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Vomiting Flashcards

1
Q

Infant vomiting can be split into 4 types? [4]

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

Describe vomiting with retching in 3 phases:

A

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

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3
Q

What can cause vomiting with retching in a child? [6]

A

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
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4
Q

What could cause a child to projectile vomit? [3]

A

GORD
Overfeeding
Pyloric Stenosis

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5
Q

Pyloric stenosis: age, gender?

A

Expect to see it 3-8 weeks old and more often in boys

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6
Q

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]

A 
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
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7
Q

What would you expect to see on a pyloric stenosis ABG? [3]

A

Metabolic Alkalosis
Hypokalaemia
Hypochloraemia

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8
Q

Management of pyloric stenosis [2]

A

Fluid resuscitation

Ramstedt’s Pyloromyotomy

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9
Q

Bilious vomiting is an intestinal obstruction until proven otherwise, can be caused by? [5]

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

How would you approach a child with bilous vomiting? [3]

A

Abdo X-ray
Contrast meal
~Exploratory Laparotomy

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11
Q

What causes effortless vomiting? [1]

A

Mostly GORD

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12
Q

How would GORD look in a child? [4]

A

Effortless vomiting, hematemesis
Feeding aversion/distress, FTT
~Resp symptoms e.g. apnoea, cough, wheeze or LRTI
~Sandifer’s syndrome

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13
Q

Sandifer’s syndrome [2]

How to cure [1]

A

Spastic Torticollis & dystonic body movements due to GORD
Resolved by treating GORD

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14
Q

How do we test kids for GORD? [4]

A
  • Clinical dx
  • Endoscopy (eosinophilic esophagitis)
  • pH study (gold standard)
  • Barium swallow with video fluoroscopy (hiatus hernia, strictures)
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15
Q

There are 4 modalities to treating childhood GORD [4]

A
  • Feeding advice: feeding position
  • Exclusion diet
  • Rx
  • Surgery
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16
Q

What nutritional support can you offer in GORD? [4]

What feeding advice is appropriate? [3]

A

Calorie supplements
Exclusion diet (mostly Milk)
NG tube
Gastrostomy

Feeding advice:
- avoid over-feeding, oral stimulation, feeding position at 45o

17
Q

What Rx can help with GORD? [4]

A
  1. Thickener’s e.g. Carobel
  2. Prokinetic Drugs
  3. Acid Suppressants (H2 receptor blockers & PPIs) - ranitidine, omeprazole
  4. Antacid + sodium/mg alginate
18
Q

What surgical interventions are there for GORD? [1]
Side effects of surgery [4]
Prognosis?

A

Nissen Fundoplication

Beware of bloating, dumping and retching. Esp in cerebral palsy

Pro: usually resolves by 6-9 months

19
Q

Intussusception: imaging options [1]
Presentation [2]
Age

A

US for target sign
Bilious vomiting, redcurrant jelly stool
Age: 6-18 months

20
Q

How can you treat intussusception? [2]

A

Air enema

Surgical

21
Q

Cow’s milk protein allergy
Ep
Ax [2]

A

Ep: <1yo
Ax: IgE mediated food allergy or non-IgE mediated food intolerance

22
Q

Describe IgE mediated food allergy. [2]

What are the clinical manifestations? [4]

A

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

23
Q

Describe duration of symptoms non-IgE mediated food allergy.

How does it manifest?

A

Develops over hours or days and may last many days

Manifests with non-specific multi-system features eg vomiting, pruritus, erythema, diarrhea

24
Q

Cows milk protein allergy

Ix

A
  • 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)
25
Q

Cows milk protein allergy

Mx [4]

A
  • Allergen avoidance, epi-pen if IgE mediated

Non-IgE mediated food allergy:

  • Use of special feeds for cows milk protein allergy eg extensively hydrolysed 6-8w
  • Breast feeding
  • Milk challenge at home
26
Q

What should you suspect if dehydrated

A

Obstruction as CMPI doesn’t cause

27
Q

DDX dehydration[5]

A 
Reflux
Coeliac - not if baby
Pyloric stenosis
NEC
Infection
28
Q

What is NEC [2]

RF [2]

A

Inflammatory bowel necrosis
Presents in 2nd week of life

Pre-term is main risk factor
Increased risk when empirical antibiotics are given to infants beyond 5 days

29
Q

How does NEC present [6]

A 
Poor feed
Abdo distension
Bloody / mucous stool
Lethargy
Vomiting bile
Sepsis
30
Q

How do you Ix NEC [3]

A

Stool culture
X-match blood
AXR

31
Q

What does AXR show in NEC [4]

A

Asymmetrical dilated bowel
Bowel oedema: thickened bowel walls
Pneumatosis intestinalis - gas in gut wall
Free air

32
Q

NEC Mx [3]

A

Stop oral feed, NG, TPN if long term
Triple Abx therapy (perforation risk high)
Surgical laparotomy if perforate

33
Q

Causes of NEC [4]

A

maternal exposure to antibiotics: ampicillin
enteral feeds
bacterial colonisation
mucosal injury

34
Q

Duodenal atresia
Presentation [4]
Association [4]

A

Presentation:

  • Dx on ultrasound with signs of polyhydramnios
  • Bilious vomiting (pre-ampullary, non-bilious)
  • First hours of life
  • Scaphoid abdomen

Association:

  • Trisomy 21 (30%)
  • CHD
  • Malrotation
  • Renal abnormalities
35
Q

Duodenal atresia:
Investigation
Definitive treatment

A

Double bubble sign AXR

Laparotomy with diamond shaped duodeno-duodenostomy (Kimura technique)

36
Q

Jejuno-ileal atresia: difference between DA? [3]

A
  • ischaemic insult late in-utero (after the intestine has already developed)
  • causes reabsorption of the affected segment
  • rarely associated with other abnormalities
  • presents within 24h of life while DA presents few hours of life
37
Q

JA: presentation [3]
Investigation [3]
Tx [2]

A
  • Sometimes can be picked up antenatally
  • Abdominal distension
  • Bilious vomiting

AXR - triple bubble sign

  • dilated bowel loops with no distal gas
  • contrast enema shows disused microcolon

Tx:

  • Resection of affected atretic gut
  • Primary anastomosis

Paeds (33 decks)

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