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Year 3 - Paediatrics > Vomiting and Malabsorption in Children > Flashcards

Vomiting and Malabsorption in Children Flashcards

1
Q

Physiology of vomiting - what are the stages of vomiting?

A
  • Pre-ejection phase - Pallor, Nausea, Tachycardia
  • Ejection Phase - Retch, Vomit
  • Post-ejection Phase - child is lethargic, pale, sweaty, weakness, shivering
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2
Q

what are the triggers of vomiting?

A

GI triggers are enteric pathogens or food allergies which send impulses to vomiting centre through vagus nevre causing vomiting

Inner ear stimulus of the labyrinth occurs in motion sickness

Vomiting centre when stimulated triggers the chemoreceptor trigger zone dopamine and serotonin receptors. Eg chemotherapy triggers the muscarinic receptors in the vomiting centre The CTZ is outside the blood brain barrier. The labrynth sends the signals to the vestibular nuclei in the pons which contains histamine and muscarinic receptors during motion sicknesss, these send signals to CTZ which inturn sends message to vomiting centre in medulla oblongata

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3
Q

what is retching?

A

Retching involves a deep inspiration against a closed glottis. This, along with contraction of the abdomen, leads to a pressure difference between the abdominal and thoracic cavities. As a result, the stomach and gastric contents are displaced upwards toward the thoracic cavity.

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4
Q

what are the types of vomiting?

A

Effortless vomiting otherwise known as regurgitation

Haematemesis – blood in vomit – often seen in peptic ulcers or in portal hypertension

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5
Q

what causes vomiting in infants?

A
  • GOR (most common)
  • Cow’s milk allergy
  • Infection
  • Intestinal obstruction
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6
Q

what causes vomiting in children?

A
  • Gastroenteritis
  • Infection
  • Appendicitis
  • Intestinal obstruction
  • Raised ICP
  • Coeliac disease
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7
Q

what causes vomiting in young adults?

A
  • Gastroenteritis
  • Infection
  • H.Pylori infection
  • Appendicitis
  • Raised ICP
  • DKA
  • Cyclical vomiting syndrome
  • Bulimia
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8
Q

Case study:

6 week old baby boy

3 week history of vomiting after every feed

Bottle fed 6 ounces 3 hourly

Vomitus- large volume, milky or curdy, mostly projectile

Irritable and crying

Not gaining weight adequately

o/e looks slightly dehydrated

what are the differential diagnosis?

A

Gastroesophageal reflux (most common cuase)

Overfeeding (can occur but the volume is this case seems okay)

Pyloric stenosis

Cow’s milk protein allergy (can present as irritability and vomiting)

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9
Q

case continued:

Palpation of “olive” tumour (thickened pylorus)

Visible gastric peristalsis

Projectile non bilious vomiting

whats the diagnosis?

A

Pyloric Stenosis

Ultrasound appearance of pyloric stenosis with long, thickened muscle at pylorus

US show thickened pylorus which is classic of pylorus stenosis

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10
Q

what is Pyloric Stenosis, who does it occur in and what does it cause?

A

Babies 4-12 weeks

Boys > Girls

Projectile non-bilious vomiting

Weight loss

Dehydration +/- shock

Characteristic electrolyte disturbance:

  • Metabolic alkalosis (↑pH)
  • Hypochloraemia (↓Cl)
  • Hypokalaemia (↓K)
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11
Q

how do you treat pyloric stenosis?

A

Fluid resuscitation (Fluid to correct metabolic alkalosis and dehydration)

Refer to surgeons- Ramstedt’s pyloromyotomy

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12
Q

what is Effortless Vomiting?

A

This is almost always due to gastro-oesophageal reflux

Very common problem in infants

Self limiting and resolves spontaneously in the vast majority of cases

A few exceptions: Cerebral palsy, Progressive neurological problems, Oesophageal atresia +/- TOF operated, Generalised GI motility problem

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13
Q

LOS and diaphragmatic crura prevent expulsion of gastric contents into the oesophagus

why does reflux occur in babies?

