Published on March 7, 2014
AN APPROACH TO A CASE OF VOMITING
CASE: A 5 Years old male child presented in ER with: Vomiting -7 to 8 episodes/day for 2 days. The child was in his usual state of good health 2 days back when he developed acute onset of non-projectile vomiting, contained nondigested food particles. It was non-bilious and not blood stained. There were episodes of colicky, non-radiating abdominal pain. The child had no fever but was passing stools of loose consistency,5-6 episodes. The feeding decreased since the illness. There were no respiratory or urinary symptoms. No irritability, altered sensorium, drowsiness, neck stiffness, headache.
No known medical illnesses s/o inborn errors of metabolism, cerebral palsy, down’s syndrome, neurological deficits. No h/o any drugs/allergy to any drugs/food Birth was uneventful There was no h/o travelling. The child had taken water outside and his friend was also suffering from similar illness.
O/E: GCS:15/15, lethargic T-98, HR-128, RR-56, BP-90/50 Jaundice- absent, dehydration- some signs+ No signs of meningeal irritation The remainder of the examinations were normal Inv: TC-15,500 Na-143, K-3.2, urea/creat-N Urine-N
The child was managed conservatively with IV fluids and electrolytes, IV antibiotics and symptomatic management was done.
Nausea: The unpleasant sensation of the imminent need to vomit, usually referred to the throat or epigastrium; a sensation that may or may not ultimately lead to the act of vomiting Vomiting: Vomiting is the means by which the upper gastrointestinal tract rids itself of its contents when almost any part of the upper tract becomes excessively irritated, over distended, or even over excitable Regurgitation: The act by which food is brought back into the mouth without the abdominal and diaphragmatic muscular activity that characterizes vomiting.
PHYSIOLOGY OF VOMITING: The sensory signals from the pharynx, esophagus, stomach and upper portions of the small intestines. the nerve impulses are transmitted by both vagal and sympathetic afferent nerve fibers to multiple distributed nuclei in the brain stem that all together are called the “vomiting center” motor impulses that cause the actual vomiting are transmitted from the vomiting center by way of the 5th,7th, 9th,10th,and 12th cranial nerves to the upper gastrointestinal tract, through vagal and sympathetic nerves to the lower tract, and through spinal nerves to the diaphragm and abdominal muscles
Act of vomiting: a deep breath raising of the hyoid bone and larynx to pull the upper esophageal sphincter open closing of the glottis to prevent vomitus flow into the lungs lifting of the soft palate to close the posterior nares strong downward contraction of the diaphragm along with simultaneous contraction of all the abdominal wall muscles. This squeezes the stomach between the diaphragm and the abdominal muscles, building the intragastric pressure to a high level. Finally, the lower esophageal sphincter relaxes completely, allowing expulsion of the gastric contents upward through the esophagus.
Causes of vomiting: Neonatal period: Bilious vomiting: Non-bilious vomiting: Atresias Feeding excessive volume Midgut volvulus Milk(human or formula intolerance Annular pancreas Decreased motility Hirschprungs disease prematurity Aberrant sup. Mes. Artery antenatal exposure to MgSO4 or narcotics Preduodenal portal vein sepsis (meningitis)with ileus,NEC Peritoneal bands CNS lesion Persistent omphalomesenteric duct Lesion above ampulla of Vater Duodenal duplication pyloric stenosis Meconium plug upper duodenal stenosis Annular pancreas GER, inborn errors of metabolism
Causes in infancy: Medical causes: Surgical causes: GER gastroenteritis CHPS CNS infections Volvulus UTI Inborn errors of metabolism Uremia Cow milk protein allergy Over feeding Faulty feeding technique Malrotaion Intussusception ICSOL Peritonitis Hydrocephalus Subdural hematoma
Causes in childhood: Medical causes: Surgical causes: GER gastroenteritis CNS infections UTI Inborn errors of metabolism Uremia, toxins Cow milk protein allergy Over feeding Faulty feeding technique Post nasal dripping DKA Psychogenic Hepatitis, pneumonia Intestinal obstruction Appendicitis ICSOL Peritonitis Hydrocephalus Subdural hematoma
History: Age of the patient Duration /Frequency Onset Associated with food intake Color and contents Non digested food :proximal obstruction Semi digested food : distal obstruction instantly : esophageal obstruction Bilious content : distal to 2nd part of duodenum After a while : stomach or duodenal obstruction Fecal material : obstruction at the large intestine Nature (projectile / non projectile) Associated symptoms Fever / Abdominal Pain /Diarrhea /constipation/ dysphagia.
