Approach to the Child with Nausea and Vomiting

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Approach to the Child with Nausea and Vomiting

• by Dr.Ryan Al.Ghanemi

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Introduction

• 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.
• VomitingForceful oral expulsion of gastric
  contents associated with contraction of the
  abdominal and chest wall musculature.
• RegurgitationThe act by which food is brought
  back into the mouth without the abdominal and
  diaphragmatic muscular activity that
  characterizes vomiting.

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Introduction

• A standardized approach is not recommended
  because it may be caused by many pathologic
  states involving several systems (including
  gastrointestinal, neurologic, renal, and
  psychiatric).
• The best course of action should be dictated by
  the medical history.

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Neurophysiology

• Nausea and vomiting are innate responses that
  induce a learned and conditioned aversion to
  ingested toxins
• There are four major pathways by which nausea and
  vomiting are induced.
• Vagal afferents
• Area postrema
• Vestibular system
• Amygdala

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Vagal Afferents

• Abdominal vagal afferents are involved in the
  emetic response.
• Can be evoked by either mechanical or
  chemo-sensory sensations.
• Examples of sensations that trigger this pathway
  include overdistension, food poisoning, mucosal
  irritation, cytotoxic drugs, and radiation.

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Area Postrema

• Its a chemoreceptor trigger zone. Anatomically,
  this region is located at the caudal extremity of
  the floor of the fourth ventricle.
• Its a permeable blood-brain barrier region in
  which systemic chemicals act to induce emesis can
  reach
• This area contains receptors for neuroactive
  compounds such as dopamine, morphine,
  acetylcholine, endorphin, and many others

A diagram summarizing the pathways involved in
emesis. Rache Nucleus Rache, AP area postrema,
IV 4 th ventricle, 5-HT 5-hydroxytryptamine
(serotonin), EC enterochromaffin cell, GI
gastrointestinal.
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Vestibular System

• It involved in the emetic response to motion
• Exacerbated by visual sensations, Irritation or
  labyrinthine inflammation.

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Somatomotor Events

• The diaphragm descends and the intercostal
  muscles contract while the glottis is closed.
• The abdominal muscles contract and the gastric
  contents are forced into upper gastric vault and
  lower esophagus.
• The abdominal muscle relaxes and the esophageal
  refluxate empties back into the gastric vault.
• Several cycles of retching, each more rhythmical
  and forceful in nature, occur, with shorter
  intervals in between.
• Abdominal contraction associated with elevation
  of diaphragms results in forceful expulsion of
  gastric contents.

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Diagnosis by Age
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Diagnosis by Age
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Neonates Young Infants

• Forceful and repeated vomiting in newborns is not
  normal and should be taken seriously,
  particularly if there are other signs of illness
  (eg, fever, weight loss, or feeding refusal).
• The most frequent diagnostic considerations are
  gastroesophageal reflux, pyloric stenosis, and
  intestinal obstruction.
• it may be sepsis, excessive feeding volume, or
  increased intracranial pressure.
• Although much less common, inborn errors of
  metabolism also can present with vomiting.

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Neonates Young Infants
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Gastroesophgeal Reflux Disease

• Physiologic reflux in newborns and infants is
  common, and is characterized by effortless
  regurgitation in an othewise healthy infant (a
  "happy spitter").
• A minority of infants who regurgitate have
  pathological gastroesophageal reflux.
• No features definitively identify these infants,
  but they may have recurrent fussiness or
  irritability and feeding aversion.
• These symptoms are thought to result from pain
  caused by esophageal acid exposure.

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Gastroesophgeal Reflux Disease

• Bradycardia or cyanotic episodes also may occur,
  particularly in preterm or neurologically
  impaired infants.
• Poor weight gain despite an adequate intake of
  calories should prompt evaluation for causes of
  vomiting and weight loss other than GERD.

