Vomiting and Malabsorption Flashcards
What types of vomiting are there?
- Vomiting with Retching
- Projectile vomiting
- Bilious vomiting
- Effortless vomiting
What are the phases of vomiting with retching?
Pre-ejection phase
- Pallor
- Nausea
- Tachycardia
Ejection phase
- Retch
- Vomit
Post-ejection phase
How can the vomiting centre be stimulated?
- Enteric pathogens
- Intestinal inflammation
- Metabolic derangement
- Infection
- Head injury
- Visual stimuli
- Middle ear stimuli
Who does pyloric stenosis occur in?
- Babies 4-12 weeks
- M>F
How does pyloric stenosis present?
- Projectile non-bilious vomiting
- Weight loss
- Dehydration +/- shock
What electrolyte disturbance is associated with pyloric stenosis?
- Metabolic alkalosis
- Hypochloraemia
- Hypokalaemia
What type of vomiting rings alarm bells?
Bilious vomiting
What is bilious vomiting due to?
Intestinal obstruction until proven otherwise
What can cause bilious vomiting?
- Intestinal atresia (in newborn babies only)
- Malrotation +/- volvulus
- Intussusception
- Ileus
- Crohn’s disease with strictures
How is bilious vomiting investigated?
- Abdominal x-ray
- Consider contrast meal
- Surgical opinion re exploratory laparotomy
What is effortless vomiting usually due to?
Gastro-oesophageal reflux
What is the usual outcome of GOR in infants?
Self limiting and resolves spontaneously in the vast majority of cases
Who may GOR not resolve in?
- Cerebral palsy
- Progressive neurological problems
- Oesophageal atresia +/- TOF operated
- Generalised GI motility problem
How can GOR present?
Gastrointestinal
- Vomiting
- Haematemesis
Nutritional
- Feeding problems
- Failure to thrive
Respiratory
- Apnoea
- Cough
- Wheeze
- Chest infections
Neurological
-Sandifer’s syndrome
How is GOR assessed?
- History & examination often sufficient
- Radiological investigations (Video fluoroscopy, Barium swallow)
- pH study
- Oesophageal impedance monitoring
- Endoscopy
What are the aims of barium swallow?
To identify
- Dysmotility
- Hiatus hernia
- Reflux
- Gastric emptying
- Strictures
What are the problems with barium swallow?
- Aspiration
- Inadequate contrast taken by NG
What are the advantages of video fluoroscopy and barium meal?
- May detect aspiration
- Defines anatomy well
What are the advantages of pH study?
-Detects acid reflux missed by barium
What are the advantages of endoscopy?
- Best test for oesophagitis
- Can be combined with pH impedance study
What are the advantages of trial of feeding?
- Most physiological test
- May be best discriminator if child needs surgery
What are the disadvantages of video fluoroscopy and barium meal?
- May miss reflux
- Radiation
What are the disadvantages of pH study?
- Only detects acid reflux
- May be unpleasant for child
What are the disadvantages of endoscopy?
-Needs anaesthetic
What are the disadvantages of trial of feeding?
- NG tube required
- Needs 2-3 days in hospital
How is GOR treated?
- Feeding advice
- Nutritional support
- Medical treatment
- Surgery
What feeding advice can be given for GOR?
- Use of thickeners
- Appropriateness of foo texture and amount
- Oral stimulation and removal of aversive stimuli
- Feedin position
What nutritional support can be used in GOR treatment?
- Calorie diet
- Milk free diet
- NG tube
- Gastrostomy
What medical treatment is there for GOR?
- Feed thickeners such as Gaviscon and thick and easy
- Prokinetic drugs
- Acid suppressing drugs such as PPIs and H2 receptor blockers
What are the indications for surgery in GOR?
- Failure of medical treatment
- Persistent FTT, aspiration or oesophagitis
What surgery can be carried out for GOR?
Nissan Fundoplication
What complications can children with cerebral palsy have after fundoplication surgery?
