Day 13 Pediatric Cardiology and Emergency Department

Patient 1: Diabetic mom with triplets, difficult echo because need to make sure not examining same heart twice.
One has little bit of pericardial effusion.
Diabetic mothers run the risk of fetal hypertrophy of septum and congenital heart defect.
Depends on how well they are maintaining their diabetes
Very small possible pericardial effusion with one heart.
Suspected ventricular hypertrophy in other heart
Limited view on third heart


Patient 2: Kawasaki disease 1 yr old           http://en.wikipedia.org/wiki/Kawasaki_disease
Messes up coronary arteries 
Right and left coronary artery aneurysm
Left looks big
Hgb 11.4, ESR 46 but CRP 0.44 normal
PE cardiac normal
Treat with aspirin low dose
Had large aneurysms 
Rhuematic arthritis with MR?
Has problem with mitral valve
MV thickens
Mitral regurgitation-Mild
2cm jet
Strep 3rd world disease due to strep pharyngitis not treated in a timely manner
Africa has lots too
Mild-moderate Mr thick valve with peristernal?
20-30% will get rheumatic fever after strep throat, genetic predisposition
Since 2010 RF gotten a little worse
Was prescribed: antibiotics every 3 weeks, but now in army and has problem. 21 IM prophylaxis
6 month return to see if stable.

Patient 3: ASD closure 3yrs ago
Tired think cause of weight gain not previous surgery.
Fight with parents over weight gain 
Recommend dietician 
No murmers, pulses good
45 kilo
141.5 meters
Cathiterization through femoral valve used device like a balloon...easier than surgery if enough room. Device will remain in heart for life. 
Right ventical big should be small after surgery
Weight makes difficult to do echo


Patient 4: Soft murmer in middle of systole otherwise healthy one month old.
Heard in back too, so more serious
PPS peripheral pulmonary stenosis  
http://www.childrenshospital.org/health-topics/conditions/peripheral-pulmonary-stenosis
Could be normal up to six months of age.
Not a wide S2
Prenatal echo with a questionable whole in heart.
ECG NSR normal for age
Patent foramen ovale normal for age no RV dialation
Return in a year to reevaluate, murmer should resolve by then.


Patient 5: WPW (wolf parkinson white syndrome) and dilitation 
Twice in yr had syncope
Systolic murmer
See wpw on ecg avl lead shows famous delta wave
MR jet of 24mm
Aortic valve normal
Mild Mr and valve thickening
Pulmonary septal delta wave
Return if feels inappropriate palpitations
Trace tricuspid regurgitation
Normal right and left venticular function
Stills murmer and no click
Stress test bpm 198 no loss of delta wave
Rare APBs and VPBs
Sports controversial 
Normal physiological split
No excessive sport, 
Good dental care cause risk of endocarditis


Patient 6: Came 2 days old with SVT Which caused cardiomyopathy.
SVT getting deralin and beta blocker
Has wpw syndrome
Deralin 5mg 4x day...want to change to 2x a day
Has not been growing enough
Stills murmer
10th child with GDM during pregnancy
Tachypniac
Now on 3x day 7.5 3x day propanolol(deralin)
Narrow QRS tachycardia
Stable on daralin
Count pr interval...120 normal for his age
30% wpw will pass on own, no delta wave mow, 
30%after age 7 will come back, not sure which though 
Doc want to take of deralin and see how he does
Low pitched vibritory systolic ejection.
Drenalin 10mg2x day po- mother changed dosing
Now no drenalin-doctors choice to see if he does well.
Follow up in 3 months
No special therapy no restrictions
Daily check pulse at home to make sure no svt

Patient 7: ALTE- Apparent life threatening event, possibly SIDS  http://pediatrics.uchicago.edu/chiefs/inpatient/ALTE.htm
Do a holter exam http://en.wikipedia.org/wiki/Holter_monitor
Premature ventricular beats
PVC
Make sure no cardiomyopathy
Just one cell that is sick and does not wait for sinus rhythm and causes PVC
If ok send home for yr and another echo.

Patient 8: Noonan disease pulm stenosis and catdiomyopathy
http://en.wikipedia.org/wiki/Noonan_syndrome
Stills murmer 2.5 wk old
Twin a with cyanotic spells...here for Alta workup 
Infrequent Monomorphic PVCs 
Here for workup
Ecg second pic
Pfo right to lft normal
Ductus closed
Looks normal
Asymptomatic monomorphic PVC normal anatomy and function heart
Benign
Needs repeat halter and echo within a yr

((Note to self: Arabic marrying cousins is more accepted than not....more birth defects than Jewish population.))

