MOD 4 - VOMITING Flashcards
1
Q
•Coordinated reflex process via the medullary vomiting center
A
Vomiting
2
Q
Where is the vomiting center located?
A
Medullary
3
Q
What are the events during vomiting?
A
- Salivation and involuntary retching
- Violent descent of the diaphragm
- Constriction of abdominal muscles
- Relaxation of the gastric cardia
- Gastric contents actively forced up the esophagus
4
Q
Is Vomiting Physiologic behavior in children?
A
YES
5
Q
What are the possible causes oif vomiting?
A
- GI disease
Systemic disturbances
Intracranial pathology
Inborn errors of metabolism
Non-GI infections
Systemic poisoning
Eating disorders
Pregnancy
6
Q
What is the pathophysio of vomiting?
A
- Protective reflex
- Removes toxic substances fr the body
- Removes pressure in hollow organs distended by distal obstruction
- May be accompanied by nausea & retching
7
Q
________ – unpleasant, vague epigastric sensation
A
Nausea
8
Q
What happens in nausea?
A
DECREASE
- gastric tone,
- secretions,
- contractions,
- mucosal blood flow.
• **INCREASE **
- salivation,
- sweating,
- pupil diameter,
- HR.
9
Q
____________- – strong involuntary effort to vomit with spasmodic contraction of the diaphragm, relaxation of lower esophageal sphincter
A
Retching
10
Q
What happens in retching?
A
•gastric material moved into esophagus but not expelled from the mouth.
11
Q
Regurgitation – Gastroesophageal reflux due to lower esophageal sphincter dysfunction and reverse propulsion of stomach contents by somatic muscle contraction.
A
Regurgitation
12
Q
________– regurgitation also occurs but the ruminated material is reswallowed (rather than ejected from the mouth).
A
Rumination
13
Q
What stimulates the vomiting center?
A
- GI receptors
- chemoreceptor trigger zone
- vestibular center
14
Q
When the vomiting center has been stimulated, what nerves are affected?
A
- phrenic nerve
- Vagus nerve
- Spinal nerve
15
Q
The pherenic nerve affects what organ?
A
diaphragm
16
Q
The vagus nerve affects which organs?
A
- esophagus
- stomach
- duodenum
17
Q
Spinal nerves affect what?
A
Abdominal Rectus intercostals
18
Q
What to ask in history in vomiting?
A
- WHEN
- TIMING
- WHAT
- COLOR
- AMOUNT
- ACUTE OR CHRONIC SYMPTOMS
19
Q
Associated symptoms:
A
Abdominal pain/irritability in infants
•Nausea
•Headache
•Bowel disturbance
•Pyrexia
•Respiratory symptoms
•Neurological symptoms
•Anorexia, weight loss
20
Q
Differential Diagnosis of Vomiting by Anatomic Locus of Stimulus
A
- Stimulation of supramedullary receptors
- Stimulation of chemoreceptor trigger zone
- Stimulation of peripheral receptors and/or obstruction of the GIT
21
Q
Stimulation of supramedullary receptors
A
- psychogenic vomiting
- •Increased intracerebral pressure: subdural effusion, cerebral edema, hydrocephalus, meningitis, encephalitis
- •Vascular: migraine, severe hypertension
- •Seizures
- •Vestibular disease,“motion sickness”
22
Q
Stimulation of chemoreceptor trigger zone
A
- Drugs: opiates, ipecac, digoxin, anticonvulsants
- Toxins
- Metabolic products: ketones, ammonia, lactic acid, aminoacids, urea
- Dopamine neurotransmitters
23
Q
Stimulation of peripheral receptors and/or obstruction of the GIT
A
- Pharyngeal: gag reflex:
- Esophageal:
- Gastric
24
Q
Stimulation of peripheral receptors and/or obstruction of the GIT
•Pharyngeal: gag reflex:
A
sinusitis secretions, post tussive, self induced, rumination
25
* Stimulation of peripheral receptors and/or obstruction of the GIT
* Esophageal:
What are the functional causes?
