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3rd Year Paeds > Vomiting > Flashcards

Vomiting Flashcards

1
Q

Infnat vomiting can be split into 5 types?

A
  • With retching
  • Projectile
  • Bilious
  • Effortless
  • Haematemesis
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2
Q

What do you expect to see in vomiting with retching?

A

A prodrome of pallor, nauseas and tachycardua

Retching and vomiting

Often a follow on of weakness, shivering and lethargy

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3
Q

What can cause vomiting with retching in a child?

A

Anything really:

  • Enteric pathogen
  • Other inf e.g. uti
  • Intestinal inflammation
  • Metabolic
  • Head injury
  • Visual or middle ear stimuli
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4
Q

What could cause a child to projectile vomit?

A

GORD
Overfeeding
Pyloric Stenosis

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5
Q

Who gets pyloric stenosis?

A

Expect to see it 4-12wks and more often in boys

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6
Q

6wk old boy comes in with projectile vomiting, weight loss and dehydration? How do you test for pyloric stenosis?

A

Test feed in hospital and look for:

  • Palpable “olive” tumour
  • Visible gastric peristalsis
  • Non-bilious vomit

From there you can do an ABG & US

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7
Q

What would you expect to see on a pyloric stenosis ABG? and can you explain it?

A 
Metabolic Alkalosis (vomiting HCl)
Hypokalaemia (Secondary Hyperaldosteronism due to dehydration)
Hypochloraemia (Vomiting HCl)
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8
Q

How do you treat Pyloric Stenosis?

A

Dehydrated from all the vomiting so Fluid Resus

Followed by Ramstedt’s Pyloromyotomy

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9
Q

Bilious vomiting is an intestinal obstruction until proven otherwise, due to?

A
  • Intestinal Atresia (newborns only)
  • Malrotation +/- volvulus
  • Intussusception
  • Crohn’s + strictures
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10
Q

How would you approach a child with bilous vomiting?

A 
Abdo X-ray (looking for bowel obstruction)
Contrast meal
surgical opinion (sought early) re ~Exploratory Laparotomy
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11
Q

What causes effortless vomiting?

A

Mostly GORD

v common in infants

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12
Q

How would GORD look in a child?

A

Effortless vomiting +/- haematemesis

Feeding Aversionm & FTT

~Resp symptoms e.g. apnoea, cough, wheeze or inf
~Sandifer’s syndrome

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13
Q

Sandifer’s syndrome?

A

neurological

Spastic Torticollis & dystonia due to GORD, resolved by treating GORD

spastic torticollis = neck muscles contract involuntarily so head twists or turns to one side

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14
Q

How do we test kids for GORD?

A

In most cases you can just ressure them that it’s self-limiting, if necessary do:

  • Video fluoroscopy or Barium Swallow
  • Oesophageal Impedance Monitoring
  • UGIE (if >2yrs old, looking for oesophagitis)
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15
Q

There are 4 stages to treating childhood GORD, what feeding advice would you give?

A
  • Thickener’s
  • Appropriate texture/amount of food
  • Feeding position
  • Oral stimulation & removal of aversive stimuli

self limiting and resolves spon in majority of cases. Exceptions: cerebral palsy, progressive neuro problems, generalised GI motility problem, oesophageal atresia +/- TOF operated

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16
Q

What nutritional support can you offer in GORD?

A

Calorie supplements
Exclusion diet (mostly Milk)
Ng tube
Gastrostomy

17
Q

What medical interventions can help with GORD?

A

Thickener’s e.g. Gaviscon
Prokinetic Drugs
Acid Suppressants (H2 receptor blockers & PPIs)

18
Q

What surgical interventions are there for GORD?

A

Nissen Fundoplication

beware of comps: bloating, dumping and retching. Esp in cerebral palsy

successful surgert may unmask more generalised GI motility problems in child

19
Q

How could you image for intussusception?

A

US for target sign

20
Q

How can you treat intussusception?

