Vomiting and Malabsorption in Children 1 Flashcards
What are the different phases of vomiting
- Pre-ejection phase
- Pallor
- Nausea
- Tachycardia
- Ejection phase
- Retch
- Vomit
- Post-ejection phase
- Lethargy
- Pain
- Sweaty
What are the clinical features of each vomiting phase:
- pre-ejection phase
- ejection phase
- post-ejection phase
- Pre-ejection phase
- Pallor
- Nausea
- Tachycardia
- Ejection phase
- Retch
- Vomit
- Post-ejection phase
- Lethargy
- Pain
- Sweaty
Physiologically, what causes vomiting?
Happens due to stimulation of vomiting centre, located medulla:
- Triggered by chemicals and toxins, such as chemotherapy
Where is the vomiting centre located?
Medulla
What is stimulationof the vomiting centre triggered by?
Chemicals adn toxins, such as chemotherpy
What are some triggers of vomiting?
- Vomiting with renching
- Projectile vomiting
- Bilious vomiting
- Effortless vomiting
- Haemetemesis
What are the different kinds of vomiting?
- Vomiting with renching
- Projectile vomiting
- Bilious vomiting
- Effortless vomiting
- Haemetemesis
- Usually seen in peptic ulcers or portal hypertension
What is haemetemesis usually seen in?
Peptic ulcers or portal hypertension
What are causes of vomiting in:
- infants
- children
- young adults
- Infants
- GOR
- Cow’s milk allergy
- Infection
- Intestinal obstruction
- Children
- Gastroenteritis
- Infection
- Appendicitis
- Intestinal obstruction
- Raised ICP
- Coeliac disease
- Young adults
- Gastroenteritis
- Infection
- H. Pylori infection
- Appendicitis
- Raised ICP
- DKA
- Cyclical vomiting syndrome
- Bulimia
Pyloric stenosis - epidemiology
(age group, sex)
- Babies 4-12 weeks
- Boys > girls
Pyloric stenosis - presentation
- Projectile non-bilious vomiting
- Weight loss
- Dehydration +/- shock
- Characteristic electroylyte disturbance
- Metabolic alkalosis (increased pH)
- Hypocholeraemia (decreased chlorine)
- Hypokalaemia (decreased potassium)
What kind of vomiting does pyloric stenosis cause?
Projectile non-bilous vomiting
What are the characteristic electroylyte disturbances of vomiting due to pyloric stenosis?
- Characteristic electroylyte disturbance
- Metabolic alkalosis (increased pH)
- Hypocholeraemia (decreased chlorine)
- Hypokalaemia (decreased potassium)
Pyloric stenosis - investigations
- Test feed
- Blood gases
- Often see hypokalemic, hypocholermic metabolic alkalosis after prolonged vomiting
- USS
What is seen in blood gases after prolonged vomiting?
- Often see hypokalemic, hypocholermic metabolic alkalosis after prolonged vomiting
Pyloric stenosis - management
- Fluid resuscitation
- To correct from vomiting
- Refer to surgeons if obstruction
What is effortless vomiting also called?
Also called regurgitation, reflux
Effortless vomiting- aetiology
- Almost always due to gastro-oesophageal reflux
Efforless vomiting - epidemiology
- Very common in infants
Effortless vomiting - presentation
- GI
- Vomiting
- Haematemesis
- Nutritional
- Feeding problems
- Failure to thrive
- Reparatory
- Apnoea
- Cough
- Wheeze
- Chest infections
- Neurological
- Sandifer’s syndrome
Effortless vomiting - investigations
- History and examination often sufficient
- Oesophageal pH study/impedance monitoring
- pH in oesophagus dropping below 4 indicates reflux
- Endoscopy
- Imaging
- Video fluoroscopy
- Barium swallow
- Shows hiatus hernia, reflux, gastric emptying, stricturing
Effortless vomiting - management
- Self-limiting and resolves spontaneously with age
- Few exceptions
- Cerebral palsy
- Progressive neurological problems
- Oesophageal atresia
- Generalised GI motility problem
- Feeding advice
- Thickeners for liquid
- Appropriateness of food
- Behavioural programme
- Feeding position
- Check feed volumes – 150mls/kg/day for neonates, 100ml/kg/day for infants
- Nutritional support
- Calories supplements
- Exclusion diet (cows milk protein free trial for 4 weeks)
- Nasogastric tube
- Gastrostomy
- Calories supplements
- Medical treatment rarely
- Acid suppressing drugs
- H2 receptor blockers
- Proton pump inhibitors
- Surgery rarely
- Indications – failure of medical treatment, persistent failure to thrive or aspiration or oesophagitis, vomiting without complications is not indication
- Procedure is Nissen fundoplication
What are indications for surgery for effortless vomiting?
- Indications – failure of medical treatment, persistent failure to thrive or aspiration or oesophagitis, vomiting without complications is not indication
What medical treatment can be used for effortless vomiting?
- Acid suppressing drugs
- H2 receptor blockers
- Proton pump inhibitors
What should bilous vomiting always be presumed to be due to?
Due to intestinal obstruction until proved otherwise
- ALWAYS ring alarm bells
Bilous vomiting - aetiology
- Intestinal atresia (in newborn babies only)
- Malrotation
- Intussusception
- Ileus
- Crohn’s disease with strictures
Bilous vomiting - investigations
- Abdominal x-rays
- Consider contrast meal
- Surgical opinion regarding laparotom