reflux, achalasia, dysmotility;
26
Stimulation of peripheral receptors and/or obstruction of the GIT
Esophageal:
structural
stricture, ring, atresia
27
Differential Diagnosis of Vomiting by Age
Newborn
* Congenital obstructive gastrointestinal malformations
* •Inborn errors of metabolism
28
Differential Diagnosis of Vomiting by Age
Infant
* Acquired or mild obstructive lesions
•Metabolic diseases
•Nutrient intolerances
•Functional disorders: Gastroesophageal reflux
•Psychosocial disorders: rumination, child abuse
29
Newborn
Infectious
Sepsis, meningitis, UTI, thrush
30
Etiologies of Vomiting
Anatomic
* Atresia and webs,
* malrotation,
* stenosis,
* meconium ileus,
* Hirschsprung's disease
31
Etiologies of Vomiting
Infant
Infectious
Pneumonia, otitis media, thrush
32
Etiologies of Vomiting
Infant
Anatomic
Pyloric stenosis, intussuscep-tion, Hirschsprung’s disease
33
Etiologies of Vomiting
Child
Infectious
Gastro-enteritis
34
Etiologies of Vomiting
Anatomic
Child
Bezoars, chronic granulo-matous disease
35
Etiologies of Vomiting
Adolescent
Infectious
Gastro- enteritis, URI
36
Etiologies of Vomiting
Adolescent
Anatomic
PUD, superior mesenteric syndrome
37
Etiologies of Vomiting
Newborn
Gastro-intestinal
* Reflux,
* overfeeding,
* gastric outlet obstruction,
* volvulus
38
Etiologies of Vomiting
Newborn
Neurologic
Subdural hematoma, hydroce-phalus
39
Etiologies of Vomiting
Infant
Gastro-intestinal
Reflux, gastritis, milk intolerance
40
Etiologies of Vomiting
Infant
Neurologic
Subdural hematoma
41
Etiologies of Vomiting
Child
Gastro-intestinal
Appendicitis, pancreatic, hepatitis, other food intolerance
42
Etiologies of Vomiting
Child
Gastro-intestinal
* Appendicitis,
* pancreatic,
* hepatitis, other food intolerance
43
Etiologies of Vomiting
Child
Neurologic
* Neoplasia,
* migraine,
* Reye syndrome,
* motion sickness,
* hypertension
44
Etiologies of Vomiting
Adolescent
Gastro-intestinal
Achalasia,
hepatitis
45
Etiologies of Vomiting
Adolescent
Gastro-intestinal
* Achalasia,
* hepatitis
46
Etiologies of Vomiting
Adolescent
Neurologic
* Neoplasia,
* migraine
* , motion sickness,
* hypertension
47
Temporal Association of Chronic and Recurrent Vomiting
Time of day: early am
Other clues:
* Headache,
* papilledema
* sinus tenderness
* amenorrhea
48
Temporal Association: During/after meals:**anytime**
Other clues:
* Epigastric pain
* Heartburn
PUD
Reflux
49
Temporal Association of Chronic and Recurrent Vomiting
Temporal Association:
* cow/soy milk
* Gluten
Other clues:
* Failure to thrive
Intolerance
Glutensensitive
Enteropathy
50
Temporal Association of Chronic and Recurrent Vomiting
Temporal Association:
* Egg,wheat,cheese,
* fish,nuts,strawberry
Other clues:
* Hx of asthma, hives, ↑eos
* Family hx
Allergies,
eosinophilic gastro enteropathy
51
Temporal Association of Chronic and Recurrent Vomiting
Temporal Association:
* After fasting: Food vomited
Other clues:
* Distention &
* Tympany
Gastric stasis/ obstruction
52
Temporal Association of Chronic and Recurrent Vomiting
Temporal Association:
* After fasting:Food ***_not_*** vomited
Metabolic dis
53
Temporal Association :
* other precipitants
* Cough
* Infections
Other clues
* Respiratory disease
Post-tussive
Recurrent gastroenteritis
54
Temporal Association :
* Vestibular stimulation
Other clues:
* Nystagmus
Vertigo
Motion sickness
Menetrier’s dis
55
Temporal Association: Hyperhydration
Other clues: Resolves with normal hydration
Ureteropelvic jxn obstruction
56
Temporal Association:
* Menses
Other clues:
* Relief with NSAIDs
Dysmenorrhea assoc vomiting
57
Temporal Association:
* Medications/toxins
Other clues:
* Opiate withdrawal
Medication side effect
