectives

1. By the end of the session, participants should be able to accurately identify the symptoms and signs associated with common pediatric gastroenterological conditions including appendicitis and celiac disease. 2. Participants should be able to interpret the specific pathophysiology associated with common gastroenterological conditions. 3. Participants will improve their understanding of the different diagnostic methods for pediatric gastroenterology conditions, such as antibody tests for celiac disease and ultrasound for appendicitis. 4. Participants should be able to apply the ALD scoring system in assessing the presence of appendicitis and understand the importance of Key signs such as Rosving’s Sign and the So sign. 5. Participants should be familiar with the specific first-line treatments for conditions discussed in the session, such as the importance of prophylactic antibiotics prior to surgery in appendicitis cases and the role of lifelong gluten-free diet in managing celiac disease.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Yes. Ok. And your life now? Hello everyone. Uh Thank you for waiting and um yeah, and welcome. I find that uh who has just joined in. Uh My name is Doc, I'm a medical student uh on behalf of the ba student. W welcome to this um today's teaching session as well. Uh Today we have uh doctor Sahil here, we are going to be uh doing some pediatric teachings and today it's about gastroenterology and um feel free to drop any of your questions and queries into chat and uh I will be reading them out and er without further ado I'll hand over to Doctor Sahil over to you. Hello, everybody. Good evening. Um So yeah, this is a teaching session on um gastroenterology for finals. Er, can you know, you can go for 3rd, 4th and final year depending on what stage you're at. Um It was written by me and my colleague Shruti. So I'm gonna present it on our behalf today. Ok. Um Fine. So just a quick introduction is that I'm gonna run over a couple of conditions. I'm gonna give you some cases just to see just so you guys can relate it to the exam itself. Um, give you good, good sort of practice for the MC QS that you can see in the exam, the two textbooks I've illustrated there. I mean, they're a bit overkill. I mean, the one the, the yellow book is actually really, really good for, for just, you know, opening up as a sort of an encyclopedia or as a guide, zero to finals and pass. But I'm sure you guys are all aware of. So, um the question marks in my opinion, have always been the best for getting an exam. So these are some of the top um some of the topics we're looking over appendicitis like disease, just all the way down. Um And we'll go through them and discuss some cases about them as well. Fine. So we'll start off with appendicitis um and a bit of background about it. So, i it's one of the most common conditions it can present in adults and Children in Children. It is a little bit more vague. Um You're not sure you, you're never really sure if it's appendicitis until, until you get the specimen in front of you. Or if you get a CT scan, positive CT findings in terms of pathophysiology, you just get a um it becomes inflamed due to an infection and then it gets strapped at the appendix linking to the colon and then if there's a and if this develops and you don't treat it adequately, it can rupture perforate. Now, when it perforates, the main complication is you have fecal content which will be sort of um deposited into the peritoneal space and that develops, you know, purulent, you know, fela peritonitis. These patients are very, very unwell. So in a situation, if you see a patient in the wards or, or in an exam situation where there's a patient that's come in abdominal pain, right sided, uh white cells up and you know, they, they've delayed and come in, they've not had antibiotics and then all of a sudden they've got an acute abdomen. You should be worried about peritonitis or sepsis because of a rupture. In terms of the symptoms, I'm sure you guys are all aware, you know, start centrally, then move to the right hand side. Mcburney's point. You know, it, it's always good to be aware of that. Um The two key signs that sometimes come up in exams is rosing. Sign is pain on the left side. When, when pa pain pain on the left, I like fossa when palpating the right ileac fossa. Er I don't know if it's the other way around actually. And then the so sign, er, so sign is when the patient er, passively extends their right thigh, they get quite, they get, they'll get a lot of pain around the hip region. Classically, these patients will also have nausea and vomiting and er rebound tenderness, percussion tenderness and hemodynamic instability. If the case gets severe. Um it's good to be aware of something called the Al Rado scoring system. I've not mentioned it on this, but it's a, it's an interesting way and how you can categorize these patients with appendicitis. So when you see a patient that comes into the into A&E for example, Children with, with a with abdominal pain, you know, there's 100s of causes of abdominal pain. So sometimes the ALD scoring system is utilized and it can, it, it gives you, I think it's a pre ct scan probability of the patient developing uh having developed appendicitis things to consider um