Pediatrics [VOMITING]

Introduction
Kids can spit up. They don’t know when enough is enough and may eat
more than their bellies can hold. A little bit of regurgitation (small
volume, non-projectile, formula colored) is totally normal. Most
pathologic vomiting occurs very early in life (like hours to days). Once
kids hit 2 years old their vomiting is usually just about the same as
adults. All causes of pathologic vomiting are anatomic - meaning
surgery to correct.

1) Bilious Vomiting
Green vomit is never normal. It’s indicative of an obstruction distal to
the Ampulla of Vater. Fluid can go into the duodenum from the
stomach, but the only way out is the way it came in. Because these
disease constitute total obstruction they present very early - usually
after the first feed. The workup begins with an x-ray (babygram).
From there, the gas patterns differentiate between diseases.
i. Duodenal Atresia Double-Bubble + No Distal Air = Duodenal Atresia
The duodenum fails to recanalize in utero. It presents as Surgery
polyhydramnios in utero and bilious vomiting as a neonate. The Downs
XR reveals a double-bubble sign, but there’s no distal air. The
repair is surgical. This is commonly associated with Down
syndrome.
ii. Annular Pancreas Double-Bubble + No Distal Air = Annular Pancreas
If there’s a double-bubble without distal air, it’s possible that the Surgery
duodenum actually isn’t atretic. Instead, it’s just that the half of the Ø Downs
pancreas that should have gone through apoptosis didn’t. It’s the
same presentation and treatment as duodenal atresia but without
association to Down syndrome.
iii. Malrotation Double-Bubble + Normal Gas = Malrotation
The worst case scenario for bilious vomiting and a double-bubble Emergency Surgery
sign is malrotation. If there are normal gas patterns beyond the
double-bubble layer, there’s no embryonic failure - a normal bowel
has twisted on itself coming back into baby. Usually normal
uterine course. A barium enema should be done first (less
sensitive, but safer). If negative, follow with an upper GI series.
If ever positive, do immediate surgery before the vascular supply
dies.
iv. Intestinal Atresia
If there’s a double-bubble or triple bubble and multiple-air Double-Bubble + Air Fluid Levels = Intestinal Atresia
fluid levels it’s time to talk to mom about her cocaine use. This is Tell mom to stop cocaine
caused by a vascular accident in utero. Surgically remove the
atretic areas.

2) Pyloric Stenosis
If a nursing baby who has not had any problems suddenly develops Boy with olive-shaped mass, projectile vomiting
projectile vomiting after feeds, consider pyloric stenosis. Physical Ultrasound = Donut
exam will reveal an olive-shaped mass and visible peristaltic waves. Surgery = Myomectomy
A CMP will reveal a hypochloremic, hypokalemic, metabolic
alkalosis, which should prompt immediate IVF for rehydration.
Definitive diagnosis is made with Ultrasound showing a “donut sign.”
Treatment is with partial myomectomy. It’s more common in boys.

© OnlineMedEd. http://www.onlinemeded.org