7.2. Gastroenterology - Vomiting and Malabsorption in Childhood

Question 1

What are the Different Types of Vomiting?

Answer 1

1. Vomiting with Retching
2. Projectile Vomiting
3. Bilious Vomiting
4. Effortless Vomiting

Question 2

What are the Phases of Vomiting with Wretching?

Answer 2

1. Pre-Ejection Phase - Pallor / Nausea / Tachycardia
2. Ejection Phase - Retch / Vomit
3. Post-Ejection Phase - Weakness / Shivering / Lethargy

Question 3

What can cause the Stimulation of the Vomiting Centre?

Answer 3

1. Enteric Pathogens
2. Intestinal Inflammation
3. Metabolic Derangement
4. Infection
5. Head Injury
6. Visual Stimuli
7. Middle Ear Stimuli

Question 4

What is the Aetiology of Pyloric Stenosis?

Answer 4

1. Babies 4-12 Weeks

2. Boys > Girls

Question 5

What is the Presentation of Pyloric Stenosis?

Answer 5

1. Projectile Non-Bilious Vomiting
2. Weight Loss
3. Dehydration +/- Shock
4. Characteristic Electrolyte Disturbance:
5. a) Metabolic Alkalosis
6. b) Hypochloraemia
7. c) Hypokalaemia

Question 6

What are the Causes of Bilious Vomiting?

Answer 6

1. Intestinal Atresia (in Newborn Babies Only)
2. Malrotation +/- Volvulus
3. Intussusception
4. Ileus
5. Crohn’s Disease with Strictures
   Note - Should Always Ring Alarm Bells - Due to Intestinal Obstruction until Proven Otherwise

Question 7

What are the Investigations of Bilious Vomiting?

Answer 7

1. Abdominal X-Ray
2. Consider Contrast Meal
3. Surgical Opinion Regarding Exploratory Laparotomy

Question 8

What are the Causes of Effortless Vomiting?

Answer 8

Gastro-Oesophageal Reflux

Note - This is very common in Infants

Question 9

What is the Treatment of Effortless Vomiting (Gastro-Oesophageal Reflux)?

Answer 9

Self-Limiting and Resolves Spontaneously in most cases, except:

1. Cerebral Palsy
2. Progressive Neurological Problem
3. Oesophageal Atresia
4. Generalised G.I. Motility Problem

Question 10

In Relation to Effortless Vomiting (Gastro-Oesophageal Reflux), what are the:

1. Gastrointestinal Symptoms?
2. Nutritional Symptoms?
3. Respiratory Symptoms?
4. Neurological Symptoms?

Answer 10

1. Vomiting / Haematemesis
2. Feeding Problems / Failure to Thrive
3. Apnoea / Cough / Wheeze / Chest Infection
4. Sandifer’s Syndrome

Question 11

What is involved in the Assessment of someone with Effortless Vomiting (Gastro-Oesophageal Reflux)?

Answer 11

1. History / Examination - Often Sufficient
2. Radiological Investigation - Video Fluoroscopy / Barium Swallow
3. pH Study
4. Oesophageal Impedance Monitoring
5. Endoscopy

Question 12

What will a Barium Swallow Meal show?

Answer 12

1. Dysmotility
2. Hiatus Hernia
3. Reflux
4. Gastric Emptying
5. Strictures
   Note - Can cause Aspiration

Question 13

What are the Positive Points (a) and the Negative Points (b) for:

1. Videofluoroscopy and Barium Meal?
2. pH Study?
3. Endoscopy?
4. Trial of Feeding?

Answer 13

1. a) May Detect Aspiration / Defines Anatomy Well
2. b) May Miss Reflux / Radiation
3. a) Detects Acid-Reflux Missed by Barium
4. b) Only Detects Acid-Reflux / May be unpleasant
5. a) Best Test for Oesophagitis / Can add pH Study
6. b) Needs Anaesthetic
7. a) Most Physiological Test / Discriminator for Surgery
8. b) NG Tube Required / Needs 2-3 Days in Hospital

Question 14

What is the Treatment for Effortless Vomiting (Gastro-Oesophageal Reflux)?

Answer 14

1. Feeding Advice
2. Nutritional Support
3. Medical Treatment
4. Surgery

Question 15

What is included in Feeding Advice, in Treatment of Effortless Vomiting (Gastro-Oesophageal Reflux)?

Answer 15

1. Thickeners for Liquids
2. Appropriateness of Food - Texture / Amount
3. Behavioural Programme - Oral Stimulation / Removal of Aversive Stimuli
4. Feeding Position

Question 16

What is included in Nutritional Support, in Treatment of Effortless Vomiting (Gastro-Oesophageal Reflux)?

Answer 16

1. Calorie Supplements
2. Exclusion Diet - Milk Free
3. Nasogastric Tube
4. Gastrostomy

Question 17

What is included in Medical Treatment, in Treatment of Effortless Vomiting (Gastro-Oesophageal Reflux)?

Answer 17

1. Feed Thickener - Gaviscon / Thick and Easy
2. Prokinetic Drug
3. Acid Suppressing Drugs - H2RA / PPI

Question 18

What are the Indications for Surgery, in Treatment of Effortless Vomiting (Gastro-Oesophageal Reflux)?

Answer 18

1. Failure of Medical Treatment
2. Persistent - Failure to Thrive / Aspiration / Oesophagitis
   Note - Nissen Fundoplication is used

Question 19

What is the Definition of Chronic Diarrhoea?

Answer 19

1. 4+ Stools per Day
2. > 4 weeks:
3. a) < 1 week = Acute Diarrhoea
4. b) 2-4 Weeks = Persistent Diarrhoea
5. c) > 4 Weeks = Chronic Diarrhoea

Question 20

What are the Causes of Chronic Diarrhoea?

Answer 20

1. Motility Disturbance - Toddler Diarrhoea / IBS
2. Active Secretion - Acute Infective Diarrhoea / IBD
3. Malabsorption of Nutrients - Allergy / Coeliac / C.F.
4. Inflammatory - Malabsorption due to Intestinal Damage / Secretory Effects of Cytokines

Question 21

What is the Clinical Approach to Diagnosis of Diarrhoea?

Answer 21

1. History - Age / Onset / Family History / Nocturnal
2. Growth / Weight Gain of Child
3. Faeces Analysis - Appearance / Stool Culture / Determination of Secretory vs Osmotic

Question 22

What is Fat Malabsorption indicative of?

Answer 22

1. Pancreatic Disease - Classically C.F.

2. Hepatobiliary Disease - Cholestasis / Liver Disease

Question 23

What are the Symptoms of Coeliac Disease?

Answer 23

1. Abdominal Bloatedness / Distension
2. Diarrhoea
3. Failure to Thrive
4. Short Stature
5. Constipation
6. Tiredness
7. Dermatitis Herpatiformis

Question 24

What are the Screening Tests for Coeliac Disease?

Answer 24

1. Duodenal Biopsy
2. Genetic Testing - HLA DQ2 / HLA DQ8
3. Serological Screen:
4. a) Anti-Tissue Transglutaminase
5. b) Anti-Endomysial
6. c) Anti-Gliadin
7. d) Concurrent IgA Deficiency

Question 25

What is the Treatment of Coeliac Disease?

Answer 25

Gluten Free Diet for Life