Vomiting%20In%20Children

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Vomiting In Children

• Salma Elkhabier
• Morehouse School of Medicine
• Pediatrics Residency Program-PGY3

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Physiology of Vomiting
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Classification of Vomiting

• According to nature
• Projectile---------- ? ICP or pyloric stenosis
• Non Projectile------ GER or any other causes.
• According to quality
• Bilious ( dark green)----------- Always
  pathological and indicate obstruction beyond the
  ampulla of vater.
• Bloody red blood----- Upper GI or massive lower
  GI bleed, coffee ground----- old upper GI or
  lower GI bleeding
• Non bloody, non bilious usually clear or
  yellowish with remnants of previously ingested
  food--------most types of vomiting.

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Differential diagnosis of vomiting
Age Common Causes Type of Vomiting Comment/Associated Features
Newborn Intestinal atresia/webs Meconium ileus 3. Hirschsprung disease 4. Necrotizing Enterocolitis 5. Inborn irrors of metabolism 1. Bilious, depending on level of lesion 2. Bilious 3. Bilious or nonbilious 4. Bilious or nonbilious 5. Bilious or nonbilious 6. Nonbilious 1. May occur at level of esophagus, Duodenum or jejunum 2. Strongly associated e CF 3. History of non-passage of stools in nursery suggestive suction rectal biopsy may demonstrate lack of ganglion cells. 4. Plain films of abdomen may reveal intestinal pneumatoses 5. May have acidosis or Hypoglycemia
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Differential diagnosis of vomiting
Age Common Causes Type of vomiting Comment/Associated features
O to 3 months Pyloric stenosis 2. Malrotation with midgut volvulus 3. Inborn errors of Metabolism 4. Milk/soy protein allergy 5. Gastroesophageal Reflux 6. Child abuse 7. infections/sepsis Nonbilious Bilious Bilious or nonbilious Bilious or nonbilious Nonbilious Nonbilious 1. Hypochloremic metabolic Alkalosis 2. Abdominal distention may be present, plain X rays may show air fluid levels paucity of distal bowel gas. 3. Newborn metabolic screen may be abnormal acidosis or hypoglycemia may be present 4. may have gross or occult blood h/o extreme fussiness,fecal occult blood testing of stools may be positive 5. may have gross or occult blood Emesis usually within 30 minutes of feeding symptoms worse in supine flat position 6. AF fullness may be present CNS imaging studies may reveal acute or subacute Bleeding 7. HP may suggest infections( GBS, Herpes) bandemia, CSF.
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Differential diagnosis of vomiting
Age Common Causes Type of Vomiting Comment/Associated features
3 to 12 Months 1. AGE 2. Intussusception 3. Child abuse 4. Intacranial mass or meningitis 5. Non specific causes like infections ( UTI/ OM) Nonbilious initially may progress to bilious Bilious Nonbilious Nonbilious/ projectile Nonbilious 1. Stool studies may help establish offending pathogen 2. Abdomen distention may be present plain radiographs may show air-fluid levels and paucity of distal bowel gas stools may be grossly bloody with currant jelly Appearance 3. AF fullness may be present CNS imaging studies may reveal acute or subacute bleeding 4. AF fullness may be present CNS imaging studies and LP diagnostic 5. Exam likely suggest dx.
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Infantile Hypertrophic Pyloric Stenosis

• 3 in 1000 livebirths
• Ist born males
• 2-6 weeks
• Projectile /nonbilious emesis
• Unclear etiology but some cases attributed to
  deficiencies in neuropeptidergic innervation and
  nitric oxide.
• Erythromycin in 1st 2 weeks of birth should be
  avoided ( eight times fold inc in PS due to
  interaction with intestinal motilin receptors)

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Infantile Hypertrophic Pyloric Stenosis

• Diagnosis mainly by typical history and exam
  findings.
• May or may not see prestaltic waves
• Palpable olive strongely support diagnosis.
• Hyperchloremic hypokalemic metabolic alkalosis is
  classic
• Abdominal US is diagnostic
• Surgical pyloromytomy after correction of
  electrolytes is the preferred mode of management.

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Infantile Hypertrophic Pyloric Stenosis
Pyloric muscle thickness of 4 mm or more and
muscle length of 14 mm or more are diagnostic of
pyloric stenosis
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Malrotation with Midgut Volvulus

• Stages of intestinal develpment
• Rapid growth of the midgut outside the abdominal
  cavity through a herniation of the umbilical
  orifice.
• The midgut returns to the abdominal cavity,
  rotating 180 degrees and pushing the hindgut to
  the left.
• Retroperitonealization of portions of the right
  colon, left colon, duodenum, and intestinal
  mesentery, helping them serve as anchors for the
  bowel.
• Disruption of this normal development in 2nd or
  3rd stage may lead to an aberrant return or
  anchoring of the midgut within the abdominal
  cavity.

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Malrotation with Midgut Volvulus

• Typically presnent in 1st week of life
• May go for years undetected if not associated
  with volvulus.
• The midgut twists in a clockwise direction
  around the superior mesenteric vessels, leading
  to obstruction of vascular supply to most of the
  small and large intestine.
• Clinical presentation starts with bilious
  vomiting and can proceed quickly to a shock like
  state with hemodynamic instability and metabolic
  acidosis if bowel ischemia occurs---- if not
  emergently surgically treated will lead to bowel
  perforation, sepsis and death
• If bowel ischemia is prolonged, loss of bowel and
  resultant short gut syndrome may occur.

