Diarrhoea and Vomiting Flashcards
What are the 4 types of vomiting?
Vomiting with retching
Projectile vomiting
Bilious vomiting
Effortless vomiting
What are the stages of vomiting with retching?
Pre-ejection - tachycardia, pallor, nausea
Ejection - retching, vomiting
Post-ejection - floppy, weak, lethargic, shivering
What can stimulate the vomiting centre?
Enteric pathogens Visual stimuli Middle ear stimuli Metabolic derangement Infection (UTI, encephalitis/meningitis) Head trauma Intestinal inflammation
How do you test for pyloric stenosis?
Test feed - visible gastric peristalsis, palpation of olive tumour
Blood gas - should show metabolic alkalosis, low K and Cl
USS - shows thickening of pylorus and narrowing of lumen
How do you manage pyloric stenosis?
Fluid resus
Ramstedts pyloromyotomy
What age group and gender is pyloric stenosis most common in?
4-12 weeks
Boys
What is a typical presentation of pyloric stenosis?
Projectile non-bilious vomiting
Weight loss
Dehydration +/- shock
What should bilious vomiting raise alarm bells for?
Intestinal obstruction
What things can cause intestinal obstruction?
Intestinal atresia (newborns only) Malrotation +/- volvulus Intussception Ileus (slowing of gastric motility due to infection) CD with strictures
What investigations should you do in bilious vomiting?
Abdominal XRay
Consider contrast meal
Surgical exploration via laparotomy
What is effortless vomiting normally due to?
Gastro-oesophageal reflux
Usually self-limiting
What is GOR a problem?
In cerebral palsy, progressive neurological problems, oesophageal atresia +/- TOF operated
Generalised GI motility problem
Why is reflux especially common in the first few months –> years?
LOS not matured yet and is a lot more laxed
What are the symptoms of GOR?
GI - vomiting/haematemesis
Nutritional - FFT/feeding problems
Respiratory - apnoea, wheeze, chest infections, cough
Neurological - Sandifer’s syndrome
What is Sandifer’s syndrome?
GOR & spastic movements etc.
How do you investigate GOR?
Usually just Hx and Ex May need: Video fluoroscopy/barium swallow pH study Oesophageal impedance monitoring Endoscopy
What might you be able to see in a barium swallow with someone with GOR?
Dysmotility, hiatus hernia, reflux, gastric emptying, strictures
How do you do a pH study?
Monitor at 5cm above LOS to measure reflux
Should correlate with symptom diary
How do you do impedance monitoring?
Several sensors from proximal to distal oesophagus which monitor bile, air and acid reflux and how far it comes up
What might you see on endoscopy?
Ulcerated oesophagus
Best test to diagnose oesophagitis
What is a trial of feeding test?
Maybe best to see if child needs surgery
NG tube req and needs a few days in hospital
given antireflux meds and NG feeding
How do you Rx GOR?
Feeding advice - keep upright, avoid aversive behaviours, eat little and often, oral stimulation
Nutritional support
Medical Rx
Surgery
What is involved in medical Rx of GOR?
Feed thickener - Gaviscon, thick and easy
Prokinetic drugs
Acid supressing drugs - H2 receptor blockers, PPI
What are the indicators for surgery in GOR?
Persistent FFT, aspiration, oesophagitis
What is the surgical Rx for GOR?
Nissen fundoplication
Children with cerebral palsy more likely to have bloating, dumping, retching and other problems after surgery
How must fluid is lost in faeces per day?
<200ml
What secretory functions does the small bowel carry out?
Water for fluidity/enzyme transport/absorption
Irons, e.g. duodenal HCO3-
Defence mechanisms against pathogens/antigens/harmful substances
Where do stem cells come from in the small intestine mucosa?
Crypts of Leiberkhuns - they move up and are shed into the lumen
Define chronic diarrhoea
4+ stools/day for more than 4 weeks
Define acute diarrhoea
<1 week
Define persistent diarrhoea
2-4wks
What are the three categories of diarrhoea?
Motility disturbance - toddler’s diarrhoea, IBS
Active secretion - acute infective diarrhoea, IBS
Malabsorption of nutrients (osmotic) - food allergy, coeliac disease, CF
What is the mechanism of osmotic diarrhoea?
Food not being absorbed so stays in lumen and pulls water from the cells –> diarrhoea
All to try and equilibrate the osmotic balance
Usually due to enzymatic defect (lactase) or transport defect (CF)
Generally accompanied by macroscopic and microscopic intestinal injiury
How can we nutritionally support children with chronic diarrhoea?
Calorie supplements
Exclusion diets (e.g. milk free)
NG tube
Gastrostomy
Name two osmotic laxatives
Lactulose, movicol
What is secretory diarrhoea often assoc with?
Toxin production from vibrio cholerae and enterotoxigenic Escherichia coli
Active Cl secretion via CFTR
Bloody diarrhoea in a child here in Aberdeen is what until proven otherwise?
E. coli
What are the causes of motility problem associated diarrhoea?
Usually toddler’s diarrhoea
Others: IBS, congenital hypothyroidism, chronic intestinal pseudo-obstruction
What is inflammatory diarrhoea due to & what does it result in?
Malabsorption due to intestinal damage
Secretory effect of cytokines
Accelerated transmit time due to inflammation
Protein exudate across inflamed epithelium
What do you want to gather in your history of a child with diarrhoea?
Age at onset Gradual/abrupt onset FH Nocturnal defaecation always pathological Consider wt and height of child
What do you want to do with the faeces of a child with diarrhoea?
Observe appearance
Stool culture
Determine whether secretory/osmotic
What are the differences in the stool from osmotic and secretory diarrhoea?
Osmotic - smaller, fasting –> diarrhoea stops, high stool osmolality & osmotic gap
Secretory - higher volume, diarrhoea continues despite fasting, lots of electrolytes in secretory diarrhoea
What can cause fat malabsorption leading to diarrhoea?
Pancreatic disease (e.g. CF) - lack of lipase –> steatorrhoea
Hepatobiliary dx (e.g. chronic liver dx/cholestasis) - don’t have bile salts to dissolve fat
What is coeliac disease?
Gluten sensitivity enteropathy
Only 30% with genetic potential to get it, will end up with it
What are the symptoms/signs of coeliac disease?
Abdominal bloatedness, diarrhoea, FFT, short stature, constipation, tiredness, dermatitis herpatiformis
What are the screening tests for coeliac disease?
Anti-tissue transglutaminase
Anti-endomysial
Anti-gliadin
Check IgA levels (as 2% of population have low levels and may get false -ve)
What is the gold standard for diagnosis of coeliac disease?
Duodenal biopsy
Can also do genetic testing
What are the HLA genotypes most prone to coeliac disease?
HLA DQ2 and DQ8
What findings may you see on endoscopy with coeliac disease?
Red, inflamed, scalloped
What findings might you find on endoscopy with coeliac disease?
Villous atrophy
Crypt hyperplasia
Lymphocytic infiltration of surface epithelium
Under what circumstances can you diagnose coeliac disease without biopsy?
Symptomatic children with anti-TTG >10x upper limit normal
Positive anti-endomysial antibodies
HLA DQ2/8 +ve
How do you Mx coeliac disease?
Gluten free diet for life
If v. young (,2y) can re-challenge later
What are people with coeliac disease at risk of if they don’t receive Rx?
Small bowel lymphoma