clinical diagnosis, endometry markers, ultrasound of pelvis, abdomen for differential. So, ultrasound of abdomen is pelvic abdo pelvis slash abdomen is very, very important in females. Um because you can have well the most important, more important than that as a pregnancy test because you want to be worried about ectopic pregnancy, nausea, nausea, plus vomiting, plus abdominal pain, plus a pregnancy test. You are always worried about ectopic pregnancies. Er Ovarian cysts are are small things that can occur presenting with similar symptoms. And me from something that will come to um mesenteric adenitis is interesting. So this is a sort of uh lymphoid inflammation that occurs in the same area because around the appendix, there's a lot of lymphoid tissue. So when the lymphoid tissue gets inflamed, you can have a presentation with the mesenteric adenitis. Um and classically, I mean, and you see it in maybe in the exam situation, maybe not so much from your life. When you see the, um, blood results, you're more likely to have a left shift of neutrophilia with appendicitis and mesenteric adenitis, you might have a lymphocytosis. So you have things to consider in terms of management. You have prophylactic antibiotics prior to surgery and then a laparoscopic appendectomy. Um, just a quick note that we've written at the bottom is if you have an exam situation where your patients presented and they say what is the first line in the management? And the first thing that you're gonna do and there's antibiotic exam surgery. This, this sometimes tricks a lot of people up. Although you wanna go for surgery, I would probably go for the, for the, for the antibiotics in that situation just because prophylactic antibiotics are given prior to surgery and then you can do the surgery and in some cases, some centers now they're actually doing trials in which they just manage it just with antibiotics alone. And, er, remember when you're giving these antibiotics, you wanna look at things that have a gram grand, um, anaerobic cover as well. So things like metroNIDAZOLE would be quite good in this situation. Moving forward. Celiac disease. So, celiac disease, it's a, it's a bit of a complicated disease. It's very, very common as well. It's autoimmune disease with that is evident, which is basically an intolerance of Gleason. Ok. So classically normally occurs in the in the, in the villa of the small intestine um diagnosis can be mmm er, multiple, there's multiple ways of making a diagnosis in terms of what we're seeing here is anti T TG and anti E MA er antibodies. So these are the type of antibodies you'll see. So sometimes when we test on the ward, we'll test for GI GGT TG. So this is a um antibodies that we'll test for or we'll test for IG att G. Now, one thing I'm just gonna mention before you even progress to anything is that some patients have selective IG A deficiency. Ok. So this is um uh hematological condition. It's not common but it can occur, you will see it when you become a doctor. So selective IGA deficiency, these patients, one exam thing is a very prone to anaphylaxis secondary to blood transfusions and the other is that they might have a false negative er celiac screen because they don't have the IG, they've not generated enough IG A and that's why the um IG IG A er antibodies in celiac disease are gonna be low. So that's why you should do an I GG as well. Obviously, to check if you have, if you're worried about it, if you think it's a wrong er, false negative. Ok. Anyways, so what happens is it damages the vla of the small intestine resulting in a malabsorption of nutrients. And then that's where the disease presents. The disease is primarily due to the inflammation, cry to the Glusin that we can see in examples such as wheat varley and rye draining episodes quite early in childhood. One key sign, I don't know if we mentioned it here. But one key sign that you can see in exams is uh over distension of the abdomen. So if you see babies with over distended abdomens and buttock, but buttock atrophy, these are things to consider um for celiac disease. Um ok. So, symptoms wise, you have just classic gi symptoms, diarrhea, fatigue, lethargy, abdominal distension, bloating, abdominal pain, difficulty in grow growing Somas hepatis. Ok. So it's a very common, I mean, I don't know if it's common in real life, but it's a very common exam finding in which you'll see very, very, very, very itchy rashes, especially on the extensor surfaces, it says trunk there. But you do primarily also get it on the extensive surfaces. So the dermatitis hepatic forms, if they see if you see an exam question and the patient does not have an itchy rash, it's not gonna be this, it's not gonna be this er dermatologic presentation and then mouth ulcers. So, anemia due to B12 and folate deficiency or iron deficiency. So, iron deficiency is very, very common in celiac disease, b12 folate is it it it is there, but especially in early in Children. Iron deficiency is one of the most common presentations you'll have in this situation. Now, in terms of the symptoms that we've written and the neurological symptoms with regards to B12 deficiency folate deficiency, you wanna be a, be you, you wanna be aware of a cerebral ataxia, peripheral neuropathy, these sort of symptoms. And