Steroid withdrawal
Poisoning
Ipecac abuse in anorexia nervosa
58
Temporal Association:
* Episodic/cyclic
Metabolic inborn errors
Malrotation/volvulus
59
Clues to the Dx & Localization of the Cause of Emesis
Assoc sx
Local abdom pain
**Epigastric**
Diagnosis to consider
PUD, reflux, pancreatitis
60
Clues to the Dx & Localization of the Cause of Emesis
Assoc sx
Local abdom pain
**Periumbilical**
Small int. obstruction; non-specific
61
Clues to the Dx & Localization of the Cause of Emesis
Assoc sx
Pelvic
Cystitis, PID, ovarian torsion
62
Clues to the Dx & Localization of the Cause of Emesis
Assoc sx
Local abdom pain
LUQ
* Pneumonia,PUD,
* pancreatitis, splenic torsion,
* L pyelonephritis
63
Clues to the Dx & Localization of the Cause of Emesis
R**L**Q
Appendicitis, R tuboovarian disease
64
Clues to the Dx & Localization of the Cause of Emesis
LLQ
L tuboovarian disease, sigmoid disease
65
Clues to the Dx & Localization of the Cause of Emesis
Right flank
* Ureteropelvic jxn/obstruction/infection,
* biliary obstruction,
* adrenal hemorrhage
66
Clues to the Dx & Localization of the Cause of Emesis
Ureteropelvic jxn/obstruction/infection
67
Clues to the Dx & Localization of the Cause of Emesis
Assoc sx
Headache
Vomiting
↑ICP,sinusitis,migraine
68
69
Clues to the Dx & Localization of the Cause of Emesis
Chest pain dysphagia
Esophagitis, achalasia, pneumonia
Clues to the Dx & Localization of the Cause of Emesis
Chest pain dysphagia
70
Clues to the Dx & Localization of the Cause of Emesis
Diarrhea
Vomiting
Partial intestinal obstruction, poisoning, infectious enteritis, inborn errors metab
71
Clues to the Dx & Localization of the Cause of Emesis
Vertigo,visual changes, seizures, full fontanel
72
Metabolic disease, CNS disease, hepatic failure
73
Clues to the Dx & Localization of the Cause of Emesis
Vertigo,visual changes, seizures, full fontanel
Metabolic disease, CNS disease, hepatic failure
74
Clues to the Dx & Localization of the Cause of Emesis
Respiratory sx
Pneumonia, otitis ,
aspiration of vomitus
75
Clues to the Dx & Localization of the Cause of Emesis
Urinary sx
Pyelonephritis, hydronephrosis, calculi, renal hypertension, cholestasis
76
Clues to the Dx & Localization of the Cause of Emesis
Gynecologic sx menstrual irreg vaginal discharge
Pregnancy, PID, endometriosis
77
Physical Examination
•A complete PE is essential:
vomiting can be a manifestation of diseases involving multiple systems of the body
78
BP/VS derangements – determine urgency of the situation
79
RR – ______________ slow prolonged respiratory phase: respiratory compensation for metabolic acidosis
Kussmaul breathing –
80
Funduscopy– absence of venous pulsations or sharp optic disc margins: brain tumor\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
brain tumor
81
Abdominal
scars
obstruction from adhesions
82
•Abdominal exam
visible distention –
ascites due to intraluminal distention from intestinal obstruction/ileus
83
Physical Examination
\_\_\_\_\_\_\_\_\_\_\_\_\_ – ↑in gastroenteritis/bowel
bowel sounds
84
Physical Examination
bowel sounds – ↑
in gastroenteritis/bowel obstruction;
85
bowel sounds: ↓or absent –
ileus/peritonitis
86
localized sharp pain –\_\_\_\_\_\_\_\_\_\_\_\_\_\_, requires immediate attention
inflammation of peritoneum
87
Physical Examination
Rectal exam - should be performed
\_\_\_\_\_\_\_\_\_ – generally object to exam – explain then proceed gently but firmly
12-24mos
88
Physical Examination
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_– respond much as adults if their sensitivity and privacy are respected.
older children/adolescents
89
Physical Examination
How will you do the Rectal exam?
