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Paediatrics > Vomiting and malabsorption in children > Flashcards

Vomiting and malabsorption in children Flashcards

1
Q

What are the physiological phases of vomiting?

A

Pre-ejection phase (nausea, tachycardia, pallor)

Retching (deep breaths taken against a closed glottis and reverse peristaltic movements)

Vomiting

Post-ejection phase (lethargic, pallor, sweat)

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2
Q

Where is the vomiting centre of the brain located?

A

In the Medulla

The chaemoreceptor trigger zone that is triggered by certain chemicals and toxins is located at the base of the 4th ventricle

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3
Q

What are the triggers of vomiting?

A 
Enteric pathogens
Infections 
Visual / olfactory stimuli (& fear)
Head injury / raised ICP
Inner ear stimuli
Metabolic derangements / chaemotherapy
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4
Q

What are the different types of vomiting?

A

Vomiting with retching

Projectile vomiting

Bilious vomiting

Effortless vomiting

Haemetemesis (usually peptic ulcers / portal hypertension)

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5
Q

What are the most common causes of vomiting in infants?

A

gastro-oesophageal reflux

cow’s milk allergy

Infection

Intestinal obstruction

Pyloric stenosis

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6
Q

What are the most common causes of vomiting in children?

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

What are the most common causes of vomiting in young adults?

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

What are the recommended values for feeding volume for neonates ans infants?

A

Neonates: 150 mL/kg/day

Infants: 100 mL/kg/day

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9
Q

In neonates and infants that have been vomiting constantly what investigation needs to be done? What is commonly seen on investigation? Initial management?

A

Blood gas test

Often see hypokalaemic hypochloric metabolic alkalosis (been vomiting all HCl)

Fluid resuscitation is first treatment, then treat underlying cause of vomiting

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10
Q

When does pyloric stenosis tend to occur? How does it present?

A

Babies 4-12 weeks (more common in boys)

Presents with projectile non-bilious vomiting and associated weight loss, dehydration and +/- shock

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11
Q

What is the characteristic electrolyte disturbance seen in pyloric stenosis?

A

Metabolic alkalosis (Increased pH)

Hypochloraemia

Hypokalaemia

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12
Q

What is effortless vomiting? How is it treated?

A

Vomiting that is almost exclusively due to gastro-oesophageal reflux

Tends to reslove spontaneously
(omeprazole or something for symptomatic treatment)

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13
Q

What are some factors that predispose babies to gastro-oesophageal reflux?

A

They have a relaxed LOS

Often placed in lying down position

Most of their feeds are liquid

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14
Q

What are some of the symptoms that may accompany gastro-oesophageal reflux in children?

A

Vomiting
Haematemesis
Feeding problems
Failure to thrive
Apnoea / cough / wheeze / chest infections
Sandifer’s syndrome (spasmodic torsional dystonia)

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15
Q

Describe the common natural history of reflux in infants?

A

Starts at about 2 weeks of age

Worse around 4-6 months of age

Usually resolves after a year of age

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16
Q

What radiological investigations may be done on a child experiencing reflux?

A

Barium swallow

Oesophageal ultrasound

Oesophageal pH meter (does pH drop below 4)

Upper GI endoscopy (in serious cases)

17
Q

How is gastro-oesophageal reflux treated in children?

A

Usually just:
Feeding advice + nutritional support

In serious cases:
Drugs +/- surgery

18
Q

What feeding advice may be given to a parent with a child experiencing GOR?

A

Thickeners for liquids (keeps food in stomach)

Advice on appropriate food

Feeding positions

Check feed volumes

19
Q

What are some examples of nutritional support that may be given to a child with GOR?

A

Calorie supplements

Exclusion diet (eg. cows milk)

Nasogastric tube

Gastrostomy

20
Q

What are some drugs that may be given for GOR in children?

A

H2 receptor blockers

PPI’s

21
Q

What surgery may be done in children with severe, persistent GER? Who is more likely to get this? Side effects?

A

Nissen fundoplication (Wrap the fundus around the LOS)

Done often in kids with cerebral palsy

May suffer from bloat, dumping and retching after surgery

22
Q

What causes bilious vomiting? What does it look like?

A

Intestinal obstruction usually

Looks green or bright yellow in colour

23
Q

What investigations may be done in a child with bilious vomiting?

A

Abdominal Xray

Contrast meal

24
Q

What is chronic diarrhoea?

A

4 or more stools per day for 4+ weeks

25
Q

What are some of the causes of diarrhoea?

A
  • Motility disturbances (toddler diarrhoea / IBS)
  • Active secretion of water (secretory)
    (infective diarrhoea, inflammatory bowel disease)
  • Malabsorption of nutrients (osmotic)
    (Food allergy, coeliac disease, cystic fibrosis)
26
Q

What occurs in osmotic (malabsorption) diarrhoea?

A

Movement of water into the bowel to equilibrate the osmotic gradient - food not getting absorbed so needs more water to remain equally tonic

Usually due to malabsorption caused by:

  • Enzymatic defect
  • Transport defect

(this is the mechanism many laxatives work by)

27
Q

What occurs in secretory (active) diarrhoea?

A

There is excessive secretion of water due to the active secretion of Cl by CFTR

This is usually precipitated by infection

28
Q

How does stool volume compare between secretory and osmotic diarrhoea? Which one responds to fasting

A

Secretory diarrhoea has a larger stool volume

Osmotic diarrhoea responds to fasting, secretory does not

29
Q

What are some causes of fat malabsorption?

A

Pancreatic disease - diarrhoea due to lack of lipase and resultant steatorrhoea (CF)

Hepatobiliary Disease - chronic liver disease, cholestasis

30
Q

What is the most common cause of malabsorption in children?

A

Coeliac disease

a gluten sensitive enteropathy - affects about 1% population

31
Q

What are the classic signs of coeliac disease?

A
  • Abdominal distension (pot belly)
  • Diarrhoea
  • Failure to thrive
  • Short stature
  • Constipation
  • Tiredness
  • Dermatitis herpatiformis
32
Q

What serological tests should be done when coeliac disease is suspected in a child?

A

Anti-tissue transglutaminase

Anti-endomysial

Check serum IgA because deficiency in 2% may result in false negatives

33
Q

What non-serological screening for coeliac disease may be done?

A

Duodenal biopsy (gold standard)

Genetic testing

34
Q

In coeliac disease what do you see on endoscopy?

A

Absence of villi

Erythematous mucosa (looks red / pink)

Scalloping (deepening) of the mucosal folds

35
Q

What is needed for diagnosis of coeliac disease without biopsy?

A

ALL OF:
Patient must be symptomatic

Anti TTG > 10 times normal

Positive anti endomysial antibodies

HLA DQ2 / DQ8 positive (genes)

36
Q

What treatment is given to children with coeliac disease?

A

Sent to a dietician:
- Gluten free diet for life

(don’t remove gluten before diagnosis because serological signs will resolve)

37
Q

What do undigested vegetables in a childs stool suggest?

A

Chronic, non-specific “toddlers diarrhoea”

Tends to improve by itself with age

Paediatrics (33 decks)

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