VOMITING

AHMED AFIFI
Lecturer of Pediatrics and Neonatology
MD Pediatrics and Neonatology
MRCPCH, IBCLC
 CASE SCENARIO

 History

 Tom is a 7-week-old infant who presents with a 1-week history of non-bilious

vomiting. His mother describes the vomit as ‘shooting out’. He has a good
appetite but has lost 300 g since he was last weighed a week earlier. He has mild
constipation. The family have recently returned from Spain. There is no vomiting
in any other members of the family. His sister suffers from vesicoureteric reflux
and urinary tract infections.
 Examination

 Tom is apyrexial and mildly dehydrated. His pulse is 170 beats/min, blood pressure
82/43 mmHg, and peripheral capillary refill 2 s. There is no organomegaly, masses
or tenderness on abdominal examination. There are no signs in the other systems
INVESTIGATIONS
Haemoglobin 11.7 g/dL 10.5–13.5 g/dL
White cell count 10.0 109/L 4.0–11.0 109/L
Platelets 332 109/L 150–400 109/L
Sodium 134 mmol/L 135–145 mmol/L
Potassium 3.1 mmol/L 3.5–5.0 mmol/L
Chloride 81 mmol/L 98–106 mmol/L
Urea 9.0 mmol/L 1.8–6.4 mmol/L
Creatinine 60 μmol/L 18–35 μmol/L
Capillary gas
pH 7.56 7.36–7.44
PCO2 6.0 kPa 4.0–6.5 kPa
PO2 3.2 kPa 12–15 kPa
HCO3 38 mmol/L 22–29 mmol/L
Base excess 10 ( 2.5)–(2.5) mmol/L
Urine dipstick No abnormality detected
 Questions
▪ What is the likely diagnosis?
▪ What is the differential diagnosis?
▪ How would you confirm the diagnosis?
▪ What is the treatment?
VOMITING
DEFINITION

oVomiting is a coordinated, sequential series of events that leads to forceful oral

emptying of gastric contents.

oIt is a common problem in children and has many causes.

❑Vomiting should be distinguished from regurgitation “spitting up.”

❑Vomiting is usually preceded by nausea and is accompanied by forceful gagging and

retching.

❑Regurgitation, on the other hand, is effortless and not preceded by nausea.

CAUSES
 I. NEONATAL VOMITING
Healthy neonate:
❑Milk: over/irregular feeding, GERD
❑Mucoid: amniotic gastritis
❑Blood: neonatal, maternal (swallowed maternal blood)
Sick neonate:
2) Medical:
❑Infection: Septicemia, GE, UTI
❑Inborn errors of metabolism: Galactosemia, tyrosinemia, urea cycle defects
❑Increased ICP: ICH, CNS infections
2) Surgical:

 Non-bile stained: TOF(1st feed) and CHPS

 Bile stained: congenital I.O.(e.g., intestinal atresia), acquired as NEC
B.VOMITING IN INFANCY
AND CHILDHOOD
1) Medical:
❑Dietetic & GIT disorders: over/irregular feeding, gastritis, peptic ulcer
❑Infections: either focal (abdominal, CNS, pyelonephritis) or septicemia
❑Drugs: digitalis toxicity
❑Metabolic: DKA, CAH, RTA, CRF, IEM (hyperammonemia, organic acidemia)
❑Central (↑ ICP): ICH, CNS infection, brain tumors
❑Others: migraine, cyclic vomiting, familial dysautonomia, factious syndrome
2) Surgical:

❑GIT obstruction: e.g. CHPS, I.O.(intussusception, volvulus)

