Vomiting Flashcards
Infnat vomiting can be split into 5 types?
- With retching
- Projectile
- Bilious
- Effortless
- Haematemesis
What do you expect to see in vomiting with retching?
A prodrome of pallor, nauseas and tachycardua
Retching and vomiting
Often a follow on of weakness, shivering and lethargy
What can cause vomiting with retching in a child?
Anything really:
- Enteric pathogen
- Other inf e.g. uti
- Intestinal inflammation
- Metabolic
- Head injury
- Visual or middle ear stimuli
What could cause a child to projectile vomit?
GORD
Overfeeding
Pyloric Stenosis
Who gets pyloric stenosis?
Expect to see it 4-12wks and more often in boys
6wk old boy comes in with projectile vomiting, weight loss and dehydration? How do you test for pyloric stenosis?
Test feed in hospital and look for:
- Palpable “olive” tumour
- Visible gastric peristalsis
- Non-bilious vomit
From there you can do an ABG & US
What would you expect to see on a pyloric stenosis ABG? and can you explain it?
Metabolic Alkalosis (vomiting HCl) Hypokalaemia (Secondary Hyperaldosteronism due to dehydration) Hypochloraemia (Vomiting HCl)
How do you treat Pyloric Stenosis?
Dehydrated from all the vomiting so Fluid Resus
Followed by Ramstedt’s Pyloromyotomy
Bilious vomiting is an intestinal obstruction until proven otherwise, due to?
- Intestinal Atresia (newborns only)
- Malrotation +/- volvulus
- Intussusception
- Crohn’s + strictures
How would you approach a child with bilous vomiting?
Abdo X-ray (looking for bowel obstruction) Contrast meal surgical opinion (sought early) re ~Exploratory Laparotomy
What causes effortless vomiting?
Mostly GORD
v common in infants
How would GORD look in a child?
Effortless vomiting +/- haematemesis
Feeding Aversionm & FTT
~Resp symptoms e.g. apnoea, cough, wheeze or inf
~Sandifer’s syndrome
Sandifer’s syndrome?
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
How do we test kids for GORD?
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)
There are 4 stages to treating childhood GORD, what feeding advice would you give?
- 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
What nutritional support can you offer in GORD?
Calorie supplements
Exclusion diet (mostly Milk)
Ng tube
Gastrostomy
What medical interventions can help with GORD?
Thickener’s e.g. Gaviscon
Prokinetic Drugs
Acid Suppressants (H2 receptor blockers & PPIs)
What surgical interventions are there for GORD?
Nissen Fundoplication
beware of comps: bloating, dumping and retching. Esp in cerebral palsy
successful surgert may unmask more generalised GI motility problems in child
How could you image for intussusception?
US for target sign
How can you treat intussusception?
Air enema (pneumostatic reduction) Surgical
What are causes of vomiting in infants?
- GOT
- CMA
- Infection
- intestinal obstruction
What are causes of vomiting in children?
- gastroenteritis
- infection
- appendicitis
- intestinal obstruction
- raised ICP
- coeliac disease
What are causes of vomiting in young adults?
- gastroenteristis
- infection
- H pylori infection
- infection
- raised ICP
- DKA
- cyclcical vomiting syndrome
- Bulimia
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?
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
If test feed observed:
- palpation of olive tumour (thickened pylorus)
- visible gastric peristalsis
- projectile non-billous vomiting
what is the diagnosis?
pyloric stenosis
What investigation can be done for pylporic stenosis?
US
thickened pylorus
What would blood gas show for pyloric stenosis?
hypokalaemia hypocholoermic metabolic alkalosis (as vomiting)
What is the management of pyloric stenosis?
- 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
How does pyloric stenosis present?
Babies 4-12 weeks Boys > Girls Projectile non-bilious vomiting Weight loss Dehydration +/- shock Characteristic electrolyte disturbance: Metabolic alkalosis (↑pH) Hypochloraemia (↓Cl) Hypokalaemia (↓K)
Effortless vomiting - regurgitation and positing
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
Why is GORD so common in infants?
- 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)
How do you investigate GORD?
- H&E often sufficient to diagnose
- oesopaheageal pH study/impedance monitoring
- Upper GI endocscopy
- radiology: video fluorscopy, barium swallow
What are the aims and problems with hiatus hernia?
Aims: Dysmotility Hiatus hernia Reflux Gastric emptying strictures
Problems:
Aspiration
Inadequate contrast
taken (NG tube)
How do you treat GORD?
- 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
What are the indications for surgery in GORD?
Failure of medical treatment Persistent: Failure to thrive Aspiration Oesophagitis
Vomiting without complications may not be an indication