A

In babies the LOS is lax and also they are mainly placed in the lying posture, their feeds are liquid feeds mainly and all this predisposes them to GOR, this improved with age as solids are introduced at 6 months and with posture as when they are sitting or standing

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14
Q

what are the presenting symptoms?

A

Sandifer’s syndrome is the association of gastro-oesophageal reflux disease with spastic torticollis and dystonic body movements

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15
Q

what should be invovled in a medical assessment? (when diagnosing GOR)

A

History & examination often sufficient

Oesophageal pH study/impedance monitoring

Endoscopy

Radiological investigations:

  • Video fluoroscopy
  • Barium swallow
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16
Q

can GOR effect growth?

A

yes

Very rare

If you do see it then warrants further investigation

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17
Q

radiology - what are the aims of a barrium swallow and what are some problems?

A

Aims:

Dysmotility

Hiatus hernia

Reflux

Gastric emptying

strictures

Problems:

Aspiration

Inadequate contrast taken (NG tube)

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18
Q

how is a pH study done?

A

pH studies - pH sensor placed 5cm above LOS

Measure amount of times pH in oesophagus drops below 4

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19
Q

whenw ould you do a upper GI endoscopy?

A

General anaesthetic

Only if persistent symptoms, growth faltering, resistance to anti-reflux symptoms

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20
Q

what is the treatment for GOR?

A

Feeding advice

Nutritional support

Medical treatment

Surgery

21
Q

what feeding avice can be given?

A

Thickeners for liquids

Appropriateness of foods - Texture, Amount

Behavioural programme - Oral stimulation, Removal of aversive stimuli

Feeding position

Check feed volumes

  • Neonates- 150mls/kg.day
  • Infants – 100mls/kg/day
22
Q

what nutritional support can be given?

A

Calorie supplements

Exclusion diet (cow’s milk protein free trial for 4 weeks)

Nasogastric tube

Gastrostomy

23
Q

what medical treatment can be given?

A

Feed thickener - Gaviscon, Thick & Easy

Prokinetic drugs

Acid suppressing drugs

- H2 receptor blockers

- Proton pump inhibitors

24
Q

what arte the indications for surgery?

A

Failure of medical treatment

Persistent:

  • Failure to thrive
  • Aspiration
  • Oesophagitis

Vomiting without complications may not be an indication

Exhausted all medical treatment options and despite which there is persistence of growth failure, aspiration pneumonias, sever oesophagitis