also, er, you can have um complications if you don't manage these properly, you can eventually develop something called SE SCD, which is subacute combined degeneration of the spinal cord. But anyway, that's, that's more of a neurology lesson. So, and then back to like disease in terms of investigations, as I said, anti T TG, anti E MA and total IG A I, as I said, important to do Total IG A because you might have selective ig A deficiency. Um Mainstay diagnosis can be with biopsy. You'll see classical biopsy signs include crypt hypertrophy, verse atrophy or raised intraepithelial lymphocytes or lymphocytic infiltration. Uh I don't know if any of you have done the you assembly but the raised intraepithelial lymphocytes of the lymphocytic infiltration in the intraepithelial space is a very, very common exam question on the assembly step. One anyways, er, the management is er, lifelong gluten free is, is curative. Just one thing about the, the diagnosis is that you have to, when, when you're testing these patients for this disease, they have to be having gluten in their diet. They cannot have a gluten free diet and then you test them because they're gonna be false negative then. So that's something to be aware of. Um, next. Ok. Fine complications. Um, malnutrition, inflammation, I mean, these are, these are common things, cancer, er, enteropathy associated T cell lymphoma is an important thing to be aware about non hodgins, lymphoma. Less so much and small, more a, less and less, less, so much. But for the exams, this enteropathic associated T cell lymphoma is very, very common to come up. Um, in terms of final steps are just sort of little nuggets of knowledge that you can sort of, you commonly see in these exams. Um, I'll, I'll leave that for you guys to read and I can tell you guys sls afterwards as well. Ok. So gastroenteritis, we're not gonna go through all of these because we'll be here forever. But w when you see gastroenteritis, you'll see a lot of kids with gastroenteritis, it's very, very important that you can classify them into viral and bacterial. Now, bacterial usually has bloody diarrhea. So that's a, that's a good way to remember it. And these patients tend to be a little bit more unwell, tend to be a bit more dehydrated. Um You must always do a stool sample. So when you see a patient that comes in with, with, with nausea, vomiting and diarrhea, you have to do a stool sample to try to ice it the organism and then get sensitivities to the antibiotic and get sensitivities for that. For that, for the bacteria, viral, very, very common spread. You have rotavirus, norovirus adenovirus. Um You should be aware about no rotavirus and norovirus and especially the vaccines that can be used to counteract this because these spread throughout nurseries. Like you wouldn't believe. So, it's very important to be aware of them. E coli. Um, ok, just a couple of points. I'll look at, you know, the ones that we've mentioned here. E coli quite important. I don't know if you guys are aware of the one, what is it called of hemolytic uremic syndrome commonly comes up? Uh I think it's E coli er, 0157. yeah. 00157. So that's a very, very common exam question. You have hemolytic uremic syndrome and you'll have thrombocytopenia, you'll have an acute kidney injury treatment is always supportive in these situations, but it's important to be aware but as I said, the so the sugar toxins can cause um hum U uremic syndrome. Um So. Ok. Um otherwise Campylobacter J I is another one that you should be aware about. I don't know if you guys can hear that. Let me just mute that one second. Sorry. Um uh One side guys. Ok. Fine. Can you guys still see my sides? Yeah. OK. Um fine. Er Baci series reheating cooked rice is very, very common. It doesn't really come up much in the exams but it's something to be aware about as well. It's a very, very fast, a fast onset, similarly, a fast onset you will see with staph aureus as well. Ok. So these are two things that have a very, very fast, fast onset. But Bazil series is more commonly associated with vomiting. Staph aureus can be associated with non bloody diarrhea and proof vomiting. So it's some point to be we are to distinguish between them. Oh, ok. So management of general gastroenteritis, this is probably what you guys should be more aware of. But I think it's important to have the small little key points that we just mentioned about each different type of bacteria. But general speaking in for especially when you practice, it's more important to know about the general points of gastroenteritis. So, infection or control barrier nursing, what that means is you want to prevent the, the the spread of the disease? Ok. So you wanna put these guys in a side room, um you want using PPE when go to see these patients. Um and that's for preventing spread. Now, that's similar to your C diff and other things that you know, with COVID as well. It's similar to all these sort of things. Now preventing dehydration. Now, the m the majority of patients in the underdeveloped world who die from di from nausea, vomiting or gastroenteritis is nausea, vomiting, diarrhea is because of dehydration. One very common one is cholera, cholera, 11 that causes extreme dehydration and that's why so many people died from it because we didn't know how to