A 
Air enema (pneumostatic reduction)
Surgical
21
Q

What are causes of vomiting in infants?

A
  • GOT
  • CMA
  • Infection
  • intestinal obstruction
22
Q

What are causes of vomiting in children?

A
  • gastroenteritis
  • infection
  • appendicitis
  • intestinal obstruction
  • raised ICP
  • coeliac disease
23
Q

What are causes of vomiting in young adults?

A
  • gastroenteristis
  • infection
  • H pylori infection
  • infection
  • raised ICP
  • DKA
  • cyclcical vomiting syndrome
  • Bulimia
24
Q

6 week old baby boy
3 week history of vomiting after every feed
Bottle fed 6 ounces 3 hourly
Vomitus- large volume, milky or curdy, mostly projectile
Irritable and crying
Not gaining weight adequately
o/e looks slightly dehydrated

what is the differential diagnosis and what do we do now?

A

Differential diagnosis:

  • GOR
  • overfeeding (but this vol seems appropriate = 150ml/kilo per day in neonates and 100 for infants)
  • pyloric stenosis
  • Cow’s milk protein allergy

To do now: test feed

25
Q

If test feed observed:

  • palpation of olive tumour (thickened pylorus)
  • visible gastric peristalsis
  • projectile non-billous vomiting

what is the diagnosis?

A

pyloric stenosis

26
Q

What investigation can be done for pylporic stenosis?

A

US

thickened pylorus

27
Q

What would blood gas show for pyloric stenosis?

A

hypokalaemia hypocholoermic metabolic alkalosis (as vomiting)

28
Q

What is the management of pyloric stenosis?

A
  • fluid resus *correct metabolic alkalosis and dehydration is 1st line
  • refer to surgeons: Ramstedt’s pyloromyotomy (relives the obstruction)

also stop feeds and insert NG tube

29
Q

How does pyloric stenosis present?

A 
Babies  4-12 weeks
Boys > Girls
Projectile non-bilious vomiting
Weight loss
Dehydration +/- shock
Characteristic electrolyte disturbance:
Metabolic alkalosis (↑pH)
Hypochloraemia (↓Cl)
Hypokalaemia (↓K)
30
Q

Effortless vomiting - regurgitation and positing

A

Effortless vomiting otherwise referred to as regurgitation

Regurgitation = involuntary passage of large amounts of gastric contents thro the mouth
Positing = involuntary passage of small amounts of milk thro the mouth

Psoiting or regurg seen several times in healthy babies

31
Q

Why is GORD so common in infants?

A
  • LOS lax
  • mainly placed in lying position
  • feeds mainly liquids

(improves with age when solids introduced at 6 months and also with posturre, sitting, standing and walking)

32
Q

How do you investigate GORD?

A
  • H&E often sufficient to diagnose
  • oesopaheageal pH study/impedance monitoring
  • Upper GI endocscopy
  • radiology: video fluorscopy, barium swallow
33
Q

What are the aims and problems with hiatus hernia?

A 
Aims:
Dysmotility
Hiatus hernia
Reflux
Gastric emptying
strictures

Problems:
Aspiration
Inadequate contrast
taken (NG tube)

34
Q

How do you treat GORD?

A
  • feeding advice
    = thickners, appropriate food, feeding position, feed volumes, behavioural programme (oral stim, remove adverse stimuli)
  • nutritional support
    = calorie supplements, exlcusion diet (CM protein free trial for 4 weeks), NG tube, gastrostomy
  • medical treatment (occasionally) = feed thickener (gaviscon, thick & easy), prokinetic drugs (domperidaone), acid suppresssing drugs (H2 receptor blockers and PPIs eg omeprazole)
  • surgery (rare) = Nissen fundoplication
35
Q

What are the indications for surgery in GORD?

A 
Failure of medical treatment
Persistent:
Failure to thrive
Aspiration 
Oesophagitis

Vomiting without complications may not be an indication

3rd Year Paeds (7 decks)

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