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Milk protein Induced Enteritis

• Intolerance of dietary proteins (most commonly
  milk protein) typically manifest as colitis,
  presenting with bloody stools.
• However, in some infants the dietary protein
  causes an enteritis, with or without associated
  colitis, and affected infants may present with
  vomiting.

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Intestinal Obstruction

• Causes of intestinal obstruction that present
  during early infancy include
• Malrotation with or without volvulus
• Hirschsprung disease.
• Intussusception
• Intestinal atresia
• Pyloric stenosis

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Intestinal Obstruction

• Intestinal obstruction frequently causes bile
  staining in the vomitus.
• Bile-stained vomitus should be treated as a
  life-threatening emergency, although it can be
  seen occasionally in infants without bowel
  obstruction.
• Vomiting that is not bile-stained may be caused
  by proximal obstruction, such as pyloric
  stenosis, upper duodenal stenosis, gastric
  volvulus, or annular pancreas.

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Intestinal Obstruction

• If intestinal obstruction is suspected, the
  specific diagnosis often can be suggested by the
  patient's history and with appropriate radiologic
  imaging.
• Plain radiographs of the abdomen generally
  provide a rapid assessment of possible bowel
  obstruction with relatively little radiation
  exposure.
• Abdominal ultrasound provides high sensitivity
  and specificity for detecting intussusception.

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Pyloric Stenosis

• Infantile hypertrophic pyloric stenosis (IHPS) is
  a condition of hypertrophy of the pylorus, with
  elongation and thickening, eventually progressing
  to near-complete obstruction, of the gastric
  outlet.
• It occurs in approximately 3 in 1,000 live
  births.
• More commonly in males (41 to 61).
• Approximately 30 percent of cases occur in
  firstborn children.

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Pyloric Stenosis

• The classic presentation of IHPS is the three- to
  six-week-old baby who develops immediate
  postprandial, non-bilious, often projectile
  vomiting and demands to be re-fed soon
  afterwards(a "hungry vomiter").
• In the past, patients were classically described
  as being emaciated and dehydrated with a palpable
  "olive-like" mass at the lateral edge of the
  rectus abdominus muscle in the right upper
  quadrant of the abdomen.

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Pyloric Stenosis

• Laboratory evaluation classically showed a
  hypochloremic, metabolic alkalosis resulting from
  the loss of large amounts of gastric hydrochloric
  acid, the severity of which depended upon the
  duration of symptoms prior to initial evaluation.
• The diagnosis is made by ultrasound examination
  of the abdomen.

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Hirschsprung Disease

• Usualy diagnosed in the neonatal period.
• Patients present with symptoms of distal
  intestinal obstruction bilious emesis, abdominal
  distension, and failure to pass stool.

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Hirschsprung Disease

• The diagnosis can be suggested by a delay in
  passage of the first meconium (greater than 48
  hours of age).
• Affected children may also present initially with
  enterocolitis, a potentially life threatening
  illness in which patients have a sepsis-like
  picture with fever, vomiting, diarrhea, and
  abdominal distension, which can progress to toxic
  megacolon.

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Older Infants Children

• By far, the most common is gastroenteritis.
• However, GERD, gastroparesis, mechanical
  obstruction, anaphylaxis, Munchausen syndrome by
  proxy (factitious disorder by proxy),
  intracranial masses, peptic ulcer disease, and
  cyclic vomiting also may be diagnostic
  considerations.
• Adrenal crisis and anaphylaxis should be
  considered in children with disproportionate
  hypotension and/or predisposing factors.

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Older Infants Children
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Gasteroparesis

• It is the condition of impaired emptying of
  gastric contents into the duodenum in the absence
  of a mechanical obstruction this may cause
  postprandial vomiting.
• In gastroparesis the vomiting usually occurs many
  hours after ingestion of food, a characteristic
  that differentiates this entity from GER or
  rumination syndrome, in which the emesis is
  during or immediately after eating.

