Vomiting, GORD & pyloric stenosis

Question 1

Causes of vomiting in infants?

Answer 1

1) GORD
2) Feeding problems
3) Gastroenteritis
4) Infection - UTI, respiratory, whooping cough
5) (dietary) protein intolerance
6) Intestinal obstruction - pyloric stenosis, intussusception
7) Congenital adrenal hyperplasia
8) Hirschsprung disease

Question 2

Causes of vomiting in pre-school children?

Answer 2

1) Gastroenteritis
2) Infection - respiratory, UTI, whooping cough
3) Appendicitis
4) Intestinal obstruction - intussusception
5) Raised ICP
6) Torsion of the testis

Question 3

Causes of vomiting in school children/adolescents?

Answer 3

1) Gasteroenteritis
2) Peptic ulceration + H. pylori
3) Appendicitis
4) Migraine
5) Diabetic ketoacidosis
6) Alcohol
7) Pregnancy

Question 4

Red flags in the vomiting child?

Answer 4

1) Bile stained - intestinal obstruction
2) Haematemesis - oesophagitis, oral/nasal bleeding, peptic ulceration
3) Projectile (first few weeks) - pyloric stenosis
4) Vomiting due to excess cough - whooping cough
5) Abdominal distention - intestinal obstruction
6) Blood in stool - gastroenteritis, intussusception
7) Failure to thrive - GORD, coeliac disease

Question 5

What is GORD?

Answer 5

The involuntary passage of gastric contents into the oesophagus.

Question 6

Epidemiology and RF:

Answer 6

• Extremely common in infancy and in the first year of life
• Nearly all symptomatic reflux resolves by 12 months of age (due to maturation of lower oesophageal sphincter, more upright posture and more solids in diet).
• SEVERE reflux more common in cerebral palsy and other neurodevelopment disorders.

Risk factors:

1) Predominantly fluid diet, horizontal posture and short intra-abdominal length of oesophagus (all found in infancy)
2) CEREBRAL PALSY
3) PRE-TERM baby

Due to the inappropriate relaxation of the lower oesophageal sphincter as a result of functional immaturity.

Question 7

Clinical presentation of GORD?

Answer 7

1) Recurrent vomiting and regurgitation

2) Putting on NORMAL weight

Question 8

Diagnosis of GORD?

Answer 8

1) Usually clinical with no investigations
2) In an atypical history: 24 hour Oesophageal pH monitoring, and endoscopy with biopsy to identify oesophagitis and exclude other causes.

Question 9

Treatment of GORD?

Answer 9

Mild:
Thickening agents to feeds: Nestragel
Positioning at a 30 degree head-up prone position following feeds.

Moderate:
Acid suppression with H2 receptor antagonist Ranitidine, or PPI Omeprazole. (reduce volume of gastric contents in acid-related oesophagitis)

Severe:
If not responding to medication - further investigation to rule out other causes such as cows milk protein allergy.
Nissen fundoplication - Fundus of stomach is wrapped around intra-abdominal oesophagus (augments lower oesophageal sphincter so harder for gastric reflux).

Question 10

Complications of GORD?

Answer 10

1) Failure to thrive from severe vomiting
2) Oesophagitis resulting in haematemesis, iron-deficiency anaemia, discomfort on feeding and heartburn.
3) Recurrent pulmonary aspiration - resulting in recurrent pneumonia, cough, wheeze and even apnoea in infants.

Question 11

Ddx of GORD?

Answer 11

1) Intermittent Intussusception
2) Hirschsprungs
3) Gastroenteritis

Question 12

What is pyloric stenosis?

Answer 12

The hypertrophy of the pyloric muscle causing gastric outflow obstruction.

Question 13

Epidemiology of pyloric stenosis? Risk factors?

Answer 13

1) Presents between 2 and 7 weeks
2) More common in boys - particularly first-borns
RF: Male, family history (on maternal side), first-born

Question 14

Clinical presentation of pyloric stenosis?

Answer 14

1) Projectile vomiting - initially vomiting and increases in frequency until projectile - NOT bile-stained, large volume within minutes of feed.
2) Hunger after feeds until dehydration leads to a loss in feeding interest.
3) Weight loss if delayed presentation
4) Constipation

Question 15

Differential diagnosis of pyloric stenosis?

Answer 15

1) GORD

2) Over-feeding

Question 16

Diagnosis of pyloric stenosis?

Answer 16

1) Test feed - milk feed given to calm hungry baby enabling examination
2) O/E - Gastric peristalsis my be seen moving as a wave from left to right across abdomen, RUQ - pyloric mass palpable (feels like an olive)
3) Abdominal ultrasound (DIAGNOSTIC)

Question 17

Treatment of pyloric stenosis?

Answer 17

1) Correct any fluid and electrolyte disturbance with IV fluids (e.g. IV 0.45% saline and 5% dextrose with K+ supplements)
2) Ramstedt Pyloromyotomy - division of hypertrophied muscles down to but not including mucosa.