Vomiting and malabsorption in children

Question 1

What is the pre-ejection phase of vomiting?

Answer 1

Pallor
Nausea
Tachycardia

Question 2

What is the ejection phase of vomiting?

Answer 2

Retch

Vomit

Question 3

What are some different types of vomiting?

Answer 3

Vomiting with retching
Projectile
Bilious
Effortless
Haemetemesis

Question 4

What is retching?

Answer 4

Deep inspiration against a closed glottis
Contraction of the abdomen
Pressure difference between abdominal and thoracic cavities
Stomach and gastric contents displaced upwards toward the thoracic cavity

Question 5

What are the main causes of vomiting in infants?

Answer 5

GOR
Cow’s milk allergy
Infection
Intestinal obstruction

Question 6

What are the main causes of vomiting in children?

Answer 6

GE
Infection
Appendicitis
Intestinal obstruction
Raised ICP
Coeliac disease

Question 7

What are the main causes of vomiting in young adults?

Answer 7

Gastroenteritis
Infection
H.Pylori infection
Appendicitis
Raised ICP
DKA
Cyclical vomiting syndrome
Bulimia

Question 8

How would pyloric stenosis affect a test feed?

Answer 8

Palpation of “olive” tumour
Visible gastric peristalsis
Projectile non bilious vomiting

Question 9

What are some useful tests in suspected pyloric stenosis?

Answer 9

Blood gas (hypokalaemia, hypochloraemia, metabolic alkalosis)
Ultrasound (pyloric stenosis, thickened muscle at pylorus)

Question 10

How do we manage pyloric stenosis?

Answer 10

Fluid resuscitation

Ramstedt’s pyloromyotomy

Question 11

Is pyloric stenosis more common in boys or girls?

Answer 11

Boys

Question 12

How might pyloric stenosis present?

Answer 12

Projectile non-bilious vomiting
Weight loss
Dehydration
Electrolyte disturbance

Question 13

What is the main cause of effortless vomiting?

Answer 13

GOR

Question 14

When might effortless vomiting not be self limiting?

Answer 14

Cerebral palsy
Progressive neurological problems
Oesophageal atresia +/- TOF operated
Generalised GI motility problem

Question 15

What is Sandifer’s syndrome?

Answer 15

Association of gastro-oesophageal reflux disease with spastic torticollis and dystonic body movements

Question 16

How might Sandifer’s syndrome present?

Answer 16

Nodding and rotating of the head
Neck extension
Gurgling
Limbs writhing
Severe hypotonia

Question 17

How is Sandifer’s syndrome managed?

Answer 17

Treat GORD

Question 18

What are the main assessment aims of a barium swallow?

Answer 18

Dysmotility
Hiatus hernia
Reflux
Gastric emptying
Strictures

Question 19

What are the main features of reflux treatment?

Answer 19

Feeding advice
Nutritional support
Medical treatment
Surgery

Question 20

What are some common pieces of feeding advice?

Answer 20

Thickeners for liquid
Appropriateness of food texture and amount
Oral stimulation
Removal of aversive stimuli
Feeding position

Question 21

What is an appropriate feeding volume for neonates?

Answer 21

150mls/kg/day

Question 22

What is an appropriate feeding volume for infants?

Answer 22

100mls/kg/day

Question 23

What are some features of nutritional support?

Answer 23

Calorie supplements
Exclusion diet
Nasogastric tube
Gastrotomy

Question 24

Give an example of an exclusion diet?

Answer 24

Cow’s milk protein free trial for 4 weeks

Question 25

What are some medical treatments for reflux?

Answer 25

Gaviscon for feed thickener Prokinetics H2 receptor blockers or PPI's for acid suppression

Question 26

When is surgery indicated for reflux?

Answer 26

Failure of medical treatment Failure to thrive Aspiration Oesophagitis

Question 27

What is Nissen fundoplication?

Answer 27

Fundus wrapped around oesophagus

Question 28

What is the usual cause of bilious vomiting?

Answer 28

``` Due to intestinal obstruction until proved otherwise Intestinal atresia Malrotation Ileus Crohn's with stricture ```

Question 29

Which investigations are used for bilious vomiting?

Answer 29

Abdominal x-ray Contrast meal Exploratory laparotomy

Question 30

How is persistence of diarrhoea classified?

Answer 30

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

Question 31

What are the main causes of diarrhoea?

Answer 31

Motility disturbance Active secretion Malabsorption

Question 32

What may cause motility disturbance?

Answer 32

Toddler diarrhoea | IBS

Question 33

What may cause active secretion?

Answer 33

Acute infective diarrhoea | IBD

Question 34

What are some causes of malabsorption?

Answer 34

Food Allergy Coeliac Disease Cystic Fibrosis

Question 35

How is osmotic diarrhoea resolved?

Answer 35

Clinical remission with removal of causative agent

Question 36

What are the main pathogens behind secretory diarrhoea?

Answer 36

Vibrio cholerae | Escherichia coli

Question 37

What is the moa in secretory diarrhoea?

Answer 37

Intestinal fluid secretion predominantly driven by active Cl- secretion via CFTR

Question 38

How might pancreatic disease cause fat malabsorption?

Answer 38

Lack of lipase and resultant steatorrhoea | CF

Question 39

How might hepatobiliary disease cause fat malabsorption?

Answer 39

Chronic liver disease | Cholestasis

Question 40

How might coeliac's disease?

Answer 40

``` Abdominal bloating Diarrhoea Failure to thrive Short stature Constipation Tiredness Dermatitis herpatiformis Associated with other autoimmune conditions like IDDM ```

Question 41

What is the gold standard screening test for coeliacs?

Answer 41

Duodenal biopsy

Question 42

How might villous histology differ in coeliacs?

Answer 42

Lymphocytic infiltration of surface epithelium Partial/total villous atrophy Crypt hyperplasia

Question 43

How might coeliac diagnosis be made without biopsy?

Answer 43

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

Question 44

How is coeliac managed?

Answer 44

Gluten-free diet | Re-challenging and re-biopsy maybe in very young

Question 45

What kind of tumour has increased risk in untreated coeliac?

Answer 45

Small bowel lymphoma