Resident Rotation

Residents are assigned by the resident program director to the DDNC for a 3 week rotation. During that rotation the residents are expected to work with the attendings and the fellow. Residents should set their own schedule in consultation with the faculty who is covering the in patient/procedure service. Residents are expected to see and where assessed as safe and appropriate by the attending physician, perform procedures. The resident are expected to perform a minimum of 6 consultations on hospitalized children. Residents are expected to attend a minimum of 2 clinic sessions; each clinic session is a half-day.

Since residents are now in the process of life long learning, it is expected that residents will consult the literature before presenting cases to the attending physicians. It is expected that at the case presentation, at a minimum the resident will have an overall understanding of the problem for which the service was consulted.

During the rotation residents are expected to participate in the fellows conference, pathology, radiology and post clinic conferences.

Residents will be evaluated on their performance in each of these areas.

Residents are encouraged through independent study and asking questions of the attending and fellow to meet the educational goals of the rotation as outlined below. In addition, residents should request tutorial (informal or formal) of the attending physician to be sure they are able to manage the following problems in a primary care setting.

• Evaluation of Neonatal Cholestasis
• Liver disease in teenagers
• Reflux/GI motility
• Chronic Diarrhea - CF, dietary induced, celiac disease
• Public health nutrition – obesity, growth and development, formulas, new policies
• Abdominal pain/hyperalgesia
• Inflammatory bowel disease – histopathology, diagnosis, treatment
• Topic of interest to resident group or assess where new science exists, i.e. gene
• For IBD identified, increase in anemia, etc.

Program Goals for Pediatric Gastroenterology, Hepatology, and Nutrition

GOAL: Normal versus abnormal. Understand how to differentiate between normal and pathological states related to gastroenterology.

OBJECTIVES:

Demonstrate an understanding of normal feeding patterns from birth through adolescence for eating, weight gain, reflux, spitting, and recognize significant variations that warrant evaluation.

Differentiate transient and functional abdominal pain from pathologic pain.

Recognize transient liver abnormalities from significant ones.

Demonstrate an understanding of normal stooling patterns from birth through adolescence, know when to evaluate significant variations and when and how to treat.

Identify and manage gastrointestinal and nutritional sequelae of systemic conditions.

GOAL: Common conditions not referred. Understand the management of gastrointestinal conditions generally not requiring referral.

OBJECTIVES:

Recognize, describe the pathophysiology of, and manage these conditions:

• Infectious enteritis
• Chronic nonspecific diarrhea
• Common nutritional deficiencies
• Constipation, encopresis
• Exogenous obesity
• Gastroesophageal reflux
• Giardiasis
• Irritable bowel syndrome
• Jaundice associated with breast feeding
• Lactose intolerance
• Mallory Weiss esophageal tear
• Milk protein intolerance
• Recurrent abdominal pain of childhood
• Viral gastroenteritis
• Viral hepatitis, uncomplicated

Develop a step-wise approach to diagnosis, including appropriate history, physical exam, and laboratory studies; treat common conditions as listed above and refer appropriately the following complaints related to the gastrointestinal system:

• Abdominal pain
• Abdominal mass
• Abnormal liver exam or liver function tests
• Eating disorders
• Failure to thrive
• Hematochezia
• Hematemesis
• Malabsorption
• Vomiting and diarrhea

GOAL: Conditions generally referred. Understand how to recognize and initiate management of gastrointestinal conditions which generally require referral.

OBJECTIVES:

• Identify, provide initial management of, and refer appropriately these conditions:
• Conditions warranting urgent surgical or gastroenterology referral (appendicitis, 0bowel obstruction, volvulus, intussusception, pyloric stenosis, coin ingestions lodged in esophagus, caustic ingestions, biliary atresia/stones or congenital, GI bleeding, blunt abdominal trauma, Hirschspring’s disease).
• Hepatobiliay diseases (hepatitis which is either neonatal, chronic, or persistent; undiagnosed hyperbilirubinemia, alppha-1-antitrypsin, pancreatitis, hepatosplenomegaly).
• Intestinal conditions (inflammatory bowel disease, colitis, significant gastrointestinal bleeding).
• Nutritional deficiencies which are severe or uncommon (rickets, kwashiorkor, marasmus).
• Malabsorption entities (celiac disease, cystic fibrosis, following serious GI infection, undiagnosed).
• Others such as morbid obesity, anorexia nervosa, bulimia, severe failure to thrive.

