Vomiting in children - PowerPoint Presentation

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Vomiting in children

Dr .

Fariborzi

Pediatric

Gastroentrologist

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Definition

Vomiting

:

is a coordinated, sequential series of events that leads to forceful oral emptying of gastric contents.

Vomiting is usually preceded by nausea, followed by forceful gagging and retching.

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Regurgitation :

effortless and not preceded by nausea

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Differential Diagnosis

In neonates

congenital obstructive lesions should be considered.

Allergic reactions to formula also are common in the first 2 months of life.

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Infantile GER

occurs in most infants and can be large in volume, but is effortless and these infants do not appear ill.

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Pyloric

stenosis

occurs in the first month of life and is characterized by steadily worsening

forceful vomiting which occurs immediately after feedings.

Prior to vomiting a distended stomach

often with visible peristaltic waves is often seen.

Pyloric

stenosis

is more common in male infants, and there may be a positive family history.

Other obstructive lesions, such as intestinal duplication cysts,

atresias

, webs, and

midgut

malrotation

must be ruled out.

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Metabolic disorders

organic

acidemias

,

galactosemia

, urea cycle defects, etc.) can cause vomiting in infants

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In older children

with acute vomiting, viral illnesses are common.

Other infections, especially streptococcal

pharyngitis

, urinary tract infections, and

otitis

media, commonly result in vomiting.

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When vomiting is chronic, central nervous system (CNS) causes (increased intracranial pressure, migraine) must be considered

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When abdominal pain or bilious emesis accompanies vomiting, evaluation for bowel obstruction, peptic disorders, and appendicitis must be immediately initiated

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Assessment

Physical examination

include assessment of the child's hydration status, including examination of capillary refill, moistness of mucous membranes, and skin

turgor

.

The chest should be

auscultated

for evidence of pulmonary involvement.

The abdomen must be examined carefully for

distention

,

organomegaly

, bowel sounds, tenderness, and guarding.

A rectal examination and testing stool for occult blood should be performed.

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Differential Diagnosis of Vomiting by Historical Features

Viral gastroenteritis

Fever,

diarrhea

, sudden onset, absence of pain

Gastroesophageal

reflux

Effortless, not preceded by nausea

chronic Hepatitis

Jaundice, history of exposure

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Extragastrointestinal

Otitis

media:

Fever, ear pain  

 

Urinary tract infection:

Dysuria

, unusual urine

odor

, frequency, incontinence  

 

Pneumonia:

Cough, fever, chest discomfort

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Allergic

  

Milk or soy protein intolerance (infants):

Associated with particular formula or food, blood in stools

 

 Other food allergy (older children)

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Peptic ulcer or gastritis

Epigastric

pain, blood or coffee-ground material in emesis

pain relieved by acid blockade

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Appendicitis:

Fever, abdominal pain migrating to the right lower quadrant, tenderness

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Anatomic obstruction :

  

Intestinal

atresia

:

Neonate, usually

bilious,polyhydramnios

  

Midgut

malrotation

:

Pain, bilious vomiting, gastrointestinal bleeding, shock  

 

Intussusception

:

Colicky pain, lethargy, vomiting, currant jelly stools, mass occasionally

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Duplication cysts:

Colic, mass  

 

Pyloric

stenosis

:

Nonbilious

vomiting, postprandial, <4 mo old, hunger

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Bacterial gastroenteritis:

Fever, often with bloody

diarrhea

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Central nervous system

 

Hydrocephalus

:

Large head, altered mental status

  

Meningitis:

Fever, stiff neck

 

 

Migraine syndrome:

Attacks scattered in time, relieved by sleep; headache

  

Cyclic vomiting syndrome :

Similar to migraine, usually no headache

 

 

Brain

tumor

:

Morning vomiting, accelerating over time, headache,

diplopia

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Motion sickness:

Associated with travel in vehicle

Labyrinthitis

:

Vertigo

Metabolic disease :

Presentation early in life, worsens when catabolic or with exposure to substrate

Pregnancy:

Morning, sexually active, cessation of menses

Drug reaction or side effect:

Associated with increased dose or new medication

Cancer chemotherapy:

Temporally related to administration of chemotherapeutic drugs

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Laboratory evaluation

1- serum electrolytes

2- tests of renal function

3-complete blood count

4- amylase

5- lipase

6-liver function tests.