Recumbent position, lying on left side, flex hips and knees maximally (prevents gluteal contraction)
Do not hurry the examination (spasm of the external anal sphincter)
90
Pelvic masses/tenderness –
appendicitis, ovarian torsion, PID
91
Well appearing infants/children with typical regurgitant reflux –
no need for lab evaluation
92
GI Obstruction
• : drooling of oropharyngeal secretions/contents
Esophageal Lesions
93
* Esophageal atresia
* at birth: **intolerance of initial feeding**
* Prenatal hx: **polyhydramnios**
* Assoc with other anomalies – **VACTERL (vertebral, anorectal, cardiac, tracheoesophageal, renal, radial, limb)**
* Dx: plain films demonstrate coiled feeding tube in the upper esophageal pouch
* Tx: surgical
•Esophageal atresia
94
What is the prenatal history of Esophageal atresia
polyhydramnios
95
What are the associated anomalies of Esophageal atresia?
VACTERL
**v**ertebral, **a**norectal, **c**ardiac, **t**racheoesophageal, **r**enal, **r**adial, **li**mb
96
What is demonstrated in the plain film of esophageal atresia?
plain films demonstrate coiled feeding tube in the upper esophageal pouch
97
Esophageal atresia
98
Hypertrophy of the muscular layers of the pylorus resulting in a functional gastric outlet obstruction.
Pyloric Stenosis
99
Most common intestinal obstruction in infancy
Pyloric Stenosis
100
What is the epidemiology of pyloric stenosis?
2-4 per 1000 live births
•4:1 (male:female)
•30% first born males
•7% incidence in children of affected parents
101
Pyloric Stenosis
What type of vomiting?
**Non-bilious projectile vomiting** at **2-3 wks of age**: lethargy, dehydration, poor wt gain, metabolic alkalosis, jaundice
102
palpable **“olive**” in the **epigastrium(RUQ)** – **hypertrophic pyloric mm (felt best after feeding)**
Pyloric Stenosis
103
In plain film contrast study, what is the appearance of Pyloric Stenosis?
gastric distention
104
What is the appearance of Pyloric stenosis in UTZ?
**“string sign”** ultrasonography
105
What is the treatment of Pyloric Stenosis?
Tx: **correct fluid, acid-base imbalance, electrolyte losses, Surgery:pyloromyotomy (splitting of antro- pyloric mass longitudinally leaving the mucosal layer intact)**
106
107
In Intestinal Obstruction must identify if it is what?
Simple vs. Strangulating
108
What are the classic symptoms of Intestinal Obstruction?
nausea, vomiting, abdominal distention, obstipation
109
What are the sympstoms of intestinal obstruction if it is high?
(duodenum, proximal jejunum):
vomiting-bilious, non-feculent, **acute onset**, with **crampy intermitent pain** **relieved by vomiting and minimal distention**
110
What are the symptoms in low obstruction?
Low obstruction:(distal):
**feculent, less acute,** **more distention,** **diffuse pain over entire abdomen**
**" **Malamang sa may colon na so kaya FECULENT tapos more distented kasi may laman"
111
What are the clinical manifestation of
## Footnote
**Duodenal Atresia/stenosis/web**
bilious vomiting without abdominal distention on the 1st day of life
**•Hx: polyhydramnios**
•Jaundice in 1/3 of patients
112
How to diagnose Duodenal atresia/ stenosis/ web in plain film?
