Sariu Ali:

A Vomiting Child

Introduction

• Vomiting is a symptom, presenting complaint in multitude of disorders– Range from gastrointestinal pathology to

disease in distant organ (otitis media or intracranial lesion)

• In children, especially infants, must distinguish from regurgitation – effortless expulsion of gastric contents

Vomiting is an active process , composed of 3 linked activities : Nausea , retching, active propulsion of stomach contents

Control of vomiting by 2 anatomic centers in the mudulla

Chemoreceptor trigger zone CTZcentral vomiting center.

Physiology

Common causes of vomiting

Infants Child Adolescent

GastroenteritisGastroesophageal refluxOverfeedingAnatomic obstructionSystemic infectionPertussis syndromeOtitis media

GastroenteritisGastritisToxic ingestionReflux (GERD)MedicationSystemic infectionPertussis syndromeSinusitisOtitis media

GastroenteritisGERDGastritisInflammatory bowel diseaseAppendicitisToxic ingestionSystemic infectionSinusitisMigrainePregnancyMedication

Infants Child Adolescent

•CAH

•Inborn error of metabolism

•Brain tumor (increased intracranial pressure)

•Subdural hemorrhage

•Food poisoning•Renal tubular acidosis

•Reye syndrome•Hepatitis•Peptic ulcer•Pancreatitis•Brain tumor•Increased ICP•Middle ear disease•Chemotherapy•Achalasia•Cyclic vomiting (migraine)•Esophageal stricture•Duodenal hematoma•Inborn error of metabolism

•Reye syndrome•Hepatitis•Peptic ulcer•Pancreatitis•Brain tumor•Increased ICP•Middle ear disease•Chemotherapy•Cyclic vomiting (migraine)•Biliary colic•Renal colic

Rare causes of vomiting

Gastrointestinal Causes Infection

GasteroenteritisPeritonitisAppendicitsHepatitis

Motility disordersAchalasiaPseudoobstructionHirschsprung diseaseGastroparesis

Mechanical obstruction

Congential anomalies Malrotation +volvulusIntussusceptionForeign bodiesMeconium ileusIncarcerated hernia

InflammationGERIntrinsic outlet inflammationGastric outlet inflammationDuodenal ulcersEosinophilic gastroenteritisFood allergy /intoleranceCeliac diseasePancreatitis

Causes of Vomiting by systems

Causes of Vomiting by systems

CNS Incresed ICP, Hydrocapahlus, Brain tumors , drugs ( chemotherapy)

Infections Meningitis , UTI, pneumonia, otitis media, sepsis

Metabolic DKA, Urea cycle disorders, galactosemia

Endocrine adrenal insufficiency

Intoxication alcohol, aspirin, PCM

Renal obstructive uropathy , renal failure , renal tubular acidosis

Age of the patient Duration /Frequency Onset Associated with food intake

instantly : esophageal obstruction After a while : stomach or duodenal obstruction

Nature (projectile / non projectile) Color and contents

Non digested food :proximal obstruction Semi digested food : distal obstruction Billous content : distal to 2nd part of duodenum Fecal material : obstruction at the large intestine

Associated symptoms Fever / Abdominal Pain /Diarrhea /constipation/

dysphagia.

History

History Respiratory – cough, chest discomfort Urinary – dysuria,hematuria CNS – irritability, altered sensorium,drowsy, neck stiffness,

headache, visual disturbance

Past medical historyAny known medical illness such as metabolic inborn error,

cerebral palsy, down syndrome, neurological deficit Drug and allergy history Birth history Nutritional history

Recently change into cow milk/ food allerrgy/ type of food Other relevant history

Recent eating outside, recent travelling, family member or friends in school have similar illness

Physical ExaminationGeneral condition

Comparison of patient’s weight before and after onset of illness

Concious level- GCS Hydration status

Sunken frontanelle Eyes sunken and tearless Dry mucous membrane Prolonged capillary refill time Reduced skin turgor Tachycardia, tacypnea

Look for any evidence of any specific disorder/ disease based on history

Abdominal Examination• Distension/ Visible peristalsis• Tenderness/ hepatospelnomegaly • abdominal masses • Bowel soundsCNS Examination• Power, Tone, reflexes • Changes in vision

Physical Examination

• Respiratory Examination• Ear examination by otoscopy• Fundoscopy

Imaging

CXRPlain Abdominal XrayBarium meanBarium follow throughCranial CTUpper GI endoscopy

Urine

UFEMEUrine C/S

Investigations

Full Blood Count Leukocyctosis (infection )

BUSE/ creatinine Effects of vomiting on electrolytes ( hypokalemia), Renal insufficiency

Blood glucose Levels exclude DKA

Blood gases Acidosis :organic acidemia, Alkalosis: pyloric stenosis

Blood Investigations

Guided by history/ PE

• Asses the severity of dehydration• Rehydrate accordingly• Correct electrolyte imbalances • Encourage oral intake• Treat according to the underlying cause

Management

• Nelson Text book of Peadiatrics 17th edition• Hand book of Hospital peadiatrics 2nd edition• Illustrated text book of paediatrics 3rd edition

References

Thank You

Disease/condition Therapy-drug class

Reflux Dopamine antagonist: metoclopramide (Reglan) ( 0.1-0.2 mg/kg qid PO/IV)Peripheral dopamine antagonist: domperidone (Motilium) ( 0.2-0.6 mg/kg tid-qid PO)

Gastroparesis Metoclopramide, domperidoneMotilin agonist: erythromycin ( 2-4 mg/kg tid-qid PO/IV)

Intestinal pseudoobstruction

Octreotide ( sandostatin)

Chemotherapy MetoclopramideSerotoninergic 5-HT3 antagonist; ondansetron ( zofran)Phenothiazines; prochlorperazine (compazine)Steroids: dexamethasone ( decadron)Cannabiniods: nabilone

Postoperative Ondansetron, phenothiazine

Motion sickness; vestibular disorder

Antihistamine: dimenhydrinate ( dramamine)Anticholinergic: scopolamine ( transderm scop)