APPROACH TO PEDIATRIC VOMITING

➢HISTORY:
A complete vomiting history will thoroughly investigate
the history of presenting illness. As with many standard
complaints, the onset, frequency, time frame, provoking
and alleviating factors should be explored. The vomit
should be characterized in detail including the amount,
color, and consistency.
 First, it should be categorized as bilious or non-bilious. Bilious vomit has a
greenish appearance due to the presence of bile and is indicative of
obstruction distal to the ampulla of Vater. Thus, determining whether
vomit is bilious or non-bilious helps to localize GI problems within the GI
tract.
 Second, it should be categorized as bloody or non-
bloody. Blood in the vomit indicates inflammation or
damage to the GI mucosa and may indicate need for
endoscopy to rule out acute upper GI bleed.
 Third, the vomit should be identified as projectile or
non-projectile, as projectile vomiting may point to a
specific diagnosis – namely, pyloric stenosis and/or ↑
ICT. True expulsive vomiting should be distinguished
from regurgitation, which is not associated with
retching or prodromal features like nausea, sweating
and tachycardia.
 Fourth, the age of presentation should be considered. The
most common causes of vomiting in the neonatal period include
gastroenteritis, malrotation, pyloric stenosis, TEF and
necrotizing enterocolitis. In infancy, common causes are GERD,
gastroenteritis, bowel obstruction, milk protein allergy and UTI.
In children, one must think of gastroenteritis, UTI, DKA, post-
tussive vomiting and increased intracranial pressure. In
adolescents, consider gastroenteritis, appendicitis, DKA and
increased intracranial pressure on the differential.
 Fifth, one should determine whether the child is febrile
or afebrile. The presence of fever increases the
likelihood of an infectious etiology.
 One should also ask about the presence of any
associated GI symptoms, including nausea, abdominal
pain, distension, diarrhea, and constipation. Infectious
symptoms should be elicited, including fever, dysuria,
ear pain, cough, coryza, shortness of breath and
meningismus. Other important associated symptoms to
ask about are headache, changes in vision, polyuria,
polydipsia and weight loss, to rule out increased
intracranial pressure or DKA.
 Red flag symptoms that you do not want to miss include
meningismus, costovertebral tenderness, abdominal pain
and any evidence of increased intracranial pressure. Do not
miss a child who is vomiting due to a life-threatening
condition such as meningitis, DKA or pyelonephritis.

 Finally, it is very important to elucidate the child’s hydration

status, so one should always ask about oral intake, urine
output, tear production and weight changes.
Differential Diagnosis and Historical Features of Vomiting

DIFFERENTIAL DIAGNOSIS HISTORICAL CLUES

Viral gastroenteritis Fever, diarrhea, sudden onset, absence of pain
Gastroesophageal reflux Effortless, not preceded by nausea, chronic
Hepatitis Jaundice, history of exposure
Extragastrointestinal
infections
Otitis media Fever, ear pain
Urinary tract infection Dysuria, unusual urine odor, frequency, incontinence
Pneumonia Cough, fever, chest discomfort
Allergic
Milk or soy protein Associated with particular formula or food, blood in stools
intolerance (infants)
Other food allergy (older
children)
Differential Diagnosis and Historical Features of Vomiting cont.
Peptic ulcer or gastritis
Appendicitis
Pancreatitis
Anatomical obstruction
Intestinal atresia
Midgut malrotation
Intussusception
Duplication cysts
Pyloric stenosis
Bacterial gastroenteritis
Epigastric pain, blood or coffee-ground material in emesis,
pain relieved by acid blockade
Fever, abdominal pain migrating to the right lower quadrant,
tenderness
Severe epigastric abdominal pain
Neonate, usually bilious, polyhydramnios
Pain, bilious vomiting, GI bleeding, shock
Colicky pain, lethargy, vomiting, currant jelly stools, mass
occasionally
Colic, mass
Nonbilious vomiting, postprandial, <4 mo old, hunger,
progressive weight loss
Fever, often with bloody diarrhea
Differential Diagnosis and Historical Features of Vomiting cont.

CNS
Hydrocephalus Large head, altered mental status, bulging fontanelles
Meningitis Fever, stiff neck
Migraine syndrome Attacks scattered in time, relieved by sleep; headache
Cyclic vomiting syndrome Similar to migraine, usually no headache
Brain tumor Morning vomiting, accelerating over time, headache, diplopia
Motion sickness Associated with travel in vehicle
Labyrinthitis Vertigo
Metabolic disease Presentation early in life, worsens when catabolic or exposure
to substrate
Pregnancy Morning, sexually active, cessation of menses
Drug reaction or side effect Associated with increased dose or new medication
Differential Diagnosis and Historical Features of Vomiting cont.

