ANOREXIA, NAUSEA & VOMITING

Anorexia : Reduction in food intake due to loss of appetite

Physiological control of appetite






Regulation of food intake
Short term regulation
1] Stimulation of stretch receptors and transmitting stretch inhibitory signals from distended
stomach and duodenum.
2] GIT hormones suppress feeding : CCK, PYY, Insulin via GLP
Long term regulation
1] Lipostatic hypothesis
2]Aminostatic hypothesis
3] Glucostatic hypothesis [When blood glucose increase; increase firing rates of glucoreceptor in
satiety center and reduce firing of gluco sensitive neurones in feeding center]
4] Thermostatic hypothesis
5] Leptin : When food intake increase adipose tissue increases leptin in plasma increase[leptin
produced by adipose tissue] leptin act on hypothalamus and reduce action of neuropeptide Y on
feeding center therefore reduces food intake
Orexigenic substances : Cause a need to eat
more
Anorexigenic substances : Induce satiety
Neuropeptide Y Alpha MSH
AGRP Leptin
MCH Serotonin
Orexin A and B CRH
Endorphin Insulin
Cortisol CCK
Ghrelin GLP
CART
Peptide YY



Feeding center @
Lateral nuclei of hypothalamus
Satiety center @
entromedail nuclei of hypothalamus
When stimulated : Hyperphagia
When not functioning : loss of appetite
When stimulated : Aphagia
When not functioning : Obesity
Clinical approach to anorexia
Detect/ exclude common & sinister causes such as,
Example
Infections TB
Malignancies Gastric CA, intestinal, pancreatic, hepatic etc.
Metabolic diseases Diabetes, Hyperthyroidism,
Hyperparathyroidism, Addisons,
Hypercalcaemia
Other GI problems Coeliac disease, intestinal parasitosis
Intracranial lesions
Physiological conditions Anorexia nervosa in pregnancy


NAUSEA & VOMITING
Nausea : Feeling of desire to vomit/ An involuntary urge to vomit, not always accompanies vomiting
Vomiting : Forceful expulsion of intestinal contents
Physiology of vomiting
Stimulus for vomiting
Afferents : Vagal afferents, sympathetic afferents
Stimulation of the vomiting center
Efferents: Cranial nerves : V, VII, IX, X, XII
Phrenic nerve : To diaphragm
Spinal nerves : To diaphragm and abdiminal muscles
Antiperistalsis movements Lower SI contents moves to duodenum and stomach
Onset of vomiting Strong, intrinsic contraction in stomach and duodenum
Partial relaxation of LES
Moving of vomitus from stomach to oesophagus
Vomiting act - Deep breath
Raising hyoid bone and larynx Open UES
Closing the glottis
Lifting the soft palate : closure of posterior nares
Strong downward contraction of diaphragm together with contraction of all
abdominal muscles
Squeezing of stomach between diaphragm and abdominal muscles increasing
intragastric pressure
Complete relaxation of LOS
Expulsion of gastric contents through oesophagus
Vomiting can be due to;
Acute abdominal emergencies Cholecystitis, gastritis, peritonitis
Acute infectious disease UTI, gastro enteritis
Disorders of nervous system Increased ICP, encephalitis, Acute labyrinthitis, Menieres
disease, migraine headaches, acute meningitis
Disorders of heart Acute MI[specially if inferior wall]
Metabolic and endocrine Diabetic acidosis, morning sickness in pregnancy
Drugs and chemicals eg. NSAIDS
VOMITING IN NEW BORN
Differentiate from regurgitation
Regurgitation is gastro oesophageal reflux : effortless ,backward flow of gastric content to
oesophagus.
Vomiting : Intestinal contents are forcefully ejected through mouth
Regurgitation is common in children due to, 1] Small stomach
2] Immature lower oesophageal valve
To minimize regurgitation,
Burp often and effectively to prevent air swallowing.
Hold the baby upright/45
0
half an hour after feeding
Offer one breast per feeding to avoid forceful milk ejection.
Attach the baby to the breast after expressing the forceful spray, and once the flow has subsided.
If constant nursing is needed, pull off after 15 min and comfort.
Identify foods passes to baby from mother which may cause allergy, [eg. Cows milk allergy,
increase acidity tomatoes, citrus etc. , High fat foods- reduce gastric emptying.

Pathological regurgitation if associated,
Inadequate weight gain
Oesophagitis
Respiratory disease wheeze, pneumonia
Oral aversions
Managing pathological regurgitation
Small frequent meals
Food thickeners
Reduce acidity Antacids, H2 receptor blockers, PPI
Increase gastric emptying
If above fails : Surgical Funduplication

VOMITING
Consequences in vomiting in new born
Dehydration
Metabolic alkalosis
Electrolyte depletion hypokalaemia
Malnutrition
Aspiration pneumonia

RED FLAGS in vomiting in children
Bile stained vomiting Intestinal obstruction distal to opening of bile duct untill proven
otherwise.
Mx: NBM, IV fliud, IV antibiotic, open gastric drainage via NG tube

Most dangerous :volvulus in malrotation of midgut
Blood stained vomiting Common : swallowed maternal blood
APT test to differentiate mothers and childs blood. HbF is
preserved destroying HbA. Baby has 70% HbF.
Other causes : HDN,Stress ulceration, swallowed baby blood in
procedures[ET tube, NG tube etc], Oesophagitis
Projectile vomiting At birth : duodenal atresis [Double bubble in XR]
Pyloric stenosis:
Present b/w 2 7 weeks of age,
More common in males[ more in 1
st
born,
maternal family Hx]
Sym + Sign :
vomiting increase in frequency & forcefulness & be projectile
Hunger after vomiting untill dehydration leads to interest in feeding
LOW if delayed presentation

Give a test feed settle baby for Ex
Visible peristalsis from left to right across abdomen
Pyloric mass in right upper quadrant
Stomach overdistended with air

Ix :
Hypochloraemic metabolic alkalosis , Low plasma Na+ & K+
USS if in doubt

Mx:
Fluid and electrolyte correction[ IV 0.45% saline+5% dextrose+K supplements]
Pyloromyotomy definitive Tx post op fed within 6hrs, discharge in 2 days
Vomiting with diarrhoea Gastroenteritis.
May cause dehydration and shock
Mx : Breast feeding, ORS, IV fluids, Anti emetics
Vomiting in unwell baby Unwell with fever Infection until proven otherwise
Pertussis vomiting after coughing
Ear infection crying, ear drum bulging
UTI crying during micturition
Meningitis bulging fontanelle, irritable

Mx: IV antibiotics based on empirical diagnosis

Unwell without fever
Infection UTI
Increase ICP hydrocephalus
Congenital adrenal hyperplasia
Inborn errors of metablolism[IEM]
Vomiting with failure to thrive Gastro oesophageal reflux disease
Coeliac disease
Infection : UTI
IEM
Vomiting with abdominal
tenderness
Surgical abdomen
Vomiting with blood in stools Intussusception, Gastroenteritis

PLEASE DO THE MCQS UNDER VOMITING AFTER REFFERING TO THIS NOTE.
ONE SEQ RELATED TO THE TOPIC IS UNDER METOCLOPRAMIDE IN A/L 2004