Double bubble sign on upright film; absent gas in distal bowel
113
What imaging study to use to confirm duodenal atresia/ stenosis/ web vs volvulus and malrotation?
do contrast studies
114
Duodenal Atresia/stenosis/web
115
Duodenal Atresia/stenosis/web
116
Duodenal Atresia/stenosis/web
•Treatment
* Nasogastric/orogastric decompression
* IV fluid replacement
* 2D echocargrogram and radiology of chest and spine (assoc. anomalies)
* Surgical repair: duodenoduodenostomy
117
Intestinal Obstruction
Jejunal atresia, Ileal atresia, Ileal stenosis
118
Jejunal atresia, Ileal atresia, Ileal stenosis present with\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
bilious vomiting, more abdominal distention
119
How Jejunal atresia, Ilal atresia, Ileal stenosis may be diagnosed prenatally by
ultrasonography
120
In intestinal obstruction, polyhydramnios occurs in \_\_\_\_\_\_\_\_\_
25%
121
Intestinal Obstruction
•Jejunal atresia, Ileal atresia, Ileal stenosis associated with:
Associated with LBW, multiple births, maternal cocaine and cigarette smoking
122
What is the treatment for intestinal obstruction?
* Treatment of small bowel obstruction
* Resection of dilated proximal gut then end to end anastomosis
123
* Twisting of the bowel loop on the mesentery
* Can be extremely hazardous when luminal obstruction is closed at both ends – leading to sepsis and ischemia of small intestine
Malrotation/Volvulus
124
Why is malrotation/ volvulus extremely hazardous when luminal obstruction is closed at both ends
leading to sepsis and ischemia of small intestine
125
What is the manifestation of malrotation/ vulvulus in the 1st year of life?
Clinical manifestations: (1st yr of life) bilious emesis, s/sx of acute obstruction
126
What is the manifestation of malrotation/ vulvulus in the
older infants/children of life?
recurrent colic, recurrent vomiting and abdom pain
127
What is the finding of Malrotation/ Volvulus in the UTZ?
Ultrasonography – inversion of superior mesenteric artery and vein location
128
What is the finding of malrotation/ Volvulus in abdominal plain film?
Abdominal plain film – double bubble sign/corkscrew pattern
129
What is the finding in Barium enema of Malrotation/ volvulus?
Abdominal plain film – double bubble sign/corkscrew pattern
130
What is the diagnosis in Upper GI series of Malrotation/ Volvulus?
Upper GI series – malposition of the ligament of Treitz
131
What is the treatment of Malrotation/ Volvulus
Surgical Intervention
132
Malrotation/Volvulus
133
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ of proximal intestine into the distal intestine - luminal obstruction and mesenteric vascular compromise.
Telescoping
134
Intussusception
Pathology – usually\_\_\_\_\_\_\_\_\_\_
ileocolic
135
\_\_\_\_\_\_\_\_\_\_\_\_– upper bowel segment that invaginates into the lower segment (includes its mesentery)
Intussusceptum
136
\_\_\_\_\_\_\_\_\_\_ – the lower bowel segment that receives the intussusceptum
Intussuscipiens
137
What is the pathophysio of the presentation of symptoms of Intussusception?
Mesenteric constriction obstructs venous return, intussusceptum engorges – edema, bleeding from the mucosa: bloody stools
138
What are the clinical manifestation of Intussusception?
Clinical manifestations:
**•Sudden onset** o**f severe paroxysmal colicky pain** that **recurs at frequent intervals**, **straining effort, flexed knees**, **loud cries, shock-like state**
•Vomiting becoming bilious, currant jelly stools (mucosal hemorrhage)
**•Tender sausage shaped mass in abdomen**
139
Coiled spring sign
Intussusception
140
141
GI Dysmotility
Ileus
Gastroesophageal Reflux
142
**Failure of intestinal peristalsis without evidence** of mechanical obstruction
Ileus
143
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
•**effortless regurgitation**:
## Footnote
***_most common cause of vomiting in infants_***
Gastroesophageal Reflux
144
What is Ileus?
•Lack of normal gut motility
145
What are the clinical manifestation of Ileus?