Cancer chemotherapy Temporarily related to administration of chemotherapeutic

drugs
Eosinophilic esophagitis May have dysphagia or abdominal pain
I. PHYSICAL EXAMINATION:

❑Should include:
o assessment of the child’s hydration status
o Capillary refill
o moistness of mucous membranes
o skin turgor
❑The chest should be auscultated for evidence of rales or other signs of pulmonary
involvement.
❑ The abdomen must be examined carefully for distention, organomegaly, bowel
sounds, tenderness, and guarding.
❑A rectal examination and testing stool for occult blood should be considered.
❑A neurological exam should also be done to rule out signs of increased
intracranial pressure. This should include assessment for papilledema, bulging
fontanelles and the presence of focal neurological signs.
❑Examination for evidence of infection is also important and should include
inspection of the tympanic membranes and pharynx, auscultation of the chest
and assessment for meningismus.
❑Lastly, particularly in neonates and infants, the presence of dysmorphic features,
ambiguous genitalia or unusual odours should be noted as they may point to an
underlying congenital or metabolic cause.
II. LABORATORY EVALUATION:

❑Full septic work-up including blood cultures, urine cultures and a lumbar puncture
in small infants presenting with vomiting, fever, lethargy (suggestive symtoms of
sepsis).
❑Serum Electrolytes
❑Renal Function Test
❑Complete Blood Count,
❑Amylase, Lipase
❑Liver Function Tests.
❑Additional testing may be required immediately when history and examination
suggest a specific etiology, e.g. ABG (arterial blood gases) and acetone in urine for
DKA.
III. IMAGING

A. Pelvi-abdominal ultrasound
pyloric stenosis
Gallstones
renal stones
Hydronephrosis
Biliary obstruction
Pancreatitis
Malrotation
intussusception, and other anatomical abnormalities.
B. CT abdomen: may be indicated to rule out appendicitis or to observe structures that
cannot be visualized well by ultrasound.
C. Barium studies: can show obstructive or inflammatory lesions of the gut and can be
therapeutic, as in the use of contrast enemas for intussusception
IV. TREATMENT

 Dehydration must be treated with fluid resuscitation. This can be accomplished in

most cases with oral fluid-electrolyte solutions, but intravenous (IV) fluids may be
required.
 Electrolyte imbalances should be corrected by appropriate choice of fluids.
 Underlying causes should be treated when possible.
 The use of antiemetic medications is controversial.
 These drugs should not be prescribed until the etiology of the vomiting is known.
 Anticholinergics (e.g., scopolamine) and antihistamines (e.g., dimenhydrinate) are
useful for the prophylaxis and treatment of motion sickness.
 No antiemetic should be used in patients with surgical emergencies or when a
specific treatment of the underlying condition is possible.
 Correction of dehydration, ketosis, and acidosis is helpful to reduce vomiting in
most patients with viral gastroenteritis.
 Domperidone
 Metoclopramide
 Drugs that block serotonin 5-HT3 receptors, such as ondansetron and granisetron,
are frequently used for viral gastroenteritis and can improve tolerance of oral
rehydration therapy. They are helpful for chemotherapy-induced vomiting, often
combined with dexamethasone.
 CASE SCENARIO

 History

 Tom is a 7-week-old infant who presents with a 1-week history of non-bilious

vomiting. His mother describes the vomit as ‘shooting out’. He has a good
appetite but has lost 300 g since he was last weighed a week earlier. He has mild
constipation. The family have recently returned from Spain. There is no vomiting
in any other members of the family. His sister suffers from vesicoureteric reflux
and urinary tract infections.
 Examination

