Vomiting

Question 1

Infnat vomiting can be split into 5 types?

Answer 1

• With retching
• Projectile
• Bilious
• Effortless
• Haematemesis

Question 2

What do you expect to see in vomiting with retching?

Answer 2

A prodrome of pallor, nauseas and tachycardua

Retching and vomiting

Often a follow on of weakness, shivering and lethargy

Question 3

What can cause vomiting with retching in a child?

Answer 3

Anything really:

• Enteric pathogen
• Other inf e.g. uti
• Intestinal inflammation
• Metabolic
• Head injury
• Visual or middle ear stimuli

Question 4

What could cause a child to projectile vomit?

Answer 4

GORD
Overfeeding
Pyloric Stenosis

Question 5

Who gets pyloric stenosis?

Answer 5

Expect to see it 4-12wks and more often in boys

Question 6

6wk old boy comes in with projectile vomiting, weight loss and dehydration? How do you test for pyloric stenosis?

Answer 6

Test feed in hospital and look for:

• Palpable “olive” tumour
• Visible gastric peristalsis
• Non-bilious vomit

From there you can do an ABG & US

Question 7

What would you expect to see on a pyloric stenosis ABG? and can you explain it?

Answer 7

Metabolic Alkalosis (vomiting HCl)
Hypokalaemia (Secondary Hyperaldosteronism due to dehydration)
Hypochloraemia (Vomiting HCl)

Question 8

How do you treat Pyloric Stenosis?

Answer 8

Dehydrated from all the vomiting so Fluid Resus

Followed by Ramstedt’s Pyloromyotomy

Question 9

Bilious vomiting is an intestinal obstruction until proven otherwise, due to?

Answer 9

• Intestinal Atresia (newborns only)
• Malrotation +/- volvulus
• Intussusception
• Crohn’s + strictures

Question 10

How would you approach a child with bilous vomiting?

Answer 10

Abdo X-ray (looking for bowel obstruction)
Contrast meal
surgical opinion (sought early) re ~Exploratory Laparotomy

Question 11

What causes effortless vomiting?

Answer 11

Mostly GORD

v common in infants

Question 12

How would GORD look in a child?

Answer 12

Effortless vomiting +/- haematemesis

Feeding Aversionm & FTT

~Resp symptoms e.g. apnoea, cough, wheeze or inf
~Sandifer’s syndrome

Question 13

Sandifer’s syndrome?

Answer 13

neurological

Spastic Torticollis & dystonia due to GORD, resolved by treating GORD

spastic torticollis = neck muscles contract involuntarily so head twists or turns to one side

Question 14

How do we test kids for GORD?

Answer 14

In most cases you can just ressure them that it’s self-limiting, if necessary do:

• Video fluoroscopy or Barium Swallow
• Oesophageal Impedance Monitoring
• UGIE (if >2yrs old, looking for oesophagitis)

Question 15

There are 4 stages to treating childhood GORD, what feeding advice would you give?

Answer 15

• Thickener’s
• Appropriate texture/amount of food
• Feeding position
• Oral stimulation & removal of aversive stimuli

self limiting and resolves spon in majority of cases. Exceptions: cerebral palsy, progressive neuro problems, generalised GI motility problem, oesophageal atresia +/- TOF operated

Question 16

What nutritional support can you offer in GORD?

Answer 16

Calorie supplements
Exclusion diet (mostly Milk)
Ng tube
Gastrostomy

Question 17

What medical interventions can help with GORD?

Answer 17

Thickener’s e.g. Gaviscon
Prokinetic Drugs
Acid Suppressants (H2 receptor blockers & PPIs)

Question 18

What surgical interventions are there for GORD?

Answer 18

Nissen Fundoplication

beware of comps: bloating, dumping and retching. Esp in cerebral palsy

successful surgert may unmask more generalised GI motility problems in child

Question 19

How could you image for intussusception?

Answer 19

US for target sign

Question 20

How can you treat intussusception?

