Vomiting and Malabsorption in Childhood Flashcards
Types of vomiting
Vomiting with retching
Projective vomiting
Bilious vomiting
Effortless vomiting
What does bilious vomiting generally indicate?
Malabsorption
What does effortless vomiting generally indicate?
Gastro oesophageal reflux
Phases of vomiting with retching and their presentations
Pre ejection phase - pallor - nausea - tachycardia Ejection phase - retch - vomit Post ejection phase - floppy
Causes of vomiting
Enteric pathogens - release toxins Intestinal inflammation Metabolic derangement Infection - e.g. UTI/ meningitis, sepsis Head injury Visual stimuli - migraines, headaches Middle ear stimuli (infections) Gastro oesophageal reflux Overfeeding Pyloric stenosis
How is vomiting triggered?
By stimulation of the vomiting centre
What is the commonest cause of vomiting?
Infection
Investigations for vomiting
Test feed
Blood gas
- metabolic alkalosis = hyperchloric acid
Any slight tinge of yellow / green indicates that the cause is NOT…
Pyloric stenosis
Treatment of vomiting
Fluid resuscitation
Refer to surgeons
What surgical procedure can relieve obstruction causing vomiting?
Ramstedts Pyloromyotomy
Who gets pyloric stenosis?
Babies aged 4 - 12 weeks
B > G
Presentation of pyloric stenosis
Projective non-bilous vomiting
Weight loss
Dehydration / shock
Characteristic electrolyte disturbance
What is the characteristic electrolyte disturbance of pyloric stenosis?
Metabolic alkalosis - increase pH
Hypochloraemia (decreased Cl)
Hypokalaemia (decreased K)
What type of vomiting should always ring alarm bells?
Bilious vomiting
Causes of bilious vomiting
Intestinal atresia (newborns only) Malrotation + / - volvulus Intussusception Ileus Crohn's disease with strictures
What is intussusception?
A process in which a segment of intestine invaginates into the adjoining intestinal lumen, causing bowel obstruction.
What is ileus?
Painful obstruction of the ileum
Investigations of bilious vomiting
Abdo X ray
Contrast meal
Surgical opinion re exploratory laparotomy
What is effortless vomiting almost always due to?
Gastro oesophageal reflux
What type of vomiting is a very common problem in infants?
Effortless vomiting
Effortless vomiting often resolves spontaneously except in….
CP
Progressive neurological problems
Oesophageal atresia +/- TOF operated
Generalised GI motility problem
Presentation of effortless vomiting
Vomiting Haematemesis Feeding problems (due to acid coming up) Failure to thrive Apnoea Cough Wheeze Chest infections Sandifer's syndrome
Investigations of effortless vomiting
History and exam often sufficient Video fluoroscopy Barium swallow Ph study oesophageal impendance monitoring endoscopy
Treatment of effortless vomiting
Feeding advice
- thickeners for liquids
- appropriateness of foods (texture, amount)
- behavioural (oral stimulation, removal of aversive stimuli)
- Feeding position (head at 45 degrees)
Nutritional support
- calorie supplements
- exclusion diet (milk dree)
- NG tube
- gastrotomy
Medical treatment
- feed thickener (Gaviscon, thick and easy)
- Prokinetic drugs
- Acid Suppressing Drugs (H2 receptor blockers, PPIs)
surgery
Indications for surgery in effortless vomiting
Failure of medical treatment Persistent - FTF - aspiration - oesophagitis
When would you do a Nissen Fundoplication?
In children who are more likely to have complications of bloat, dumping and retching after surgery e.g. CP
How much volume of faeces are lost per day in a child?
< 200 ml
How is the surface area of the small intestine increased?
Mucosal folds
Villi
Definition of chronic diarrhoea
4 or more stools per day for more than 4 weeks
How long is acute diarrhoea?
< 1 week
How long is persistent diarrhoea?
2 - 4 weeks
How long is chronic diarrhoea?
