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Paediatrics > Diarrhoea and Vomiting > Flashcards

Diarrhoea and Vomiting Flashcards

1
Q

What are the 4 types of vomiting?

A

Vomiting with retching
Projectile vomiting
Bilious vomiting
Effortless vomiting

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2
Q

What are the stages of vomiting with retching?

A

Pre-ejection - tachycardia, pallor, nausea
Ejection - retching, vomiting
Post-ejection - floppy, weak, lethargic, shivering

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3
Q

What can stimulate the vomiting centre?

A 
Enteric pathogens 
Visual stimuli 
Middle ear stimuli 
Metabolic derangement 
Infection (UTI, encephalitis/meningitis)
Head trauma 
Intestinal inflammation
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4
Q

How do you test for pyloric stenosis?

A

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

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5
Q

How do you manage pyloric stenosis?

A

Fluid resus

Ramstedts pyloromyotomy

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6
Q

What age group and gender is pyloric stenosis most common in?

A

4-12 weeks

Boys

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7
Q

What is a typical presentation of pyloric stenosis?

A

Projectile non-bilious vomiting
Weight loss
Dehydration +/- shock

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8
Q

What should bilious vomiting raise alarm bells for?

A

Intestinal obstruction

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9
Q

What things can cause intestinal obstruction?

A 
Intestinal atresia (newborns only) 
Malrotation +/- volvulus
Intussception 
Ileus (slowing of gastric motility due to infection)
CD with strictures
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10
Q

What investigations should you do in bilious vomiting?

A

Abdominal XRay
Consider contrast meal
Surgical exploration via laparotomy

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11
Q

What is effortless vomiting normally due to?

A

Gastro-oesophageal reflux

Usually self-limiting

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12
Q

What is GOR a problem?

A

In cerebral palsy, progressive neurological problems, oesophageal atresia +/- TOF operated
Generalised GI motility problem

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13
Q

Why is reflux especially common in the first few months –> years?

A

LOS not matured yet and is a lot more laxed

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14
Q

What are the symptoms of GOR?

A

GI - vomiting/haematemesis
Nutritional - FFT/feeding problems
Respiratory - apnoea, wheeze, chest infections, cough
Neurological - Sandifer’s syndrome

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15
Q

What is Sandifer’s syndrome?

A

GOR & spastic movements etc.

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16
Q

How do you investigate GOR?

A 
Usually just Hx and Ex 
May need:
Video fluoroscopy/barium swallow
pH study 
Oesophageal impedance monitoring
Endoscopy
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17
Q

What might you be able to see in a barium swallow with someone with GOR?

A

Dysmotility, hiatus hernia, reflux, gastric emptying, strictures

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18
Q

How do you do a pH study?

A

Monitor at 5cm above LOS to measure reflux

Should correlate with symptom diary

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19
Q

How do you do impedance monitoring?

A

Several sensors from proximal to distal oesophagus which monitor bile, air and acid reflux and how far it comes up

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20
Q

What might you see on endoscopy?

A

Ulcerated oesophagus

Best test to diagnose oesophagitis

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21
Q

What is a trial of feeding test?

A

Maybe best to see if child needs surgery
NG tube req and needs a few days in hospital
given antireflux meds and NG feeding

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22
Q

How do you Rx GOR?

A

Feeding advice - keep upright, avoid aversive behaviours, eat little and often, oral stimulation
Nutritional support
Medical Rx
Surgery

23
Q

What is involved in medical Rx of GOR?

A

Feed thickener - Gaviscon, thick and easy
Prokinetic drugs
Acid supressing drugs - H2 receptor blockers, PPI

24
Q

What are the indicators for surgery in GOR?

A

Persistent FFT, aspiration, oesophagitis

25
Q

What is the surgical Rx for GOR?

A

Nissen fundoplication

Children with cerebral palsy more likely to have bloating, dumping, retching and other problems after surgery

26
Q

How must fluid is lost in faeces per day?

A

<200ml

27
Q

What secretory functions does the small bowel carry out?

