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VOMITING IN CHILDREN
HANDOUT
OS 214
Exam 1
B
LOCK 
A
WEEK 1
Shelly |
0917 8431953
Page 1 of 4
DIGESTIVEAN INTRODUCTION TO VOMITING IN CHILDREN
ELIZABETH G. MARTINEZ, M.D., WILMA A. BALTAZAR, M.D., ESTHER A. SANGUIL, M.D.
DEFINITION
Vomiting is a physical act that results in thegastric contents forcefully brought up to and outof the mouth, aided by a sustained contractionof the abdominal muscles and the diaphragm ata time when the cardia of the stomach is raisedand the pylorus is contracted.
ASSOCIATED PHENOMENA
1.Hypersalivation2.Cardiac Rhythm disturbances3.Pupillary dilatation4.Defecation
VOMITING SYNDROMESRegurgitation
Effortless regurgitation of gastriccontents is a characteristic symptom of gastroesophageal reflux in infants. It is not clearwhether this behavior is centrally or locallycontrolled, or whether it should be considered“vomiting” at all. Most episodes of regurgitationare not associated with nausea; retching is rare;expulsion is not forceful or complete. Whenregurgitation of gastric contents causesaspiration, cough, probably mediated byafferents from the pharynx and esophagus.
Cyclic Vomiting Syndrome
 This disorder is characterized byrecurrent episodes of nausea and vomitingwithout identifiable organic cause. The episodesare of rapid onset, often starting during sleep orearly morning. Children may vomit many timesper hour, to the point of dehydration. Theepisodes may end spontaneously, may ceaseafter a period of sleep, or may progress to suchsevere dehydration and electrolyte imbalancethat intravenous fluids, sedatives, andantiemetics are required. There are few residuato most episodes, and the patient suddenlyseems better and complains of hunger. Stress orminor intercurrent illness are frequently noted atthe onset. The episodes are separated bycompletely symptom-free intervals. Thesymptom-free interval ranges from severalweeks to more than a year. A similarity tomigraine attacks and even seizures has longbeen noted, and headaches of various types arepresent in up to 25 percent in some series. Thediagnosis rests on the characteristic history, thenormal physical examination, and a meticulousevaluation for other organic diseases causingrecurrent episodes of vomiting.Important in the differential diagnosis of cyclic vomiting are such disorders as urea cycledefects, disorders of organic acid metabolism,gastric and intestinal motility disorders , centralnervous system lesions (specially those causingseizures), obstructive uropathy, obstructivecholangiopathy, familial pancreatitis, intestinalmalrotation , duplication, strictures anddiverticulae of prolonged symptom-free intervalsand normal physical examinations for sometime. Peptic disease may cause vomiting, butthe emesis is more chronic and less episodic.
Rumination
Rumination is the frequent regurgitationof previously ingested food into the mouth.Regurgitated food may be rechewed andswallowed or voluntarily spit out. Rumination isnot Accompanied by apparent nausea, retching,or forceful expulsion. It occurs most often inmentally retarded children. The origin of rumination appears behavioral in mostinstances. The syndrome has been described incases of child neglect, in neonates duringprolonged hospitalization, in children and infantswith untreated gastroesophagel reflux, and inolder children as an associated symptom of bulimia. Except in infants with gastroesophagealreflux and bulimia, the symptom often respondsto increased personal attention, especiallyduring feedings, and mild negativereinforcement. If untreated, it may result in lifethreatening inanition.
Bulimia
Bulimia is an eating disordercharacterized by recurrent episodes of bingeeating followed by purging induced by vomiting,diarrhea, diet, and exercise. It is commonly seenin adolescent and young adult females (up to10% of this age group). Patients describe afrightening sensation that that they have lostcontrol of themselves during vomiting andpersistent anxiety over body shape and weight.Vomiting may be induced by edications such asipecac, hypertonic saline, or other emetogenicsubstances. It may be a result of self-inducedgagging. They often come from dysfunctionalfamilies characterized by enmeshment with overcontrolling parents. Parental substance abuse iscommon. Sexual abuse by a family member hasbeen reported in up to 15 percent of cases.Depression and feelings of helplessness arecommon. As in anorexia nervosa, complicationsof purging include malnutrition, electrolyteimbalance, esophageal erosion and bleeding,deantal erosion, and dehydration.Gastrointestinal symptoms seen in up to 50percent of patients include abdominal pain,constipation, bloating, nausea, and postprandialfullness. Pancreatitis may be falsely indicated bythe presence of hyperamylasemia secondary toconstant salivary gland stimulation. A carefulhistory is the most important diagnostic tool. Incases where recurrent vomiting is an admittedsymptom of bulimia, antiemetics are of littleuse. Psychotherapy and antidepressants aremainstays of therapy.