manage it. And now aggressive rehydration is very, very common. It, it, it's the main stay of management. Obviously, you have your pediatric fluid formula, which you, you guys should learn. We're not going to touch on that on this, but it's IV fluids is the mainstay of treatment. Antibodies are given if you can isolate the culture from the stool samples, er, antidiarrheals do not give anti dials. It is so common. You see them in the exams, maybe not so mention but you see on the ward. So, so commonly patients has a patient comes to you saying doctor I've got really bad diarrhea. They, well the n will come to you. This patients got really, really bad diarrhea. Let's give him an antidiarrheal. Ok? So we'll give him loperamide. Ok? But that's beside the point. If a patient has an infectious diarrhea, you do not give antidiarrheals because you're increasing the risk of perforation occurring in that situation. So anyways complications, transient lactose intolerance. Yeah, very common. So what happens is when patients have gastroenteritis, they can have this period of lactose intolerance afterwards. Now, lactose intolerance actually is something to be mentioned about is a benign condition. I'm sure some of you guys have it. Maybe some, someone you know, has it. Now what happens is as we age the lac, the lactase enzyme that we have in our small intestine. What happens is that actually depletes as we age. So many, many people, it just occurs naturally and that's because there's a theory that the breast milk that we have when we were young actually maintains the lactase enzyme. And that's why as we grow older, we're more and more prone to developing lactose intolerance. Also, when you have post infective lactose intolerance that can also develop, as I mentioned in this case, Guillainbarre syndrome. Um I think you guys should be aware about this commonly. It also we call Camp Bacter July in in exams, it's an ascending peripheral neuropathy with loss of reflexes, er managed via IV IG plasmapheresis. And in patients that develop, you know, respiratory compromise, they're going to require um intubation and and it support one thing in the exam if they mention Guillain Barre Syndrome. And they say, OK, this patient's got ascending peripheral neuropathy, a er ascending peripheral paralysis, sorry, not a neuropathy, ascending paralysis. You know what is it that we want to consider here? Like and it it's ascending, it's really gone up to the region of the abdomen. So it's coming to the diaphragm. What you wanna check is you wanna do um you know your, your, your flow spiro flow spirometries or your, you know your peak flow or your expiratory volumes. These are things that we actually do on the ward in patients who have developed Guillain Barre Syndrome, especially done in itu. Um This interestingly in a Gilla syndrome is not the only cause of ascending paralysis. You can also have tickborne paralysis, which is a very fast onset paralysis. So if you see a child who in the exam who's, you know, gone hiking and then all of a sudden it is having a rapid onset of paralysis. It, it can be tickborne paralysis and these patients generally have a very good recovery. Um ok, fine. Next. Uh intestinal obstruction, intestinal obstruction, very, very common. You see it in adults and kids, in kids, it generally progresses a little bit quicker than in, in comparison to adults. There's many, many causes male ileus. So, so with the meconium, you guys should be aware at this point, what the mm meconium is, the medium is the first stool that the patient will pass. Now, if you have a delayed meconium, you have worried about obstruction, but you'll also be worried about hip's disease. So if you see a delayed mecom in a patient, um be thinking about these two conditions. Ok? Duodenal esophageal atresia, I mean, yes, they can, these can cause obstruction as well, especially with a duodenal obstruction, a duodenal atresia. Er interestingly, you know, as esoph is mentioned, I sometimes ii like to bring in just, you know, other parts of medicine because otherwise it's just, you know, learning one thing that you guys should be aware of is the Vacterl association. So VRL associations are patients who have a huge range of congenital abnormalities. If I'm honest, I can't even remember all of them off the top of my head because it's been a while since I studied it myself. But it's something that I remember learning, committing to memory because it can come up in exams. And if you're going for honors distinction, then it's something you should be aware about. It's associated with esophageal atresia. I think it's trach, um, tracheal abnormalities, you can have cardiac malformations, renal malformations. Um uh it's just, it's one of them. So actal associations is something that you guys should be aware about. Ok. Anyways, presentation wise for intestinal obstruction, you have constipation as we thought, abdominal distension, vomiting, no bowel sounds. I mean, these are basic things that you know, everybody should know at this point, right? Investigation, abdominal legs which show dilated loops of bowel. Now, the management is, is dependent on where it is essentially. But the general management of obstruction is all the same nail by mouth energy tube to suck up the contents. Ok? Um, and