Clinical manifestations:
•Emesis with increasing abdominal pain as distention progresses
**•Decreasing bowel sounds with increasing abdominal distention**
**" Malamang decrease bowel sound kasi nga walang motility diba diba ;)"**
146
What are the causes of ileu?
peritonitis, intestinal ischemia, sepsis
drugs - narcotics,atropine, laxatives
electrolyte disturbances - ↓K,↑Ca
endocrinopathies – hyperthyroidism
147
What is found in the plain abdominal radiographs in ILEUS?
multiple air-fluid levels throughout the abdomen
Slow movement of contrast material through patent lumen
148
What is the treatment for ILEUS?
Treatment:
•correction of underlying provocative abnormalities, NGT decompression until peristalsis begins
•Prokinetic agents: metoclopramide
149
Ileus
150
Retrograde movement of gastric contents across the lower esophageal sphincter into the esophagus
Gastroesophageal Reflux
151
What is the sequelae of GERD?
Pathologic
•Frequent or persistent episodes leading to esophagitis, esophageal symptoms, respiratory sequelae
152
What is the pathophysiology of GERD?
**•Antireflux barrier:**
* •Lower Esophageal Sphincter
* •Diaphragm (crura) at the Gastroesoph jxn
* •Esophagogastric Junction - valve
**•Primary mechanism of reflux**
* •Transient Lower Esophageal Sphincter relaxation
* •Aggravating factors: straining, increased movement, obesity, large volume meals, hyperosmolar meals, coughing, increased respiratory effort
153
Gastroesophageal Reflux
•Pathophysiology
•Antireflux barrier:
* •Lower Esophageal Sphincter
•Diaphragm (crura) at the Gastroesoph jxn
•Esophagogastric Junction - valve
154
Gastroesophageal Reflux
Primary mechanism of reflux
* Transient Lower Esophageal Sphincter relaxation
* •Aggravating factors: straining, increased movement, obesity, large volume meals, hyperosmolar meals, coughing, increased respiratory effort
155
Gastroesophageal Reflux
Infant reflux:
peaks at?
1-4mos
156
Gastroesophageal Reflux
•Epidemiology and Natural History
•Infant reflux: resolves by
12mos,.
157
Gastroesophageal Reflux
Epidemiology and Natural History
Infant reflux
completely gone by 24 mos.
158
Gastroesophageal Reflux
•Epidemiology and Natural History
Older children: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
chronic waxing and waning, resolve in 50%
159
Is genetic predisposition is likely in GERD?
YES
160
What are the Clinica of l Manifestation of GERD in infants?
Clinical Manifestations
•Infantile reflux: postprandial regurgitation, esophagitis, **failure to thrive**
•Airway manifestations
•Sx resolve by 12-24 mos.
161
What are the clinical manifestation of GERD in older children?
**Older children**: regurgitation starting in pre-school years, abdominal/chest pain;
**Sandifer syndrome**: neck contortions
Airway manifestations: asthma, laryngitis, sinusitis
162
What is the managment of GERD?
Management
•Conservative; lifestyle changes
•Dietary measures
* •Normalization of feeding techniques, volumes and frequency
* •Thickening of formula:
* 1tbsp rice cereal/ oz. formula
* •Hypoallergenic diet
* •Avoidance of reflux-inducing food/drinks
* Weight reduction for obese
* Elimination of smoke exposure
163
What are the positioning maneuvers in the management of GERD in infants?
•Infants:**supine position during sleep**;
prone and upright carried position when awake
164
What are the positioning maneuvers in the management of GERD in Children?
Children**:left side position** and **head elevation during sleep**
165
What are the pharmacotherapy in the mgt of GERD?
Pharmacotherapy
•Antacids, H2 receptor antagonists, PPI, Prokinetic agents
166
Most common intestinal condition in neonates
Necrotizing Enterocolitis (NEC)
167
What is the frequently affecting area in NEC?
t**erminal ileum and proximal ascending colon**
168
What is the pathogenesis of NEC?
Pathogenesis:
* gut hypoxia/ischemia,
* abnormal intestinal flora,
* intestinal immaturity,
* excessive inflammation, genetic
169
NEC usually affects:
Usually affects prematures/**10% - term babies**
170
What is the clinical presentation of NEC?