Bloat, dumping and retaching
What is the fluid balance of the GI system?
Each day
- 9L fluid enters duodenum
- 1.5L gets to colon
- <200ml lost in faeces
How is the surface area of the small intestine increased?
- Mucosal folds
- Villi
What is the definition of chronic diarrhoea?
4 or more stools per day for more than 4 weeks
Acute diarrhoea
4 or more stools per day for <1 week
Persistent diarrhoea
4 or more stools per day for 2-4 weeks
What can cause diarrhoea?
Motility disturbance
- Toddler Diarrhoea
- Irritable Bowel Syndrome
Active secretion
- Acute Infective Diarrhoea
- Inflammatory Bowel Disease
Malabsorption of nutrients
- Food Allergy
- Coeliac Disease
- Cystic Fibrosis
What types of diarrhoea are there?
- Osmotic
- Secretory
- Motility
- Inflammatory
What is the pathophysiology behind osmotic diarrhoea?
- Movement of water into the bowel to equilibrate osmotic gradient
- Usually a feature of malabsorption (Enzymatic defect or Transport defect) -Mechanism of action of lactulose/movicol
- Generally accompanied by macroscopic and microscopic intestinal injury
- Clinical remission with removal of causative
What is secretory diarrhoea classically associated with?
Classically associated with toxin production from Vibrio cholerae and enterotoxigenic Escherichia coli
What drives intestinal fluid secretion in secretory diarrhoea?
Intestinal fluid secretion predominantly driven by active Cl- secretion via CFTR
What causes of motility diarrhoea are there?
- Toddler’s diarrhoea
- IBS
- Congenital hyperthyroidism
- Chronic intestinal pseudo-obstruction
What contributes to inflammatory diarrhoea?
- Malabsorption due to intestinal damage
- Secretory effect of cytokines
- Accelerated transit time in response to inflammation
- Protein exudate across inflamed epithelium
What is the clinical approach to chronic diarrhoea?
- History
- Consider growth and weight gain of child
- Faeces analysis
What should you obtain in a history of diarrhoea?
- Age at onset
- Abrupt/gradual onset
- Family history
- Nocturnal defecation suggests organic pathology
What should be determined in faeces analysis?
- Appearance
- Stool culture for organisms
- Determination of secretory vs osmotic
How is osmotic diarrhoea differentiated from secretory diarrhoea?
Osmotic diarrhoea
- Diarrhoea stops on fasting
- Small volume of stool
- Stool pH low
Secretory diarrhoea
- Diarrhoea continues of fasting
- Large volumes of stool
- Stool pH >6
What types of disease does fat malabsorption occur in?
- Pancreatic disease
- Hepatobiliary disease
Give examples of pancreatic disease in which fat malabsorption occurs.
- Cystic fibrosis
- Lack of lipase
Give examples of hepatobiliary disease in which fat malabsorption occurs
- Chronic liver disease
- Cholestasis
How does coeliac disease present in children?
- Abdominal bloatedness
- Diarrhoea
- Failure to thrive
- Short stature
- Constipation
- Tiredness
- Dermatitis herpatiformis
What screening tests are there for coeliac disease?
Serological screens
- Anti-tissue transglutaminase
- Anti-endomysial
- Anti-gliadin
- IgA screen
Duodenal biopsy
Genetic testing
-HLA DQ2, DQ8
What histological characteristics are associated with coeliac disease?
Lymphocytic infiltration of surface epithelium, partial /total villous atrophy,
crypt hyperplasia
What guidelines determine whether a biopsy is required to diagnose coeliac disease?
ESPHGHAN/BSPGHAN
What is the ESPGHAN/BSPGHAN criteria?
- Symptomatic children
- Anti TTG >10 times upper limit of normal
- Positive anti endomysial antibodies
- HLA DQ2, DQ8 positive
What is the treatment for coeliac disease?
- 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
What is there increased risk of in untreated coeliac disease?
Small bowel lymphoma