then you manage it depending on the location. If it's a large bowel obstruction, small bowel obstruction, the age of the patient. But in kids who generally have a good physiological reserve, it's just n by er nil by mouth and an NG tube. Ok. Moving forward. Interception. Ok. So interception, something to remember is um what happens is, is the telescoping of the bowel. Ok. So the b the bowel telescopes into itself and what can happen is, is the area of the bowel that has become telescoped, actually becomes necrotic. So what happens is if you have the, if you have the bowel here and it goes through on each other, this area around here will actually become recorded because you're compressing the blood supply. Now, what happens when it compresses? That's when you get, uh, a bloody stool or, um, real symptoms are really start developing and you can see, er, like we've written on the, on the slides, a section of bowel is trapped, avoid a blood supply ischemia. And then the mucosa respond by sloughing into the gut and that's where you have this blood and mucus stool can happen following a recent viral upper respiratory tract infection. It's just one of the things that you should be aware about. Yeah. Er, colic abdominal pain and red currant jelly stool, the red collar and jelly stools is a late time that occurs following the necrosis. It's also shaped mass. Yeah. Ok. That's fine. Um, pale lethargic on a little child that's important to be aware about as well. Management is the ultrasound and the therapeutic animal to basically, it's an EMA. Ok. So it's, it's, I know that it's water but generally we give air animals, er, complications are gangrenous bowel and the air EMA is basically just pushed the back, the bowel back into its normal position. Ok. Hirschprung's disease. Ok. Fine. Now, the thing about hips is it's a failure of the descent of the myenteric plexus to the distal bowel. Ok. So essentially the rectum is almost always involved. Ok. So let me say that again, it's a failure of the, of the descent of the myenteric myenteric plexus to the distal bowel. Ok. So these patients will have an impaired peristalsis at the distal bowel or in the rectum. Ok. These patients present with delayed meconium. Um, and that, that's a, that, that's the main form of presenting. Also, it can be associated with cystic fibrosis down syndrome. There's a lot of things that can be associated with it. Ok. Congenital, con Bye. Uh fine. Uh fine. Ok. So, um yeah, so, er, it's a failure of the descent of the my plexus which controls the peristaltic movements that you have in the rectum. And that's why when you have a loss of that, that's why you don't have the bell mo the bowel motions early on. Ok. Um Associated with down's uh multiple endocrine neoplasia and neurofibromatosis. More common in boys. It's also associated with cystic fibrosis as well. Ok. So classical symptoms are no mecom passing than 44 48 hours post birth. You have b, vomiting, chronic constipation says birth in toddlers and apr exam will cause explosive diarrhea. Ok. Diagnosis of your abdominal X ray and Gold Standard is a rectal biopsy to determine colonic angl neos. Ok. And the, these are things that you need to know for the exam. The gold standard is a rectal biopsy and the treatment is your an excision of the, of the GGL segment and the then a sort of an anastomosis developed. Ok, fine. It's important to be aware of her disease. It's a very common presentation. Ok. Pyloric stenosis is a bit different. This is an upper gi s er upper gi sort of area. These patients present with projectile vomiting. Ok. Projectile vomiting in an infant, we worry about p er pyloric stenosis. These people will have an olive shaped sort of lump in the abdomen as well. It's just a hypertrophy of the smooth muscle. The pyloric sphincter can be managed via sphincterectomy, um which is essentially you're just cutting the sphincter really um within reason to allow for the the content of the stomach to pass the pyloric sphincter. This is non bilious vomiting and it's important to be aware of that because bilious vomiting happens after we pass it into the duodenum. In this situation, we're still in that junction between the stomach and the duodenum. That's why non bilious vomiting. Ok. Diagnosis is ultrasound abdomen. Um ok. For the exams, you guys should be aware about hypochloremic hypokalemic metabolic alkalosis. And that is just because of vomiting of a patient. For example, if you see a patient with bulemia as well or uh yeah, bulemia um as well. That's a common presentation as well. Hypochloremic hypokalemic metabolic alkalosis on the ABG or the BBg. And that is the picture that you see in vomiting. Ok. Fine. And the Ramstad operation is basically is, is a special type of operation. And what we're talking about is the incision of the pin fine. OK. Moving for biliary atresia. No, OK. So I understand believe it treats you. You guys have to be aware about jaundice in the newborn. Now, jaundice in the newborn Alex divided into three sections. This is very important. Actually J jaundice in the newborn is divided into early uh physiological and late. OK. When we're over 14 days of jaundice, we always consider pathophysiological, we consider that's a problem. OK. S 7 to 14 days, you have a lot of patients that develop