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Program MCPS/MRCGP/CEFM CME ©

Course Paediatrics

Module GI

Topic Vomiting

Credit Hours 1 CME credit hour

Total Educational hours 2 educational hours

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

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Prof. Nasir Shah
MCPS, FCPS, MRCGP [INT], FRCGP [INT]

Dean Family Medicine Faculty, College of Physicians and

Surgeons Pakistan

Convener National Family Medicine Committee of

Pakistan

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

VOMITING ®
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• Mostly acute vomiting and diarrhea are due to viral infection
• Short-lived (2–5d) and self-limiting

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

NAUSEA ®
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• Nausea is an unpleasant symptom
• Most conditions which cause vomiting can also cause nausea

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

GI CAUSES OF VOMITING ®
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1. Gastroenteritis
2. Appendicitis
3. GERD
4. Obstruction
I. Intussusception
II. Volvulus
III. Obstructed hernias
IV. Pyloric stenosis

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

LIVER CAUSES OF VOMITING ®

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1. Acute Viral Hepatitis
2. Drugs
3. Liver abscess

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

GALL BLADDER CAUSES OF VOMITING ®
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1. Cholecystitis
2. Gall stones (biliary colic)

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

PANCREATIC CAUSES OF VOMITING ®

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• Pancreatitis? Mumps

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

RENAL CAUSES OF VOMITING ®
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1. Pyelonephritis
2. UTI
3. Parenchymal diseases

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

ENDOCRINE CAUSES OF VOMITING ®

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• Diabetic ketoacidosis (DKA)

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

CNS CAUSES OF VOMITING ®
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1. Meningitis
2. Encephalitis
3. Migraine
4. Hematomas
5. Hemorrhage
6. Space occupying lesions
7. Raised intracranial pressure

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

DRUG CAUSES OF VOMITING ®

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• Long list

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

PREGNANCY IN CHILDREN? ®
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• Possible

• After menarche

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

VOMITING | HISTORY ®
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• Duration and frequency Sources of infection
• Ability to retain food and fluids • Foreign travel
• Relationship to eating • Food exposure
• Reheated rice, uncooked
Nature of vomitus chicken
• Bilious • Any contacts with person
having similar symptoms
• Food contents
• Presence of blood
• Coffee ground colored

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

VOMITING | HISTORY ®
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• Other associated symptoms • Medication
- Fever - Opioids
- Diarrhea - Chemotherapy
- Pain

• Other illnesses
- DM
- Cancer
- Migraine

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

VOMITING | EXAMINATION ®
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• ASSESS HYDRATION STATUS
− BP
− Pulse rate
− Dry mouth, decreased skin turgor, sunken eyes, or sunken
fontanelle (babies) are all late signs

• ABDOMEN—masses, distention, tenderness, bowel sounds

• FOR CHILDREN—look for other sources of infection e.g., ENT,

chest, UTI, meningitis

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

VOMITING | EXAMINATION ®
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MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

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MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

APPROACH TO VOMITING ®
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• Standardized approach not recommended

• Many pathologic states

• Involving several systems

• The best course of action dictated by the medical history

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

TREATMENT ®
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• Directed toward;

A. Treating the underlying causes

B. Treating the consequences of excessive vomiting

1. Fluid management
2. Electrolyte management

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

ROLE OF GP IN CASES OF VOMITING ®
Cause Identify the cause ©

Vomiting Stop vomiting if indicated

Consequences Treat consequences

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

ANTIMETICS ®
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• Contraindicated in infants
• Contraindicated in vomiting of unknown cause

• Indicated in
1. Motion sickness
2. Cyclic vomiting syndrome
3. Gastrointestinal disorders
4. Drug related
5. Vomiting causing dehydration and electrolyte imbalance

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

ONDANSETRON ®
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• Injection: 2mg/mL
• Oral solution: 4mg/5mL
• Tablets: 8mg

• 1 m-12 years: <40 kg, 0.1 mg/kg IV , >40 kg, 4 mg IV

• >12 years: 4 mg IV/IM

• Used to prevent nausea and vomiting caused by surgery or

chemotherapy

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

ONDANSETRON ®
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• Single dose ondansetron may facilitate oral rehydration in
children with gastroenteritis who are unable to tolerate oral
intake

• Pediatricians now routinely administer ondansetron in ER to

promote ORS success

• No evidence to support additional doses after ER discharge

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

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MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

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MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

METOCLOPRAMIDE (MAXOLON) ®
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• <6 years old: 0.1 mg/kg/dose PO q8hr

• ≥6 years old: 0.5 mg/kg/day PO divided q8hr

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

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MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

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MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

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MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

Motilium versus Motilium V ®
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• Motilium tablets: Domperidone 10 mg

• Motilium V tablets: Domperidone maleate 12.72 mg

equivalent to Domperidone 10 mg

• Coated Domperidone

• No significant difference

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

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MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

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MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

DIMENHYDRINATE (GRAVINATE) ®
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• Dose: 12.5-25 mg PO q6-8hr

• >12 years old: Same as adult dosing

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

PROLONGED VOMITING ®
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• Prolonged vomiting should not be ignored:

1. >12 hours in a neonate

2. >24 hours in < 2 years age

3. >48 hours in older children

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

PROLONGED VOMITING: INVESTIGATIONS ®

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• Screening tests prolonged vomiting:
1. CBC
2. BUN, creatinine
3. Amylase
4. Blood sugar
5. LFTs
6. Urine C/E
7. Stool C/E
• Additional testing should be based upon the history and
physical examination

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

PROLONGED VOMITING: INVESTIGATIONS ®
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• Additional testing should be based upon the history and
physical examination

1. Pregnancy Test if post menarche

2. Electrolytes
3. Ultrasound for gall bladder problems
4. X-ray abdomen for obstruction
5. Lumbar puncture if meningitis
6. MRI for SOL

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

REFERRAL ®
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1. Abnormal neurologic exam
2. Peritoneal signs on abdominal examination
3. Severe abdominal pain
4. Bowel obstruction
5. Bowel perforation
6. Gastrointestinal bleeding
7. Significant weight loss
8. Appendicitis
9. Hyperventilation, hypotension, altered consciousness

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

REFERENCES ®
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• https://www.patient.co.uk
• https://www.medscape.com
• Oxford Handbook of General Medicine, 5th edition

MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting

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MCPS-MRCGP[INT]-CEFM | Pediatrics | Liver | Vomiting