Vomiting and Malabsorption Flashcards
1
Q
What types of vomiting are there?
A
- Vomiting with Retching
- Projectile vomiting
- Bilious vomiting
- Effortless vomiting
2
Q
What are the phases of vomiting with retching?
A
Pre-ejection phase
- Pallor
- Nausea
- Tachycardia
Ejection phase
- Retch
- Vomit
Post-ejection phase
3
Q
How can the vomiting centre be stimulated?
A
- Enteric pathogens
- Intestinal inflammation
- Metabolic derangement
- Infection
- Head injury
- Visual stimuli
- Middle ear stimuli
4
Q
Who does pyloric stenosis occur in?
A
- Babies 4-12 weeks
- M>F
5
Q
How does pyloric stenosis present?
A
- Projectile non-bilious vomiting
- Weight loss
- Dehydration +/- shock
6
Q
What electrolyte disturbance is associated with pyloric stenosis?
A
- Metabolic alkalosis
- Hypochloraemia
- Hypokalaemia
7
Q
What type of vomiting rings alarm bells?
A
Bilious vomiting
8
Q
What is bilious vomiting due to?
A
Intestinal obstruction until proven otherwise
9
Q
What can cause bilious vomiting?
A
- Intestinal atresia (in newborn babies only)
- Malrotation +/- volvulus
- Intussusception
- Ileus
- Crohn’s disease with strictures
10
Q
How is bilious vomiting investigated?
A
- Abdominal x-ray
- Consider contrast meal
- Surgical opinion re exploratory laparotomy
11
Q
What is effortless vomiting usually due to?
A
Gastro-oesophageal reflux
12
Q
What is the usual outcome of GOR in infants?
A
Self limiting and resolves spontaneously in the vast majority of cases
13
Q
Who may GOR not resolve in?
A
- Cerebral palsy
- Progressive neurological problems
- Oesophageal atresia +/- TOF operated
- Generalised GI motility problem
14
Q
How can GOR present?
A
Gastrointestinal
- Vomiting
- Haematemesis
Nutritional
- Feeding problems
- Failure to thrive
Respiratory
- Apnoea
- Cough
- Wheeze
- Chest infections
Neurological
-Sandifer’s syndrome
15
Q
How is GOR assessed?
A
- History & examination often sufficient
- Radiological investigations (Video fluoroscopy, Barium swallow)
- pH study
- Oesophageal impedance monitoring
- Endoscopy
16
Q
What are the aims of barium swallow?
A
To identify
- Dysmotility
- Hiatus hernia
- Reflux
- Gastric emptying
- Strictures
17
Q
What are the problems with barium swallow?
A
- Aspiration
- Inadequate contrast taken by NG
18
Q
What are the advantages of video fluoroscopy and barium meal?
A
- May detect aspiration
- Defines anatomy well
19
Q
What are the advantages of pH study?
A
-Detects acid reflux missed by barium
20
Q
What are the advantages of endoscopy?
A
- Best test for oesophagitis
- Can be combined with pH impedance study
21
Q
What are the advantages of trial of feeding?
A
- Most physiological test
- May be best discriminator if child needs surgery
22
Q
What are the disadvantages of video fluoroscopy and barium meal?
A
- May miss reflux
- Radiation
23
Q
What are the disadvantages of pH study?
A
- Only detects acid reflux
- May be unpleasant for child
24
Q
What are the disadvantages of endoscopy?
A
-Needs anaesthetic
25
What are the disadvantages of trial of feeding?
- NG tube required
| - Needs 2-3 days in hospital
26
How is GOR treated?
- Feeding advice
- Nutritional support
- Medical treatment
- Surgery
27
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
28
What nutritional support can be used in GOR treatment?
- Calorie diet
- Milk free diet
- NG tube
- Gastrostomy
29
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
30
What are the indications for surgery in GOR?
- Failure of medical treatment
| - Persistent FTT, aspiration or oesophagitis
31
What surgery can be carried out for GOR?
Nissan Fundoplication
32
What complications can children with cerebral palsy have after fundoplication surgery?
Bloat, dumping and retaching
33
What is the fluid balance of the GI system?
Each day
- 9L fluid enters duodenum
- 1.5L gets to colon
- <200ml lost in faeces
34
How is the surface area of the small intestine increased?
- Mucosal folds
| - Villi
35
What is the definition of chronic diarrhoea?
4 or more stools per day for more than 4 weeks
36
Acute diarrhoea
4 or more stools per day for <1 week
37
Persistent diarrhoea
4 or more stools per day for 2-4 weeks
38
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
39
What types of diarrhoea are there?
- Osmotic
- Secretory
- Motility
- Inflammatory
40
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
41
What is secretory diarrhoea classically associated with?
Classically associated with toxin production from Vibrio cholerae and enterotoxigenic Escherichia coli
42
What drives intestinal fluid secretion in secretory diarrhoea?
Intestinal fluid secretion predominantly driven by active Cl- secretion via CFTR
43
What causes of motility diarrhoea are there?
- Toddler's diarrhoea
- IBS
- Congenital hyperthyroidism
- Chronic intestinal pseudo-obstruction
44
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
45
What is the clinical approach to chronic diarrhoea?
- History
- Consider growth and weight gain of child
- Faeces analysis
46
What should you obtain in a history of diarrhoea?
- Age at onset
- Abrupt/gradual onset
- Family history
- Nocturnal defecation suggests organic pathology
47
What should be determined in faeces analysis?
- Appearance
- Stool culture for organisms
- Determination of secretory vs osmotic
48
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
49
What types of disease does fat malabsorption occur in?
- Pancreatic disease
| - Hepatobiliary disease
50
Give examples of pancreatic disease in which fat malabsorption occurs.
- Cystic fibrosis
| - Lack of lipase
51
Give examples of hepatobiliary disease in which fat malabsorption occurs
- Chronic liver disease
| - Cholestasis
52
How does coeliac disease present in children?
- Abdominal bloatedness
- Diarrhoea
- Failure to thrive
- Short stature
- Constipation
- Tiredness
- Dermatitis herpatiformis
53
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
54
What histological characteristics are associated with coeliac disease?
Lymphocytic infiltration of surface epithelium, partial /total villous atrophy,
crypt hyperplasia
55
What guidelines determine whether a biopsy is required to diagnose coeliac disease?
ESPHGHAN/BSPGHAN
56
What is the ESPGHAN/BSPGHAN criteria?
- Symptomatic children
- Anti TTG >10 times upper limit of normal
- Positive anti endomysial antibodies
- HLA DQ2, DQ8 positive
57
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
58
What is there increased risk of in untreated coeliac disease?
Small bowel lymphoma