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Gasteroparesis

• The following conditions may cause gastroparesis
• Surgery with vagus nerve damage (eg,
  fundoplication)
• Use of drugs such as opioids or anticholinergics
• Metabolic disturbances such as hypokalemia,
  acidosis, or hypothyroidism
• Eosinophilic gastroenteropathy
• Neuromuscular disorders such as cerebral palsy,
  diabetes mellitus, pseudo-obstruction and
  muscular dystrophy
• Viral illness (postviral gastroparesis)
• In most cases, the symptoms resolve
  spontaneously within 6 to 24 months.

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Intussusception

• It is the most common cause of intestinal
  obstruction in infants between 6 and 36 months of
  age.
• typically patients develop the sudden onset of
  intermittent, severe, crampy, progressive
  abdominal pain, accompanied by inconsolable
  crying and drawing up of the legs toward the
  abdomen.
• The episodes become more frequent and more severe
  over time.

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Intussusception

• Vomiting may follow episodes of abdominal pain.
  Initially emesis is non-bilious, but it may
  become bilious as the obstruction progresses.
• A sausage-shaped abdominal mass may be felt in
  the right side of abdomen. As symptoms progress,
  increasing lethargy develops, which can be
  mistaken for meningoencephalitis.

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Intussusception

• In up to 70 percent of cases, the stool contains
  gross or occult blood.
• In infants, intussusception may present as
  lethargy, with or without vomiting or rectal
  bleeding.
• In young infants, intussusception is more often
  caused by a pathological lead point, such as
  Meckel diverticulum or a duplication cyst.

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Infections

• Pharyngitis (particularly streptococcal
  pharyngitis).
• Urinary tract infections frequently present with
  nausea and/or vomiting.

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Intracranial Hypertension

• Brain tumors and other intracranial masses can
  cause nausea, vomiting, or both, by increasing
  the intracranial pressure at the area postrema of
  the medulla.
• Several characteristics suggest tumor-associated
  emesis, such as triggering emesis by an abrupt
  change in body position, neurogenic nausea and
  other neurologic symptoms such as headache or
  focal neurologic deficit these signs and
  symptoms may be subtle.

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Intracranial Hypertension

• Idiopathic intracranial hypertension refers to
  increased intracranial pressure (ICP) with normal
  cerebrospinal fluid (CSF) content, normal
  neuroimaging, the absence of neurologic signs
  except cranial nerve VI palsy, and no known
  cause.
• The clinical manifestations of idiopathic
  intracranial hypertension vary with age.
• Younger children, for example, who cannot
  complain of headache or visual impairment, may
  present with irritability, sleep, or behavior
  disturbance.
• In older children, headache is a more common
  chief complaint in older children and frequently
  is described as being pulsatile, occasionally
  awakening the child from sleep. Associated nausea
  or vomiting may be present, as may neck or
  retroocular pain that is worse with eye movement.

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Munchausen Syndrome by Proxy

• Also known as factitious disorder by proxy,
  Meadow syndrome, and proxy factitia
• Its consists of fabricating or inducing illness
  in a child in order to get attention.
• The patient may have a history of frequent
  recurrent illnesses without a clear etiology

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Adolescents

• In addition to the disorders affecting children
  listed above, some of the more common causes
  include gastroenteritis, appendicitis,
  inflammatory bowel disease, pregnancy, and toxic
  ingestions.

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Clinical Approach
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Clinical Approach
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Clinical Approach
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Clinical Approach
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Clinical Approach

• A detailed history and astute clinical acumen are
  necessary to narrow down the diagnostic
  possibilities.
• The appropriate urgency depends on duration of
  illness, overall clinical status of the patient
  (especially hydration, circulatory, and
  neurologic status) and associated findings on the
  physical examination and history.

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Clinical Approach

• Prolonged vomiting (gt12 hours in a neonate, gt24
  hours in children younger than two years of age,
  or gt48 hours in older children) should not be
  ignored. Screening laboratory tests should
  include Additional testing should be based
  upon the history and physical examination
• complete blood count
• electrolytes,
• blood urea nitrogen,
• amylase, lipase,
• liver function tests,
• urinalysis, urine culture, and stool studies for
  occult blood, leukocytes, and parasites.