 Tom is apyrexial and mildly dehydrated. His pulse is 170 beats/min, blood pressure
82/43 mmHg, and peripheral capillary refill 2 s. There is no organomegaly, masses
or tenderness on abdominal examination. There are no signs in the other systems
INVESTIGATIONS
Haemoglobin 11.7 g/dL 10.5–13.5 g/dL
White cell count 10.0 109/L 4.0–11.0 109/L
Platelets 332 109/L 150–400 109/L
Sodium 134 mmol/L 135–145 mmol/L
Potassium 3.1 mmol/L 3.5–5.0 mmol/L
Chloride 81 mmol/L 98–106 mmol/L
Urea 9.0 mmol/L 1.8–6.4 mmol/L
Creatinine 60 μmol/L 18–35 μmol/L
Capillary gas
pH 7.56 7.36–7.44
PCO2 6.0 kPa 4.0–6.5 kPa
PO2 3.2 kPa 12–15 kPa
HCO3 38 mmol/L 22–29 mmol/L
Base excess 10 ( 2.5)–(2.5) mmol/L
Urine dipstick No abnormality detected
 CASE DISCUSSION

 In an infant this age with non-bilious projectile vomiting, pyloric stenosis is the most likely
diagnosis. This condition presents between 2 weeks and 5 months of age (median 6
weeks) and projectile vomiting is typical. The vomitus is never bile-stained as the
obstruction is proximal to the duodenum. As in this case, infants may also be constipated.
The hypochloraemic alkalosis is characteristic and is due to vomiting HCl. The low
potassium is due to the kidneys retaining hydrogen ions in favour of potassium ions. The
raised urea and creatinine suggest that there is also mild dehydration. The male-to-female
ratio is 4:1 and occasionally there is a family history (multifactorial inheritance).
❖Differential diagnosis
❑Gastro-oesophageal reflux
❑Gastritis
❑Urinary tract infection
❑Overfeeding
 Gastro-esophageal reflux usually presents from or shortly after birth. Gastritis
usually occurs with an enteritis and diarrhea. A urinary infection at this age may
present in a very non-specific way and therefore it is mandatory to test the urine.
The absence of nitrites and leucocytes in the urine dipstick makes a urinary
infection very unlikely. Overfeeding should be elucidated from a careful history.
 The diagnosis could be clinically confirmed by carrying out a test feed. A feed
leads to peristalsis which occurs from left to right. The abdominal wall is usually
relaxed during a feed, making palpation easier. A pyloric mass, which is the size of
a 2-cm olive, may be felt in the right hypochondrium by careful palpation. An
ultrasound is also usually done for further confirmation.
 Tom is slightly tachycardic (pulse rate <1 year, 110–160 beats/min) with a normal
blood pressure and capillary refill time. His urea is slightly elevated. Initial
treatment consists of treating the dehydration, acid–base and electrolyte
abnormalities with intravenous fluids. Feeds should be stopped, a nasogastric
tube inserted and the stomach emptied. The definitive operation is Ramstedt’s
pyloromyotomy.
GASTROESOPHAGEAL REFLUX DISEASE ( GERD )
I. DEFINITION
 Gastroesophageal reflux (GER) is defined as the effortless retrograde movement of
gastric contents upward into the esophagus or oropharynx. In infancy, GER is not
always an abnormality.
 Physiological GER (“spitting up”) is normal in infants younger than 8-12 months
old. Nearly half of all infants are reported to spit up between 2 and 4 months of
age.
 Infants who regurgitate meet the criteria for physiological GER so long as they
maintain adequate nutrition and have no signs of respiratory complications or
esophagitis.
CONTRIBUTING FACTORS OF INFANTILE GER
INCLUDE:
oLiquid diet
oHorizontal body position
oShort, narrow esophagus
oSmall, noncompliant stomach
oFrequent, relatively large-volume feedings
oAn immature lower esophageal sphincter (LES)
 As infants grow, they spend more time upright, eat more solid foods,
develope a longer and larger diameter esophagus, have a larger and
more compliant stomach, and experience lower caloric needs per unit
of body weight.
 As a result, most infants stop spitting up by 9-12 months of age.
 Gastroesophageal reflux disease (GERD) occurs when GER leads to troublesome
symptoms or complications such as poor growth, pain, or breathing difficulties.
GERD occurs in a minority of infants but is often implicated as the cause of
fussiness.
 Abnormalities that cause GER in older children and adults include reduced tone of
the LES, transient relaxations of the LES, esophagitis (which impairs esophageal
motility), increased intraabdominal pressure, cough, respiratory difficulty (asthma
or cystic fibrosis), and hiatal hernia.
II. ETIOLOGY
 ↓ LES tone & transient LES relaxation.
 ↑ intra-abdominal pressure due to delayed gastric emptying.
 Weak esophageal motility.
 Weak diaphragmatic muscle e.g. hiatal hernia.
 Genetic predisposition.
III. CLINICAL PICTURE
❑GIT manifestation:
 Vomiting & regurgitation esp. postprandial
 FTT & weight loss
 Esophagitis and pain
❑Respiratory manifestation:
 Recurrent aspiration
 Chronic cough and recurrent wheezes
 Reflux laryngitis, Hoarseness, apnea & stridor
 Sandifer syndrome: attacks of GERD + neck stiffness & opisthotonos ± apnea &
staring, usually associated with iron def. anemia.
IV. INVESTIGATION
➢A clinical diagnosis is often sufficient in children with classic effortless regurgitation and no
complications.

