Upper and Lower GI - Part 1 Flashcards
Describe the physiology of vomiting
Pre-ejection phase - pallor, nausea, and tachycardia
Ejection phase - retch and vomit
Post-ejection phase - lethargic, pale and sweaty
What are some of the triggers for vomiting?
Enteric pathogens, infection, visual/ olfactory stimuli, head injury, increased ear stimuli and chemotherapy
What are the types of vomiting?
Vomiting with retching, projectile vomiting, bilious vomiting, effortless vomiting and haematemesis
What are the causes for vomiting in infants?
GOR, cow’s milk allergy, infection and intestinal obstruction
What are some causes of vomiting in children?
Gastroenteritis, infection, appendicitis, intestinal obstruction, raised ICP and coeliac disease
What are some causes of vomiting in young adults?
Gastroenteritis, infection, H. pylori, appendicitis, raised ICP, DKA, cyclical vomiting syndrome and bulimia
What is an olive tumour?
Thickening of the pyloric opening
What can been seen on blood gas for pyloric stenosis?
Metabolic alkalosis
Hypochloraemia
Hypokalaemia
What is the management for pyloric stenosis?
Fluid resuscitation
Refer to surgeons - Ramstedt’s pyloromyotomy
Describe pyloric stenosis
Babies 4-12 weeks and more boys
Projectile non-bilious vomiting
Weight loss, dehydration and maybe shock
Characteristic electrolyte disturbance
Describe effortless vomiting
Always due to gastro-oesophageal reflux
Very common in infants
Self limiting and resolves spontaneously in majority
Exceptions - CP, progressive neurological problems, oesophageal atresia and generalised GI motility problem
What are the presenting features of reflux?
GI - vomiting and haematemesis
Nutritional - feeding problems and failure to thrive
Respiratory - apnoea, cough, wheeze and chest infections
Neuro - Sandifer’s syndrome
What is the medical assessment of reflux?
History and examination
Oesophageal pH study/ impedance monitoring
Endoscopy
Radiological investigations - video fluoroscopy and barium swallow
pH meter could also be used
What can a barium swallow show?
Dysmotility, hiatus hernia, reflux, gastric emptying and strictures
What is the treatment of reflux?
Feeding advice (thickeners, texture and amount), nutritional support (calorie supplements, nasogastric tube and exclusive diet), medical treatment and sometimes surgery
What is the medical treatment for reflux in children?
Feed thickener
Prokinetic drugs
Acid suppression drugs - H2 receptor blocks and PPIs
What is the indications for surgery in reflux?
Failure for medical treatment
Persistent failure to thrive, aspiration and oesophagitis
Describe Nissen fundoplication
Fundus wrapped aaround the LOS
CP children may have complications with bloat, dumping and retching after surgery
Can cause more generalised GI motility problems in children
What is the cause of bilious vomiting until proven otherwise?
Due to intestinal obstruction until proven otherwise
What are the causes of bilious vomiting?
Intestinal atresia, malrotation, intussusception, ileus and chron’s disease with strictures
What are the investigations for bilious vomiting?
Abdominal x-ray, consider contrast meal and surgical opinion
Describe gastrointestinal anatomy for absorption
Enormous surface area of the small intestine for absorption - 600 fold increase by mucosal folds and villi
Essential secretory component - water, ions, enzymes and defence mechanism
What is the definition of chronic diarrhoea?
4 or more stools per day for more than 4 weeks
What are the causes of chronic diarrhoea?
Motility disturbance - toddler diarrhoea and IBS
Active secretion - acute infective and IBD
Malabsorption of nutrients - food allergy, coeliac disease and CF
Describe osmotic diarrhoea
Movement of water into the bowel to equilibrate osmotic gradient
Usually a feature of malabsorption - enzymatic or transport defect
Mechanism of action of lactulose/ movicol
Describe secretory diarrhoea
Classically associated with toxin production from Vibrio cholerae and enterotoxigenic E. coli
Intestinal fluid secretion predominantly driven by active Cl secretion via CFTR
What should be thought about during clinical history of diarrhoea?
Age, abrupt/ gradual, FH, travel history, nocturnal defaecation, appearance, stool culture and determination of secretory or osmotic
Describe osmotic diarrhoea compared to secretory
Osmotic has smaller volume, osmolarity is high, bigger osmotic gap, less than 70 sodium, less potassium and chloride, pH <5.5 and positive reducing substance
Does osmotic and secretory diarrhoea respond to fasting
Osmotic stops but secretory continues
What are causes of fat malabsorption?
Pancreatic disease - lack of lipase and resultant steatorrhea and classically CF
Hepatobiliary disease - CLD and cholestasis
Describe coeliac disease
Gluten sensitive enteropathy - wheat, rye and barley
Affects 1% of population
What are the symptoms of coeliac disease?
Abdominal bloating, diarrhoea, failure to thrive, short stature, constipation, tiredness, and dermatitis herpatiformis
What are the screening tests for coeliac disease?
Anti-tissue transglutaminase - high sensitivity
Check anti-edomysial, serum IgA and concurrent IgA
Duodenal biopsy
Describe the histology in coeliac disease
Lymphocytic infiltration of surface epithelium
Partial/ total villous atrophy and crypt hyperplasia
When can a diagnosis of coeliac disease be made without a biopsy?
Symptomatic children, anti TTG > 10 times upper limit of normal, positive anti-endomysial antibodies and HLA DQ2 or DQ8 positive
What is the treatment for coeliac disease?
Gluten free diet
Increased risk of rare small bowel lymphoma if untreated
If under 2 then re-challenge later on
