Vomiting and Malabsorption Part 1 Flashcards
What are the features of the pre-ejection phase?
Pallor
Nausea
Tachycardia
What are the features of the ejection phase?
Retch
Vomit
What may occur in the post-ejection phase?
Weakness
Shivering
Lethargy
How may chemicals induce vomiting?
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
How might vomiting be caused by motion?
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 are the triggers for vomiting?
Enteric pathogens Infection Visual/olfactory stimuli Fear Head injury/raised ICP Inner ear stimuli Metabolic derangements/chemotherapy
What are the types of vomiting?
Vomiting with retching Projectile vomiting Bilious vomiting Effortless vomiting Haemetemesis
What is retching?
- 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
What are the causes of vomiting in infants?
Infection
GOR
Cow’s milk allergy
Intestinal obstruction
What are the causes of vomiting in children?
Infection Gastroenteritis Appendicitis Raised ICP Intestinal obstruction Coeliac disease
What are the causes of vomiting in young adults?
Infection H.Pylori infection Gastroenteritis Appendicitis Raised ICP DKA Cyclical vomiting syndrome Bulimia
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?
Gastroesophageal reflux
Overfeeding
Pyloric stenosis
Cow’s milk protein allergy
Who gets pyloric stenosis?
Babies 4-12 weeks
Boys > Girls
How does pyloric stenosis present?
Projectile non-bilious vomiting
Weight loss
Dehydration +/- shock
What are the electrolyte disturbances characteristic of pyloric stenosis?
Metabolic alkalosis (↑pH)
Hypochloraemia (↓Cl)
Hypokalaemia (↓K)
What is effortless vomiting almost always caused by?
GOR
Who gets GOR?
Very common problem in infants
Self limiting and resolves spontaneously in the vast majority of cases
What are exceptional causes of effortless vomiting?
Cerebral palsy
Progressive neurological problems
Oesophageal atresia +/- TOF operated
Generalised GI motility problem
What is Sandifer’s syndrome?
The association of gastro-oesophageal reflux disease with spastic torticollis and dystonic body movements
What are the features of Sandifer’s syndrome?
- 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
What are the features of Sandifer’s syndrome?
- 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
How do you investigate vomiting?
History & examination often sufficient
Oesophageal pH study/impedance monitoring
Endoscopy
Radiological investigations:
- Video fluoroscopy
- Barium swallow
How do you investigate vomiting?
History & examination often sufficient
Oesophageal pH study/impedance monitoring
Endoscopy
Radiological investigations:
- Video fluoroscopy
- Barium swallow
What can be imaged using a barium swallow?
Dysmotility Hiatus hernia Reflux Gastric emptying Strictures
What are the issues with a barium swallow?
Aspiration
Inadequate contrast taken (NG tube)
What are the issues with a barium swallow?
Aspiration
Inadequate contrast taken (NG tube)
How is oesophageal pH measures?
With an endoscopic meter
pH catheter
Measurement taken 5cm above LOS
What are the treatments given for vomiting?
Feeding advice
Nutritional support
Medical treatment
Surgery
What is the feeding advice 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 is given?
Calorie supplements
Exclusion diet (cow’s milk protein free trial for 4 weeks)
Nasogastric tube
Gastrostomy (fed strain into stomach)
What medical treatment can be given?
Feed thickener
- Gaviscon
- Thick & Easy
Prokinetic drugs
Acid suppressing drugs
- H2 receptor blockers
- Proton pump inhibitors
What are the indications for surgery?
Failure of medical treatment
Persistent:
- Failure to thrive
- Aspiration
- Oesophagitis
Vomiting without complications may not be an indication
What is a Nissen fundoplication?
Laparoscopic fundoplication
What are possible negative outcomes of fundoplication?
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
What does bilious vomiting tell us?
Should always ring alarm bells
Due to intestinal obstruction until proved otherwise
What are potential causes of bilious vomiting?
Intestinal atresia (in newborn babies only) Malrotation +/- volvulus Intussusception Ileus (ileum obstruction) Crohn’s disease with strictures
What are the investigations carried out for bilious vomiting?
Abdominal x-ray
Consider contrast meal
Surgical opinion re exploratory laparotomy