* •Feed intolerance
* **•Bilious vomiting & aspirates**
* •Abdominal distension
* **•Bloody stools**
* •Abdominal wall tenderness/edema/discoloration
* •Decreased bowel sounds
* •Systemic disturbances
171
In NEC, what can be found in abdomina x-ray?
* abnormal gas pattern,
* dilated/thickened bowel loops
* **pneumatosis intestinalis-pathognomonic**
* bowel perforation – intraperitoneal air (lat decubitus)
172
What is phatognomonic for NEC?
**pneumatosis intestinalis-pathognomonic**
173
What is the mgt for NEC?
Management:
* supportive tx – bowel rest, TPN, gastric decompression with NGT, broad spectrum Abs, surgery if with evidence of perforation/intestinal necrosis
174
What is the mortality rate for NEC?
10-50% mortality
highest for LBW/premature
175
NEC outcome for 50% survivors:
50% survivors – complications:
int strictures,
short bowel syndrome
176
NEC
177
IgE or non-IgE mediated/ seen in 15% of infants
Cow Milk Protein Allergy
178
What is the presentation of Cow Milk Protein Allergy?
GI symptoms: non-IgE mediated
**•Vomiting
•Diarrhea
•Constipation
•Frank or occult blood in stools
•Slow weight gain**
**Note: **
Other sx suggestive of CMPA:
•Chronic cough, rhinitis, wheezing
•Atopic dermatitis, urticaria, angioedema, anaphylaxis
179
How to diagnose CMPA?
Skin prick and allergen-specific IgE testing is unhelpful
180
What is the gold standard (even for mother) for CMPA?
Elimination diet
181
Formula fed infants:
extensively hydrolysed formula for at least 2-4wks
182
\_\_\_\_\_\_\_\_\_\_\_\_\_: for those **not improving or those with severe sx**
Amino acid formula
183
not recommended (not nutritionally suitable)
Sheep, goat, soy or rice milk
184
In CMPA, If improved with elimination diet?
continue until 9-12 mos of age
Then gradually **reintroduce milk-containing foods**
185
CMPA: If sx return
If sx return, **restart milk-free diet** for another **3 mos, reattempt challenge later**
186
Good prognosis, CMPA resolves in majority by 5 yrs of age
187
Metabolic Disorders
* Inborn Errors of Metabolism
* Congenital Adrenal Hyperplasia
* •Diabetic Ketoacidosis
188
Present with a variety of s/sx
* •Poor feeding, persistent vomiting, lethargy, seizure unresponsive to glucose or calcium
* •Metabolic acidosis, failure to thrive, developmental delays
* •blood or urinary levels of particular metabolite (amino a,organic a, ammonia)
* •Peculiar odors and physical changes
Inborn Errors of Metabolism
189
What is the reason for Congenital Adrenal Hyperplasia?
Due to 21-hydroxylase deficiency
190
When do symptoms manifest in Congenital Adrenal hyperplasia?
(1st 2wks of life)
191
What are the clinical manifestation of Congenital Adrenal Hyperplasia?
* **•Deficiency** of **aldosterone and cholesterol (Salt-losing)**
* •**Hypoglycemia**, **hyponatremia**, **hyperkalemia,** **progressive** wt loss, a**norexia, vomiting, dehydration, hypotension, weakness**
* ***_•Female masculinization of external genitalia_***
192
•End result of metabolic abnormalities due to **severe insulin deficiency or insulin ineffectiveness**
Diabetic Ketoacidosis
193
Accumulation of ketoacids:
* •Inappropriate polyuria in a dehydrated child with poor weight gain or flu-like sx
* •Abdom discomfort, nausea, vomiting,dehydration, weakness, kussmaull respiration, acetone breath
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vomiting assoc with **diarrhea**: **Rotavirus, food poisoning**
•PUD, mesenteric adenitis(l.n. inflamm)
•Appendicitis, GI perforation, peritonitis
•Inflammatory bowel disorders
•Allergic enteropathy
GI Inflammation
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when is the highest incidence of ACute appendicitis?
10-19 yrs
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What is the incidence of Acute appendicitis?
19-28 children/10000 children under 14 yrs of age
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What is the classic presentation of ACute appendicitis?
