vomiting + malabsorption in children

Question 1

pyloric stenosis features

Answer 1

projectile non-bilious vomiting
weight loss
dehydration +/- shock

Question 2

pyloric stenosis characteristic electrolyte disturbance

Answer 2

metabolic alkalosis
hypochloraemia
hypokalaemia

Question 3

effortless vomiting

Answer 3

regurgitation
involuntary passage of gastric contents through the mouth

self limiting and resolves spontaneously in vast majority of cases

Question 4

when may effortless vomiting not resolve spontaneously with age

Answer 4

cerebral palsy
progressive neurological problems
oesophageal atresia +/- TOF operated
generalised GI motility problem

Question 5

what is effortless vomiting almost always due to

Answer 5

gastro-oesophageal reflux

Question 6

pathophysiology of reflux in infants

Answer 6

LOS lax, mainly lying down and feeds are mainly liquid –> all predisposes them to GOR

tends to improve w age when solids are introduced from 6mo and when begin to sit/stand/walk

Question 7

presenting symptoms GOR

Answer 7

vomiting 
haematemesis 
feeding problems 
failure to thrive
apnoea 
cough 
wheeze
chest infection 
sandifer's syndrome

Question 8

sandifer’s syndrome

Answer 8

association of GOR disease with torticollis and dystonic body movements

Question 9

diagnosing GOR

Answer 9

hx and exam often sufficient
oesophageal pH study/impedance monitoring
endoscopy
radiological investigations: video fluroscopy, barium swallow

Question 10

GOR treatment

Answer 10

feeding advice, nutritional support

medical treatment
surgery

Question 11

GOR feeding advice

Answer 11

• thickeners for liquids
• appropriateness of foods: texture, amount
• behavioural stimulation: oral stimulation, removal of adverse stimuli
• feeding position
• check feed volumes

Question 12

GOR nutritional support

Answer 12

calorie supplements
exclusion diet - cows milk protein free trial for 4 weeks
NG tube
gastrostomy

Question 13

GOR medical treatment

Answer 13

feed thickener - gaviscon, thick + easy

acid suppressing drugs; H2 receptor blockers, proton pump inhibtors

Question 14

GOR indications for surgery

Answer 14

failure of medical treatment

persistent: failure to thrive, aspiration, oesophagitis

vomiting without complications may not be an indication

Question 15

GOR surgery

Answer 15

nissen fundoplication

fundus is wrapped round LOS

Question 16

bilious vomiting

Answer 16

should always ring alarm bells

due to intestinal obstruction until proven otherwise

Question 17

causes of bilious vomiting

Answer 17

intestinal atresia - newborns only
intussusception
ileus
crohn’s disease w strictures

Question 18

bilious vomiting investigations

Answer 18

abdo x-ray
consider contrast meal
surgical opinion re exploratory laparotomy

Question 19

chronic diarrhoea

Answer 19

4+ stools per day for more than 4 weeks

Question 20

causes of diarrhoea: motility disturbance

Answer 20

toddler diarrhoea

irritable bowel syndrome

Question 21

causes of diarrhoea: active secretion

Answer 21

(secretory)
acute infective diarrhoea
inflammatory bowel disease

Question 22

causes of diarrhoea: malabsorption of nutrients

Answer 22

(osmotic)
food allergy
coeliac disease
CF

Question 23

osmotic diarrhoea

Answer 23

movement of water into bowel lumen to equilibrate osmotic gradient

usually a feature of malabsorption: enzymatic defect, transport defect

Question 24

osmotic diarrhoea: enzymatic defect

Answer 24

e.g. secondary lactase deficiency due to loss of brush-border enzymes after diarrhoeal illness

Question 25

osmotic diarrhoea: transport defect

Answer 25

e.g. glucose-galactose transported defect

Question 26

secretory diarrhoea

Answer 26

classically assoc with toxin productions from vibrio cholerae and enterotoxienic e.coli

intestinal fluid secretion predominantly driven by active Cl- secretion via CFTR

Question 27

clinical approach to chronic diarrhoea

Answer 27

thorough history
consider growth + weight gain of child
faeces analysis: appearance, stool culture, determination of secretory vs osmotic

Question 28

history taking chronic diarrhoea

Answer 28

age onset 
abrupt/gradual onset
Fam Hx
travel history/local outbreaks 
nocturnal defecation suggests organic pathology

Question 29

fat malabsorption causes

Answer 29

pancreatic disease: diarrhoea due to lack of lipase and recurrent steatorrhoea, classically CF

hepatobiliary disease: chronic liver disease, cholestasis

Question 30

coeliac disease

Answer 30

autoimmune condition

gluten sensitive enteropathy

wheat, rye, barley

Question 31

presenting features coeliac disease

Answer 31

abdo bloating
dirrhoea 
failure to thrive
short stature
constipation 
tiredness
hepatiformis

Question 32

coeliac disease screening tests

Answer 32

serological screens

• anti-tissue transglutaminase
• anti-endomysial
• serum IgA

duodenal biopsy

genetic testing: HLA DQ2, DQ8

Question 33

treatment of coeliac disease

Answer 33

gluten-free diet for life

gluten must not be removed prior to diagnosis as serological and histological features will resolve

Question 34

histology coeliac duodenum

Answer 34

lymphocytic infiltration surface epithelium
partial/total villous atrophy
crypt hyperplasia

Question 35

when to do endoscopy + biopsy for coeliac

Answer 35

• symptomatic
• anti TTG +ive
• anti-endomysial +ive
• HLA DQ2, Q8 +ve

all present diagnosis without endoscopy
any missing then endoscopy