Vomiting

Dr C Kock Paediatric Gastroenterology SBAH

Definitions
Vomiting: Forceful retrograde expulsion of gastric content through mouth consequent to coordinated contraction of diaphragm, abdominal and respiratory muscles Associated with autonomic response (pallor, lethargy, hypersalivation, tachycardia)

Differentiate from..
1. Regurgitation: Effortless involuntary reflux of undigested gastric contents Not associated with abdominal/diaphragmatic contractions or autonomic responses.

2. Rumination: Voluntary reflux of gastric contents within the first hour after eating and is associated with chewing undigested food.

3. Retching: Spasmodic respiratory movements against a closed glottis with contractions of the abdominal musculature without expulsion of any gastric contents, Known as dry heaves 4. Coughing or spitting of mucus from lungs

Emetic centre/ Pathogenesis

Different neuroendocrine pathways and neurotransmitters mediating vomiting Stimulation of Vomiting centre:

Figure 2-2. Emetic centre pathway. WP Bishop. Pediatric practice Gastroenterology

Aetiology
Primary: Originate from gastrointestinal tract Emergent- intussception Non-emergent viral gastroenteritis Secondary: Outside gastrointestinal tract

Diagnostic Approach
Is the child adequately hydrated? Is the emesis vomiting or regurgitation? What is the content of the vomiting? What is the age of the patient? What is the temporal pattern of vomiting? Are there any red flag symptoms? Are there any associated symptoms and signs?

HISTORY TAKING IS CRUCIAL!

Is the child adequately hydrated?

FINDINGS URINE OUTPUT APPEARANCE FONTANELLE TEARS EYES MUCOUS MEMBRANES SKIN TURGOR CAPP REFILL TIME PULSE RATE BLOOD PRESSURE RESPIRATION MILD (5%) Normal Alert Normal Present Normal Moist/slightly dry Instant recoil <2seconds Normal Normal Normal MODERATE (5-10%) SEVERE (>10%) Reduced Irritable Depressed Decreased tears Slightly sunken Very dry <2seconds Prolonged Tachycardia Normal of low Rapid No output for 12h Lethargic Markedly depressed No tears Markedly sunken Parched >2 seconds Markedly prolonged Marked tachycardia Low Rapid and deep

Is the emesis vomiting or regurgitation?

FEATURE
EVENT PRODROME CAUSES COMPLICATIONS IMPLICATIONS

REGURGITATION
Effortless expulsion None Gastro-esophageal reflux, rumination Uncommon Few

VOMITING
Forceful expulsion of gastric contents Pallor, salivation, tachycardia + retching Many disorders Esophagitis, hematemesis Post-Nissen retching syndrome

What is the content of the vomiting?

Undigested food
Gastric outlet obstruction

Bile
intestinal obstruction

Blood fresh or coffee ground

esophagitis, esophageal varices, gastritis, peptic ulcer, secondary swallowing nasopharyngeal blood

What is the age of the patient?

4 weeks old baby with non-bilious, nonbloody, projectile vomiting and failing to gain weight. UKE: Hypochloremic, hypokalaemic, hyponatremic metabolic alkalosis

Hypertrophic Pyloric Stenosis

Hypertrophic pyloric stenosis

Hypertrophy and hyperplasia of muscular layers of pylorus which causes a functional gastric outlet obstruction Most common cause of gastric outlet obstruction and vomiting in infants Vomiting typically starts at 4-8 weeks of life, gets progressively worse. 1.5-4 cases/1000 live births Male predominance (2:1 5:1) Less prevalent among black and Asian American populations 6-20% have associated congenital anomalies

 No definite cause found ? Musculature failing to relax? Various environmental and hereditary factors

Infantile hypergastrinemia Abnormal myenteric plexus innervation Cows Milk Protein allergy Exposure to Macrolide AB

Affects 7% of infants of affected parents (genetic component?)

 Not ill-looking and not febrile. Early in disease baby remains hungry and sucks vigorously Often mistaken for milk intolerance... and formula changed numerous times Retrograde peristalses sometimes visible Olive-mass in epigastrium

 UKE: hypokalemic, hypochloremic metabolic alkalosis Abdominal sonar: Pyloric muscle thickness and pyloric channel length:
Muscle wall thickness >3mm Pyloric channel length>14mm Abnormal in kids <30 days.

 Barium meal: -Elongated pylorus with antral indentation -Double track sign -Shoulder sign
contrast collects in the pre-pyloric antrum

Ramstedt Pyloromyotomy: Wound infection in <1% of patients Perforation of pyloric mucosa in <3% Long term sequelae are minimal

What is the age of the patient?

