Approach to the

Child with Vomiting

By

Dr. C. Kannan,

1st year PG, Pediatrics Department, MGMCRI

Nausea

The unpleasant sensation of the imminent need to vomit,Usually referred to the throat or epigastriumA sensation that may or may not ultimately lead to the act of vomiting.

Retching

muscular activity of the abdomen and thorax, often voluntarilyleading to forced inspiration against a closed mouth and glottis without oral discharge of gastric contents

Vomiting

Forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest wall musculature.

Regurgitation

The act by which food is brought back into the mouth.without the abdominal and diaphragmatic muscular activity.

Rumination

Food that is regurgitated in the postprandial period, re-chewed and then re-swallowed (psychological)

NEUROPHYSIOLOGY

There are four major pathways by which nausea and vomiting are induced,

Vagal afferents

Abdominal vagal afferents are involved in the emetic response. Can be evoked by either mechanical or chemo-sensory sensations. Examples of sensations that trigger this pathway include over distension, food poisoning, mucosal irritation, cytotoxic drugs, and radiation.

Area postrema

Chemotrigger receptor zone

Vestibular system

It involved in the emetic response to motion Exacerbated by visual sensations, Irritation or labyrinthine inflammation.

Amygdala

ETIOLOGY OF VOMITTING

Central

Vestibular - motion sickness and vertigo

Infectious - gastroenteritis, septicemia, non-GI infections

Cortical - pain, strong emotions, smell, taste

Drugs - chemotherapy, opiates

Metabolic - acidosis, uremia, hyperthyroidism, hypercalcemia, adrenal disorders

Peripheral

Pharyngeal stimulation

Gastric mucosal irritation

Gastric and intestinal obstruction/dilation

INTRODUCTION TO APPROACH

A standardized approach is not recommended

Vomiting may be caused by many pathologic states involving several systems including

Gastrointestinal, Neurologic, Renal, and Psychiatric

The best course of action should be dictated by the medical history.

History of presenting illnessCharacteristics of vomitus

Smell Quantity Colour Blood - Bright red/dark red/coffee-ground BiliousTiming - Onset, Duration, Frequency and Time of day

Triggers / Associated symptoms

Diarrhoea Fever Abdominal pain/distension Anorexia Stool frequency Urinary output Headache Vertigo Lethargy Stiff neck Cough Sore throat

Past medical history

Chronic illnesses like Diabetes

Travel history (infectious gastroenteritis)

Recent head trauma

Toxin exposure

Medications

Allergies

Few important interpretations of history

Undigested Achalasia

Bilious Post ampullary obstruction

Blood or coffee ground Gastritis , Ulcer

Bloody after forceful vomiting Mallory wiess tear

Malodorous Stasis with bacterial overgrowth

Feculent Obstruction

Force of vomiting

Forceless Regurgitation , gastroesophagial reflux

Projectile Pyloric stenosis, obstruction, metabolic disease

Temporal associations of chronic or recurrent vomitting

Temporal associations Diagnosis

Time of day

Early morning increased ICP, sinusitis with postnasal mucous, pregnancy, uremia(headache, papilledema, sinus tenderness, secondary amenorrhea)

During or after meals peptic ulcer disease, reflux(epigastric pain, heart burn)for specific foods(Heredetary fructose intolerance, galactocemia, metabolic inborn error, cows milk intolerance, etc.,

After fasting food vomitted gastric obstructionfood not vomitted metabolic disease

Other precipitants

Cough posttussive

Infections metabolic, reccurent gastroenteritis

Vestibular stimulation motion sickness, menetrriers disease

Hyperhydration uretropelvic junction obstruction

Menses dysmenorrhea associated vomitting, acute intermittent porphyria

Medications and toxins medication side effects – pancreatitis, hepatitis, AIPsteroid withdrawal – Addisons diseasepoisonings – NSAIDS

Episodic / cyclic

Abdominal migraine, abdominal epilepsy, pheochromocytoma, pophyria, familial dysautonomia, metabolic inborn error, FMF, self induced, cyclical vomitting

Food associations

Cow milk, soy, gluten - Protein intolerance

Multiple food exacerbants - Esinophilic gastroenteritis, fructose intolerance

Periodicity of vomiting

Paroxysmal, cyclic

- cyclic vomiting syndrome, porphyria, carcinoid, pheochromocytoma, familial dysautonomia

Neurological symptoms

Headache, vertigo, visual changes - Metabolic, toxin, CNS disease

Fundoscopic evidence of increased ICP - CNS mass

Others

Lack of nausea CNS mass

Esophagial pain Esophagitis

Diarrhea Infectious enteritis

Abdominal peristaltis Obstruction, pyloric stenosis

Peritoneal signs Surgical abdomen, perforated appendicitis

Jaundice Hepatobiliary etiology or urinary tract infection in a neonate

Surgical scars Obstruction secondaryto adhesions

Early morning vomiting Pregnancy and CNS mass

Vomiting with meals Peptic ulcer disease, Psychogenic disease, Disproportionate hypotention, Hyperkalemia, Adrenal crisis

Prolonged vomiting

>12 hours in a neonate,

>24 hours in children younger than two years of age, or

>48 hours in older children should not be ignored.