25
what is Nissen Fundoplication?
a laparoscopic procedure performed for patients with gastroesophageal reflux disease Fundus wrapped around the LOS Children with cerebral palsy are more likely to have complications of bloat, dumping and retching after surgery Successful surgery may unmask more generalised GI motility problems in the child
26
is vomit colour important?
yes You now know bile is green, so ask what colour the vomit is; better so if can actually look at the vomitus
27
is Bilious Vomiting alarming?
Should always ring alarm bells Due to intestinal obstruction until proved otherwise
28
what causes Bilious Vomiting?
Intestinal atresia (in newborn babies only) Malrotation +/- volvulus Intussusception (toddlers) Ileus (toddlers) Crohn’s disease with strictures (adolescents)
29
what investigations would you do for Bilious Vomiting?
Abdominal x-ray (to look for bowel obstruction) Consider contrast meal Surgical opinion re exploratory laparotomy
30
what is the Essential secretory component of the small intestine?
Water for fluidity/enzyme transport/absorption Ions e.g. duodenal HCO3- Defense mechanism against pathogens/harmful substances/antigens
31
what is the defnition of chronic diarrhoea?
4 or more stools per day For more than 4 weeks A little contentious, lots of definitions exist! \<1 week: acute diarrhoea 2 to 4 weeks: persistent diarrhoea \>4 weeks: chronic diarrhoea
32
what causes diarrhoea?
Motility disturbance: Toddler Diarrhoea (gets better with age usually) Irritable Bowel Syndrome Active secretion (secretory): Acute Infective Diarrhoea Inflammatory Bowel Disease Malabsorption of nutrients (osmotic): Food Allergy Coeliac Disease Cystic Fibrosis
33
what is osmotic diarrhoea?
Osmotic diarrhea occurs when too many solutes — the components of the food you eat — stay in your intestine and water can't be absorbed properly. This excess water causes your bowel movements to be loose or more liquid than solid Movement of water into the bowel to equilibrate osmotic gradient Usually a feature of malabsorption - Enzymatic defect (eg. Secondary lactase deficiency), Transport defect ( eg glucose galactose transporter defect) Mechanism of action of lactulose/movicol (laxatives)
34
what makes osmotic diarrhoea better?
Clinical remission with removal of causative agent
35
what is 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 Secretory diarrhea occurs when your body secretes electrolytes into your intestine. This causes water to build up
36
what is the clinical approach for diarrhoea?
History: ## Footnote - Age at onset - Abrupt/gradual onset - Family history - Travel history/local outbreaks - Nocturnal defecation suggests organic pathology Consider growth and weight gain of child Faeces analysis: - Appearance - Stool culture (for infections) - Determination of secretory vs. osmotic
37
how do you differentiate between osmotic and secretory diarrhoea?
38
what is malabsorption?
Malabsorption refers to decreased intestinal absorption of carbohydrate, protein, fat, minerals or vitamins. There are many symptoms associated with malabsorption. Weight loss, diarrhea, greasy stools (due to high fat content), abdominal bloating and gas are suggestive of malabsorption
39
what causes fat malabsorption?
Pancreatic Disease: ## Footnote Diarrhoea due to lack of lipase and resultant steatorrhoea Classically cystic fibrosis Hepatobiliary Disease: Chronic liver disease Cholestasis
40
Case study: 2 year old child presented with 4 month history of Passage of foul smelling explosive stools 3-4/day Tiredness Pallor Poor weight gain what is the cause?
Malabsorption Commonest cause in children is coeliac disease
41
what is coeliac disease?
Coeliac disease is a condition where your immune system attacks your own tissues when you eat gluten. This damages your gut (small intestine) so you are unable to take in nutrients Autoimmune condition Genetic predisposition If you don’t have genetics then unlikely to get it but if you do then you may get it more common in children with other autoimmune conditions like IDDM and first degree relatives
42
what does coalic disease cause?
Abdominal bloatedness Diarrhoea Failure to thrive Short stature Constipation Tiredness Dermatitis herpatiformis
43
how do you screen for coeliac disease?
Serological Screens - Anti-tissue transglutaminase (high sensitivity), Anti-endomysial ( high specificity), Check Serum IgA, Concurrent IgA deficiency in 2% may result in false negatives Gold standard- duodenal biopsy Genetic testing- HLA DQ2, DQ8
44
what are endoscopy findings of coeliac disease?
Coelic – oedema, erythematous mucosa, flattening of villi, dipping in folds
45
what are histological findings of coeliac disease?
Helps make diagnosis of coeliac disease Coeliac blunting of villi with infiltration of lymphocytes in the lamina propria and crypt hyperplasia
46
what is needed to make a diagnosis of coeliac disease?
- Symptomatic children - Anti TTG \>10 times upper limit of normal - Positive anti endomysial antibodies - HLA DQ2, DQ8 positive If all the above are present then diagnoses made without biopsy If any of the above are not present then proceed to endoscopy
47
how do you treat coeliac disease?
Gluten-free diet for life (Once diagnosis made refer to dietician as treatment is lifelong gluten free diet) 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 (If diagnosis under 2 then check again later as other conditions can mimic coeliac disease) Increased risk of rare small bowel lymphoma in untreated
48
Summary: Vomiting in infants and children can be due to __ and non __ causes Gastroesophageal reflux is common in infants and usually resolves with \_\_\_ Coeliac disease is a common cause for ___________ in children In a well toddler, undigested vegetables in the stool suggests chronic non-specific ‘toddlers’ diarrhea and it __________ with age
GI GI age malabsorption improves

Year 3 - Paediatrics (40 decks)

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