Vomiting Child Flashcards
How might you divide neonatal vomiting according the characteristic of the vomit?
Bilious or non-bilious
If vomiting is bilious where does the locate the obstruction to?
The obstruction must be distal to the ampulla of vater in order for bile to be present in the vomit. The ampulla of vater opens into the second part of the duodenum at the major duodenal papilla, it is formed by the union of the pancreatic duct and the common bile duct.
What features might indicate that vomiting is normal?
Low volumes
Shortly after eating
Non-projectile
Milky/formula coloured
What features indicate that vomiting may be pathological?
Projectile Bilious/Green Large volumes Distended abdomen Any other signs of illness- fever, lethargy, diarrhoea
What are some causes of bilious vomiting for children under three months?
Bilious= obstruction after ampulla of vater (2nd part of duodenum)
Intestinal Atresia
Intestinal Malrotation + Volvulus
Intestinal Stenosis
Hirschsprung’s Disease
What are some causes of non-bilious vomiting in a child under 3 months?
Non-bilious= Proximal to the ampulla of vater
Pyloric Stenosis
Annular Pancreas
What can parents do to reduce normal reflux after eating?
Feeding in upright position
Winding/burping the baby after and during feeding
Avoid active play after feeds
What is intestinal malrotation?
A congenital abnormality of the small intestine where there is absent attachment which can lead to rotation and volvulus. The caacum and apendix are located in the upper right quadrant rather than the lower left.
What are three important complications of intestinal malrotation?
Volvulus/Obstruction
Bowel Ischaemia
Sepsis (following bowel ischaemia)
How can intestinal malrotation be investigated for?
Abdominal X-Ray in upright Position
Abdominal USS
Upper GI Contrast Series/ Barium Follow Through
What is seen on an AXR for intestinal malrotation with volvulus?
Distended bowel with air fluid level
What is the broad initial management for bowel obstruction?
NBM
Fluid Resus if dehydrated
NG Decompression
ABx if at risk of intestinal ischaemia and sepsis
What is volvulus?
An obstruction caused by a loop of bowel becoming twisted
What are the core symptoms of bowel obstruction?
Vomiting
Abdominal distension
Nausea
Abdo pain
Why is bowel infarction an important complication?
Death of the bowel can allow for the bacteria found within the bowel to enter the bloodstream and ultimately lead to sepsis.
How must a midgut volvulus due to intestinal malrotation ultimately be managed?
Surgically
Any necrotic bowel must also be removed during surgery.
What symptoms might indicate bowel ischaemia with volvulus?
Bloody stool/diarrhoea
Abdominal pain
Abdominal distension
Vomiting
Note- also get a raised lactate due to ischaemic process
What unique feature may be seen with contrast series in intestinal malrotation with volvulus?
Corkscrew appearance of the duodenum and jejunum.
What is atresia?
Atresia is a lack of patency leading to obstructive symptoms
What condition is duodenal atresia associated with?
Down’s Syndrome- Trisomy 21
What sign might be present meaning atresia is picked up before birth? Why?
Polyhydramnios- due to obstruction the fetus is less able to swallow amniotic fluid meaning there is a build up of it. Bilious vomiting is then seen soon after birth.
What investigations would you do if suspecting duodenal atresia?
Abdominal X-ray
Contrast Series
Abdominal USS
Karyotyping may be done to investigate for trisomy 21.
What feature may be seen for duodenal atresia on an AXR?
Double bubble
Obstruction causes air-fluid levels to be visible proximal to the obstruction. Double as bubble separated by the pyloric valve.
What would the initial management for duodenal atresia be?
NBM
NG Tube Decompression
Fluid Resus
What is the definitive management for intestinal atresia?
Surgical correction- duodenoduodenostomy removing the problematic section.
What is the difference between stenosis and atresia?
Stenosis= Narrowed Atresia= Closed or Absent
What process failure leads to duodenal atresia?
There is failure of recanalisation/vacuolation of the duodenum
Why does polyhydramnios occur with duodenal atresia?
Obstruction means there is difficulty swallowing amniotic fluid which leads to increasing levels in the amniotic sac. This can be detected prenatally.
What are the sx of duodenal atresia?
Bilious vomiting in the first few days of life
Abdominal distension
What is Hirschsprung’s disease?
Congenital aganglionic megacolon- absence of ganglia in a portion of the small intestine. Leads to failure of peristalsis in that area and so intestinal obstruction.
Where does Hirschsprung’s disease commonly affect?
Distal/Sigmoid colon and rectum
What condition is associated with Hirschsprung’s disease?
Down’s Syndrome- Trisomy 21
What are the symptoms of Hirschsprung’s disease?