A

Water for fluidity/enzyme transport/absorption
Irons, e.g. duodenal HCO3-
Defence mechanisms against pathogens/antigens/harmful substances

28
Q

Where do stem cells come from in the small intestine mucosa?

A

Crypts of Leiberkhuns - they move up and are shed into the lumen

29
Q

Define chronic diarrhoea

A

4+ stools/day for more than 4 weeks

30
Q

Define acute diarrhoea

A

<1 week

31
Q

Define persistent diarrhoea

A

2-4wks

32
Q

What are the three categories of diarrhoea?

A

Motility disturbance - toddler’s diarrhoea, IBS
Active secretion - acute infective diarrhoea, IBS
Malabsorption of nutrients (osmotic) - food allergy, coeliac disease, CF

33
Q

What is the mechanism of osmotic diarrhoea?

A

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

34
Q

How can we nutritionally support children with chronic diarrhoea?

A

Calorie supplements
Exclusion diets (e.g. milk free)
NG tube
Gastrostomy

35
Q

Name two osmotic laxatives

A

Lactulose, movicol

36
Q

What is secretory diarrhoea often assoc with?

A

Toxin production from vibrio cholerae and enterotoxigenic Escherichia coli
Active Cl secretion via CFTR

37
Q

Bloody diarrhoea in a child here in Aberdeen is what until proven otherwise?

A

E. coli

38
Q

What are the causes of motility problem associated diarrhoea?

A

Usually toddler’s diarrhoea

Others: IBS, congenital hypothyroidism, chronic intestinal pseudo-obstruction

39
Q

What is inflammatory diarrhoea due to & what does it result in?

A

Malabsorption due to intestinal damage
Secretory effect of cytokines
Accelerated transmit time due to inflammation
Protein exudate across inflamed epithelium

40
Q

What do you want to gather in your history of a child with diarrhoea?

A 
Age at onset
Gradual/abrupt onset
FH
Nocturnal defaecation always pathological 
Consider wt and height of child
41
Q

What do you want to do with the faeces of a child with diarrhoea?

A

Observe appearance
Stool culture
Determine whether secretory/osmotic

42
Q

What are the differences in the stool from osmotic and secretory diarrhoea?

A

Osmotic - smaller, fasting –> diarrhoea stops, high stool osmolality & osmotic gap

Secretory - higher volume, diarrhoea continues despite fasting, lots of electrolytes in secretory diarrhoea

43
Q

What can cause fat malabsorption leading to diarrhoea?

A

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

44
Q

What is coeliac disease?

A

Gluten sensitivity enteropathy

Only 30% with genetic potential to get it, will end up with it

45
Q

What are the symptoms/signs of coeliac disease?

A

Abdominal bloatedness, diarrhoea, FFT, short stature, constipation, tiredness, dermatitis herpatiformis

46
Q

What are the screening tests for coeliac disease?

A

Anti-tissue transglutaminase
Anti-endomysial
Anti-gliadin
Check IgA levels (as 2% of population have low levels and may get false -ve)

47
Q

What is the gold standard for diagnosis of coeliac disease?

A

Duodenal biopsy

Can also do genetic testing

48
Q

What are the HLA genotypes most prone to coeliac disease?

A

HLA DQ2 and DQ8

49
Q

What findings may you see on endoscopy with coeliac disease?

A

Red, inflamed, scalloped

50
Q

What findings might you find on endoscopy with coeliac disease?

A

Villous atrophy
Crypt hyperplasia
Lymphocytic infiltration of surface epithelium

51
Q

Under what circumstances can you diagnose coeliac disease without biopsy?

A

Symptomatic children with anti-TTG >10x upper limit normal
Positive anti-endomysial antibodies
HLA DQ2/8 +ve

52
Q

How do you Mx coeliac disease?

A

Gluten free diet for life

If v. young (,2y) can re-challenge later

53
Q

What are people with coeliac disease at risk of if they don’t receive Rx?

A

Small bowel lymphoma

Paediatrics (35 decks)

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