> 4 weeks
Causes of diarrhoea
Motility disturbance - toddler diarrhoea - IBS Active secretion - acute infective diarrhoea - IBD Malabsorption of nutrients (osmotic) - food allergy - coeliac disease - Cystic fibrosis (fat malabsorption)
4 types of diarrhoea
Osmotic
Secretory
Motility
Inflammatory
Pathology of osmotic diarrhoea
Movement of water into the bowel to equilibrate osmotic gradient
Mechanism of action of lactulose/movicol
What is osmotic diarrhoea usually a feature of?
Enzymatic defect
Transport defect
What is osmotic diarrhoea usually accompanied by?
Macroscopic and microscopic intestinal injury
How do you get clinical remission of osmotic diarrhoea?
Removal of causative agent
What is secretory diarrhoea classically associated with?
Toxin production from vibrio cholerae and enterotoxigenic E coli
Pathology of secretory diarrhoea
Intestinal fluid secretion predominately driven by active Cl- secretion via CFTR
Causes of motility diarrhoea
Toddlers diarrhoea
IBS
congenital hyperthyroidism
Chronic intestinal pseudo-obstruction
Most common cause of motility diarrhoea
Toddlers diarrhoea
Pathology of inflammatory damage
Malabsorption due to intestinal damage
Secretory effect of cytokines
Accelerated transit time in response to inflammation
Protein exudate across inflamed epithelium
What kind of diarrhoea is ALWAYS pathological?
Nocturnal
Stool volume in osmotic vs secretory diarrhoea
osmotic = small (generally < 200ml / 24 hours) Secretory = large (>200 ml/ 24 hours)
Response to fasting, osmotic vs secretory diarrhoea
Osmotic = diarrhoea stops Secretory = diarrhoea continues
Features of molecules in stool in osmotic vs secretory diarrhoea
Osmotic - low Na - low K - low Cl Secretory - high sodium - high K - high Cl
Causes of fat malabsorption
Pancreatic disease - lack of lipase and resultant steatorrhoea causing diarrhoea - classically in CF Hepatobiliary disease - chronic liver disease - cholestasis
What is coeliac disease?
Gluten sensitive enteropathy
What triggers coeliac disease?
Wheat
Rye
Barley
How many people does coeliac disease affect of the western population?
1%
Genetics of coeliac disease
DQ2
DQ8
Symptoms of coeliac disease
Abdo bloating Diarrhoea Failure to thrive Short stature Constipation Tiredness Dermatitis herpatiformis (vasicular skin rash) Autoimmune hepatitis
Screening for coeliac disease
Serological screens - anti tissue transglutaminase - anti-endomysial - anti-gliadin - concurrent IgA deficiency in 2% may give false negatives Genetic testing
Gold standard investigation for coeliac disease
Duodenal biopsy
Genetic testing of coeliac disease
HLA DQ2
DQ8
Features required of coeliac disease to diagnose without a biopsy
Symptomatic children
Anti TTG > 10x upper limit of normal
+ve anti endomysial antibodies
HLA, DQ2, DQ8
Treatment of coeliac disease
Gluten free diet for life
In very young under 2 years, re challenge and re biopsy
Why should gluten not be removed prior to diagnosis of coeliac disease?
As serological and histological features will resolve
What is there a increased risk of if coeliac disease is left untreated?
Rare small bowel lymphoma
How do you ask the parents if the child has projectile vomiting?
Is the vomit on their clothes or on the floor and miss their clothes?
When should a H2RA or PPI be trialled in infants with GORD?
Who do not respond to alginates/food thickener And who have 1. feeding difficulties 2. Distressed behaviour or 3. Faltering growth
What is highly suggestive of intestinal malrotation and volvulus?
Scaphoid abdomen
Bilious vomiting
Investigations of intestinal malrotation
Urgent Upper GI contrast study
USS
What is suggestive of congenital diaphragmatic hernia?
Displaced apex beat
Decreased air entry