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Clinical Approach

• Clues on physical examination  Certain physical
  findings may offer diagnostic clues that can aid
  in narrowing the differential diagnosis
• A tense, bulging fontanelle in a neonate or
  young infant should increase the
• level of suspicion for meningitis.
• Projectile vomiting in an infant three to six
  weeks of age suggests pyloric
• stenosis as a diagnosis.
• Ambiguous genitalia and/or hyperkalemia suggest
  the possibility of
• adrenal crisis (usually due to congenital adrenal
  hyperplasia),.
• Headache, positional triggers for vomiting, lack
  of nausea, and/or
• vomiting on awakening should suggest the
  possibility of intracranial hypertension

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Clinical Approach

• An unusual odor emanating from the
  patient should prompt an
• investigation for metabolic causes of vomiting.
• Marked distension, visible bowel loops, absent
  bowel sounds, green or
• yellow bile, or increased "rumbling" bowel
  sounds ("borborygmi") should raise
• suspicion for intestinal obstruction.
• Enlarged parotid glands in an adolescent should
  raise suspicion for bulimia
• Vomiting in association with trauma should
  prompt imaging studies to rule
• out intracranial or intraabdominal injury.
• Hypotension disproportionate to the apparent
  illness and/or hyperkalemia
• suggests the possibility of adrenal crisis

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Laboratory Investigations
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Referrals

• When to refer the patient?
• Patients should be referred to a pediatric
  gastroenterologist or other appropriate
  specialist (eg, pediatric surgeon, neurologist)
  when there are symptoms or physical findings that
  are of particular concern.
• These include an abnormal neurologic exam,
  peritoneal signs on abdominal examination, severe
  abdominal pain, gastrointestinal bleeding, or
  significant weight loss.
• Immediate pediatric surgical consultation is
  warranted if appendicitis, bowel obstruction, or
  bowel perforation are suspected.

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Treatment

• Treatment should be directed toward the
  underlying etiology.
• Electrolyte abnormalities, metabolic
  abnormalities, or nutritional deficiencies should
  be corrected.
• Cognitive-behavioral interventions are useful for
  vomiting associated with functional dyspepsia,
  adolescent rumination syndrome, and bulimia.
• Prokinetic medications such as metoclopramide,
  domperidone (where available), and erythromycin
  are beneficial when there are abnormalities in
  esophago-gastric motility.
• Antiemetics, which are useful in persistent
  vomiting to avoid electrolyte abnormalities or
  nutritional sequelae, typically have not been
  recommended in the case of vomiting of unknown
  etiology. These agents are contraindicated in
  infants .
• Likewise, they are not indicated for anatomic
  abnormalities or surgical abdomen.

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Treatment
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Clinical Approach

• Instead, antiemetics are most useful for motion
  sickness, postoperative vomiting, cyclic vomiting
  syndrome, and gastrointestinal motility disorders
  .
• In addition, a double-blind study suggests that
  single dose ondansetron may facilitate oral
  rehydration in children with gastroenteritis who
  are unable to tolerate oral intake.
• During the last two decades, there have been
  considerable advances in the development of
  antiemetics. These include the emergence of
  5-hydroxytryptamine 3 receptor antagonists
  (Ondansetron, Granisetron), which have one
  primary site of antagonism and have helped in the
  treatment of post-operative nausea and vomiting
  and chemotherapy-associated emesis.
• These include neurokinin 1 receptor antagonists
  that likely mediate nausea and vomiting triggered
  by chemotherapeutic agents, motion, gastric
  irritants, and other stimuli .

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Alternative Medicine

• There is some evidence for efficacy of some
  nutraceuticals, such as ginger for functional
  dyspepsia and other motility disorders.
• Hypnotherapy is often helpful for treatment of
  anticipatory nausea and vomiting (eg, prior to
  chemotherapy).

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THANKS A LOT!
DR. Ryan Al.Ghanemi