health-process-evidence- based clinical practice guidelines for vomiting jgguerra, md surgery-ommc...
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Health-Process-Evidence-based Clinical Practice
Guidelines for Vomiting
JGGuerra, MD
Surgery-OMMC
072706
Vomiting
A. Overview of the Problem– Concept– Common Types– Common Causes
B. General Management Guidelines– Clinical Diagnosis– Paraclinical Diagnosis– Treatment
Clinical Questions1. What is the operational concept of
vomiting?
Definition
• Expulsion of gastrointestinal contents through the mouth due to a mechanical cause
2. How is vomiting classified in terms of etiology?
• Systemic
• Infectious
• Neurologic
• GIT (Mechanical)
Clinical Questions
3. How is vomiting classified in terms of GIT origin?
• Upper GIT
• Lower GIT
Clinical Questions
4. How is vomitus classified in terms of its character?
• Nonbilous• Bilous • Fecaloid
Clinical Questions
5. How does the character of vomitus localize the site of obstruction?
• Nonbilous – proximal to ligament of treitz• Bilous – distal to Ligament of Treitz• Fecaloid – distal bowel
Clinical Questions
9. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient is vomiting due to esophageal obstruction?
• Onset – immediately postprandial
• Characteristic – undigested food particles (chyme)
• Abdominal distention - none
Clinical Questions
10. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient is vomiting due to gastric outlet obstruction?
• Onset – early postprandial
• Characteristic – partially digested food
• Abdominal distention – minimal epigastric distention
Clinical Questions
11. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient is vomiting due to small intestinal obstruction?
• Onset – >2 days postprandial*
• Characteristic – bilous*
• Abdominal distention – minimal* Snape: Best Practice of Medicine. 2003
Clinical Questions
12. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient is vomiting due to colonic obstruction?
• Onset – late
• Characteristic – fecaloid*
• Abdominal distention - marked* Tan Lay Zye: Merck. 2002
Clinical Questions
Vomiting
General Management Guidelines
•Clinical Diagnosis
•Paraclinical Diagnosis
•Treatment
VOMITING
Systemic Mechanical
NeurologicInfectious
UGIT LGIT
Stomach Small BowelEsophagus Duodenum Colon
Sphincter Fnxn
Mechanical Obstruction
Mechanical ObstructionA. Stricture (PUD)B. Mass (benign, malignant)
Postoperative Adhesions
Mass
Clinical Diagnosis
Clinical Questions13. If a paraclinical diagnostic procedure is needed
in a patient with esophageal cause of vomiting, what is the most cost-effective procedure to do?
Benefit Risk Cost Availability
UGIS Sn rate: 80-85%
SP rate: 82%
radiation 2k /
Endoscopy Sn rate: 95%
SP rate: 98%
perforation 5k /
CT scan Sn rate: 82%
SP rate: 80%
radiation 3k /
Clinical Questions14. If a paraclinical diagnostic procedure is needed
in a patient with gastric outlet obstruction, what is the most cost-effective procedure to do?
Benefit Risk Cost Availability
UGIS Sn rate: 80-85%
SP rate: 82%
radiation 2k /
Endoscopy Sn rate: 95%
SP rate: 98%
perforation 5k /
CT scan Sn rate: 82%
SP rate: 80%
radiation 3k /
Clinical Questions15. If a paraclinical diagnostic procedure is needed in
a patient with small intestinal cause of vomiting, what is the most cost-effective procedure to do?
Benefit Risk Cost Availability
PFA Sn rate: 80%
SP rate: 62%
radiation 2k /
CT scan Sn rate: 82%
SP rate: 80%
radiation 3k /
Clinical Questions16. If a paraclinical diagnostic procedure is needed
in a patient with colonic cause of vomiting, what is the most cost-effective procedure to do?
Benefit Risk Cost Availability
PFA Sn rate: 80%
SP rate: 62%
radiation 2k /
Colonoscopy Sn rate: 95%
SP rate: 93%
perforation 5k /
CT scan Sn rate: 82%
SP rate: 80%
radiation 3k /
Clinical Questions17. What is the most cost-effective initial
treatment for vomiting due to obstruction?
• NGT
Clinical Questions18. What is the most cost-effective
treatment for esophageal cause of obstruction?
• Depends on the nature and extent of the disease
Clinical Questions19. What is the most cost-effective
treatment for Gastric outlet obstruction?
• Benign – vagotomy + pyloroplasty• Malignant – resection with reconstruction
Clinical Questions20. What is the most cost-effective
treatment for small intestinal obstruction?
• Surgery
Clinical Questions21. What is the most cost-effective
treatment for colonic obstruction? • Surgery
1. Jaffin BW, Kaye MD: The prognosis of gastric outlet obstruction. Ann Surg 1985 Feb; 201(2): 176-9.
2. Levine MS, eds. Textbook of Gastrointestinal Radiology. 2nd ed. Philadelphia, Pa: WB Saunders; 2000: 514-45.
3. Rosen, RT. Rosen's Emergency Medicine: Concepts and Clinical Practice,Nausea and Vomiting 5th ed. St. Louis: Mosby; 2002:178-85.
4. Snape, WJ. Best Practice in Medicine. 536.2.Aug, 2003.