Vomiting Flashcards
Infant vomiting can be split into 4 types? [4]
- With retching
- Projectile
- Effortless
- Bilious
Describe vomiting with retching in 3 phases:
Pre-ejection phase: A prodrome of pallor, nauseas and tachycardia
Ejection phase: Retching and vomiting
Post-ejection phase: Often a follow on of weakness, shivering and lethargy
What can cause vomiting with retching in a child? [6]
Causes that stimulate vomiting centre:
- Enteric pathogen, urine infection
- Neuro: increased ICP eg head injury
- Metabolic: DKA
- ENT: travel/motion sickness
- GU: testicular torsion, nephrolithiasis
- GI: appendicitis, pancreatitis
What could cause a child to projectile vomit? [3]
GORD
Overfeeding
Pyloric Stenosis
Pyloric stenosis: age, gender?
Expect to see it 3-8 weeks old and more often in boys
6wk old boy comes in with non-bilious projectile vomiting - what do you suspect?
What are key features of the vomitus? [3]
Associated symptoms [2]
What can you find on examination [2]
Investigations [2]
Dx: Pyloric stenosis Non-bilious, white projectile vomiting - large volumes after feeding Weight loss, electrolyte disturbances Examination [2] - Palpable "olive" tumour - Visible gastric peristalsis - Dehydrated Investigations: Test feed in hospital, U&E
What would you expect to see on a pyloric stenosis ABG? [3]
Metabolic Alkalosis
Hypokalaemia
Hypochloraemia
Management of pyloric stenosis [2]
Fluid resuscitation
Ramstedt’s Pyloromyotomy
Bilious vomiting is an intestinal obstruction until proven otherwise, can be caused by? [5]
- Intestinal Atresia (newborn)
- Malrotation +/- volvulus
- Intussusception
- Crohn’s + strictures
- Ileus
How would you approach a child with bilous vomiting? [3]
Abdo X-ray
Contrast meal
~Exploratory Laparotomy
What causes effortless vomiting? [1]
Mostly GORD
How would GORD look in a child? [4]
Effortless vomiting, hematemesis
Feeding aversion/distress, FTT
~Resp symptoms e.g. apnoea, cough, wheeze or LRTI
~Sandifer’s syndrome
Sandifer’s syndrome [2]
How to cure [1]
Spastic Torticollis & dystonic body movements due to GORD
Resolved by treating GORD
How do we test kids for GORD? [4]
- Clinical dx
- Endoscopy (eosinophilic esophagitis)
- pH study (gold standard)
- Barium swallow with video fluoroscopy (hiatus hernia, strictures)
There are 4 modalities to treating childhood GORD [4]
- Feeding advice: feeding position
- Exclusion diet
- Rx
- Surgery
What nutritional support can you offer in GORD? [4]
What feeding advice is appropriate? [3]
Calorie supplements
Exclusion diet (mostly Milk)
NG tube
Gastrostomy
Feeding advice:
- avoid over-feeding, oral stimulation, feeding position at 45o
What Rx can help with GORD? [4]
- Thickener’s e.g. Carobel
- Prokinetic Drugs
- Acid Suppressants (H2 receptor blockers & PPIs) - ranitidine, omeprazole
- Antacid + sodium/mg alginate
What surgical interventions are there for GORD? [1]
Side effects of surgery [4]
Prognosis?
Nissen Fundoplication
Beware of bloating, dumping and retching. Esp in cerebral palsy
Pro: usually resolves by 6-9 months
Intussusception: imaging options [1]
Presentation [2]
Age
US for target sign
Bilious vomiting, redcurrant jelly stool
Age: 6-18 months
How can you treat intussusception? [2]
Air enema
Surgical
Cow’s milk protein allergy
Ep
Ax [2]
Ep: <1yo
Ax: IgE mediated food allergy or non-IgE mediated food intolerance
Describe IgE mediated food allergy. [2]
What are the clinical manifestations? [4]
Within 2h of ingestion and resolution of symptoms within 12h; cow’s milk is relatively rare (egg, nuts, pulses, fish, grains more common)
o GI: vomiting, pain, diarrhoea
o Skin: urticaria, angioedema, pruritus, erythema
o Resp: rhino conjunctivitis, wheeze, cough, stridor
o Immune: anaphylaxis and collapse
Describe duration of symptoms non-IgE mediated food allergy.
How does it manifest?
Develops over hours or days and may last many days
Manifests with non-specific multi-system features eg vomiting, pruritus, erythema, diarrhea
Cows milk protein allergy
Ix
- IgE mediated food allergy: RAST or skin prick may be helpful but hx is best test
- Non-IgE mediated cow’s milk intolerance: no ix (ensure thorough allergy focussed hx)
