Vomiting. overt reflux. passage of gastric contents into the mouth
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1 VOMITING Atan Baas Sinuhaji Sub Division of Pediatrics Gastroentero-Hepatology Department of ChildHealth,School of Medicine University of Sumatera Utara /Adam Malik Hospital Medan
2 Vomiting overt reflux passage of gastric contents into the mouth
3 Reflux Movement of gastric contents retrograde Into esophagus or more proximal Food/ Drink Gases Gastric Acid
4 REFLUX OVERT SILENT INTO THE MOUTH INTO THE ESOPHAGUS TO RESP. TRACT VOMITING LARYNGITIS PNEUMONIA ASPIRATION
5 REFLUX GASTRIC PRESS. > ESOPH. PRESS. GASTRIC PRESS. = ESOPH. PRESS. OBSTRUCTION RETROGADE PERISTA LSIS FUNCTION HIATAL HERNIA IN Gastric Outlet Obstruc. Pyloric Stenosis OUT AbdomInal Tumor Lower Esophageal Sphincter (LES) RELAXATION
6 LES RELAXATION TRANSIENT CONTINOUS Gastroesophageal reflux Chalasia
7 SLIDING HIATUS HERNIA HIATAL HERNIA = PARTIAL THORACIC STOMACH PARAESOPHAGEAL HERNIA = ROLLING
8 REFLUX FOOD/DRINK GASES GASTRIC ACID = ACID REFLUX ERUCTATION HICCUP = SINGULTUS = CEKUKAN HEARTBURN = PYROSIS = SENDAWA Metaplasia Epithel of esophagus Barrett s esophagus ADENO CA ULCUS bleeding stricture
9 CONSEQUENCES OF REFLUX 1.- SINGULTUS - ERUCTATION 2. HEART BURN = SENDAWA 3. ESOPHAGITIS & BARRET S ESOPHAGUS 4. CHRONIC PNEUMONIA ASPIRATION 5. FAILURE TO THRIVE (FTT) 6. LARYNGITIS 7. RUMINATION 8. SANDIFER S SYNDROME 9. FOOD REFUSAL
10 VOMITING RETURN OF FOOD/DRINK FROM THE STOMACH TO THE MOUTH TRUE VOMITING REGURGITATION = SPITTING = MINTAR = GUMOH PHYSIOLOGIC GER PATHOLOGIC COMPLICATION (GASTROESOPHAGEAL DISEASE = GER Disease)
11 Gastroesophageal reflux (GER) Physiologic passage of gastric content to esophagus Transient LES relaxation
12 Gastroesophageal reflux - 50% of infant 0-3 months of age - 25% of infant 3-6 months of age - 5% of infant months of age Resolving in most by 12 months and nearly all by 24 months
13 Gastro Esophageal Reflux Disease (GERD) GER that causes symptoms or complications that effect quality of life
14 GERD VOMITING - Not all vomiting are GERD - Many GERD children do not vomit
15 TRUE VOMITING NAUSEA RETCHING FORCEFUL GASTRIC CONTENTS/ INTRA ABDOMINAL PRESSURE SYMPTOMS OF AUTONOMIC NERVUS SYSTEM (+)
16 REGURGITATION THE YOUNG BABY NOT MATURE L.E.S. NAUSEA (-) NOT FORCEFUL SYMPTOMS OF ANS (-)
17 RUMINATION - RETURN OF FOODS INTO THE MOUTH - FOODS RECHEWED - FOODS REINGESTED
18 NAUSEA - UNPLEASANT SENSATION & OFTEN CULMINATING IN VOMITING - CONTRACTION OF PYLORIC ANTRAL - SYMPTOMS OF ANS (+)
19 VOMITING IN INCREASE INTRACRANIAL PRESSURE - PROJECTILE - NAUSEA (-) - RETCHING (-)
20 DIAGNOSIS GER 1. History 2. Body weight poor weight gain? 3. Diagnostic Test - Upper GI series rule out anatomical abnormalities - ph probe (12-24 hours) GOLD STANDARD - Scintigraphy - Endoscopy complication
21 TREATMENT GER 1. Conservative therapy 2. Pharmacotherapy 3. Surgery Nissen Fundoplication
22 THE NISSEN FUNDOPLICATION A. The lower esophagus is mobilized,allowing the fundus of the stomach to be pulled up and around the lower esophagus B and C.The fundic wrap has sutures placed to form a collar around the lower esophagus
