Lecture 19 - N/V/D Flashcards
What are some DDx for persistent N/V?
Gastroparesis
Gastric outlet obstructions
Dysmotility
CNS or systemic disorders
What are some DDx for N/V before breakfast?
Pregnancy Alcohol intake Uremia Increased intracranial pressure Cannabis use
What are some DDx for N/V immediately after a meal?
Bulimia or psychogenic cause
What are some DDx for vomiting undigested food >1 hour after a meal?
Gastric outlet obstruction
Gastroparesis
What are some associated sx for N/V?
Acute sx without abdominal pain or acute sudden sx with severe abd pain
Neurologic sx
Misc (decreased urine output or dark urine, hematuria, CP or SOB)
Describe non inflammatory diarrhea
<2 weeks (acute infectious) Watery, non bloody Usually mild and self limit mixed Viral or noninvasive bacteria Sx originate from small intestinal which may result in higher volume stool
Describe acute inflammatory dysentery
Blood or pus, fever
Usually caused by an invasive or toxin producing bacteria
Sx originate in the colon which result in lower volume stool
Which medications are associated with chronic diarrhea?
SSRI, PPI, NSAIDs, metformin, allopurinol, orlistat, ACE II inhibitors
Describe osmotic diarrhea
Post prandial diarrhea
Resolves with fasting
Carbohydrate malabsorption —> lactose, fructose, sorbitol, high fructose corn syrup, alcohol
Magnesium or phosphate compounds —> laxatives or antacids
What can cause chronic diarrhea?
Secretory Inflammatory conditions Malabsorption conditions Motility disorders Chronic infections Systemic conditions
What can cause chronic secretory diarrhea?
Endocrine tumors Bile salt malabsorption Microscopic colitis (IBD)
What can cause inflammatory chronic diarrhea?
IBD
Associated with a variety of sx such as abd pain, fever, weight loss, hemotchezia
What malabsorptive conditions can cause chronic diarrhea?
Small mucosal intestinal disease Intestinal rejections Lymphatic obstruction Small intestinal bacterial overgrowth Pancreatic insufficiency Characterized by wt loss, osmotic diarrhea, steatorrhea, nutritional deficiencies
Significant diarrhea in the absence of weight loss is most likely not due to what?
Malabsorption
Which motility disorders can cause chronic diarrhea?
IBD
Secondary to other causes such as systemic disorders, radiation enteritis, surgery
Which chronic infections can cause chronic diarrhea?
Giardia, E histolytica, cyclospora, nematodes, C diff
Affects immunocomprised pts
Which systemic conditions can cause chronic diarrhea?
Thyroid conditions, DM, collagen vascular disorders
Osmotic diarrhea can cause what?
A loss of water and subsequent hypernatremia
What is orthostatic hypotension?
Sustained reduction of systolic BP of at least 20 mmHg OR diastolic BP of at least 10mmHg within mins of standing
What is gastroenteritis?
Includes vomiting and diarrhea
May be from viral, bacterial or parasites
If signs of volume depletion obtain serum electrolytes
Tx is supportive care
What is dysentery?
A type of infectious diarrhea usually caused by invasive or toxin producing bacteria with blood or pus and fever
Severe illness, blood stools or persistent diarrhea >7 should undergo microbial assessment
What is the tx for dysentery?
Bland diet, rehydration with electrolytes, antidiarrheal agents, abx
Hospital admission for severe cases (inability to maintain oral hydration)
Describe malabsorption syndromes
Weight loss, abnormal lab values, fecal fat >10g/24h
Lymphatic obstruction, pancreatic disease, motility disorders
What is osmotic diarrhea?
Stool volume decreases with fasting
Increased stool osmotic gap
Ex. Disaccharidase deficiency
What is secretory diarrhea?
Large volume
Little changes with fasting
Normal stool osmotic gap
Ex. Hormonally mediated, villous adenoma
Describe N/V of pregnancy
Morning sickness but often continues throughout the day
Common soon after the first missed menses (approx 6 weeks)
Ceases by 5th month
Reassurance and dietary modifications
New onset of N/V that occurs after week 10 of gestation is unlikely to be related to what?
Pregnancy and must be evaluated further
What is hyperemesis gravidarum (HEG)?
Persistent severe vomiting associated with wt loss, dehydration, hypochoremic alkalosis and hypokalemia
More common with multi-fetal pregnancy or hydatiform mole pregnancy or hydatiform mole
Can be associated with hyperthyroidism
What are some DDx for N/V after 10 weeks of gestation?
Gastroenteritis, biliary tract disease, hepatitis, PUD, pancreatitis, appendicitis, pyelonephritis, ovarian torsion, DKA, migraine, drug toxicity or withdrawal, psychological conditions, acute fatty liver of pregnancy, pre-eclampsia
Diarrhea is usually not associated with what?
Pregnancy and should be evaluated
Describe pyloric stenosis
Progressive gastric outlet obstruction
Non-bilious vomiting, dehydration and alkalosis in infants younger <12 weeks
US demonstrates a hypoechoic muscle ring >4mm thickness
Retention of contrast in the stomach and a long narrow pyloric channel on US
What is Hirschsprung’s disease?
Failure to pass meconium followed by vomiting, abd distention, reluctance to feed within first 24 hours of life
Describe congenital atresia and stenosis
Often ID’ed by US while in utero
Present with bile stained vomiting and abd distention within first 48 hours of life
X-ray features dilated loops of small bowel and absence of colonic gas
Barium enema IDs narrow caliber microcolon at site of atresia
Describe inborn errors of metabolism
Critically ill newborns, children with recurrent vomiting, seizures, unexplained metabolic acidosis, hyperammonemia and hyperglycemia OR children that regress developmentally
What is intussusception?
Invagination of one segment of intestine into another
Paroxyms of abd pain with screaming and drawing up knees, lethargy between episodes
Rapidly develop vomiting and diarrhea with hematochezia within 12 hours
What is malrotation?
Incomplete rotation of the midgut at around 10 weeks gestation
Generally diagnosed within the first year of life
Diagnosed with barium swallow with small bowel follow through
What is an incarcerated hernia?
Presents as painless mass particular in the inguinal area
May become tender after long periods of standing or coughing
Can be associated with vomiting and abd distention (if becomes trapped can have sx of bowel obstruction)
Hx and PE are diagnostic
Surgical repair required
Describe hydrocephalus, subdural hematoma and tumors (increased intracranial pressure)
Persistent N/V, AMS, ataxia, weakness, diplopia, abnormal eye movements, severe and persistent HA
Bulging fontanelles
Changes in VS (bradycardia, HTN, altered respiratory rate)
Describe hydrocephalus
Newborn and young infants (US identifies the size of ventricles
Older infants and children (CT or MRI)
Lumbar puncture not indicated
What can be infectious causes of mild N/V in peds cases?
Otitis media
UTI
Strep pharyngitis
Can pregnancy be a caused of mild N/V in peds pts?
Yes in adolescence
Late or missed menses, index of suspicion, positive urine or serum pregnancy test
What is cannabis hyperemesis syndrome?
Seen in peds pts
Daily cannabis users for at least one year
Severe episodes of N/V, abd pain, relieved by hot showers
Refractory to antiemetics and antidopamine agents
TX: cessation of canabis use, sx resolve within 2 days