➢ Diagnostic studies are indicated if there are persistent symptoms or complications or if

other symptoms suggest the possibility of GER in the absence of regurgitation.

➢A child with recurrent pneumonia, chronic cough, or apneic spells without overt emesis
may have occult GER.
❑A barium upper gastrointestinal (GI) series ( swallow and meal )
❑A 24-hour esophageal pH probe monitoring ( the best diagnostic test )
❑Esophageal manometry
❑Esophageal impedance monitoring
❑esophagoscopy
❑Empiric anti-reflux treatment ( e.g. PPI)
V. COMPLICATIONS
❑Esophageal:
o Esophagitis → dysphagia, heartburn & chest pain
o Esophageal stricture
o Barrett esophagus
❑Extra-esophageal:
o Respiratory
o Nutritional
VI. TREATMENT
 In otherwise healthy young infants, no treatment is necessary.
Treatment of Gastroesophageal Reflux
THERAPIES COMMENTS
CONSERVATIVE THERAPIES
Towel on caregiver’s shoulder Cheap, effective; useful only for physiological reflux

Thickened feedings Reduces number of episodes, enhances nutrition

Smaller, more frequent feedings Can help some; be careful not to underfeed child

Avoidance of tobacco smoke and alcohol Always a good idea; may help reflux symptoms

Abstaining from caffeine Inexpensive, offers some benefit

Positional therapy—upright in seat, Prone positioning with head of crib or bed up is helpful, but
elevate not for young infants because of risk of SIDS
Weight loss when indicated Increased weight (especially abdominal) increases
intraabdominal pressure, leading to reflux
Treatment of Gastroesophageal Reflux

THERAPIES COMMENTS
MEDICAL THERAPY

Proton pump inhibitor Effective medical therapy for heartburn and esophagitis

H2-receptor antagonist Reduces heartburn, less effective for healing esophagitis

Metoclopramide Enhances stomach emptying and LES tone; real benefit is often
minimal

SURGICAL THERAPY

Nissen or other fundoplication procedure For life-threatening or medically unresponsive cases

Feeding jejunostomy Useful in child requiring tube feeds; delivering feeds

downstream eliminates GERD
Indications of surgical treatment:
❑Sever esophagitis with no response to 6 weeks trial of medical ttt.
❑Stricture due to reflux esophagitis
❑Significant morbidity from chronic pulmonary disease
PROGNOSIS
✓Infant reflux: usually resolves spontaneously by the age of 1 year (about 90%).

✓Reflux in older children: tend to be chronic (resolves in 50 %).