• Respiratory – cough, chest discomfort • Urinary – dysuria, hematuria • CNS – irritability, altered sensorium, drowsy, neck stiffness, headache, visual disturbance • Past medical history Any 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 allergy/ type of food • Other relevant history Recent eating outside, recent travelling, family member or friends in school have similar illness
Physical Examination General condition Comparison of patient’s weight before and after onset of illness Conscious level- GCS Hydration status Sunken fontanel Eyes sunken and tearless Dry mucous membrane Prolonged capillary refill time Reduced skin turgor Tachycardia, tachypnea
Look for any evidence of any specific disorder/ disease based on history Abdominal Examination Distension/ Visible peristalsis Tenderness/ hepatospelnomegaly abdominal masses Bowel sounds CNS Examination Power, Tone, reflexes Changes in vision Respiratory Examination Ear examination by otoscopy Fundoscopy
Complications: Metabolic: dehydration, hypokalemic hypochloremic alkalosis, hyponatremia Malnutrition Mallory Weiss tear Esophagitis Aspiration Shock Pnemomediastinum, pneumothorax Petechiae, retinal hemorrhages
Investigations: Blood Investigations Full Blood Count-Leukocyctosis (infection) BUN/ creatinine/electrolytes -Effects of vomiting on electrolytes ( hypokalemia), Renal insufficiency Blood glucose Levels - exclude DKA Blood gases-Acidosis :organic acidemia, Alkalosis: pyloric stenosis Urine –RE/ME, Urine C/S Imaging CXR, Plain Abdominal X-ray, Barium meal, Barium follow through, Cranial CT, Upper GI endoscopy
Management: Asses the severity of dehydration Rehydrate accordingly Correct electrolyte imbalances Encourage oral intake Treat according to the underlying cause Treat cause:
Reflux/ gastroparesis: dopamine antagonist(metoclopramide) Chemotherapy: metoclopramide, ondensetron, prochlorperazine, chlorpromazine Post-operative: ondensetron, phenothiazine Motion sickness/ vestibular disorders: dimenhydrinate, scopolamine Adrenal crisis: cortisol
APPROACH: VOMITING AGE, otitis media, hepatitis, CNS and other infections fever abnormal neurologic examination CNS infection, SOL pyloric stenosis, intussusception, adhesions, appendicitis, hernia projectile vomiting recurrent vomiting or poor growth or weight loss signs of intestinal obstruction diarrhea psychogenic migraine Renal, metabolic disease medications toxins, drugs gastroenteritis, food poisoning
Cyclical vomiting syndrome: Numerous episodes of vomiting interspersed with well intervals Onset between 2 to 5 years of age Usually occur in the early morning or upon awakening Tend to start about the same time of day, same length of time and present the same symptoms at the same level of intensity Theories: migraine- related mechanism, mitochondrial disorders, autoimmune dysfunction.
D/D: GI anomalies(malrotation, duplication cysts, choledochal cysts, recurrent intussusceptions), CNS disorders(neoplasm, epilepsy, vestibular pathology), nephrolithiasis, cholelithiasis, hydronephrosis, metabolic endocrine disorders(urea cycle, fatty-acid metabolism, Addison disease, porphyria, hereditary angioedema), chronic appendicitis and inflammatory bowel disease
s/s: nausea, pallor, intolerance of noise and light, lethargy, headache, epigastric pain, abdominal pain, diarrhea and fever. Inv: endoscopy, contrast GI radiography, brain MRI, metabolic studies(lactate, organic acids, ammonia)
Treatment: enough rest and sleep, hydration, antiemetics (ondensetron) Prevention: lifestyle changes, prophylactic medications(cyproheptadine, propranolol, amitriptyline, phenobarbital)
Key messages: Differentiate vomiting, nausea and regurgitation Sort out the cause for vomiting by history, examination and investigations r/o surgical causes Manage Prevent with IV fluids,antiemetics and treat the cause and manage complications
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