ER pediatric department

Patient 1: Gross hematiria IGN nephropathy
Hemoglobinuria 


Patient 2: Ureterohydronephrosis ureter- mild
Nurofen 80 mg ibuprofen for fever

((Note: Look at percent WBC
Neutrophils 80-90 in bacterial infection
If all WBC high leukocytes, neutrophil percent low around 50% , its viral.))

Day 12 Pediatric Cardiology

Patient 1: Fetal echo 27 weeks

Single umbilical artery; should be two artery, one vein
Could be associated with congenital abnormalities like congenital heart disease.
Flow of vsd both arterial and venous flow, So two colors on echo are seen going back and forth through the VSD
Muscular seplal defect has a greater chance of recovery and closing than other septal defects.
Usually closes on own depending on size.
Ductus spenousis can tells us about umbilical and heart, stenosis, acts as sphincter...if born without it, the heart will get flooded and we can see flow abnormalities.
Doplar it on echo to see flow of blood.
Look for aorta and ductal arch 
Patients other child had muscular VSD which closed after birth
Ductal arch stenosis than right ventricle becomes sick and needs early delivery.
VSD shunting bi-directional flow, common finding, usually closes spontaneously sometimes before birth.
Patent ductus foramen ovale right to left shunt.
If murmer after birth means vsd not closed, the louder the murmer, the smaller the vsd
(Note to self from doc, this is the middle east so don't want to upset ppl...like taking patients out of order).

Patient 2: Normal exam, 30 weeks
No pericardial effusion
Birth defect-twins 
One girl blind
Microopthalmia
Dolichicephaly
Looking for heart defect also.

Patient 3: In neonatal ward: Anus inperforated
Fistula into vagina, not very healthy
Vater:  vertebral problemes, fistula, renal problems, anal atresia, cardiac problems

Patient 4: BPD: broncho pulmonary displasia, 
Premature and on oxygen more 28 days has BPD
Has PDA
Pulmonary problems
Not because right ventricle but because pulmonary pressure so high.
Right ventricle hypertrophic
Abdomen so big pushing heart
PR gradient can get diastolic pressure 20mmhg high 
Give home NO or give Viagra for pulmonary hypertension
Viagra cheaper than NO
Very edematous child
Big PDA- left to right shunt? Gradient of 4 previously
All right to left shunt, worse now.
Maybe ductus closed, can't see it on echo.left to right when it was open.now right to left.
Right ventricle not as big as it should be. 
IVC and hepatic veins small
No retrograde into hepatic vein
Right to left BC pfo flow not open to lungs and systemic flow BC pressure in diastole 
130 days old, has bad lungs premature birth no surfactant and alveoli not mature
Right ventrical was not contractiong so put on NO (nitric oxide) 

Patient 5: Blood sat 60! BPD patient, 3 months old
300 per min high frequency ventilation pushes and pulls oscillation
Bpd, just closed huge ductus
Swollen child due to PDA not being closed on time.
3 months old, PDA closed 2 days ago.
Intracranial bleeding in brain itself on both hemispheres
Possible treatment of premature lungs;
Beta agonist if needed, Viagra, NO. O2.
Right to left at pfo

Day 11 Pediatric Cardiology

Patient 1: Interrupted aortic arch and VSD had fixed after birth 
Arch not complete more than coarctation
Good pulses
Scars from drainage tube
Scar down chest open surgery
Systolic murmer of vsd
Check Bp response from aortic arch

Aortic stenosis RV hypertrophy
Gradient of stenosis in sound waves.
Did not have AS before but now does, may need another surgery.
Eating and growing well.
Qrs complete break on the branch.
Normal sinus rhythm.
Lvh with normal function
Aortic stenosis up to 36mmhg gradient.
20mmhg with discrete subaortic membrane.
Small vsd closed spontaneously, excellent repair.
No PDA 
Mild AR

Follow up 3 months
Recommendation now a developing sub AS with mild AR with previous seen BAV repeat study in 3 months my need AS repair soon. 
No restrictions or need for therapy in mean time.
ECT- positive in VII, should be negative in kids, because of LVH makes it positive.

