Health-Process-Evidence-based Clinical Practice Guidelines for Vomiting

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Health-Process-Evidence-based Clinical Practice
Guidelines for Vomiting

• JGGuerra, MD
• Surgery-OMMC
• 072706

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Vomiting

• A. Overview of the Problem
• Concept
• Common Types
• Common Causes
• B. General Management Guidelines
• Clinical Diagnosis
• Paraclinical Diagnosis
• Treatment

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Clinical Questions

• What is the operational concept of vomiting?
• Definition
• Expulsion of gastrointestinal contents through
  the mouth due to a mechanical cause

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Clinical Questions

• 2. How is vomiting classified in terms of
  etiology?
• Systemic
• Infectious
• Neurologic
• GIT (Mechanical)

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Clinical Questions

• 3. How is vomiting classified in terms of GIT
  origin?
• Upper GIT
• Lower GIT

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Clinical Questions

• 4. How is vomitus classified in terms of its
  character?
• Nonbilous
• Bilous
• Fecaloid

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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

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Clinical Questions

• 6. How is vomiting classified in terms of its
  onset?
• Early (postprandial)
• Late

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Clinical Questions

• 7. How does the onset of vomiting localize the
  site of obstruction?
• Early (postprandial) upper GIT
• Late lower GIT

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Clinical Questions

• 8. What are the levels of GIT obstruction that
  exhibit vomiting?
• Esophagus
• Stomach
• Small intestine
• Colon

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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

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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

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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 gt2 days postprandial
• Characteristic bilous
• Abdominal distention minimal
• Snape Best Practice of Medicine. 2003

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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

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Vomiting

• General Management Guidelines
• Clinical Diagnosis
• Paraclinical Diagnosis
• Treatment

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Clinical Diagnosis
VOMITING
Mechanical
Systemic
Neurologic Infectious
UGIT
LGIT
Stomach
Esophagus
Duodenum
Colon
Small Bowel
Mass

• Mechanical Obstruction
• Stricture (PUD)
• Mass (benign, malignant)

Postoperative Adhesions
Sphincter Fnxn
Mechanical Obstruction
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Clinical Questions

• 13. 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 /
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Clinical Questions

• 14. 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 /
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Clinical Questions

• 15. 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 /
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Clinical Questions

• 16. 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 /
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Clinical Questions

• 17. What is the most cost-effective initial
  treatment for vomiting due to obstruction?
• NGT

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Clinical Questions

• 18. What is the most cost-effective treatment for
  esophageal cause of obstruction?
• Depends on the nature and extent of the disease

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Clinical Questions

• 19. What is the most cost-effective treatment for
  Gastric outlet obstruction?
• Benign vagotomy pyloroplasty
• Malignant resection with reconstruction

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Clinical Questions

• 20. What is the most cost-effective treatment for
  small intestinal obstruction?
• Surgery

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Clinical Questions

• 21. What is the most cost-effective treatment for
  colonic obstruction?
• Surgery

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• 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 2002178-85.
• 4. Snape, WJ. Best Practice in Medicine.
  536.2.Aug, 2003.