breast milk jaundice because they just can't cope with the increased turnover of cells that is uh of increased turnover of red cells that is prompted by the increase in breast milk. Ok? Um These patients will generally develop jaundice and the management of these patients is generally um conservative. But if the bilirubin level is too high, then they benefit from photo light therapy and sometimes even exchange transfusion therapy. OK. That's, and that's in general jaundice. OK? And in the 1st 24 hours, you wouldn't be thinking about your another patho pathophysiological condition such as hematological problems, such as a b incompatibility versus disease of the newborn G SIX PD deficiency. So, these are things you have to be considering in the 1st 24 hours after 24 hours to two weeks, you can consider more physiological conditions. Obviously, these conditions can also present in this time but it's more likely to be physiological. Then after two weeks, if it's persisting, you really wanna be aware about another other, you know, really uh pathophysiological diseases. Ok. So if you have conjugated bilirubin, it's important to be b biliary treated. Now, biliary treated by definition is just a treat of the biliary tract, meaning the biliary system is not formed properly. Ok. So these patients will develop, um, er, these patients will become a prolonged jaundice and they can, you know, they become very, very unwell and the treatment for this is something called a CACI procedure. And the CACI procedure is a sort of, is a, is, um, how do you describe it's a, it's a sort of anatomical creation of a false bilary tract to get rid of the sort of the, the bile and then get rid of the, the um, conjugated B. Ok. Uh, as I said, ok, so jaundice for more than 14 days, er, 21 days in pre. So more than 14 days is normal, er, up for more than 14 days. Normal babies, 21 days in preterm babies is, is a, is a red flag. Ok. That like with splenomegaly er, investigations, um, conjugated bilirubin is a gold standard of high alpha antitrypsin alpha, one antitrypsin levels. Um, is another cause of increased conjugated bilirubin. The heel prick test to test for cystic fibrosis, which can cause problems with bile duct obstruction, um, protein electrophoresis for other liver diseases. As well. Ok. As I said, the first line treatment is Caci Portoenterostomy, which is just a creation of a false b of a false bile duct. Ok. Uh, and the curative management is a liver transplant and the adjuvant therapy. In the meantime, you wanna use your cholic acid, which is very, very important as well. So, these are the three things you guys have to be aware about in patients with bilary resia. Ok. Um, moving forward. Ok. So inflammatory bowel disease is very, very similar to patients. Um, inflammatory bowel disease is very, very common in patients in adults. Ok. Adults and Children very, very similar. So you have ulcerative colitis and you have Crohn's disease. Ok. Ulcerative colitis tends to affect the distal, the distal colon. Whereas the peds, it's more in, in, in pediatrics, it's more pancreatis. So it's the entire colon. Now, the reason why we are going for a total colectomy in pediatric population is because it's, it's, it's curative. Now, ulcerative colitis as we know, is only rendered, is only limited to the er, is only limited to the, to, to uh one region of the, of the, of the, the gi tract. And that's why a resection of this area is generally curative. Whereas Crohn's disease has these skip lesions that goes from the mouth all the way to the rectum and that's why you can never really cure Crohn's disease with surgical resection. Ok. Symptoms of inflammatory bowel disease. You have diarrhea, bleeding and anemia, weight loss and they just poor, poor, poor development, developmental delay. Um, and when they have system, when they have flare ups, they're quite systemically unwell. Um, especially in ulcerative colitis flare ups, they can be quite unwell with repeated bloody diarrhea, dermatological manifestation. Ehe mendosum pyma ganglio are common presentations of ulcerative colitis. Ok, scleritis, episcleritis are eye presentations which are also associated with these inflammatory bowel diseases. In terms of blood tests and investigations you want to do. The main state of diagnosis is via endoscopy is involved, but it's more or not colonoscopy with biopsy is the gold standard, especially for ulcerative colitis. Fecal carp protection is also a very important test which you guys I probably worry about as well. And then you can do a full work up for Crohn's with ultrasound CT S and MRI S because the complications of Crohn's are multifactorial going all the way from mouth ulcers to perirenal abscesses, fistula developments, um and and so forth and so forth. But it is quite important. I think you guys should know the systemic manifestations of inflammatory bowel disease. Fine. Ok. So moving into the, the spec specification of Crohn's muscles, ulcerative colitis, when you look at ulcerative colitis, I'll start with that. You have a continuous inflammation which is limited to the colon and the rectum in adults with the distal colon and peds. It's generally the whole colon and the treatment is amisil, um which are used for flare ups or, and steroids as well. And the actual, the