Vomiting and Malabsorption in Children Flashcards
Physiology of vomiting - what are the stages of vomiting?
- Pre-ejection phase - Pallor, Nausea, Tachycardia
- Ejection Phase - Retch, Vomit
- Post-ejection Phase - child is lethargic, pale, sweaty, weakness, shivering
what are the triggers of vomiting?
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
what is retching?
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.
what are the types of vomiting?
Effortless vomiting otherwise known as regurgitation
Haematemesis – blood in vomit – often seen in peptic ulcers or in portal hypertension
what causes vomiting in infants?
- GOR (most common)
- Cow’s milk allergy
- Infection
- Intestinal obstruction
what causes vomiting in children?
- Gastroenteritis
- Infection
- Appendicitis
- Intestinal obstruction
- Raised ICP
- Coeliac disease
what causes vomiting in young adults?
- Gastroenteritis
- Infection
- H.Pylori infection
- Appendicitis
- Raised ICP
- DKA
- Cyclical vomiting syndrome
- Bulimia
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?
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)
case continued:
Palpation of “olive” tumour (thickened pylorus)
Visible gastric peristalsis
Projectile non bilious vomiting
whats the diagnosis?
Pyloric Stenosis
Ultrasound appearance of pyloric stenosis with long, thickened muscle at pylorus
US show thickened pylorus which is classic of pylorus stenosis
what is Pyloric Stenosis, who does it occur in and what does it cause?
Babies 4-12 weeks
Boys > Girls
Projectile non-bilious vomiting
Weight loss
Dehydration +/- shock
Characteristic electrolyte disturbance:
- Metabolic alkalosis (↑pH)
- Hypochloraemia (↓Cl)
- Hypokalaemia (↓K)
how do you treat pyloric stenosis?
Fluid resuscitation (Fluid to correct metabolic alkalosis and dehydration)
Refer to surgeons- Ramstedt’s pyloromyotomy
what is Effortless Vomiting?
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
LOS and diaphragmatic crura prevent expulsion of gastric contents into the oesophagus
why does reflux occur in babies?
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
what are the presenting symptoms?
Sandifer’s syndrome is the association of gastro-oesophageal reflux disease with spastic torticollis and dystonic body movements
what should be invovled in a medical assessment? (when diagnosing GOR)
History & examination often sufficient
Oesophageal pH study/impedance monitoring
Endoscopy
Radiological investigations:
- Video fluoroscopy
- Barium swallow
can GOR effect growth?
yes
Very rare
If you do see it then warrants further investigation
radiology - what are the aims of a barrium swallow and what are some problems?
Aims:
Dysmotility
Hiatus hernia
Reflux
Gastric emptying
strictures
Problems:
Aspiration
Inadequate contrast taken (NG tube)
how is a pH study done?
pH studies - pH sensor placed 5cm above LOS
Measure amount of times pH in oesophagus drops below 4
whenw ould you do a upper GI endoscopy?
General anaesthetic
Only if persistent symptoms, growth faltering, resistance to anti-reflux symptoms
what is the treatment for GOR?
Feeding advice
Nutritional support
Medical treatment
Surgery
what feeding avice can be given?
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
what nutritional support can be given?
Calorie supplements
Exclusion diet (cow’s milk protein free trial for 4 weeks)
Nasogastric tube
Gastrostomy
what medical treatment can be given?
Feed thickener - Gaviscon, Thick & Easy
Prokinetic drugs
Acid suppressing drugs
- H2 receptor blockers
- Proton pump inhibitors
what arte the indications for surgery?
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
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
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
is Bilious Vomiting alarming?
Should always ring alarm bells
Due to intestinal obstruction until proved otherwise
what causes Bilious Vomiting?
Intestinal atresia (in newborn babies only)
Malrotation +/- volvulus
Intussusception (toddlers)
Ileus (toddlers)
Crohn’s disease with strictures (adolescents)
what investigations would you do for Bilious Vomiting?
Abdominal x-ray (to look for bowel obstruction)
Consider contrast meal
Surgical opinion re exploratory laparotomy
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
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
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
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)
what makes osmotic diarrhoea better?
Clinical remission with removal of causative agent
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
what is the clinical approach for diarrhoea?
History:
- 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
how do you differentiate between osmotic and secretory diarrhoea?
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
what causes fat malabsorption?
Pancreatic Disease:
Diarrhoea due to lack of lipase and resultant steatorrhoea
Classically cystic fibrosis
Hepatobiliary Disease:
Chronic liver disease
Cholestasis
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
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
what does coalic disease cause?
Abdominal bloatedness
Diarrhoea
Failure to thrive
Short stature
Constipation
Tiredness
Dermatitis herpatiformis
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
what are endoscopy findings of coeliac disease?
Coelic – oedema, erythematous mucosa, flattening of villi, dipping in folds
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
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
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
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
