Vomiting and malabsorption 2 (bilious vom & coeliac) Flashcards
What is billious vomiting?
Why does it occur?
Vomiting with bile in it
Occurs when there is intestinal obstruction - ie obstruction further down than the 2nd part of the duodenum (beyond the hepatopancreatic ampulla)
Is bilious vomiting bad?
What are the causes of it?
Yeah pretty bad
Intestinal atresia (newborns)
Malrotation +/- volvulus
Intussusception
Ileus
Crohn’s w strictures
What is meant by malrotation +/- volvulus?
Intestinal malrotation is a congenital anomaly of rotation of the midgut
It can lead to Volvulus - which is when the intestine twists around itself and the mesentery that supports it - leading to obstruction
What is intussusception?
When part of the intestine folds into the section immediately ahead of it
like dis
What is an ileus?
When the intestines dont do the peristalsis business as they should be
What investigations and treatments are avaliable in the case of intestinal obstruction
Abdominal xray
Contrast meal
Surgical re-exploratory laparotomy
In the context of water usage by the GI tract…
How much:
a) enters the duodenum
b) is lost in the colon
c) is lost in the faeces
a) 9L enters duodenum
b) 1.5L enters colon
c) <200ml lost in poo
Define acute, persistent and chronic diarrhoea
4 or more stools per day for:
<1 week - acute
2-4 weeks - persistent
4 or more weeks - chronic
What are the groups of causes of diarrhoea in yungers
Motility disturbance, secretory abnormalities & malabsorption (osmotic)
Motility disturbance:
- toddler diarrhoea
- IBS
Acute secretion (secretory):
- acute infective diarrhoea
- IBD
Malabsorption (osmotic):
- allergies
- coeliac disease
- cystic fibrosis
Describe how secretory diarrhoea occurs
Classically associated with toxin production from Vibrio cholerae and enterotoxigenic Escherichia coli
These toxins cause intestinal fluid secretion - predominantly driven by active Cl- secretion via CFTR
Give an overview of the clinical approach to a child with chronic diarrhoea
History
Growth & weight gain
Faeces analysis
What aspects of history are important in a child with chronic diarrhoea?
Age at onset
Gradual or sudden onset
Family history
Travel history / local outbreaks
Nocturnal defecation - v suggestive of organic pathology
For a child presenting with chronic diarrhoea - describe what faecal analysis is?
Appearance
Stool culture
Differentiation between secretory vs. osmotic
Describe how osmotic and secretory diarrhoea are differentiated between
Describe how the values on the table would relate to each other (obvs dont care about the actual numbers really)
Osmotic diarrhoea is relatively low in volume and very much food dependant (ie when the child stops eating, diarrhoea soon stops too)
Secretory diarrhoea is very high volume and happens regardless of food intake (bc its not really to do with food)
What are the conditions that cause fat malabsorption (leading to diarrhoea)?
Pancreatic disease - insufficient lipase production leads to steatorrhoea/diarrhoea:
- cystic fibrosis
- Schwachan-diamond syndrome
Hepatobiliary disease:
- chronic liver disease
- cholestasis
Wee bit of revision - What are the main features of cystic fibrosis?
Neonatal period:
- meconium ileus
- less commonly prolonged jaundice
Malabsorption:
- steatorrhoea
- failure to thrive
Recurrent chest infections
Liver disease
Absent vas deferens
What is Schwachman-diamond syndrome?
rare congenital disorder characterized by:
exocrine pancreatic insufficiency
bone marrow dysfunction (esp neutropenia)
skeletal abnormalities
short stature
What is coeliac disease?
What mutations is it associated with?
What ingredients cant the coeliac people eat?
Autoimmune condition characterised by gluten-sensitive enteropathy
HLA-DQ2 - and - HLA-DQ8
Wheat, rye and barley
What are the features of coeliac disease?
Abdominal bloatedness (pot belly)
Diarrhoea
Failure to thrive, short stature, skinny
Lethargy
Persistent N&V
Dermatitis herpetiformis
What conditions is coeliac disease associated with?
Type 1 diabetes (IDDM)
Autoimmune thyroid disease
Dermatitis herpatiformis
Autoimmune disease in First degree relatives v important
Describe how coeliac disease is screened for
If suspicion of coeliac disease…
Serological screens:
-
TTG antibodies (anti-tissue transglutaminase) (IgA)
- if +ve - endomyseal antibody (IgA)
- Serum IgA
Genetic testing
- HLA-DQ2
- HLA-DQ8
Duodenal biopsy - if indicated
When is duodenal biopsy indicated for coeliac investigation?
If all of the following are present - no need to biopsy:
- Symptomatic children
- Anti TTG >10 times upper limit of normal
- Positive anti endomysial antibodies
- HLA DQ2, DQ8 positive
If any of them are not present - then biopsy is indicated
What are the findings on a duodenal biopsy in coeliac disease?
What is the appearance of the duodenum on the actual endoscopy?
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
On endoscopy:
Smooth, erythematous mucosa
Oedema
How is coeliac disease treated?
Gluten-free diet for life
Gluten must not be removed prior to diagnosis as serological and histological features will resolve
In very young <2yrs, re-challenge and re-biopsy may be warranted
