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Paediatrics > Vomiting and Malabsorption Part 1 > Flashcards

Vomiting and Malabsorption Part 1 Flashcards

1
Q

What are the features of the pre-ejection phase?

A

Pallor
Nausea
Tachycardia

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2
Q

What are the features of the ejection phase?

A

Retch

Vomit

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3
Q

What may occur in the post-ejection phase?

A

Weakness
Shivering
Lethargy

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4
Q

How may chemicals induce vomiting?

A

Triggering of chemoreceptor trigger zone (CTZ) dopamine and serotonin receptors

E.g. chemotherapy triggers the muscarinic receptors in the vomiting centre

The CTZ is outside the blood brain barrier

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5
Q

How might vomiting be caused by motion?

A

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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6
Q

What are the triggers for vomiting?

A 
Enteric pathogens
Infection
Visual/olfactory stimuli
Fear
Head injury/raised ICP
Inner ear stimuli
Metabolic derangements/chemotherapy
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7
Q

What are the types of vomiting?

A 
Vomiting with retching
Projectile vomiting
Bilious vomiting
Effortless vomiting
Haemetemesis
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8
Q

What is retching?

A
  • Retchinginvolves 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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9
Q

What are the causes of vomiting in infants?

A

Infection
GOR
Cow’s milk allergy
Intestinal obstruction

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10
Q

What are the causes of vomiting in children?

A 
Infection
Gastroenteritis
Appendicitis
Raised ICP
Intestinal obstruction
Coeliac disease
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11
Q

What are the causes of vomiting in young adults?

A 
Infection
H.Pylori infection
Gastroenteritis
Appendicitis
Raised ICP
DKA
Cyclical vomiting syndrome
Bulimia
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12
Q

What are possible differential diagnoses for:

  • 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?
A

Gastroesophageal reflux
Overfeeding
Pyloric stenosis
Cow’s milk protein allergy

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13
Q

Who gets pyloric stenosis?

A

Babies 4-12 weeks

Boys > Girls

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14
Q

How does pyloric stenosis present?

A

Projectile non-bilious vomiting
Weight loss
Dehydration +/- shock

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15
Q

What are the electrolyte disturbances characteristic of pyloric stenosis?

A

Metabolic alkalosis (↑pH)
Hypochloraemia (↓Cl)
Hypokalaemia (↓K)

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16
Q

What is effortless vomiting almost always caused by?

A

GOR

17
Q

Who gets GOR?

A

Very common problem in infants

Self limiting and resolves spontaneously in the vast majority of cases

18
Q

What are exceptional causes of effortless vomiting?

A

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

19
Q

What is Sandifer’s syndrome?

A

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

20
Q

What are the features of Sandifer’s syndrome?

A
  • Nodding and rotation of the head, neck extension, gurgling sounds, writhing movements of the limbs, and severe hypotonia have been reported
  • It is hypothesised that such positionings provide relief from discomfort caused by acid reflux
  • A causal relation between gastro-oesophageal reflux disease and the neurological manifestations of Sandifer’s syndrome is supported by the resolution of the manifestations on successful treatment of gastro-oesophageal reflux disease
21
Q

What are the features of Sandifer’s syndrome?

A
  • Nodding and rotation of the head, neck extension, gurgling sounds, writhing movements of the limbs, and severe hypotonia have been reported
  • It is hypothesised that such positionings provide relief from discomfort caused by acid reflux
  • A causal relation between gastro-oesophageal reflux disease and the neurological manifestations of Sandifer’s syndrome is supported by the resolution of the manifestations on successful treatment of gastro-oesophageal reflux disease
22
Q

How do you investigate vomiting?

A

History & examination often sufficient

Oesophageal pH study/impedance monitoring

Endoscopy

Radiological investigations:

  • Video fluoroscopy
  • Barium swallow
23
Q

How do you investigate vomiting?

A

History & examination often sufficient

Oesophageal pH study/impedance monitoring

Endoscopy

Radiological investigations:

  • Video fluoroscopy
  • Barium swallow
24
Q

What can be imaged using a barium swallow?

A 
Dysmotility
Hiatus hernia
Reflux
Gastric emptying
Strictures
25
Q

What are the issues with a barium swallow?

A

Aspiration

Inadequate contrast taken (NG tube)

26
Q

What are the issues with a barium swallow?

A

Aspiration

Inadequate contrast taken (NG tube)

27
Q

How is oesophageal pH measures?

A

With an endoscopic meter
pH catheter
Measurement taken 5cm above LOS

28
Q

What are the treatments given for vomiting?

A

Feeding advice
Nutritional support
Medical treatment
Surgery

29
Q

What is the feeding advice 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
30
Q

What nutritional support is given?

A

Calorie supplements
Exclusion diet (cow’s milk protein free trial for 4 weeks)
Nasogastric tube
Gastrostomy (fed strain into stomach)

31
Q

What medical treatment can be given?

A

Feed thickener

  • Gaviscon
  • Thick & Easy

Prokinetic drugs

Acid suppressing drugs

  • H2 receptor blockers
  • Proton pump inhibitors
32
Q

What are the indications for surgery?

A

Failure of medical treatment

Persistent:

  • Failure to thrive
  • Aspiration
  • Oesophagitis

Vomiting without complications may not be an indication

33
Q

What is a Nissen fundoplication?

A

Laparoscopic fundoplication

34
Q

What are possible negative outcomes of fundoplication?

A

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

dumping - early jejunal filling due to rapid gastric emptying

35
Q

What does bilious vomiting tell us?

A

Should always ring alarm bells

Due to intestinal obstruction until proved otherwise

36
Q

What are potential causes of bilious vomiting?

A 
Intestinal atresia (in newborn babies only)
Malrotation +/- volvulus
Intussusception
Ileus (ileum obstruction)
Crohn’s disease with strictures
37
Q

What are the investigations carried out for bilious vomiting?

A

Abdominal x-ray
Consider contrast meal
Surgical opinion re exploratory laparotomy

Paediatrics (37 decks)

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