management is dependent on the location of the ulcerative colitis and also the number of bowels, er, um, stools a, a patient is having per day. It also shows with primary sclerosing cholangitis, which is then in turn associated with cholangiocarcinoma, which has a very poor prognosis. So, it's important to be aware about that. Um, primary sclerosing cholangitis. It's, it's, it's just sclerosis of the, of the bilary tract of the bilary tree essentially. So, it's important to be aware about that. Ok. Um, as I said, in the management of an acute episode, you've got to be using steroids, oral pred or IV hydrocortisone depending on the severity. And second line is IV cycloSPORINE which are, these are immunomodulators, obviously, steroidss, everybody knows dampen the immune system decrease the cy the cytokine storm. In comparison, cycloSPORINE is an immune modulator which we can consider as well in mild to moderate. We can also use aminate and meslan mesalazine as well. And the second line again is steroids, er corticosteroids IV or oral pred. And that's for, you know, a mild to moderate presentation. The maintaining remission is aos or azothioprine are, these are essentially all B biologics. You can use biologics, you can know immune modulators and these are the management for maintaining remission surgery. As we said is curative shoulder colitis, you can do a, you can do a total colectomy, um, which is, which is generally curative. And that's why we, we do that. In comparison, Crohn's disease. These patients generally present with just increased frequency of stool with maybe mucus at some point. But no blood generally, it impacts the entire G A tract including on the mouth of the rectum. You can have skip lesions on endoscopy. The terminal ileum is the most effective. Now, the terminal ileum is important to be aware of it because a lot of these patients have terminal ileum resections. Terminal ileum is very, very important. And the reabsorption of bile and reabsorption of bile is synergistic with the formation of uh uh with the maintain of fat. So what happens is these patients are so classically exam. Now, you have a patient with Crohn's who had a terminal ileal resection. 10 years later, it presented with gallstone. What is the cause of the gallstone? The cause of the gallstones is that you had a terminal ileum resection which has resulted in the um er decrease in reabsorption of bile which has damaged that s synergistic relationship between fat reabsorption and bile resulting in an increase in fat, resulting in presentation of gallstones. So it's a, it's a, it's almost like a pathway that happens just because of this. Uh the development of C because of Crohn's disease. OK. In terms of management, very similar to, to colitis, we want to use hydrocortisone or oral predniSONE depending on the er depending on, depending on the location, uh, depending on severity. Sorry, second line again is, er, er, immunosuppressants such as iothia prim. And we can also use biologics such as Infliximab, maintaining remission is again, immunomodulators and uh biologics as well. And surgery is sometimes important for terminal ileal resections. And also the corrections official perirenal er, perirectal abscesses but generally, uh, it's not curative because as I said, the skip lesions and it involves the whole gi tract Wilms tumor is something to be interesting. Um interested about Wilms tumor is the most common type of pediatric tumor. Ok. It's a, essentially, it's a, it's a nephro, it's a nephroblastoma. Ok. So a a Wilms tumor classically presents with abdom abdominal mass in a child. You've al always gonna be concerned about nephroblastoma or a Wilms tumor. Ok. These patients suffer hematuria, slightly elevated BP and under five years of age, other tumors to consider with abdominal masses are neuroblastomas. Um and rhabdomyosarcomas as well. OK. The investigation is done via an ultrasound to visualize the tumor. A CT to stage. And then as I said, one of the differentials is a neuroblastoma and it generally metastasized to the lungs and tend to be asymptomatic. Ok. Management is nephrectomy because it's a nephroblastoma essentially with adjuvant chemo or radiotherapy. And if it's metastasis to the lung as a prognosis, it's generally quite poor. Ok. In terms of final steps, as we've said below Wilms tumor in all Children that present with painless abdominal mass and hematuria. Um neuroblastoma must be considered as well. Ok. As I said, so these OK. I don't know. I think you can, guys can see the answers actually. Right? Fine. It's fine. Ok. So question one, a couple of questions we'll go through question 12 year old boy, failure to thrive smelly, diarrhea multiple times a week, bloated, abdominal pain, gluteal, gluteal wasting. He's not maintaining his development milestones. What in which investigation will veal the diagnosis? Ok. So, stool sample, no, and I'll work it. We can go talk through it. Really stool sample. No, stool sample something you consider. If it's an infectious cause of diarrhea, abdominal x, you be worried about an obstruction, hydrant breath test. You want to consider H pylori maybe an adult IG att G is probably the right answer. An abdominal ultrasound not to be the first one. So as I said, classical celiac disease ig att G