Vomiting and Malabsorption in Childhood

Question 1

What are the 4 different types of vomiting?

Answer 1

• Vomiting with Retching
• Projectile vomiting
• Bilious vomiting
• Effortless vomiting

Question 2

Outline the different phases in Vomiting with Retching.

Answer 2

Pre-ejection phase

• Pallor
• Nausea
• Tachycardia

Ejection Phase

• Retch
• Vomit

Post-ejection Phase

• Weakness
• Shivering
• Lethargy

Question 3

What things stimulate the vomiting centre?

Answer 3

• Enteric pathogens
• Intestinal inflammation
• Metabolic derangement
• Infection - commonest
• Head injury
• Visual stimuli
• Middle ear stimuli

Question 4

Pyloric Stenosis

Presentation

Managment

Answer 4

• Projectile vomiting non-bilious
• • weight loss
• • dehydration (and potential shock)
• FLuid resusitation
• Pyloromyotomy

Question 5

What are some of the causes of bilious vomiting?

Answer 5

• Due to intestinal obstruction usually.
  
  • Intestinal Atresia
  • Intussussception
  • Ileus
  • Crohns w/ strictures

Question 6

Investigations in Bilious Vomiting

Answer 6

• Abdominal x-ray
• Consider contrast meal
• Surgical opinion re laparotomy

Question 7

What are the common causes of effortless vomiting?

Exceptinos

Answer 7

• 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

Question 8

What are the presenting symptoms of Reflux?

Answer 8

Gastrointestinal

• –Vomiting
• –Haematemesis

•Nutritional

• –Feeding problems
• –Failure to thrive

Respiratory

• –Apnoea
• –Cough
• –Wheeze
• –Chest infections

Neurological

–Sandifer’s syndrome

Question 9

What medical examinations needed in relfux?

Answer 9

• History & examination often sufficient
• Radiological investigations
  
  • Video fluoroscopy
  • Barium swallow
• pH study
• Oesophageal impedance monitoring
• Endoscopy

Question 10

What are you looking to find on a Barium Swallow?

Answer 10

Aims:

• Dysmotility
• Hiatus hernia
• Reflux
• Gastric emptying
• strictures

Problems

• Aspiration
• Inadequate contrast taken (NG tube)

Question 11

Treatment options of Reflux

Answer 11

• Feeding advice - little and often
• Nutritional support - high calories
• Medical treatment
• Surgery

Question 12

What feeding advice is offered in Reflux?

Answer 12

• Appropriateness of foods
  
  • Texture
  • Amount
• Behavioural programme
  
  • Oral stimulation
  • Removal of aversive stimuli
• Feeding position

Question 13

What nutritional support can be given in reflux?

Answer 13

• Calorie supplements
• Exclusion diet (milk free)
• Nasogastric tube
• Gastrostomy

Question 14

Medical Treatment of reflux?

Answer 14

• •Feed thickener
  
  • Gaviscon
  • Thick & Easy
• Prokinetic drugs
• Acid suppressing drugs
  
  • H2 receptor blockers
  • Proton pump inhibitors

Question 15

What are the indications in reflux?

Answer 15

• Failure of medical treatment
  
  • Persistent:
    
    • Failure to thrive
    • Aspiration
    • Oesophagitis
• Vomiting without complications may not be an indication

Question 16

What surgery is done in Reflux?

Answer 16

Nissen Fundoplication

Question 18

What is chronic diarrhoea?

Answer 18

• 4 or more stools per day
• For more than 4 weeks

Question 19

Timing difference between acute, persistent and chronic diarrhoea?

Answer 19

• <1 week: acute diarrhoea
• 2 to 4 weeks: persistent diarrhoea
• >4 weeks: chronic diarrhoea

Question 20

What are the 3 main causes of diarrhoea?

Answer 20

Motility Disturbance

• toddler diarrhoea
• IBS

Active Secretion (secretory)

• Acute infective
• IBD

Malabsorption of Nutrients (osmotic)

• Allergy
• CF
• Coeliac Disease

Question 21

Outline osmotic diarrhoea?

Answer 21

• 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

Question 22

Outline secretory diarrhoea?

Answer 22

• –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

Question 23

Outline inflammatory diarrhoea

Answer 23

• “Mixed bag” really
• Malabsorption due to intestinal damage
• Secretory effect of cytokines
• Accelerated transit time in response to inflammation
• Protein exudate across inflamed epithelium

Question 24

Clinical Approach to Diarrhoea?

Answer 24

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

Question 25

Differentiation between osmotic and secretory diarrhoea

Answer 25

slide 41

Question 26

What are the common causes of Fat Malabsorption in diarrhoea>

Answer 26

• Pancreatic Disease
  
  • Diarrhoea due to lack of lipase and resultant steatorrhoea
    
    • Classically cystic fibrosis
• Hepatobiliary Disease
  
  • Chronic liver disease
  • Cholestasis

Question 27

What is Coeliac Disease?

How does it present?

Answer 27

• Gluten-sensitive enteropathy

Symptoms

• Abdominal bloatedness
• Diarrhoea
• Failure to thrive
• Short stature
• Constipation
• Tiredness
• Dermatitis herpatiformis

Question 28

What are the screening tests of Coeliac Disease?

Answer 28

• 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

Question 29

What are the guidelines for diagnosis without biopsy?

Answer 29

• Symptomatic children
• Anti TTG >10 times upper limit of normal
• Positive anti endomysial antibodies
• HLA DQ2, DQ8 positive

Question 30

What is the treatment of Coeliac Disease?

Answer 30

• 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.