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Paediatrics > Vomiting and Malabsorption > Flashcards

Vomiting and Malabsorption Flashcards

1
Q

What types of vomiting are there?

A
  • Vomiting with Retching
  • Projectile vomiting
  • Bilious vomiting
  • Effortless vomiting
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2
Q

What are the phases of vomiting with retching?

A

Pre-ejection phase

  • Pallor
  • Nausea
  • Tachycardia

Ejection phase

  • Retch
  • Vomit

Post-ejection phase

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3
Q

How can the vomiting centre be stimulated?

A
  • Enteric pathogens
  • Intestinal inflammation
  • Metabolic derangement
  • Infection
  • Head injury
  • Visual stimuli
  • Middle ear stimuli
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4
Q

Who does pyloric stenosis occur in?

A
  • Babies 4-12 weeks

- M>F

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5
Q

How does pyloric stenosis present?

A
  • Projectile non-bilious vomiting
  • Weight loss
  • Dehydration +/- shock
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6
Q

What electrolyte disturbance is associated with pyloric stenosis?

A
  • Metabolic alkalosis
  • Hypochloraemia
  • Hypokalaemia
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7
Q

What type of vomiting rings alarm bells?

A

Bilious vomiting

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8
Q

What is bilious vomiting due to?

A

Intestinal obstruction until proven otherwise

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9
Q

What can cause bilious vomiting?

A
  • Intestinal atresia (in newborn babies only)
  • Malrotation +/- volvulus
  • Intussusception
  • Ileus
  • Crohn’s disease with strictures
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10
Q

How is bilious vomiting investigated?

A
  • Abdominal x-ray
  • Consider contrast meal
  • Surgical opinion re exploratory laparotomy
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11
Q

What is effortless vomiting usually due to?

A

Gastro-oesophageal reflux

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12
Q

What is the usual outcome of GOR in infants?

A

Self limiting and resolves spontaneously in the vast majority of cases

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13
Q

Who may GOR not resolve in?

A
  • Cerebral palsy
  • Progressive neurological problems
  • Oesophageal atresia +/- TOF operated
  • Generalised GI motility problem
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14
Q

How can GOR present?

A

Gastrointestinal

  • Vomiting
  • Haematemesis

Nutritional

  • Feeding problems
  • Failure to thrive

Respiratory

  • Apnoea
  • Cough
  • Wheeze
  • Chest infections

Neurological
-Sandifer’s syndrome

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15
Q

How is GOR assessed?

A
  • History & examination often sufficient
  • Radiological investigations (Video fluoroscopy, Barium swallow)
  • pH study
  • Oesophageal impedance monitoring
  • Endoscopy
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16
Q

What are the aims of barium swallow?

A

To identify

  • Dysmotility
  • Hiatus hernia
  • Reflux
  • Gastric emptying
  • Strictures
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17
Q

What are the problems with barium swallow?

A
  • Aspiration

- Inadequate contrast taken by NG

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18
Q

What are the advantages of video fluoroscopy and barium meal?

A
  • May detect aspiration

- Defines anatomy well

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19
Q

What are the advantages of pH study?

A

-Detects acid reflux missed by barium

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20
Q

What are the advantages of endoscopy?

A
  • Best test for oesophagitis

- Can be combined with pH impedance study

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21
Q

What are the advantages of trial of feeding?

A
  • Most physiological test

- May be best discriminator if child needs surgery

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22
Q

What are the disadvantages of video fluoroscopy and barium meal?

A
  • May miss reflux

- Radiation

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23
Q

What are the disadvantages of pH study?

A
  • Only detects acid reflux

- May be unpleasant for child

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24
Q

What are the disadvantages of endoscopy?

A

-Needs anaesthetic

25
Q

What are the disadvantages of trial of feeding?

A
  • NG tube required

- Needs 2-3 days in hospital

26
Q

How is GOR treated?

A
  • Feeding advice
  • Nutritional support
  • Medical treatment
  • Surgery
27
Q

What feeding advice can be given for GOR?

A
  • Use of thickeners
  • Appropriateness of foo texture and amount
  • Oral stimulation and removal of aversive stimuli
  • Feedin position
28
Q

What nutritional support can be used in GOR treatment?

A
  • Calorie diet
  • Milk free diet
  • NG tube
  • Gastrostomy
29
Q

What medical treatment is there for GOR?

A
  • Feed thickeners such as Gaviscon and thick and easy
  • Prokinetic drugs
  • Acid suppressing drugs such as PPIs and H2 receptor blockers
30
Q

What are the indications for surgery in GOR?

A
  • Failure of medical treatment

- Persistent FTT, aspiration or oesophagitis

31
Q

What surgery can be carried out for GOR?

A

Nissan Fundoplication

32
Q

What complications can children with cerebral palsy have after fundoplication surgery?

