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Paeds > Vomiting and Malabsorption in Childhood > Flashcards

Vomiting and Malabsorption in Childhood Flashcards

1
Q

Types of vomiting

A

Vomiting with retching
Projective vomiting
Bilious vomiting
Effortless vomiting

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2
Q

What does bilious vomiting generally indicate?

A

Malabsorption

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3
Q

What does effortless vomiting generally indicate?

A

Gastro oesophageal reflux

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4
Q

Phases of vomiting with retching and their presentations

A 
Pre ejection phase
- pallor
- nausea 
- tachycardia 
Ejection phase
- retch 
- vomit 
Post ejection phase
- floppy
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5
Q

Causes of vomiting

A 
Enteric pathogens - release toxins
Intestinal inflammation 
Metabolic derangement 
Infection 
- e.g. UTI/ meningitis, sepsis 
Head injury 
Visual stimuli 
- migraines, headaches
Middle ear stimuli (infections)
Gastro oesophageal reflux
Overfeeding 
Pyloric stenosis
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6
Q

How is vomiting triggered?

A

By stimulation of the vomiting centre

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7
Q

What is the commonest cause of vomiting?

A

Infection

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8
Q

Investigations for vomiting

A

Test feed
Blood gas
- metabolic alkalosis = hyperchloric acid

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9
Q

Any slight tinge of yellow / green indicates that the cause is NOT…

A

Pyloric stenosis

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10
Q

Treatment of vomiting

A

Fluid resuscitation

Refer to surgeons

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11
Q

What surgical procedure can relieve obstruction causing vomiting?

A

Ramstedts Pyloromyotomy

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12
Q

Who gets pyloric stenosis?

A

Babies aged 4 - 12 weeks

B > G

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13
Q

Presentation of pyloric stenosis

A

Projective non-bilous vomiting
Weight loss
Dehydration / shock
Characteristic electrolyte disturbance

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14
Q

What is the characteristic electrolyte disturbance of pyloric stenosis?

A

Metabolic alkalosis - increase pH
Hypochloraemia (decreased Cl)
Hypokalaemia (decreased K)

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15
Q

What type of vomiting should always ring alarm bells?

A

Bilious vomiting

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16
Q

Causes of bilious vomiting

A 
Intestinal atresia (newborns only)
Malrotation + / - volvulus
Intussusception 
Ileus 
Crohn's disease with strictures
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17
Q

What is intussusception?

A

A process in which a segment of intestine invaginates into the adjoining intestinal lumen, causing bowel obstruction.

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18
Q

What is ileus?

A

Painful obstruction of the ileum

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19
Q

Investigations of bilious vomiting

A

Abdo X ray
Contrast meal
Surgical opinion re exploratory laparotomy

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20
Q

What is effortless vomiting almost always due to?

A

Gastro oesophageal reflux

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21
Q

What type of vomiting is a very common problem in infants?

A

Effortless vomiting

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22
Q

Effortless vomiting often resolves spontaneously except in….

A

CP
Progressive neurological problems
Oesophageal atresia +/- TOF operated
Generalised GI motility problem

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23
Q

Presentation of effortless vomiting

A 
Vomiting 
Haematemesis 
Feeding problems (due to acid coming up)
Failure to thrive 
Apnoea
Cough 
Wheeze
Chest infections 
Sandifer's syndrome
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24
Q

Investigations of effortless vomiting

A 
History and exam often sufficient 
Video fluoroscopy 
Barium swallow 
Ph study 
oesophageal impendance monitoring 
endoscopy
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25
Q

Treatment of effortless vomiting

A

Feeding advice
- thickeners for liquids
- appropriateness of foods (texture, amount)
- behavioural (oral stimulation, removal of aversive stimuli)
- Feeding position (head at 45 degrees)
Nutritional support
- calorie supplements
- exclusion diet (milk dree)
- NG tube
- gastrotomy
Medical treatment
- feed thickener (Gaviscon, thick and easy)
- Prokinetic drugs
- Acid Suppressing Drugs (H2 receptor blockers, PPIs)
surgery

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26
Q

Indications for surgery in effortless vomiting

A 
Failure of medical treatment 
Persistent
- FTF
- aspiration 
- oesophagitis
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27
Q

When would you do a Nissen Fundoplication?

A

In children who are more likely to have complications of bloat, dumping and retching after surgery e.g. CP

28
Q

How much volume of faeces are lost per day in a child?

A

< 200 ml

29
Q

How is the surface area of the small intestine increased?

A

Mucosal folds

Villi

30
Q

Definition of chronic diarrhoea

A

4 or more stools per day for more than 4 weeks

31
Q

How long is acute diarrhoea?