GOAL: Vomiting. Understand the diagnosis and management of vomiting.

OBJECTIVES:

• Distinguish normal spitting up and functional gastroesophageal reflux from more serious vomiting disorders.
• Identify the common and serious disorders leading to vomiting (both intestinal and extraintestinal) and the appropriate use of laboratory and imaging studies to clarify the diagnosis.
• Identify and refer children with intestinal obstruction leading to vomiting.
• Differentiate typical viral gastroenteritis from other causes of vomiting.
• Recognize signs and symptoms of dehydration, calculate deficits, and maintenance requirements and demonstrate knowledge regarding appropriate treatment with IV fluids versus oral rehydration solutions.

GOAL: Abdominal Pain. Understand the diagnosis and management of abdominal pain.

OBJECTIVES:

• Identify the common causes of abdominal pain and differentiate recurrent abdominal pain of childhood from other organic causes.
• Demonstrate the ability to take a complete history related to abdominal pain including diet history, bowel patterns, and psychosocial history.
• Describe a step-wise approach to the work up of a patient with abdominal pain.

GOAL: Diarrhea. Understand the diagnosis and management of diarrhea.

OBJECTIVES:

• Define the infectious and non-infectious causes of diarrhea.
• Describe the appropriate diagnostic work up for the patient with acute, subacute, or chronic diarrhea.
• Describe appropriate dietary therapy for the patient with diarrhea based on etiology, including the role and use of oral rehydration solutions.

GOAL: Nutrition. Understand principles of nutrition important to the general pediatrician.

OBJECTIVES:

• Collect an age-appropriate nutrition history and perform an age-appropriate exam for nutritional disorders.
• Identify the major component (i.e., carbohydrate, protein, fat sources), the differences of and the indications for using the
following milk types: human breast milk, cow’s based infant formula, soy formula, specialized formulas, and whole milk.
For the following list of nutritional components, describe children at risk for deficiencies, list common signs and symptoms of deficiency, and identify dietary requirements and sources for and discuss the pediatrician’s role in the management of routine cases of deficiencies:
• B12
• Calcium
• Calorie
• Fluoride
• Folate
• Iron
• Protein
• Vitamins A, C, D, K
  
  
• Explain the concepts of recommended daily allowance (RDA) especially related to food labeling, food pyramid, basal
metabolic rate (BMR), stressors and food digestion, and describe changes needed in children who have serious or chronic illness or who are in the perioperative period.
• Manage exogenous obesity utilizing dietary consultation appropriately.

GOAL: Prevention. Understand the pediatrician’s role in the prevention of gastrointestinal disorders.

OBJECTIVES:

• Counsel patients effectively in the following nutritional areas:
  • Age appropriate diet
  • Eating habits
  • Food safety (choking, food preparation, storage)
  • Prevention of dietary deficiencies or excesses
  • Prudent diet to reduce cardiovascular or cancer risk in adulthood
  • Counsel parents about bowel training and dietary prevention of constipation.
    
    
• Demonstrate knowledge about the rationale and recommended immunizations pre and post exposure to prevent Hepatitis A and B.
• Discuss infection control practices for the prevention of gastrointestinal infections in the day care settings.

Suggested Curricular Resources

Gastroenterology

Walker WE, Goulet O, Kleinman R, Sherman P, Shneider B, Sanderson I Hamilton JR, Walker-Smith JA, Watkins JB: Pediatric Gastrointestinal Disease, Pathophysiology Diagnosis, Management, 4th ed. Philadelphia, BC Decker, Inc., 2004.

Walker WA, Watkins J, Duggan C. Nutrition in Pediatrics, 3rd ed.Philadelphia, BC Decker, Inc., 2003.

Willie R, Hyams J. Pediatric Gastrointestinal Disease. W B Saunders Co., Philadelphia, 1993 (new edition published in 2006).