Patient 2: Baby girl 8 month old healthy house Dr heard murmer
Femoral pulses LV pulse equal pulse and timing apex in right place, 
Systolic murmer

Maybe valvular murmer, listen to clicks
Has click opening,early systolic pulmonary click fist heart sound louder inspiration softer expiration
S1clickS2
Listen with bel--l click
Mild is because of frequency. It is related to gradient over valve
CO looks normal.
Listen to back no murmer, serious would hear in back of child
ECG-RVH high VII- R waves
Echo-look for ES pulmonary valve stenosis
Guess 20mmhg 18-25 based on frequency of murmer.
AV and  MV are ok
Pulm valve turbulance makes murmer and RVH
Measure LV wall thickness
Co sine and sine angle is used with the Doppler, we can get gradient by how fast blood moves.
Patent foramenal ovale valve open which is fine.pfo
Doppler works better at a 180 degree angle 
Red towards us blue away. 90degree angle not as good as 180
                
Patient 3: Husband stays home with kids and wife works 
Hr 150
Pulmonic ejection click
Harsh low pitch
Normal aortic valve, mildly thickens pulmonic valve up to 28mmhg gradient from LLSB
Mild MPA arteries.
Follow up need to know natural history, this age very benign, so follow up in a year. 
Genetic caused
Everything genetic except trauma in medicine.

Patient 4: Rheumatic fever, had emergency valve replacement.
Has mechanical mitral valve now.
Heard valve in front and back
Pulses normal
PMI very lateral.can see pulse.
Bp 116/68 pulse 80bpm
AR from RF
Amazing can see sutures and mech valve in echo
Shadowing on valve because not tissue US does not go thru it
No stenosis on valve 
L atruim good
BMI 19.5 height 152cm
1st degree av block from the episode ir surgery
205 milliseconds

Medications:
Coumadin 
Digoxin
Captopril
Penicillin

LV precordial impulse increaed
Loud mechanical S1
S2normal
Loud s1 click
No vegitations on mechanical valve
LV is smaller

Patient 5: PVCs lots of them 13yr old boy.
Early beat w pause because goes retrograde and causes sinus rhythm to re start
2nd heart sound normal expiration inspiration its single
Most causes by cell in heart acting up like virus...only one cell can cause premature beat without needing sinus node.
Monomorphine, all from the same spot.
Continue to follow up, 
Hard to see RV w echo so look from below.
Early beat not as much filling
Venticular arrythmia 17%of total beats.
Found initially on sports exam.
Multiple momomorphic pvcs  with RVOT with 9 episodes of accelerated venticular rhythm125-136bpm was active the same day playing basketball.
AVF coming from top down from right bundle branch, can see on ecg.
Stable rvot with normal beat functionally
No sports restrictions, no special therapy
Usually self limiting

Patient 6: Rheumatoid heart disease born in  2002 .
Second heart sound louder on inspiration and abnormal split
Systolic murmer

ECG: Last rhythm is artifact cause he moved, normal before and after so no other way to explain it.
RF in 2011
Had a lol mr pathogenic
Since several months stopped taking prophylaxis. Penicillin IM
Sydenham's Chorea ( http://medical-dictionary.thefreedictionary.com/Sydenham's+chorea ), st vincents dance uncontrolled throwing of limbs, neurological after rheumatic fever 
occurs 2-3 times a year 10%of cases. 2-3 m after strep through 2-3m later the RF
MR
ADHD ritallin
PE cardiac normal
Post rhuematic endocarditis
Recomend to continue peniccilin250mg p/o if po required
Penicillin 1.2million unit IM every 28days,
Followup 6 months

Patient 7: Baby with fever for a long time without a source, so gonna look in heart,
Drank chicken water, that was start of fever.
Normal PE
Valves all normal
(See atria best from belly but only in kids)
No vegitations
No coronary arteritis or myocarditis

Patient 8: 26 + 2 week fetus fetal probe, 3rd pregnancy, with one spontaneous early abortion and one healthy kid at home.
Now with echo foci in LV
And now dialated renal pelvices.
26yrs old woman
Pfo right to left
No vsd
No peri membranous vsd
Echogenic foci is seen but is not a cardiac problem.
Normal fetal heart

Patient 9: 22plus 5 weeks child number 9 with one spontaneous abortion. 
Son had coarctation when born in Florida
Left ventricle is smaller in coarctation..no coarctation found
Arch is little smaller than ductus but should be same size, one sign or a coarctation...must suspect a coarctation with this sign
Repeat exam in one month
Genetic trait

Patient 10: 8yrs after kidney transplant
Heart looks good.

