Upper GI Disorders Flashcards
Types of vomiting in children
Vomiting with retching
Projectile vomiting
Bilious vomiting
Effortless vomiting
Phases of vomiting with retching
Pre-ejection phase:
- pallor
- nausea
- tachycardia
Ejection phase:
- retch
- vomit
Post-ejection phase
Stimulants of vomiting centre
Enteric pathogens Intestinal inflammation Metabolic derangement Infection Head injury Visual stimuli Middle ear stimuli
Differential diagnosis of case: 6 week old baby Vomiting after every feed Vomit is large volume, projectile, millk or curdy Irritable and crying Not gaining weight
Gastroesophageal reflux
Overfeeding
Pyloric stenosis
Cows milk allergy
Presentation of pyloric stenosis (5)
Visible gastric peristalsis Projectile non bilious vomiting Weight loss Dehydration +/- shock Electrolyte disturbance
Management of pyloric stenosis
Fluid resuscitation
Surgeon referral
-Ramstedts pyloromyotomy
Electrolyte disturbance in pyloric stenosis
Metabolic alkalosis (increase pH)
Hypochloraemia (decreased Cl)
Hypokalaemia (decrease K)
Typical age and gender of pyloric stenosis
Babies 4-12 weeks
Boys > Girls
Causes of bilious vomiting (6)
Intestinal obstruction
Intestinal atresia (in newborns only) Malrotation +/- volvulus Intussusception Ileus Crohns disease with strictures
Investigations for bilious vomiting (3)
Abdominal xray
Consider contrast meal
Surgical exploratory laparotomy
Most common cause of effortless vomiting
Gastro-oesophageal reflux
Self limiting
Other than gastro-oesophageal reflux other causes of effortless vomiting
Cerebral palsy
Progressive neurological problems
Oesophageal atresia +/- TOF operates
Generalised GI motility problem
Gastro-oesophageal reflux presentaion (9)
GI:
- vomiting
- haematemesis
Nutritional:
- Feeding problems
- Failure to thrive
Respiratory:
- Apnoea
- Cough
- wheeze
- Chest infection
Neurological:
-Sandifer’s syndrome
What is sandifer’s syndrome
gastro-oesophageal reflux disease with spastic torticollis and dystonic body movements
Investigations for gastrooesophageal reflux (6)
History and examination (normally enough) Video fluoroscopy Barium swallow pH study Oesophageal impedance monitoring Endoscopy
What can a barium swallow detect
Dysmotility Hiatus hernia Reflux Gastric emptying Strictures
Problems of barium swallow
Aspiration
Inadequate contrast taken (NG tube)
Pros and cons of pH study
Pro
-Detects acid reflux missed by barium
Con
- Only detects acid reflux
- May be uncomfortable for the child
Pros and cons of endoscopy for detecting GOR
Pros
- Best test for osophagitis
- Can be combined with pH+impedance study
Cons
-Need anaesthetic
Pros and Cons of trial of feeding test for GOR
Pro
-May be best discriminator if child needs surgery
Con
- NG tube required
- Needs 2-3 days in hospital
Treatment for gastrooesophageal reflux
Feeding advice:
- Thickeners for liquids
- Appropriateness of foods (texture, amount)
- Behavioural programme (oral stimulation, removal of aversive stimuli)
- Feeding position
Nutritional advice:
- Calorie supplements
- Exclusion diet (milk free)
- Nasogastric tube
- Gastrostomy
Medical treatment:
- Feed thickener (Gaviscon)
- Prokinetic drugs
- Acid suppressing drugs
Surgery:
-Nissen fundoplication
Indications for surgery in GOR
Persistent:
- Failure to thrive
- Aspiration
- Oesophagitis
Chronic diarrhoea definition
4 or more stools per day
For more than 4 weeks
<1 week: acute diarrhoea
2-4 weeks: persistent diarrhoea
>4 weeks: chronic diarrhoea
Causes of diarrhoea
Motility disturbance:
- Toddler diarrhoea
- IBS
Active secretion (secretory):
- Acute infective diarrhoea
- IBD
Malabsorption of nutrients (osmotic):
- Food allergy
- Coeliac disease
- CF
Types of diarrhoea?
Osmotic
Secretory
Motility
Inflammatory
Define osmotic diarrhoea
Movement of water into bowel to equilibrate osmotic gradient
Normally a feature of malabsorption
- Enzymatic defect
- Transport defect
Generally accompanied by macroscopic and microscopic intestinal injury
Clinical remission with removal of causative agent
Define secretory diarrhoea
Classically associated with toxin production from vibrio cholerae and enterotoxigenic ecoli
Intestinal fluid secretion predominantly driven by active Cl- secretion via CFTR
Define inflammatory diarrhoea
“Mixed” bag
Malabsorption due to intestinal damage
Secretory effect of cytokines
Altered transit time in response to inflammation
Protein exudate across inflamed epithelium
Red flag for organic pathology to diarrhoea
Nocturnal defecation
Difference between osmotic and secretory diarrhoea
Stool volume:
Osmotic-Small
Secretory-Large
Response to fasting:
Osmotic- stops
Secretory- continues
Osmotic gap:
Osmotic- >135m0sm/l
Secretory- <50m0sm/l
Stool sodium:
Osmotic- <70mmol/l
Secretory- >70 mmol/l
Stool potassium:
Osmotic- <30mmol/l
Secretory- >40mmol/l
Stool chloride:
Osmotic- <35mmol/l
Secretory- >40mmol/l
Stool pH:
Osmotic- <5.5
Secretory- >6
Stool reducing substance:
Osmotic- Positive
Secretory- Negative
Fat malabsorption stools (steatorrhoea) causes
Pancreatic disease (due to lack of lipase) Eg CF
Hepatobiliary disease
Eg chronic liver disease, cholestasis
What is coeliac disease
Gluten-sensitive enteropathy
Presentation of coeliac disease (7)
Abdominal bloatedness Diarrhoea Failure to thrive Short stature Constipation Tiredness Dermatitis herpatiformis
Screening tests for coeliac diseases
Serological screens:
- Anti-tissue transglutaminase
- Anti-endomysial
- Anti-gliadin
- IgA
Duodenal biopsy
Genetic testing
-HLA DQ2, DQ8
According to ESPGHAN guidelines what are the criteria for coeliac disease
Symptomatic
Anti TTG >10 times upper limit of normal
Positive anti endomysial antibodies
HLA DQ2, DQ8 positive
If not all present diagnose with biopsy
If all present dont need biopsy
Treatment for coeliac disease
Gluten free diet
Risk of small bowel lymphoma if continue to have gluten
