Vomiting and Malabsorption in Childhood Flashcards
What are the 4 different types of vomiting?
- Vomiting with Retching
- Projectile vomiting
- Bilious vomiting
- Effortless vomiting
Outline the different phases in Vomiting with Retching.
Pre-ejection phase
- Pallor
- Nausea
- Tachycardia
Ejection Phase
- Retch
- Vomit
Post-ejection Phase
- Weakness
- Shivering
- Lethargy
What things stimulate the vomiting centre?
- Enteric pathogens
- Intestinal inflammation
- Metabolic derangement
- Infection - commonest
- Head injury
- Visual stimuli
- Middle ear stimuli
Pyloric Stenosis
Presentation
Managment
- Projectile vomiting non-bilious
- weight loss
- dehydration (and potential shock)
- FLuid resusitation
- Pyloromyotomy
What are some of the causes of bilious vomiting?
- Due to intestinal obstruction usually.
- Intestinal Atresia
- Intussussception
- Ileus
- Crohns w/ strictures
Investigations in Bilious Vomiting
- Abdominal x-ray
- Consider contrast meal
- Surgical opinion re laparotomy
What are the common causes of effortless vomiting?
Exceptinos
- Almost always due to Gastro-Oesophageal reflux
- Very common problem in infants
- Self limiting and resolves spontaneously.
Exceptions:
- –Cerebral palsy
- –Progressive neurological problems
- –Oesophageal atresia +/- TOF operated
- –Generalised GI motility problem
What are the presenting symptoms of Reflux?
Gastrointestinal
- –Vomiting
- –Haematemesis
•Nutritional
- –Feeding problems
- –Failure to thrive
Respiratory
- –Apnoea
- –Cough
- –Wheeze
- –Chest infections
Neurological
–Sandifer’s syndrome
What medical examinations needed in relfux?
- History & examination often sufficient
- Radiological investigations
- Video fluoroscopy
- Barium swallow
- pH study
- Oesophageal impedance monitoring
- Endoscopy
What are you looking to find on a Barium Swallow?
Aims:
- Dysmotility
- Hiatus hernia
- Reflux
- Gastric emptying
- strictures
Problems
- Aspiration
- Inadequate contrast taken (NG tube)
Treatment options of Reflux
- Feeding advice - little and often
- Nutritional support - high calories
- Medical treatment
- Surgery
What feeding advice is offered in Reflux?
- Appropriateness of foods
- Texture
- Amount
- Behavioural programme
- Oral stimulation
- Removal of aversive stimuli
- Feeding position
What nutritional support can be given in reflux?
- Calorie supplements
- Exclusion diet (milk free)
- Nasogastric tube
- Gastrostomy
Medical Treatment of reflux?
- •Feed thickener
- Gaviscon
- Thick & Easy
- Prokinetic drugs
- Acid suppressing drugs
- H2 receptor blockers
- Proton pump inhibitors
What are the indications in reflux?
-
Failure of medical treatment
- Persistent:
- Failure to thrive
- Aspiration
- Oesophagitis
- Persistent:
- Vomiting without complications may not be an indication
What surgery is done in Reflux?
Nissen Fundoplication
What is chronic diarrhoea?
- 4 or more stools per day
- For more than 4 weeks
Timing difference between acute, persistent and chronic diarrhoea?
- <1 week: acute diarrhoea
- 2 to 4 weeks: persistent diarrhoea
- >4 weeks: chronic diarrhoea
What are the 3 main causes of diarrhoea?
Motility Disturbance
- toddler diarrhoea
- IBS
Active Secretion (secretory)
- Acute infective
- IBD
Malabsorption of Nutrients (osmotic)
- Allergy
- CF
- Coeliac Disease
Outline osmotic diarrhoea?
- Movement of water into the bowel to equilibrate osmotic gradient
- –Usually a feature of malabsorption
- Enzymatic defect
- Transport defect
- Mechanism of action of lactulose/movicol
- Generally accompanied by macroscopic and microscopic intestinal injury
- Clinical remission with removal of causative agent
Outline secretory diarrhoea?
- –Classically associated with toxin production from Vibrio cholerae and enterotoxigenic Escherichia coli
- In cholera, can lose 24L per day!
- –Intestinal fluid secretion predominantly driven by active Cl- secretion via CFTR
Outline inflammatory diarrhoea
- “Mixed bag” really
- Malabsorption due to intestinal damage
- Secretory effect of cytokines
- Accelerated transit time in response to inflammation
- Protein exudate across inflamed epithelium
Clinical Approach to Diarrhoea?
History
- Age at onset
- Abrupt/gradual onset
- Family history
- Nocturnal defecation suggests organic pathology
Consider growth and weight gain of child
Faeces analysis
- Appearance
- Stool culture
- Determination of secretory vs. osmotic
Differentiation between osmotic and secretory diarrhoea
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What are the common causes of Fat Malabsorption in diarrhoea>
- Pancreatic Disease
- Diarrhoea due to lack of lipase and resultant steatorrhoea
- Classically cystic fibrosis
- Diarrhoea due to lack of lipase and resultant steatorrhoea
- Hepatobiliary Disease
- Chronic liver disease
- Cholestasis
What is Coeliac Disease?
How does it present?
- Gluten-sensitive enteropathy
Symptoms
- Abdominal bloatedness
- Diarrhoea
- Failure to thrive
- Short stature
- Constipation
- Tiredness
- Dermatitis herpatiformis
What are the screening tests of Coeliac Disease?
-
Serological Screens
- –Anti-tissue transglutaminase
- –Anti-endomysial
- –Anti-gliadin
- –Concurrent IgA deficiency in 2% may result in false negatives
- Gold standard- duodenal biopsy
- Genetic testing
- HLA DQ2, DQ8
What are the guidelines for diagnosis without biopsy?
- Symptomatic children
- Anti TTG >10 times upper limit of normal
- Positive anti endomysial antibodies
- HLA DQ2, DQ8 positive
What is the treatment of 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
- Increased risk of rare small bowel lymphoma in untreated.