GIT
GIT- luminal

NEONATE
GER Esophageal atresia Antral web Malrotation +volvulus Incarcerated inguinal hernia

INFANT
GER Pyloric stenosis Intussception Malrotation with volvulus Incarcerated inguinal hernia

CHILDHOOD
Intussception Malrotation + volvulus Incarcerated inguinal hernia

ADOLESCENT

Malrotation +volvulus Superior mesenteric artery syndrome Gastroenteritis Eosinophilic esophagitis (EoE) Peptic ulcer disease IBD Appendicitis Gastroparesis CVS Rumination IBD

Mucosal inflammation (intestinal surface)

GERD Formula protein allergy Necrotizing enterocolitis

GERD Formula protein allergy Gastroenteritis

Gastroenteritis Eosinophilic esophagitis (EoE) H Pylori gastritis Peptic ulcer disease

Muscle/nerve (GIT wall)

Achalasia Hirschsprung ds Feeding intolerance (cardiac, renal, pulmonary)

Pseudoobstruction

Gastroparesis Cyclic vomiting syndrome (CVS)

NEONATE
Hepatobilliary/ pancreas Hepatitis

INFANT
hepatitis

CHILDHOOD
Hepatitis pancreatitis

ADOLESCENT
Gallstones Pancreatitis Pancreas divisum Renal failure Bulimia/psycho genic Drug abuse Motion sickness Menieres disease

Genitourinary system CNS/ Vestibular

Sepsis/UTI Posthemorrhagic hydrocephalus Chiari MF

UTI, hydronephrosis Subdural hemorrhage (SDH) Hydrocephalus

Hydronephrosi s, RTA Space occupying lesion (SOL) SDH Chiari MF

Metabolic/ endocrine Congenital Adrenal hyperplasia Inborn errors of metabolism (galactosemia, organic acidemia, urea cycle disorders) Addisons disease Fatty acid oxidation disorder

Addisons disesae DKA Fatty acid oxidation disorder

Pregnancy Addisons disease Porphyria Drug abuse DM

What is the temporal pattern of vomiting?

1. Acute 2. Recurrent
Chronic Cyclic

Acute vomiting
Most cases are self limiting infections and uncomplicated and require no investigations or treatment. Pyloric stenosis EoE Peptic ulcer disease with H Pyloric infection Gastritis, esophagitis Pancreatitis Intestinal obstruction

Bilious emesis, cramping, abdominal pain, abdominal distention and hyperactive bowel sounds Hirschprung disease

Recurrent Chronic Vomiting

Continuous, low frequency, daily episodes of mild to moderate vomiting

GIT

H pylori Gastritis Celiac disease Gastroparesis Achalasia Crohns disease Migraine, space occupying lesion Inborn errors of metabolism Vestibular causes Partial small bowel obstruction Chronic sinusitis Giardiasis

CNS Endocrine/metabolic Miscellaneous Surgical Infective

Rule out serious causes first!

midgut volvulus, intussception, adrenal crisis

Abdominal ultrasound abdomen for UPJ obstruction and brain MRI for Chiari malformation should be obtained. FBC, electrolytes, hepatic transaminases, amylase and lipase. Endoscopy

Recurrent Cycling Vomiting

Kids 2-10 years, also adolescents and adults
-serious clusters of vomiting -associated with dehydration and admission -regular intervals (every 2 months)

Rule out serious causes of vomiting first! No specific laboratory markers for CVS Episodes starts early morning Association with migraine: - 50% develop migraine by
by age of 15 years

Red flags

Symptoms

Signs

Projectile- gastric outlet obstr Bilious obstr distal to ampulla Blood varices, peptic injury Severe/persistent abdominal pain
intussception, pancreatitis, peptic ulcer

Bulging anterior fontanelle- Meningits,

hydrocephalus, SDH

Nuchal rigidity meningitis, intracranial

hemorrhage

Headache, neck pain, weakness

SOL,chiari MF, migraine Polydipsia - DKA Dysuria UTI, renal stones

Papilledema - ICP Hyperreflexia or hypertonia metabolic

problems, upper motor lesions

Are there any associated symptoms?

Fever, diarrhoea, sick contacts - gastroenteritis Epigastric pain pancreatitis Pain radiating to the back, fever,jaundice hepatitis, cholelithiasis Bilious vomiting intestinal obstruction Failure to pass meconium for 48hours hirschsprungs disease Headache, blurred vision - ICP Failure to thrive, lethargy, seizures inborn errors of metabolism

Figure 2-8. Vomiting. P 28 .Pediatric practice gastroenterology. Warren Bishop

Pharmacological therapy
Indications for anti-emetics: Cyclic vomiting syndrome Motion sickness Postoperative chemotherapy Abdominal migraine Functional nausea

 Pharmacological agents
Use with caution Limit to patients receiving chemotherapy and radiation Extrapyrimidal side effects Mask outward signs of disease

 Ondansetron
Selective serotoninergic 5HT3 receptor antagonist no sedative effect no extrapyramidal reactions

Metoclopramide
-FDA Black Box warning -Irreversible tardive diskinesia -Not routinely used

Questions?