Failure to pass meconium within first 48 hrs of life
Abdominal distension
Vomiting
Why should a chest X-ray be done in cases of intestinal obstruction?
To check for perforation- there would be air beneath the diaphragm
How is Hirschsprung’s diagnosed?
AXR with contrast dye
Anorectal manometry
Definitive- Rectal suction biopsy obtaining samples from mucosa and submucosa (to check for nerve plexus)
What may occur during examination in Hirschsprung’s disease?
Tight anal sphincter and explosive release of stool/gas
What is the treatment for Hirschsprung’s disease?
Surgical removal of the aganglionic section
What are the symptoms of pyloric stenosis?
Projectile vomiting after eating
Constipation- little passage of stool as little food passes
What may be seen on physical examination in children with pyloric stenosis?
An olive shaped mass in the epigastrium- this is the hypertrophic pyloric sphincter
Visible peristaltic waves in the epigastrium
What electrolyte imbalance can pyloric stenosis lead to? (And other conditions with prolonged vomiting)
Metabolic alkalosis due to the loss of H+ in the vomit
Patients may also be hypochloremic due to loss of chloride ions.
Also, low fluid volume activates RAAS which causes raised sodium and reduced potassium.
How would you investigate for pyloric stenosis?
Abdominal USS
AXR with contrast series
Pyloric manometry
How does the vomit differ between obstruction due to duodenal atresia and pyloric stenosis?
Duodenal atresia causes bilious vomiting as the obstruction is distal to the ampulla of vater. The pyloric sphincter is proximal and so the vomit does not contain bile.
What is the definitive treatment for pyloric stenosis?
Pyloromyotomy- splitting of the sphincter to widen it. Also called Ramstedt’s procedure.
Important to correct fluid status and electrolyte abnormalities first!
What is annular pancreas?
A ring of pancreatic tissue surrounds and compresses the duodenum
What condition is annular pancreas associated with?
Down’s Syndrome- Trisomy 21
What kind of vomiting does annular pancreas cause?
An annular pancreas causes an obstruction that is proximal to the ampulla of vater. This therefore causes non-bilious vomiting.
What investigations should be done to investigate for annular pancreas?
AXR
Upper GI contrast series
Abdominal CT for definitive diagnosis
What is the definitive treatment for annular pancreas?
Surgical- duodenojejunostomy (duodenum is connected to the jejunum)
What is the most common cause of gastroenteritis?
Viral- Rota and Norovirus
What bacteria cause gastroenteritis?
Shigella Salmonella E.Coli Yersinia Campylobacter
How does the picture differ between viral and bacterial gastroenteritis?
Viral gastroenteritis is typically short lived and has a sudden onset
Bacterial gastroenteritis is prolonged and more severe
What parasites may cause gastroenteritis?
Giardia lamblia
Cryptosporidium
What three types of agents can cause gastroenteritis?
Viruses
Bacteria
Parasites
What factors may point towards a gastroenteritis causing vomiting and diarrhea?
Poor sanitation
Recent travel
Contacts with similar symptoms
Eating suspicious foods
What investigations may be done to investigate for a cause of gastroenteritis?
Stool Cultures- Bacterial
Stool PCR- Viral
Microscopy- Parasites
Important to check hydration status and inflammatory markers. FBC, U+Es, CRP, ESR, Creatinine/eGFR
What is the management for gastroenteritis?
Generally Supportive
Oral rehydration solution
Monitor fluid status- IV Fluids if needed
ABx guided by MC+S
Note- If vomiting oral route is contraindicated and so IV route may be needed.
What is intussusception?
Telescoping of the proximal portion of the bowel into the distal one
What are the symptoms of intussusception?
As with other abdominal obstructions- Nausea, Bilious vomiting (telescoping of small bowel distal to ampulla of vater)
Acute colicky abdominal pain
How is the pain of intussusception relieved sometimes?
By sitting with the knees brought up to the chest
For patients with intussusception what might indicate bowel ischaemia?
Intestinal ischaemia may result due to compression of the vessels that supply that area of bowel.
Results in red currant jelly stool, severe abdo pain and a raised lactate.
What is a very important complication of ischaemic bowel?
Necrosis of the bowel can lead breakdown of barriers allowing for bacteria to enter the bloodstream- leading to sepsis.
What investigations should be done to investigate for intussusception?
Abdominal USS- Shows target sign
AXR- Shows obstruction
CXR- Check for perforation
What is the treatment for intussusception?
Barium or water soluble contrast enema
If any necrotic, ischaemic or perforated bowel surgery is needed.
What is gastroparesis?
Delayed gastric emptying without any mechanical obstruction