DIFFERENTIAL DIAGNOSIS
Vomiting is a common symptom of manydisease states. The differential diagnosis of thechild with vomiting varies with the age of thepatient. Congenital anatomic, genetic, and
 
VOMITING IN CHILDREN
HANDOUT
OS 214
Exam 1
B
LOCK 
A
WEEK 1
Shelly |
0917 8431953
Page 2 of 4
DIGESTIVE
metabolic disorders are more commonly seen inthe neonatal period, and peptic, infectious, andpsychogenic causes are more prominent withincreasing age. Feeding intolerance and foodrefusal behavior, with or without vomiting, is acommon symptom of cardiac, renal, pulmonary,metabolic, genetic, and neuromotor disorders,also child abuse, and Munchaussen syndrome byproxy, especially in infancy. It is important thatthe physician not assume that all infants whovomit have gastroesophageal reflux becauseserious disease in infancy may be missed by thisapproach.
1.Nonbilious
a.Infectious: Most common causes of vomiting in children:
►
Viral: Most common viral agent isrotavirus.
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Bacterial: Salmonella, shigella,Campylobacter, E. Coli, H. Pylori,
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UTI, pyelonephritis, chronic sinusitis,otitis media, pharyngitis, pneumonia,peritonitis, hepatitis, meningitis
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Parasites: Giardiab.Inflammatory: IBD, pancreatitis,appendicitis, cholecystitis, esophagitisc.Gastritis, food allergy, cow’s milk proteinallergy, celiac diseased.Metabolic
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Inborn errors of metabolism: likeMCAD deficiency, OTC deficiency
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Usually present in early infancy,associated with neurological
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symptoms, and metabolic acidosis,hyperammonemia, hypoglycemiaand/or ketosis
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Acute intermittent porphyries
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Uremiae.Endocrine:
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Diabetes mellitus (DKA), adrenalinsufficiency (Addison’s)
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Carcinoid syndrome, Zollinger-Ellisonsyndromef.Neurologic:
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Increased ICP: hydrocephalus,intracranial tumors, intracranial
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Hemorrhageg.Cyclic Vomiting Syndrome: recurringattacks of severe vomiting,
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sporadic and unpredictable in some,and cyclic and predictable in others;usually in the mornings; with strongfamily history of migraine; diagnosedby clinical presentation and exclusionof other organic disorders
►
Abdominal migraine and migraineheadachesh.Motion sicknessi.Psychogenic: self-induced to seekattention, rumination, bulimia, anorexianervosa, depression
2.Mechanical
a.
Newborn: Esophageal atresia, pyloricstenosis, gastric atresia, duodenalatresia, esophageal stenosis, duodenalweb, intestinal duplicatiion, annularpancreas,strictures due to NEC,irschprung’s, midgut volvulus withmalrotation, meconium ileusb.Children and adolescents:intussusception, malrotation, stricturesdue to inflammation, gastric outletobstruction, inguinal hernia, SMAsyndrome, UPJ obstruction, foreign body,bezoar, duodenal hematoma , surgicaladhesionsc.Functional: achalasia, GERD,gastroparesis, scleroderma, pseudo-obstruction, ileus, familial dysautonomiad.Toxic: drugs, poisonings (lead, staphtoxin)e.Others: Overfeeding, Reye syndrome,pregnancy
Table 1. Causes of Vomiting in Infancy andChildhood (By Age)
Key:
1 = first week; 2 = 1 week to 1 month; 3 = 1 monthto 1 year; 4 = over 1 year
Digestive Tract DisordersFunctional and Psychogenic
►
Idiopathic neonatal vomiting 1
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Idiopathic infantile vomiting (“pylorospasm”)(1), 2, 3
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Feeding problems (‘rumination,’ i.e.,abnormalMother-child relationship) 2, 3
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Cyclic vomiting 4
►
Self-induced vomiting 4
Malformations and Obstructions
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Hiatal hernia and gastroesophageal reflux 1,2, 3, 4
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Gastric outlet malformation 1, (2), 3, 4
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Acquired gastric outlet obstruction, e.g.Corrosive gastritis, chronic granulomatousDisease (3), 4
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Hypertrophic pyloric stenosis (1), 2, 3
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Volvulus: gastric or intestinal 1, 2, 3, (4)
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Malrotation and partial obstructions 1, 2, 3,(4)
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Atresias 1
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Meconium ileus 1
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Menetrier’s disease 4
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Distal intestinal obstruction syndrome(meconium ileus equivalent) 4
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Inspissated milk syndrome and lactobezoar 1,2
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Duplications 1,2,3,4
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Intussusception 3, 4
