Vomiting and malabsorption Flashcards
(34 cards)
Describe the pre-ejection phase in vomiting?
□ Pallor
□ Nausea
□ Tachycardia
Describe the ejection phase of vomiting
□ Retch
□ Vomit
Describe the post-ejection phase in vomiting
□ Floppy
□ Lethargic
□ Pale
What stimulates the vomiting centre in children?
□ Enteric pathogens □ Intestinal inflammation □ Metabolic derangement □ Infection ® UTI ® Meningitis ® Encephalitis ® Cellulitis ® Sepsis □ Head injury □ Visual stimuli □ Middle ear stimuli
Describe billous vomiting and its causes?
- Should always ring alarm bells
- Due to intestinal obstruction until proved otherwise
- Causes
□ Intestinal atresia (in new-born babies only)
□ Malrotation +/- volvulus
□ Intussusception (part of the bowel “telescopes” into another part of the bowel)
□ Ileus
□ Crohn’s disease with strictures
What investigations should be done in a child with bilious vomiting?
□ Abdominal x-ray
□ Consider contrast meal
□ Surgical opinion re exploratory laparotomy
Explain effortless vomiting
- This is almost always due to gastro-oesophageal reflux
- Very common problem in infants
- Self-limiting and resolves spontaneously in the vast majority of cases
- A few exceptions:
□ Cerebral palsy
□ Progressive neurological problems
□ Oesophageal atresia +/- TOF operated
□ Generalised GI motility problem
Describe test feeding
○ Palpation of “olive” tumour
○ Visible gastric peristalsis
- Thickened pylori- the stomach is trying to push the food through
○ Projectile non bilious vomiting
What is pyloric stenosis?
○ Babies 4-12 weeks ○ Boy> girls ○ Projectile non-bilious vomiting ○ Weight loss ○ Dehydration +/- shock
What are the charecteristic electrolyte desturbances in pyloric stenosis?
® Metabolic alkalosis (increased pH)
® Hypochloraemia
® Hypokalaemia
What is the management of pyloric stenosis?
® Fluid resuscitation
® Refer to surgeons
□ Ramstedts pyloromyotomy
What are the presenting syndromes of gastric oesophageal reflux?
® Gastrointestinal □ Vomiting □ Haematemesis ® Nutritional □ Feeding problems □ Failure to thrive ® Respiratory □ Apnoea □ Cough □ Wheeze □ Chest infections ® Neurological □ Sandifer’s syndrome ® Spastic and dystonic body movements ® Nodding and rotation of the head ® Neck extension ® Gurgling sounds ® Withering movements of the limbs ® Severe hypotonia
How is gastric oesophageal reflux medicaly assessed?
® History & examination often sufficient ® Radiological investigations □ Video fluoroscopy □ Barium swallow ® pH study ® Oesophageal impedance monitoring ® Endoscopy □ Severe symptoms □ If reflux hasn't resolved after 2 years of life □ Neurodisability
What might barium swallow show you?
◊ Dysmotility ◊ Hiatus hernia ◊ Reflux ◊ Gastric emptying ◊ strictures
What are problems that could happen in a barrium swallow?
◊ Aspiration
◊ Inadequate contrast taken (NG tube)
What is the treatment of gastric oesophageal reflux?
- Feeding advice
- Nutritional support
- Medical treatment
□ Feed thickener
® Gaviscon
® Thick & Easy
□ Prokinetic drugs
□ Acid suppressing drugs
® H2 receptor blockers
® Proton pump inhibitors - Surgery
What feeding advise is given to children with gastric oesophageal reflux?
□ Thickeners for liquids □ Appropriateness of foods ® Texture ® Amount □ Behavioural programme ® Oral stimulation ® Removal of aversive stimuli □ Feeding position
What nutritional support is given to children with gastric oesophageal reflux?
□ Calorie supplements
□ Exclusion diet (milk free)
□ Nasogastric tube
□ Gastrostomy
What are the indications for surgery in children with gastro oesophageal reflux?
® Failure of medical treatment ® Persistent: ◊ Failure to thrive ◊ Aspiration ◊ Oesophagitis ® Vomiting without complications may not be an indication
What is the definition of chronic diarrhoea?
® 4 or more stools per day ® For more than 4 weeks ® A little contentious, lots of definitions exist! ® <1 week: acute diarrhoea ® 2 to 4 weeks: persistent diarrhoea ® >4 weeks: chronic diarrhoea
What are the causes of diarrhoea?
® Motility disturbance □ Toddler Diarrhoea □ Irritable Bowel Syndrome ® Active secretion (secretory) □ Acute Infective Diarrhoea ® Cholera is the commonest □ Inflammatory Bowel Disease ® Malabsorption of nutrients (osmotic) □ Food Allergy □ Coeliac Disease □ Cystic Fibrosis
What is osmotic diarrheoa?
® Movement of water into the bowel to equilibrate osmotic gradient
® Usually a feature of malabsorption
□ Enzymatic defect
□ Transport defect
® Mechanism of action of lactulose/movicol
® Generally accompanied by macroscopic and microscopic intestinal injury
® Clinical remission with removal of causative agent
What is secretory dairrhoea?
® Classically associated with toxin production from Vibrio cholerae and enterotoxigenic Escherichia coli
□ In cholera, can lose 24L per day!
® Intestinal fluid secretion predominantly driven by active Cl- secretion via CFTR
What is motility diarrhoea?
® Pretty straightforward! ® Classically toddler’s diarrhoea ® Other causes □ Irritable bowel syndrome □ Congenital hyperthyroidism □ Chronic intestinal pseudo-obstruction