A

< 1 week

32
Q

How long is persistent diarrhoea?

A

2 - 4 weeks

33
Q

How long is chronic diarrhoea?

A

> 4 weeks

34
Q

Causes of diarrhoea

A 
Motility disturbance
- toddler diarrhoea
- IBS
Active secretion 
- acute infective diarrhoea
- IBD 
Malabsorption of nutrients (osmotic) 
- food allergy 
- coeliac disease
- Cystic fibrosis (fat malabsorption)
35
Q

4 types of diarrhoea

A

Osmotic
Secretory
Motility
Inflammatory

36
Q

Pathology of osmotic diarrhoea

A

Movement of water into the bowel to equilibrate osmotic gradient
Mechanism of action of lactulose/movicol

37
Q

What is osmotic diarrhoea usually a feature of?

A

Enzymatic defect

Transport defect

38
Q

What is osmotic diarrhoea usually accompanied by?

A

Macroscopic and microscopic intestinal injury

39
Q

How do you get clinical remission of osmotic diarrhoea?

A

Removal of causative agent

40
Q

What is secretory diarrhoea classically associated with?

A

Toxin production from vibrio cholerae and enterotoxigenic E coli

41
Q

Pathology of secretory diarrhoea

A

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

42
Q

Causes of motility diarrhoea

A

Toddlers diarrhoea
IBS
congenital hyperthyroidism
Chronic intestinal pseudo-obstruction

43
Q

Most common cause of motility diarrhoea

A

Toddlers diarrhoea

44
Q

Pathology of inflammatory damage

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 kind of diarrhoea is ALWAYS pathological?

A

Nocturnal

46
Q

Stool volume in osmotic vs secretory diarrhoea

A 
osmotic = small (generally < 200ml / 24 hours)
Secretory = large (>200 ml/ 24 hours)
47
Q

Response to fasting, osmotic vs secretory diarrhoea

A 
Osmotic = diarrhoea stops
Secretory = diarrhoea continues
48
Q

Features of molecules in stool in osmotic vs secretory diarrhoea

A 
Osmotic
- low Na
- low K
- low Cl 
Secretory 
- high sodium 
- high K
- high Cl
49
Q

Causes of fat malabsorption

A 
Pancreatic disease
- lack of lipase and resultant steatorrhoea causing diarrhoea 
- classically in CF
Hepatobiliary disease
- chronic liver disease
- cholestasis
50
Q

What is coeliac disease?

A

Gluten sensitive enteropathy

51
Q

What triggers coeliac disease?

A

Wheat
Rye
Barley

52
Q

How many people does coeliac disease affect of the western population?

A

1%

53
Q

Genetics of coeliac disease

A

DQ2

DQ8

54
Q

Symptoms of coeliac disease

A 
Abdo bloating
Diarrhoea
Failure to thrive 
Short stature
Constipation 
Tiredness 
Dermatitis herpatiformis (vasicular skin rash) 
Autoimmune hepatitis
55
Q

Screening for coeliac disease

A 
Serological screens
- anti tissue transglutaminase
- anti-endomysial 
- anti-gliadin 
- concurrent IgA deficiency in 2% may give false negatives 
Genetic testing
56
Q

Gold standard investigation for coeliac disease

A

Duodenal biopsy

57
Q

Genetic testing of coeliac disease

A

HLA DQ2

DQ8

58
Q

Features required of coeliac disease to diagnose without a biopsy

A

Symptomatic children
Anti TTG > 10x upper limit of normal
+ve anti endomysial antibodies
HLA, DQ2, DQ8

59
Q

Treatment of coeliac disease

A

Gluten free diet for life

In very young under 2 years, re challenge and re biopsy

60
Q

Why should gluten not be removed prior to diagnosis of coeliac disease?

A

As serological and histological features will resolve

61
Q

What is there a increased risk of if coeliac disease is left untreated?

A

Rare small bowel lymphoma

62
Q

How do you ask the parents if the child has projectile vomiting?

A

Is the vomit on their clothes or on the floor and miss their clothes?

63
Q

When should a H2RA or PPI be trialled in infants with GORD?

A 
Who do not respond to alginates/food thickener 
And who have
1. feeding difficulties
2. Distressed behaviour or
3. Faltering growth
64
Q

What is highly suggestive of intestinal malrotation and volvulus?

A

Scaphoid abdomen

Bilious vomiting

65
Q

Investigations of intestinal malrotation

A

Urgent Upper GI contrast study

USS

66
Q

What is suggestive of congenital diaphragmatic hernia?

A

Displaced apex beat

Decreased air entry

Paeds (28 decks)

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