Patient 11: kidney transplant

Mitral regurgitation significant
Can't see on ecg, but could see LVH
11.5 yrs old child
Normal LV and RV size and function 


Patient 12: Sinus arrythmia common in kids upon breathing

Lung congestion on chest xray.
He is a premature twin

Chest X-ray
Dopler tells us pressure difference between the two ventricles
Make sure no abnormal pulmonary flow


C section gets TTN because lungs not squeezed right

Day 10 Pediatric Gastroenterology Endoscopic Theater

Patient 1: Recurrent helicobactor pylori- gastritis
Second treatment levofloxin strong new agent resistant to hp
30% pop here have it, but not all have problems.
General Anesthesia: propofol.
Duodenal valve enters CE, stomach,esophagus
Urea CLOtest...put biopsy in it.(clostridium like that's why they call it CLO).
Europe says to do endoscopy first, Israel treats first. 
Possible ibd inflammatory bowl 14yr old girl disease terminal ileus?
Crohns or uc
Inflammatory markers, iron deficient, seen in crohns disease
And pain over months in waves 
Intermittent diarrhea, Decreased energy, celiac negative, weight loss, ect.

Difference between Crohn's disease and UC is location and depth
Crohns is whole depth of intestine
Uc only mucosa, sub musosa, 
Crohns causes cancer of small bowl, 
Large bowl both cause cancer, 
Crohns has skip lesion

Uc micro ulcers
Iliocecal most common in crohns, terminal ileitis. 
Cramping if small intestine, large bowl diarrhea.
Check raised crp esr, 
Stool sample of wbc
Calprtotectin s100 inflammatory white cells can check
Endo and colonoscopy
patient had anal Skin tags 
No fiber no solid food three days prior colonoscopy

Give antibiotics: flagyl for study. And azithromycin
Normal colon, inflammed IC valve, and terminal ileum, 

Patient 2: Celiac disease, young boy
Duodenal bulb flattens so take sample
Celiac serology negative sensitivity 95-97% except for 2 yr olds.
Could be gastritis 

Treated twice for hp, still has pain although hp gone.
Esophageal polyp.
Mild gastritis
Could still be hp although urease negative or could just be psychosomatic complainer.
Belly pain
Lancon ppi has not helped.
Focal epigastric pain for a month, missing school...could be stones or many possibilities.
Normal esophagus, stomach, duodenum, biopsies taken.
Boy, mouth sores, fever, belly pain, 
Mild crp elevated.
Could be mild crohns disease? 
Gastro and colonoscopy.
In kids usually upper GI crohns
Upper not inflammed
Checking colon
Lymphatic nodules are normal in terminal ileum around villi

Lost weight
Aphoid small ulcers half mm or lass with red halo not seen.
Looks normal
Was tested for fmf- familial episodic fevers- negative. This genetic disorder is only in Israel in the Jewish population.
Reflux despite prylosect ppi
Gastroscopy
Lost 12 kilos in a month
Non acid reflux.
Eosinophillic esophagutis-has reflux symptoms,,,would see furrows and longitudinal fissurs, but had none.
Has hp-tested positive.
Treat hp
Dyspesia correlation? Hp does/ does not cause dyspepsia?

Patient 3: gastroscopy
Ketolamine, propofol
Belly pain, 
No inflammation found on procedure.

Patient 4: 9 month old with bile duct atresia.

Had no bile duct, surgery to attach liver to intestine ,now there is a two Way flow of bacteria because usually the ampulla of vater stops the flow of bacteria to liver.
Use prophylaxis antibiotics.
Ascending cholengitis

Patient 5: Hirschsprung's Disease 
Distended belly
Air fluid levels, standing shows levels better.
No air lower bowl-means no Hirschsprung's disease. 

http://www.aafp.org/afp/2006/1015/p1327.html

Day 9 Pediatric Gastroenterology

Patient 1: Crohn's disease 
SMA (SMA in full form Spinal Muscular Atrophy is a crohns disease with multiple disorders, all having in common a genetic cause and the manifestation of weakness due to loss of the motor meurons of the spinal cord and brainstem.)SMA in full form Spinal Muscular Atrophy is a crohns disease with multiple disorders, all having in common a genetic cause and the manifestation of weakness due to loss of the motor meurons of the spinal cord and brainstem.)