antibodies. Ok. Again, the question to 10 year old girl with bloating diarrhea, tummy pain, five months um falling. So she has a anemia. Uh platelets are normal white cells are normal. So this patient is presenting with an anemia. So fecal cp protection. No, you might consider that in patients with, in, with, with diarrhea. But it's a, it's an important consideration more considered with inflammatory bowel disease. Fit test. No, you're, you're not gonna consider that due. No biopsy. It's not gonna be the first line serum ig att G and total IG A or serum I GE ma and total IG A. So the answer is serum I GE ma and total IG A because that fits more with celiac disease. Ok. Again, moving forward question three, a 14 year old boy presents with gi symptoms at the Gi clinic with a diagnosis of Crohn's. What is the most common? Ok. This is just, I don't know, I didn't put these questions in, but that's just you're never going to get something this easy. But abdominal pain is the most common bloody diarrhea. More associated with ulcerative colitis. Mouth of mouth are associated with Crohn's Pernal malformation. Skin tags are associated with Crohn's persistent flu like symptoms. Not at all. That's just uh probably a red herring. Ok. Question 49 year old with 24 hours of nausea, vomiting, abdominal pain, deep and labored breathing. Ok. So you can probably see the answer. You can see DK is the answer but a couple of things, nausea and vomiting, abdominal pain. Nine year old girl with labored breathing, labored breathing is sometimes known as small breathing, which is actually associated with si situations in which you have um er in which you can associate with with an acidosis, especially with increased anion gap acidosis, which DK A is um if you guys are not aware about the anion gap, the anion gap is something that you do the positives and the negatives in the blood. So the positive ions which are sodium and potassium minus the negative, which is bicarbonate and chloride. And you, if you have a value of increase in 414, that increased, that indicates there's an increased anion gap when there's an increased anion gap. What that means is, is that other, that there's been an, there's been an acid production from elsewhere. So for example, when you ciliate poisoning, when you have DK A, when you have sepsis, these are causes of increased anion gap. In comparison. Something such as renal tubular acidosis. When you're having a loss of bicarbonate, there will be a, that will be a normal anion gap. OK. Uh These are the blood results. Sodium is a bit low potassium. So um sodium is a bit low. Potassium is 4.5 bicarb is 14. OK. So it's a metabolic acidosis. It uh it could be sepsis but unlikely rotavirus. No intestinal obst, no, basically, no. So it's gonna be DK A. OK. And that's us. So, um if you have any questions, let me know. Um that was a bit of a quick run through but I can send you, I can send you. So I just need one question for bacterial gastroenteritis, which antibody do you prescribe? It depends on the, on the, on the, on the pathogen. So that's why you need to do a stool culture prior to the er prescription of the antibiotic. You get the culture back and then you get the sensitivities from micro as well, but there are some key ones that you should be aware about. Um, obviously there's many. So if you go, if you go to a section of passed, they almost have bacteria relevant to each one. Oh yeah, that's, that was the only question I can see. Yeah, I don't think there's any further question at this stage. OK. Feel free to type any questions in the chart. And, er, doctors who do you, do you prefer the uh feedback form to, uh to be on, on the um QR code that you, that you're using? Yeah, that's fine. I mean, I think you guys also have a feedback form as well. Yeah, we have here on, on the metal as well, but if you prefer that one, that's fine. No, no, II think I it'd be better to stick to your one because that's not the one we've been using throughout. So we just stick to your one. OK. So, so you can send that to them or you guys do it? Ok, cool. Um So I've just sent out the feedback form um uh into the chat. So um thank you very much for joining us everyone and if you can just take a moment and to, to fill back, uh fill out the feedback form that will be very helpful to us. And yeah, um and after that, you can also receive your um attendance certificate. Thank you as well. Thank you. And if you guys want the slides, just let me know. We can, they can speak to you and I can set the slides up. Brilliant. Um Yeah. Um I think what, what we can do is when we once we um got the feedbacks, then we can upload it to like the same event page on a later date. Yeah. Um yes, we we will um upload the slides at at a later date. We will attach it to the same event page Disadvantage. And yeah, you're welcome. Well, um if there's no further questions, I think uh we can call it a day here. Thank you very much, Doctor Sahil for giving us this insightful talk and uh for our participants, our audience, please take a moment or two to fill out the feedback form that will be very helpful for us. And um yeah, until next time, please um follow our page here for more events in the future and phone. Thank you and um goodbye, everyone. All right, thanks guys. Cheers. Thank you.