Classic presentation:
* **•anorexia, abdom pain migrating to Rt Iliac fossa**
* **•vomiting, pyrexia, diarrhea, constipation, dysuria**
* **•Tenderness with rigidity at McBurney’s point**
* **•Generalized tenderness with guarding (peritonitis)**
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MGT for ACUTE APPENDICITIS?
Appendectomy
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Hepatitis in children – vomiting with fatigue, fever, headache, sore throat, cough
•Biliary colic and cholecystitis
•Pancreatitis
Hepatobiliary disease
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Rare in childhood but should be a differential for abdom pain and vomiting.
Pancreatitis
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What are the causes of Pancreatitis?
* •trauma 30%
* •Congenital abnormalities
* •Metabolic: cystic fibrosis/ hypertriglyceridemia
* •Infection: e.a. mumps
* •Drugs and toxins (immunosuppressants, Na valproate)
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87% of the presentation of Pancreatitis is?
Abdominal pain
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64% of the presentation of Pancreatitis is?
204
Diagnosis:Pancreatitis
* elevated wbc, se amylase, hyperglycemia
* UTZ : enlarged, edematous pancreas
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What is the mgt for pancreatitis?
Management:
* •Fluid resuscitation
* •Adequate nutrition
* •Analgesia
* •Surgery for congenital abnormalities or complications (pseudocyst)
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What is the prognosis of pancreatitis?
Prognosis : good, most recover quickly
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Urologic Disorders
* Pyelonephritis, renal colic due to stones
* Ureteropelvic junction obstruction: during increased fluid intake with hydronephrosis – pain and vomiting
* Testicular torsion
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Obstetric/Gynecologic Disorders
Dysmenorrhea, endometriosis
•PID
•Ovarian torsion
•Pregnancy/Hyperemesis gravidarum
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Obstetric/Gynecologic Disorders
* Dysmenorrhea, endometriosis
* •PID
* •Ovarian torsion
* •Pregnancy/Hyperemesis gravidarum
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Respiratory disorders
Sinusitis, pharyngitis, otitis
•Pneumonia
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CNS Disorders
•↑ICPtumors – projectile but without retching
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Vestibular disorders –
motion sickness: nausea, nystagmus, vertigo
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Condition characterized by discrete recurrent episodes of vomiting with periods of wellness in between
Cyclic Vomiting Syndrome
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When does Cyclic Vomiting Syndrome begins?
Occurs at any age but begins between 3-7 yrs
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How to diagose Cyclic Vomiting Syndrome?
Diagnosis**: by exclusion**
* •**at least five episodes,** or a **minimum of three over a 6-month period**
* **•episodic attacks** of i**ntense nausea and vomiting lasting hours to days,** occurring **at least 1 week apart**
* **•stereotypical pattern** and **symptoms in the individual patient**
* •vomiting during episodes occurs **at least four times an hour for at least 1 h**
* •a **return to baseline health during episodes**
* •**not attributed to another disorder.**
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What is the Cyclic Vomiting syndrome presenetation?
* Vomiting, nausea, abdominal pain, pallor
* •Triggers: infection, emotion, foods ( cheese, chocolate)
* **•Linked to migraine headaches (family hx in 80%)**
* •May respond to anti-migraine medications
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What is the treatment for Cyclic Vomiting Syndrome?
Treatment
•Supportive
•Admission for IV fluids/anti-emetics
•Avoid triggers
•Pizotifen – for children with frequent episodes
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Psychological Disorders
no organic cause determined, chronic, associated with stress/ meals, can be suppressed by distracting the patient
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– food is regurgitated, mouthed or chewed and reswallowed – voluntarily and pleasurably
Rumination
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Eating Disorders
Anorexia nervosa
•Bulimea nervosa
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Intense preoccupation with weight with behaviors aimed at a relentless pursuit of thinness(emaciated)
•Anorexia nervosa
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•Bulimea nervosa
Longterm dietary restraint interrupted by episodes of reactive hyperphagia and compensatory behavior: vomiting and laxative abuse (binge-purge behavior)
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