6 or more bloody stools plus one other symptom is UC
Type 2 diabetes

Treatment: 

Rafassal (Infliximab) was given 2-gram, symp worsened 
Predsisone for 
bloody diarrhea  fever vomit
IV cipro and flagyl improve 2 d then 
worse.
No uc no cmv
Iv1wk hosp hydrocortisone ab ampicillin 
gentamycin
Imuran after 1 wk after release 
Swich to azathioprine,porin 
idk
Uc 3yrs
Infliximab no resp steriod
Fever
Hosp. Ab 
hydrocort,azathiprin,
And pain 
CT
Antibiotic: vancomycin
Doxycyclin
Amoxicillin
Metronidazol

Sigmoidoscopy, protocolectomy
Cortisone try improve mortality 
Steroid resistant uc,,, salvage therapy
Fail for salvage therapy, then what?
If patient spends a longer time in the hospital before sugery, statistically, they will have more complication so we need to predict which patients will have the complications so we can give surgery at a sooner time

3rd day surgery responded better.
Thiopurine preventative in future colectomy
Tacrolimus SIM to cyclosprorin
---decreases recruitment t cells 
Infliximab vs cyclosporin
Equivelant, what to choose?
Advantages and disadvantages
Infliximab, comfortable dosing schedule, long term and safe
TLR new trmt?

Patient 2: Vitamin D deficiency in nonalcoholic liver disease

Rickets
Cod liver oil and sunlight prevent
30-60 ng/ml is minimum daily value

Vitamin D deficiency is associated with many diseases, not only rickets: 
UC 
Dvdr system
Vitamin D decreased many cancers, bacterial infections, RA,MS,cardiovascular disease, chronic kidney disease, muscle weakness, cognitive impairment, alzhemers, depression, diabetes, 
But not all vitamin D is alike...

Vitamin D responds to HCV treatment.

NAFLD
Regenerating nodules, Mallory bodies, 
Relationship of vitamin D deficiency has one or more prevalent disease....

fatty liver is first stage of hepatitis. 

Patient 3: 5 yr old boy swallowed a plastic cube, not seen on x-ray-- radioluminescent
size: 2x2cm cube
2.5 cm remove, unless esophagus wait 24 hrs, unless choking bf removal.child 2 yrs guidelines.

Patient 4: Pneumonic pulmonary restrictive disease
Manual breathing 
Infiltration complication restrictive
Muscles seizing up
Pulmonary massage, not chest compression.
Tracheal tube
Deep pumps, short just gets ride of dead space

Patient 5: Micrvillous inclusion disease
Enterocyte probably
Treatment: TPN for life, intestinal transplant.
Can cause liver damage

Patient 6: cholestasis- 16 yr old boy
infliximab
Lab normal 
On cypro flagyl
3rd US for abcess because draining was not successful
Ecoli positive
Stricture, need theater OR 
pain brought him in for 3rd US
Antibiotics trimocane? ciproflagyl
Remacade for treatment
Metronidizol used as a case study
No Sharp pain, no suggestion of blockage at stricture. 

Patient 7: Atresia cynical mengitis
IV trmt 
Fever week later
CRP, ESR raising
Liver biopsy and liver fluid.
X ray 
Start IV antibiotics
Bloods, hemoglobin dropping, infection makes drop, too quick for anemia of chronic disease,,,bone suppression, not clear what he has,,,
Picolyn antibiotics start today.
Biliary atresia, need transplant.
Bile leak caused by pressure possibly, recect section of partial serotoc netrotic liver.
Klebsiella
Could not find infection for 2 months
Surgery to drain biliary track to colon.
Had a cough, related? Nasogasteral to see if virus
Bilirunin climbing, other liver enzymes ok
Maybe diagnose with another bat of ascending cholingitis and treat it? Mom wants to wait cause she thinks its something else.
Changed from cypro to other and still anemia, so think its the infection causing it, not the meds. 

Reaction
Tube into bile for drainage, can try it if need be.