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Malrotation with Midgut Volvulus
Failure of contrast to pass beyond the second
portion of the duodenum in UGI which is
characteristic of malrotation. Abdominal US may
demonstrate malposition of superior mesenteric
vessels.
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Duodenal Atresia

• A congenital obstruction of the second portion of
  the duodenum happened due to a failure of
  recanalization of the bowel during early
  gestation.
• 1 per 5,000 to 10,000 live births
• Associated with trisomy 21 in 25 of cases.
• A surgical emergency and typically presents
  within a few hours after birth
• Infants present with clinical features of failure
  to tolerate feedings and bilious emesis shortly
  after birth.
• Due to the proximal nature of the obstruction,
  abdominal distention usually is not present.

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Duodenal Atresia
Double bubble sign on plain radiograph,
which represents air in the stomach and proximal
duodenum and indicates duodenal atresia.
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Jejunoileal atresias

• More distal obstructions
• Believed to be due to a mesenteric vascular
  accident at some point during the course of
  gestation.
• Occurs in 1 in 3000 live birts
• Present with Bilious vomiting with Abdominal
  distension in the 1st 24 hours of life.
• Anatomically, jejunoileal atresias can be
  classified into four types membranous,
  interrupted, apple-peel, and multiple.
• Abdominal radiography may show dilated loops of
  small bowel with air-fluid levels.
• Treatment for all types is urgent surgical
  correction.

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Jejunoileal atresias
Dilated loops of small bowel with air-fluid
levels, indicative of jejunoileal atresia.
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Intussusception

• Is the telescoping of one portion of the bowel
  into its distal segment, most commonly, the
  terminal ileum into the cecum
• Commonly due to lymphatic hypertrophy in the
  Peyer patches from a recent viral infection.
• peak incidence occurs between 3 months and 3
  years
• A history of intermittent episodes of severe and
  crampy abdominal pain with bilious emesis is
  classic.
• Child may be lethargic between episodes.
• Parents may describe blood tinged current jelly
  stools.

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Intussusception

• Abdominal examination may be normal or may reveal
  sausage shaped mass palpable in the right lower
  quadrant.
• Urgent surgical consultation is warranted.
• Contrast or air enemas can be diagnostic and
  theraputic.
• Surgical reduction of the intussusception is
  indicated when the contrast enema is not
  successful.

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Intussusception

• Contrast outlining the lead portion of the
  intussusception, giving the typical coiled
  spring appearance.

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Superior Mesenteric Artery Syndrome

• Is a functional upper intestinal obstructive
  condition known as Wilkie or cast syndrome.
• Occurs when the angle between the SMA and the
  aorta is narrowed to less than 25 degrees (
  normally 45), the duodenum may become entrapped
  and compressed.
• Happens usually in patient who have experienced
  rapid weight loss, immobilization in a body cast,
  or surgical correction of spinal deformities.
• presents with epigastric abdominal pain, early
  satiety, nausea, and bilious vomiting. Pain
  worsens in supine position and relieved by prone
  or knee-chest position.

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Superior Mesenteric Artery Syndrome

• Diagnosis usually is confirmed by upper GI
  radiographic series or computed tomography scan
  with dilated stomach and failure of contrast to
  pass beyond the third portion of the duodenum.

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Superior Mesenteric Artery Syndrome

• Conservative management of SMA syndrome focuses
  on gastric decompression, followed by the
  establishment of adequate nutrition and proper
  positioning after meals.
• Placement of an enteral feeding tube distal to
  the obstruction or TPN may be needed in severe
  cases.
• Surgical correction with duodenojejunostomy is a
  last resort.

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Other Causes of Vomiting

• Cyclic vomiting
• stereotypic recurrent episodes of nausea and
  vomiting without an identifiable organic cause
• Idiopathic, happened in early childhood, unknown
  pathogenesis.
• Characterized by
• Three or more episodes of recurrent vomiting
• Intervals of normal health between episodes
• Episodes that are stereotypic with regard to
  symptom onset and duration
• lack of laboratory or radiographic evidence to
  support an alternative diagnosis
• Treatment is supportive
• Amitriptyline and propranolol have been described
  as effective for prophylactic therapy

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Other Causes of Vomiting

• Abdominal Migraine
• episodic attacks of epigastric or periumbilical
  abdominal pain
• Female male ratio 32
• Onset between 7 and 12 years.
• FH of migraine may be present
• believed to share pathophysiologic mechanisms
  with CVS
• Attacks characterized by acute, intense abd pain
  that interfer with normal activities and
  accompanied by anorexia, nausea, vomiting,
  headache, photophobia and pallor.
• Periods of normal health between episodes.
• Diagnosis is supported by a favorable response to
  medications used for treatment of migraine
  headaches.

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Other Causes of Vomiting

• Rumination
• repeated and painless regurgitation of ingested
  food into the mouth beginning soon after food
  intake, followed by swallowing or spitting up of
  food.
• Symptoms do not occur during sleep and do not
  respond to the standard treatment of GER.
• To qualify for the diagnosis, symptoms must be
  present for longer than 8 weeks.
• typically seen in mentally retarded children,
  neonates during prolonged hospitalization, and
  children and infants who have GER, may also
  happened in adolescent with bulimia or neglected
  children.
• The management of rumination involves a
  multidisciplinary approach, with a primary focus
  on behavioral therapy and biofeedback.

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Conclusion

• Vomiting is a nonspecific symptom that may
  accompany a wide variety of GI and
  extraintestinal disorders
• Conditions such as mild GER may only necessitate
  reassurance, but symptoms of bilious vomiting
  should prompt immediate referral to a pediatric
  surgeon.
• Associated fluid and electrolyte imbalances
  always must be considered when assessing a child
  who has a history of vomiting.
• Results of the history and physical examination,
  keeping in mind the nature of the vomiting and
  age of the child, may help you determine the
  likely cause and the need for emergent treatment.