Nausea and Vomiting Flashcards
The effortless passage of gastric
contents into the mouth in the absence of
nausea and without diaphragmatic muscular
contractions.
Regurgitation
An involuntary act with all the movements
of vomiting without the expulsion of gastric contents because the cardiac orifice remains closed
Retching
The effortless regurgitation of recently
ingested food into the mouth, followed by rechewing and reswallowing or spitting out.
Rumination
What are the red flags for vomiting
- Marked pallor
- Signs of hypovolaemia
- Peritoneal signs
- Headache, stiff neck, confusion
- Distended tympanic abdomen
Vomiting without bile-stained vomitus =
pyloric
obstruction
Vomiting of bile =
obstruction below duodenal
ampulla
Vomiting of ingested food =
oesophageal obstruction.
Vomiting without nausea and possibly
projectile =
↑ intracranial pressure
Green vomiting = urgent surgical referral for
possible_____ and ____
intestinal malrotation with volvulus
Non bile-stained vomitus (curdled milk): consider________
pyloric stenosis, GORD, feeding problems, concealed infection (e.g. UTI, meningitis).
Important warning signs in neonates of vomiting
- Excessive drooling of frothy secretions from mouth
- Bile-stained vomitus—always abnormal
- Delayed passage of meconium (beyond 24 hours)
- Inguinal hernias
- Usually sudden onset vomiting 3rd–6th week
- Projectile vomitus
- Failure to thrive
Congenital hypertrophic pyloric stenosis
Congenital hypertrophic pyloric stenosis biochemistry
metabolic alkalosis: sodium usually
<130 mmol/L, chloride <100 mmol/L
Special investigations for Congenital hypertrophic pyloric stenosis
— barium meal (_______)—concern about
aspiration
— ________
string sign
abdominal ultrasound
________ or severely delayed gastric emptying is a moderately common condition, which is a cause of nausea and vomiting.
Gastroparesis (gastropathy)
Medications to improve gastric motility
domperidone 10–20 mg (o) tds, 15–30 minutes before meals
or
metoclopramide 5–10 mg (o) tds, 30 minutes
before meals
or
erythromycin (has prokinetic properties)
Other measures to improve gastric motility
1
2
• Injection of botulinum toxin into the pylorus
• Gastric pacing with internally implanted
neurostimulators
- severe, unexplained vomiting or nausea occurring at varying intervals in a normal healthy person
- lasts hours to days
Cyclical vomiting
The first-line management in vomiting is to _______
ensure that any fluid and electrolyte imbalance is corrected and that any underlying cause is identified and treated
Avoid the use of centrally acting dopamine antagonist drugs (DADS, e.g. metoclopramide and prochlorperazine) in children because of risk of \_\_\_\_\_\_\_
extrapyramidal side effects (EPSE), usually acute dystonic reactions.
These include ondansetron, granisetron, dolasetron, palonosetron and tropisetron and are effective at _______ and ____
preventing chemotherapy- and radiotherapyinduced
emesis when initiated prior to treatment
_______ enhances the effect of 5-HT3 agents
Dexamethasone
How to manage severe Drug-induced nausea and vomiting
ondansetron 8 mg (o) or IV prior to therapy then two doses 6 hourly
plus
dexamethasone 8 mg IV 30 minutes prior to
therapy, then two doses 6 hourly
Most effective drugs for vestibular disturbances
The phenothiazine derivatives are the most effective, while the dopamine D 2 -receptor antagonists are relatively ineffective
Mx of vomiting in pregnancy
pyridoxine hydrochloride 25–50 mg (o) tds
if still ineffective add
metoclopramide 10 mg (o) tds or IM (if oral
intolerance)
Consider the possibility of _____ and _____ in adolescent females with a history of vomiting immediately after meals, especially after binge eat
anorexia nervosa and bulimia
__________ can be caused typically by alcohol, pregnancy, kidney failure and raised intracranial pressure
Early morning nausea and vomiting
Anti-emetic drug therapy should not be used in infants and children with _______
gastroenteritis
what receptor?
Promethazine
Metoclopramide
Prochlorperazine
H1
D2 + 5-HT3
D2 (central)
Domperidone
Haloperidol
Ondansetron
D2 (peripheral)
D2 (central)
5-HT3
Most neck lumps are ______
reactive lymph nodes—to
concurrent infection
what is the 20-40s rule
— 0–20 years: congenital, inflammatory, lymphoma, tuberculosis — 20–40 years: inflammatory, salivary, thyroid, lymphoma — >40 years: lymphoma, metastases
_________of malignant nodes in the
anterior triangle have their primary tumour in
the head and neck
Eighty-five per cent
Consistency of enlarged nodes
Rules of thumb are:
- hard:_________
- rubbery: ________
- soft: _______
- tender and multiple:______
secondary carcinoma
lymphoma
sarcoidosis or infection
infection
causes of Acute cervical lymphadenitis
- Acute viral lymphadenitis
* Acute bacterial lymphadenitis—coccal infection
Widespread spread of neck lumps
1
2
- Sebaceous cysts
* Lipomas
Midline spread of neck lumps
1
2
3
• Thyroid nodule (moves upon swallowing)
• Thyroglossal cysts (moves upwards on tongue
protrusion)
• Dermoid cyst (beneath chin)
Examples of tumors in the anterior triangle 1 2 3 4
- Branchial cyst (in upper part):
- Carotid body tumour:
- Carotid aneurysm
- Lateral thyroid tumours
Determine what tumor?
— opposite thyroid cartilage — smooth and pulsatile — can be moved laterally but not vertically — usually 40–60 years — requires excision (with care)
Carotid body tumour:
Tumors of the posterior triangle
- Developmental remnants
- Pancoast tumour (from apex lung)
- Cervical rib
— chronic granulomatosis infection due to
Gram-positive Actinomyces israelii
— forms a multilocular abscess (pus has ‘sulphur granules’)
— infection follows dental extraction or poor
dental hygiene, esp. severe caries
— treat with high-dose penicillin G, 4 months
Cervicofacial actinomycosis (lumpy jaw syndrom
- A soft, squelchy, indefinite mass
- Base of left neck
- History of difficulty in swallowing
Pharyngeal pouch
The most likely cause of a solitary thyroid nodule is the _____
dominant nodule in a multinodular goitre.
In Children,
Benign lumps usually occur in
the _______ while malignant lumps are more likely in the ______
anterior triangle,
posterior triangle
The common
midline lump in children is the _____
thyroglossal cyst
Most enlarged lymph nodes are either ‘normal’ or local infections (mainly viral), especially if______ diameter, and not hard or fixed
<2 cm
Inflammatory nodes may be caused by infection in the
tonsils, the teeth or other oral or
nasopharyngeal cavities
Suspicious nodes are
1
2
3
> 2.5 cm, with firmer
consistency than normal and less mobility
(investigate especially with biopsy
MAIS lymphadenitis is caused by?
Caused by Mycobacterium avium-intracellulares crofulaceum
(MAIS) infection
•Produces chronic cervical lymphadenitis and
collar stud abscesses
• A relatively common infection of cervical nodes, yet often unrecognised
• Painless swelling due to development of a cold abscess in healthy child
MAIS lymphadenitis
Common sites of MAIS
Common sites are submandibular, tonsillar and
pre-auricular nodes
Tx of MAIS
Unresponsive to antimicrobials: treatment is by surgical excision of abscess and underlying lymph nodes
etiology of Acute bacterial lymphadenitis
Usually coccal infections— Staphylococcus,
Streptococcus