Screening laboratory tests should include

Complete blood count

Electrolytes,

Blood urea nitrogen,

Amylase, lipase,

Liver function tests,

Urinalysis, urine culture, and stool studies for occult bloodLeukocytes, and parasites.

Additional testing should be based upon the history and physical examination

Clues on physical examination

Certain physical findings may offer diagnostic cluesWhich aids in narrowing the differential diagnosis:

A tense, bulging fontanel in a neonate or young infant

Increases the level of suspicion for meningitis.

Projectile vomiting in an infant three to six weeks of age suggests

Pyloric stenosis

Ambiguous genitalia and/or hyperkalemia suggest the possibility of

Adrenal crisis (usually due to congenital adrenal hyperplasia).

An unusual odor emanating from the patient should prompt an investigation for

Metabolic causes of vomiting.

Marked distension, visible bowel loops, absent bowel sounds, green or yellow bile, or increased "rumbling" bowel sounds should raise suspicion for

Intestinal obstruction.

Enlarged parotid glands in an adolescent should raise suspicion for

Bulimia

Vomiting in association with trauma should prompt imaging studies

To rule out intracranial or intra abdominal injury.

Hypotension disproportionate to the apparent illness and/or hyperkalemia suggests

The possibility of adrenal crisis

Headache, positional triggers for vomiting, lack of nausea on awakening should suggests

The possibility of intracranial hypertension

Most common causes of vomiting in Neonates

Physiologic reflux or GERD

Pyloric stenosis

Necrotising enterocolitis

Malrotation with midgut volvulus

Gastroenteritis

Hirshprung disease

Congenital atresias, stenosis, web

Metabolic disorders

Feeding intolerance

Common causes of vomitting in Infants (1 month to 1 year)

Acute

Gastroenteritis Pyloric stenosis Hirschsprung’s disease Acutely evolving surgical abdomen Congenital atresias and stenosis Malrotation Intussusception Sepsis and non-GI infection Metabolic disorders

Chronic

Gastroesophageal reflux disease Food intolerance Congenital atresias and stenosis Malrotation Intussusception

Children and

Adolescents

ACUTE

Gastroenteritis

Appendicitis

Sepsis and non-GI

infection

Metabolic disorders

Toxic ingestion

CHRONIC

Gastroesophageal

reflux disease

Gastritis

Food intolerance

Cyclic vomiting

Intracranial

hypertension

Inborn errors of

metabolism

Eating disorders

COMPLICATIONS OF VOMITTING

Nutrition Adults - weight loss, kids - Failure to gain weight/grow

Cutaneous Petechia, Purpura

Oropharyngeal Dental erosion, sore throat)

Esophageal Esophagitis / hematoma

GE junction M-W tears, rupture of esophagus (Borhaeve’s)

Metabolic Electrolyte, acid-base, water imbalance

Renal Pre-renal azotemia, ATN, hypokalemic nephropathy

Infection Spread of infection to close contacts and caregivers(H. pylori, GI viruses)

TREATMENT

Treatment should be directed towards the underlying etiology.

Electrolyte abnormalities, metabolic abnormalities, and nutritional deficiencies should be corrected.

Cognitive-behavioral interventions are useful for vomiting associated with functional dyspepsia, adolescent rumination syndrome and bulimia.

Prokinetic medications such as metoclopramide, domperidone and erythromycin are beneficial when there are abnormalities in esophago-gastric motility.

Antiemetics, which are useful in persistent vomiting to avoid electrolyte abnormalities or nutritional sequelae, typically have not been recommended in the case of vomiting of unknown etiology. These agents are contraindicated in infants .

Likewise, they are not indicated for anatomic abnormalities or surgical abdomen.

Instead, antiemetics are most useful for motion sickness, postoperative vomiting, cyclic vomiting syndrome, and gastrointestinal motility disorders .

A single dose ondensetran may facilitate oral rehydration in children with gastroenteritiswho are unable to tolerate oral intake.

GUIDELINES FOR SICK DAY MANAGEMENT

Urine ketones Insulin(rapid acting)

Frequency of monitoring

Comments

Negative/small Q2H Q2Hif CBG >250 mg/dl

Check ketones every other void

Moderate to large Q1H Q1Hif CBG >250 mg/dl

Check ketones on each void

THANK YOU !!