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Aganglionic megacolon (Hirschsprung’sdisease) 1, 2, (3)
►
Peptic ulcer 1, 2, 3
►
 Trichobezoar 4
Food Intolerances
►
Celiac disease 3
►
Cow’s milk protein intolerance 2, 3
 
VOMITING IN CHILDREN
HANDOUT
OS 214
Exam 1
B
LOCK 
A
WEEK 1
Shelly |
0917 8431953
Page 3 of 4
DIGESTIVE
►
Other food intolerances 3
Infective disorders
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Gastroenteritis 1, 2, 3, 4
►
Epidemic vomiting 3, 3
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Food poisoning 3, 4
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 Thrush 1, 2
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Urinary tract infection (also hydronephrosisand renal calculi) 1, 2, 3, 4
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Respiratory tract infection (including otitis 1,2, 3, 4
►
Appendicitis (and other surgical emergencies)3, 4
Neurologic Disorders
►
Meningitis and encephalitis 1, 2, 3, 4
►
Intracranial birth injury 1
►
Migraine 4
►
Motion sickness 4
Increased Intracranial Pressure
►
Hydrocephalus 1, 2, 3, 4
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Subdural hematoma (1), 2, 3, 4
►
 Tumor, including diencephalic syndrome 3, 4
►
Hypertension, including renal causes (2), 3, 4
►
Kernieterus 1, 2
Toxic/Metabolic Disorders
►
Adrenal hyperplasia 1, 2, 3
►
Phenylketonuria 1, 2
►
Other aminoacidopathies and organicacidurias 1, 2
►
Galactosemia 1, 2
►
Hypercalcemia 2, 3, 4
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Uremia 1, 2, 3, 4
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Neonatal cold injury 1
►
Drugs, e.g.digoxin, cytotoxic agents,anticonvulsants 1, 2, 3, 4
►
Vitamin A excess 3
►
Diabetes Mellitus (ketoacidosis) (3), 4
►
Poisons—many 3, 4
Hepatic Disorders
►
Hepatitis 1, 2, 3
►
Cardiac failure 1, 2, 3,
►
Reye syndrome (3), 4
CONSEQUENCES OF VOMITING
1. Metabolic:a. Potassium deficiencyb. Alkalosisc. Sodium depletion2. Nutritional3. Mechanical injuries to esophagus andstomach:a. Mallory-Weissb. Boerhaave’s syndromec. Tears of the short gastric arteries resultingin shock andd. hemoperitoneum4. Dental: erosions and caries5. Purpura
DIAGNOSTIC APPROACH TO THE CHILDWITH VOMITING
A good history and physical examinationis essential in establishing a diagnosis. In thosewith vomiting, attention should be paid toaccompanying symptoms (so-called red flags)like abdominal pain, the presence of blood in thevomitus, bilous vomiting, abdominal distention,poor weight gain or weight loss symptoms thatare suggestive of a more serious disease.Suggested screening laboratory in anychild with prolonged or repetitive vomitingincludes complete blood count, serumelectrolytes, blood urea nitrogen, urinalysis andurine culture, and stool examination for occultblood, leukocytes, and parasites. Specificindications from history and physicalexamination may result in obtaining other testssuch as upper gastrointestinal series, abdominalultrasound, CT can or MRI of the head, tests of liver function, serum amylase, toxicology screen,pregnancy test, serum ammonia, urinary organicacids, urinary catecholamines, urinaryporphyrins, and electroencephalography.Endoscopic examination of the esophagus,stomach and duodenum is sometimes helpful if peptic disease or anatomic abnormality issuspected. Manometric evaluation of theesophagus, stomach, and duodenum isoccasionally helpful in defining primary orsecondary motor abnormalities causing emesis.
TREATMENT
 The routine use of antiemetic agents in infantsand children is not recommended. The use of antiemetic agents is contraindicated in mostinfants and children with vomiting secondary togastroenteritis, structural anomalies of thegastrointestinal tract, or surgical emergenciessuch as pyloric stenosis, acute appendicitis,renal stones, bowel obstruction, or an expandingintracranial lesion. There are only a fewsituations in which antiemetic agents areindicated and possibly effective. These includemotion sickness, postoperative nausea andvomiting, cancer chemotherapy, some cases of cyclic vomiting syndrome, and gastroparesis orother astrointestinal motility disorders.
REFERENCES
►
Brown J, Li B. Recurrent vomiting in children. ClinicalPerspectives in Gastroenterology, 2002; 5: 35-39.
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Fleishers DR. Functional vomiting disorders in infancy:Innocent vomiting, nervous vomiting and infant rumination syndrome. JPediatr. 1994; 125:S84-94
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Forbes D. Differential diagnosis of cyclic vomitingsyndrome. J Pediatr Gastroerology Nutr. 1995; 21: S11– 14.
►
Lee M. Vomiting. In: Sleisinger & Fordtran. Gastrointestinaland Liver Disease. WB Saunders Co. 7th ed. 2002.
►
Li B, Sferra T. Vomiting. In: Wyllie R, Hyams J, eds. PediatricGastrointestinal Disease. WB. Saunders Co. 2nd ed. 1999: 14-31.
►
Murray K, Christie D. Vomiting. Pediatrics in Review. 1998;19: 337-341.
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Sondheimer JM. Vomiting. Walker WA, Durie PR, HamiltonHR, Walker-Smith LA, Watkins JB, eds. Pediatric GastrointestinalDisease. Pathophysiology, Diagnosis, Management. BC Decker: 3rd ed.2000: 97- 102.
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fatima fatima

thanx alot and wish if i can download it coz really I like it :)

reply10 / 15 / 2009
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