23 Conservative Therapy 1. Prone position and upright position : - The infant is awake and observed SIDS 2. Small frequent feeding 3. Thickening of formula
24 Pharmacotherapy 1. Acid Neutralization : Antacids 2. Antisecretory ( Cimetidine, Ranitidine, 3. Prokinetic Omeprazole, etc) - Metoclopramide Extrapyramidal Symptoms - Bethanechole Bronchospasme - Cisapride : 0,2 mg/kg/dose 3 or 4 x daily Arrythmia
25 VOMITING SURVIVAL VALUE DEFENSE - UNDERLYING - COMPLICATION TOXIC THREATENING
26 COMPLICATION OF TRUE VOMITING 1. Body Fluids Imbalance - dehydration - hyponatremia - hypokalemia - hypochloremia - hypocalcemia ==> tetany - metabolic alkalosis 2. Mallory Weiss Syndrome 3. Pneumonia aspiration 4. Intake - hypoglicemia - starvation - Failure To Thrive - Metabolic acidosis
27 Na + VOMITING H + Water K + Cl - Hyponatremia Met. Alk. dehydration hypovolemia Hypokalemia Hypochloremia hypocalcemia RBF Renin Loss of H + Aldosteron Loss of K + Retention of Na + & Water
28 LOSS OF K + HYPOKALEMIA IN VOMITING METABOLIC ALKALOSIS ALDOSTERON
29 LOSS OF H + METABOLIC ALKALOSIS IN VOMITING HYPOKALEMIA ALDOSTERON
30 VOMITING METABOLIC ALKALOSIS METABOLIC ACIDOSIS > > > -ADRENAL INSUFF - INBORN ERROR - RENAL FAILURE - STARVATION
31 DIARRHOEA MET. ACIDOSIS METAB. ALKALOSIS > > > Congenital Chloridorrhea
32 VOMITING DIGESTIVE TRACT OUTSIDE Surgery - obstruction - inflammation - perforation Medical - gastritis - peptic ulcer - Gastroenteritis - psychogenic - neurogenic: int.cran. press. - systemic:sepsis - hemodynamic
33 1. STABILIZATION OF GENERAL CONDITION MANAGEMENT 2. PROTECTION AGAINST ASPIRATION Body Fluids Imbalance 3. CAUSAL ABDOMINAL EMERGENCY 4. CALORI/ PROTEIN 5. COMPLICATIONS 6. ANTIEMETIC DRUGS PNEUMONIA ASP. CEREBRAL EDEMA NO RECOMMENDED
34 ANTI EMETIC 1. DOPAMINE receptor antagonist - metoclopramide - domperidone 2. Cannabinoid (dronabinol) 3. Anticholinergic (Scopolamine) 4. 5 HT 3 receptor antagonist - ondansetron 5. Phenothiazine dan anti histamin - phenergan, benadryl - largactil 6. Corticosteroid
35 PERUBAHAN KIMIA DARAH (OBAT, TOKSIN, METABOLIK) -PSIKOGENIK -VASKULAR -TIK -SEIZURE CTZ BBB KORTEKS PERIFER N.X AFF. SIMFATIS VOMITING CENTRE N. FRENIKUS N.VIII VESTIBULAR N. SPINALIS -SAL.CERNA N. VAGUS -SAL.NAFAS -HEPATOBILIAR -PANKREAS -JANTUNG -GINJAL -KONTRAKSI DIAFRAGMA -KONTRAKSI OTOT DINDING PERUT -KONTRAKSI USUS -PERNAFASAN TERTAHAN 35
36 COMPLETE INVAGINATION BOWEL OBSTRUCTI0N INCOMPLETE PYLORIC STENOSIS
37 INVAGINATION = INTUSSUSCEPTION PROXIMAL BOWEL (INTUSSUSCEPTUM) DISTAL BOWEL (INTUSSUSCIPIENS) SPONTANEUS REDUCTION CONTINUING 3 months - 3 years
38 TYPE OF INVAGINATION - ILEOCOLIC > > > - ILEOILEIC - CECOCOLIC - COLICOCOLIC - ILEOILEOCOLIC
39 SIGNS & SYMPTOMS - SUDDEN ONSET - PAROXYSMAL PAIN - VOMITING - BLEEDING PERANUM - TUMOR - SIGNE de DANCE - ABDOMINAL DISTENTION - DEFECATION & FLATUS (-) Th / : - WATER & ELECTROLYTES - HYDROSTATIC - OPERATIVE
40 CLINIC PLAIN OF ABDOMINAL PHOTO DIAGNOSTIC RADIOLOGIC SIGN OF OBSTRUCTION BARIUM ENEMA - CUPPING - COIL SPRING
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