case study qs- upper GI

Question 1

how many pounds in a kg?

Answer 1

2 pounds in a kg

Question 2

how many ml is 1 oz?

Answer 2

30

3oz in 100ml

Question 3

how many grams in an ounce?

Answer 3

30grams

Question 4

A 10 week old boy presents with 4 weeks of frequent post feed effortless vomits and distress (back arching and pulling up knees).

ddx?

Answer 4

Gastro-oesophageal reflux (GORD)
+/- Milk intolerance
Consider pyloric stenosis
Consider surgical causes if bilious

Question 5

pyloric stenosis sx?

Answer 5

projectile vomitting

milk vomit not bile

Question 6

normal feed volume from 0-6 months?

Answer 6

150-200ml/kg

Question 7

What is the management for GORD?

Answer 7

Feeding advice
Feed routines (timing/ positioning/ adverse factors)
Feed volumes (~150ml/kg/day)
Reassurance (common, resolves, baby thriving)

Medical treatment
Feed thickeners* (carobel/ thick and easy/ gaviscon) sachets
Milk free feeding (Baby +/- Mum + Dietician!)
Acid reduction (Ranitidine/ Omeprazole)
Pro-kinetics (Domperidone)

Surgery (FTT/ Aspirations/CP)
Uncommon
Gastrostomy + Fundoplication

Question 8

3m old boy, bottle fed, weight gain ~100-120g/w. Has loose stools (4-5/day) and several vomits a day. Older brother had asthma and mum had eczema. HV asking about changing the milk.

treatment?

Answer 8

Probable cow’s milk protein allergy/intolerance with reflux

Trial of hydrolysed feed (not comfort, lactose free, soya or ….)
Milk free advice for weaning via Health visitor
May need thickeners/ acid suppression

Trial of Nutramigen or Aptamil pepti 1

second in line is Neocate

Question 9

4 weeks old otherwise healthy baby. Good weight gain (150g/w), breast fed, presents with streaks of fresh blood in stool for last 7 days. No fever or vomits
Dad has asthma. Mum has “irritable bowel.”
General/abdominal examination normal

diagnosis and ddx?

Answer 9

CMPA
Infection, constipation or a surgical cause.

management:
Maternal milk/dairy avoidance
Mother will need calcium/vit D supplementation and dietician input

Question 10

How common is cow’s milk protein allergy/ intolerance (CMPI)?

Answer 10

In UK 2 - 5% of children <2y react to a food

Question 11

how does IgE mediated present?

Answer 11

Reactions within 2 hours of ingestion
Resolution of symptoms within 12 hours
GI- vomiting/ pain/ diarrhoea
Skin- urticaria/ angioedema/ pruritis
Resp- rhinoconjunctivitis/ wheeze/ cough/ stridor
Anaphylaxis and collapse
Typically egg, nuts, pulses, fish, grains, milk
Significant milk reaction relatively uncommon

RAST and skin prick tests may be helpful
The BEST test is the history

Question 12

How does non-IgE mediated present?

Answer 12

Symptoms develop over hours or days
Symptoms may last for many days
Often non-specific/multi system
Vomiting, diarrhoea, abdo pain, reflux, poor feeding, failure to thrive, eczema
Tests are unhelpful,
Clinical suspicion, allergy focussed history and empirical trial of elimination diet

Question 13

child with atopic eczema treatment?

Answer 13

first topical steroids

trial of hydrolysed milk free feed for 4 weeks

Question 14

A 2 week old baby present with a 2 day history of bilious vomiting all feeds. The parents bring in one of his baby grows. Weight is down 30g.
He is unsettled on examination

ddx?

Answer 14

Due to intestinal obstruction until proved otherwise

Malrotation (a few weeks old)
Intussusception (Usually older infants (11-12 months + toddlers)
Ileus (?sepsis)- any age
Crohn’s disease (unusual in infants)
Intestinal atresia (in newborn babies only!)

Question 15

how to manage and investigate bilious vomiting?

Answer 15

Urgent surgical opinion
IV Access
IV Fluids
Nil by mouth
NG tube

Investigations
Abdominal x-ray
Contrast meal likely to be needed