Patient 8: Intermittent colitis and hepatitis B overlap
Note high fructose corn syrup same as sucrose, basically don't eat too much fructose, impairs satiety causes over eating and diseases. Fruit fructose level safe

patient with Congenital Microvillus Atrophy

In congenital microvillus atrophy, diarrhea starts in the first few days of life and is immediately life threatening

TPN for life, K+ high so need to change amount in IV fluids.

Gave consent for sending bloodwork to Austria for genetic testing.

Many cousins died from severe diarrhea, so most likely CMA.

 

The hallmark of the disease is the electron microscopic finding of disrupted enterocytic microvilli (ie, digitations of the apical membrane of the intestinal epithelial cell protruding into the lumen) and the appearance of characteristic inclusion vacuoles, the inner surfaces of which are lined by typical microvilli. Both lesions are seen only on electronic microscopy. In a notable percentage of consanguineous families, more than one child is affected; therefore, the disease appears to be transmitted as an autosomal recessive trait.   http://emedicine.medscape.com/article/928100-overview

patient 9: Diarrhea and lung problem, think about joining them together? test for CF

Liver enzyme high.
Alt, GGT 300 norm 55....both high
LDH bit high
GGT specific for cholistasis, hepatitis,,,will also see bilirunine high
But bilirubine normal
Hemolysis in test tube...prob shook tube that's why LDH high.

Elevated alt phosphatase norm. Bone or liver?
Test for GGT if norm not from liver...
Could be from bone break down disease or Ricketts
Eulysis syndrome 

Patient 10: 2 month old cholestasis patient obstruction of bile.
Dizoxide interferes with insuline release ,,,.
Lab:bilirubin raised alkaline phos raised.
IVC clot on US
Biard Chiary syndrome
Clot above liver, portal htn?
Hyperinsulinism
Pale stools sign of atresia BC bilirubin green dark stools
Also has PDA due for operation
Congested liver hepatic vein obstruction narrow ivc
Ggt low think DD pfic cholestasis

After hours liver clinic ppl sent from other places like west bank a d palestine

Patient 11: 

Liver kidney transplant at 9yr old, now 24
Polycystic kidney, polynephritis
Cyclosporin
Prednisone-since trand
Cypriflaxin because of cholengitis and cholocystitis 
Folic acid
Vitamin D
Sodium bicarbonate
Iron
Calcium
Stones in bile duct, two US now says one stone. 
Arpkd disease
Esk disease
Hepatic encephalopothy
Liver Lobe from mom
Kidney from aunt
Ascending cholengitis
Ggt elevated 4-500
Continue w cyprofloxin to prevent cholingitis? Don't want to make bacteria resistant, so decide wither to stop or not....
PE spider nevi check, and lymph nodes check finger nails check for clubbing.
Ggt elevated means the stone is blocking, so runs risk of infection,,,should we improve flow w ersalate, our body naturally produces it. Flow better less likely inf. Few month if glow better then stop antibiotics.
Try to get off cypro and on ersalate.
Joint pain.
Ursyolic colic acid 500 mg 2times a day. 3 months, us and complete blood lab, if works than quit ciprofloxin.
Can't drink grapefruit BC cyclosporin delayed by grapefruit juice...will make blood levels jump up.
Christian Arabic fastest shrinking religuos group in world in Bethlehem

Patient 12: Biliary atresia? Has cholestasis, but things getting better on own, which is often seen, just has minor obstruction.
Baby girl
allegile syndrome Canadian discovered not long ago.
PE hands nails,
http://en.m.wikipedia.org/wiki/Alagille_syndrome
US and repeat bloods in 4 weeks.
Cholestatic patient baby newborn, did biopsy
Biliary atresia
Not enough bile ducts for bile to drain through 
Stitch intestine to liver and make anastomoses called katai procedure from Japanese guy.
Ersolate atolic acid meds
I gave PE...liver big and hard eyes yellow skin yellow umbilical hernia.
4months from started chronic diarrhea, microcitic anemia, celiac negative, but be wary of false negatives 97% true beg, others false negative. off and on chronic diahrrea. Ferritin low, 
Family history:
Mom has hypercoagulation
PE look for fat stools. 
Ciliac gluten absorption problem.
Gastroscopy needed

Malabsorption, maldigestion.
Fat globules-maldigestion
Fat cristals mal absorption