A

Bloat, dumping and retaching

33
Q

What is the fluid balance of the GI system?

A

Each day

  • 9L fluid enters duodenum
  • 1.5L gets to colon
  • <200ml lost in faeces
34
Q

How is the surface area of the small intestine increased?

A
  • Mucosal folds

- Villi

35
Q

What is the definition of chronic diarrhoea?

A

4 or more stools per day for more than 4 weeks

36
Q

Acute diarrhoea

A

4 or more stools per day for <1 week

37
Q

Persistent diarrhoea

A

4 or more stools per day for 2-4 weeks

38
Q

What can cause diarrhoea?

A

Motility disturbance

  • Toddler Diarrhoea
  • Irritable Bowel Syndrome

Active secretion

  • Acute Infective Diarrhoea
  • Inflammatory Bowel Disease

Malabsorption of nutrients

  • Food Allergy
  • Coeliac Disease
  • Cystic Fibrosis
39
Q

What types of diarrhoea are there?

A
  • Osmotic
  • Secretory
  • Motility
  • Inflammatory
40
Q

What is the pathophysiology behind osmotic diarrhoea?

A
  • Movement of water into the bowel to equilibrate osmotic gradient
  • Usually a feature of malabsorption (Enzymatic defect or Transport defect) -Mechanism of action of lactulose/movicol
  • Generally accompanied by macroscopic and microscopic intestinal injury
  • Clinical remission with removal of causative
41
Q

What is secretory diarrhoea classically associated with?

A

Classically associated with toxin production from Vibrio cholerae and enterotoxigenic Escherichia coli

42
Q

What drives intestinal fluid secretion in secretory diarrhoea?

A

Intestinal fluid secretion predominantly driven by active Cl- secretion via CFTR

43
Q

What causes of motility diarrhoea are there?

A
  • Toddler’s diarrhoea
  • IBS
  • Congenital hyperthyroidism
  • Chronic intestinal pseudo-obstruction
44
Q

What contributes to inflammatory diarrhoea?

A
  • Malabsorption due to intestinal damage
  • Secretory effect of cytokines
  • Accelerated transit time in response to inflammation
  • Protein exudate across inflamed epithelium
45
Q

What is the clinical approach to chronic diarrhoea?

A
  • History
  • Consider growth and weight gain of child
  • Faeces analysis
46
Q

What should you obtain in a history of diarrhoea?

A
  • Age at onset
  • Abrupt/gradual onset
  • Family history
  • Nocturnal defecation suggests organic pathology
47
Q

What should be determined in faeces analysis?

A
  • Appearance
  • Stool culture for organisms
  • Determination of secretory vs osmotic
48
Q

How is osmotic diarrhoea differentiated from secretory diarrhoea?

A

Osmotic diarrhoea

  • Diarrhoea stops on fasting
  • Small volume of stool
  • Stool pH low

Secretory diarrhoea

  • Diarrhoea continues of fasting
  • Large volumes of stool
  • Stool pH >6
49
Q

What types of disease does fat malabsorption occur in?

A
  • Pancreatic disease

- Hepatobiliary disease

50
Q

Give examples of pancreatic disease in which fat malabsorption occurs.

A
  • Cystic fibrosis

- Lack of lipase

51
Q

Give examples of hepatobiliary disease in which fat malabsorption occurs

A
  • Chronic liver disease

- Cholestasis

52
Q

How does coeliac disease present in children?

A
  • Abdominal bloatedness
  • Diarrhoea
  • Failure to thrive
  • Short stature
  • Constipation
  • Tiredness
  • Dermatitis herpatiformis
53
Q

What screening tests are there for coeliac disease?

A

Serological screens

  • Anti-tissue transglutaminase
  • Anti-endomysial
  • Anti-gliadin
  • IgA screen

Duodenal biopsy

Genetic testing
-HLA DQ2, DQ8

54
Q

What histological characteristics are associated with coeliac disease?

A

Lymphocytic infiltration of surface epithelium, partial /total villous atrophy,
crypt hyperplasia

55
Q

What guidelines determine whether a biopsy is required to diagnose coeliac disease?

A

ESPHGHAN/BSPGHAN

56
Q

What is the ESPGHAN/BSPGHAN criteria?

A
  • Symptomatic children
  • Anti TTG >10 times upper limit of normal
  • Positive anti endomysial antibodies
  • HLA DQ2, DQ8 positive
57
Q

What is the treatment for coeliac disease?

A
  • Gluten-free diet for life
  • Gluten must not be removed prior to diagnosis as serological and histological features will resolve
  • In very young <2yrs, re-challenge and re-biopsy may be warranted
58
Q

What is there increased risk of in untreated coeliac disease?

A

Small bowel lymphoma

Paediatrics (38 decks)

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