Answer 20

Air enema (pneumostatic reduction)
Surgical

Question 21

What are causes of vomiting in infants?

Answer 21

• GOT
• CMA
• Infection
• intestinal obstruction

Question 22

What are causes of vomiting in children?

Answer 22

• gastroenteritis
• infection
• appendicitis
• intestinal obstruction
• raised ICP
• coeliac disease

Question 23

What are causes of vomiting in young adults?

Answer 23

• gastroenteristis
• infection
• H pylori infection
• infection
• raised ICP
• DKA
• cyclcical vomiting syndrome
• Bulimia

Question 24

6 week old baby boy
3 week history of vomiting after every feed
Bottle fed 6 ounces 3 hourly
Vomitus- large volume, milky or curdy, mostly projectile
Irritable and crying
Not gaining weight adequately
o/e looks slightly dehydrated

what is the differential diagnosis and what do we do now?

Answer 24

Differential diagnosis:

• GOR
• overfeeding (but this vol seems appropriate = 150ml/kilo per day in neonates and 100 for infants)
• pyloric stenosis
• Cow’s milk protein allergy

To do now: test feed

Question 25

If test feed observed: - palpation of olive tumour (thickened pylorus) - visible gastric peristalsis - projectile non-billous vomiting what is the diagnosis?

Answer 25

pyloric stenosis

Question 26

What investigation can be done for pylporic stenosis?

Answer 26

US thickened pylorus

Question 27

What would blood gas show for pyloric stenosis?

Answer 27

hypokalaemia hypocholoermic metabolic alkalosis (as vomiting)

Question 28

What is the management of pyloric stenosis?

Answer 28

- fluid resus *correct metabolic alkalosis and dehydration is 1st line - refer to surgeons: Ramstedt's pyloromyotomy (relives the obstruction) also stop feeds and insert NG tube

Question 29

How does pyloric stenosis present?

Answer 29

``` Babies 4-12 weeks Boys > Girls Projectile non-bilious vomiting Weight loss Dehydration +/- shock Characteristic electrolyte disturbance: Metabolic alkalosis (↑pH) Hypochloraemia (↓Cl) Hypokalaemia (↓K) ```

Question 30

Effortless vomiting - regurgitation and positing

Answer 30

Effortless vomiting otherwise referred to as regurgitation ``` Regurgitation = involuntary passage of large amounts of gastric contents thro the mouth Positing = involuntary passage of small amounts of milk thro the mouth ``` Psoiting or regurg seen several times in healthy babies

Question 31

Why is GORD so common in infants?

Answer 31

- LOS lax - mainly placed in lying position - feeds mainly liquids (improves with age when solids introduced at 6 months and also with posturre, sitting, standing and walking)

Question 32

How do you investigate GORD?

Answer 32

- H&E often sufficient to diagnose - oesopaheageal pH study/impedance monitoring - Upper GI endocscopy - radiology: video fluorscopy, barium swallow

Question 33

What are the aims and problems with hiatus hernia?

Answer 33

``` Aims: Dysmotility Hiatus hernia Reflux Gastric emptying strictures ``` Problems: Aspiration Inadequate contrast taken (NG tube)

Question 34

How do you treat GORD?

Answer 34

- feeding advice = thickners, appropriate food, feeding position, feed volumes, behavioural programme (oral stim, remove adverse stimuli) - nutritional support = calorie supplements, exlcusion diet (CM protein free trial for 4 weeks), NG tube, gastrostomy - medical treatment (occasionally) = feed thickener (gaviscon, thick & easy), prokinetic drugs (domperidaone), acid suppresssing drugs (H2 receptor blockers and PPIs eg omeprazole) - surgery (rare) = Nissen fundoplication

Question 35

What are the indications for surgery in GORD?

Answer 35

``` Failure of medical treatment Persistent: Failure to thrive Aspiration Oesophagitis ``` Vomiting without complications may not be an indication