Additional testing may be required immediately when history and examination suggest a specific

etiology

.

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Ultrasound

is useful to look for pyloric

stenosis

, gallstones, renal stones,

hydronephrosis

,

biliary

obstruction, pancreatitis, appendicitis,

malrotation

,

intussusception

, and other anatomic abnormalities.

CT

may be indicated to rule out appendicitis or to observe structures that cannot be visualized well by ultrasound.

Barium studies

can show obstructive or inflammatory lesions of the gut and can be therapeutic, as in the use of contrast enemas for

intussusception

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Treatment

Treatment

of vomiting needs to address the consequences and causes of the vomiting. Dehydration must be treated with fluid resuscitation.

This can be accomplished in most cases with oral fluid-electrolyte solutions, but IV fluids are commonly required.

Electrolyte imbalances should be corrected by appropriate choice of fluids.

Underlying causes should be treated when possible

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The use of

antiemetic medications

is controversial.

These drugs should not be prescribed until the

etiology

of the vomiting is known and then only for severe symptoms.

Phenothiazines

, such as

prochlorperazine

, may be useful for reducing symptoms in food poisoning and motion sickness.

Their side effect profile must be considered carefully, and the dose prescribed should be conservative.

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Anticholinergics

, such as scopolamine, and antihistamines, such as

dimenhydrinate

, are useful for the prophylaxis and treatment of motion sickness.

Drugs that block serotonin 5-HT

3

receptors, such as

ondansetron

and

granisetron

, are used for viral gastroenteritis, and can improve tolerance of oral rehydration therapy. They are clearly helpful for chemotherapy-induced vomiting, often combined with

dexamethasone

.

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No antiemetic should be used in patients with surgical emergencies or when a specific treatment of the underlying condition is possible.

Correction of dehydration, ketosis, and acidosis by oral or intravenous rehydration is helpful to reduce vomiting in most patients with viral gastroenteritis

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Gastroesophageal

Reflux

Etiology

and Epidemiology

Gastroesophageal

reflux (GER) is defined as the effortless retrograde movement of gastric contents upward into the

esophagus

or

oropharynx

.

In infancy, GER is not always an abnormality.

Physiological GER (“spitting up”)

is normal in infants younger than 8-12 months old.

Nearly half of all infants are reported to spit up between 2 and 4 months of age.

Infants who regurgitate meet the criteria for physiological GER so long as they maintain adequate nutrition and have no signs of respiratory complications or

esophagitis

.

Contributing factors of infantile GER include liquid diet; horizontal body position; short, narrow

esophagus

; small, noncompliant stomach; frequent, relatively large-volume feedings; and an immature lower

esophageal

sphincter (LES).

As infants grow, they spend more time upright, eat more solid foods, develop a longer and larger diameter

esophagus

, have a larger and more compliant stomach, and experience lower caloric needs per unit of body weight.

As a result, most infants stop spitting up by 9-12 months of age.

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Gastroesophageal

reflux

disease (GERD) occurs when GER leads to

troublesome symptoms or complications such as poor growth, pain, or breathing difficulties. GERD occurs in a minority of infants but is often implicated as the cause of fussiness. GERD is seen in fewer than 5% of older children.

In older children, normal protective mechanisms against GER include

antegrade

esophageal

motility, tonic contraction of the LES, and the geometry of the

gastroesophageal

junction.

Abnormalities that cause GER in older children and adults include reduced tone of the LES, transient relaxations of the LES,

esophagitis

(which impairs

esophageal

motility), increased

intraabdominal

pressure, cough, respiratory difficulty (asthma or cystic fibrosis), and

hiatal

hernia.

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Clinical Manifestations

Cough

Hoarseness

Wheezing

Abdominal Pain

Failure to Thrive

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The presence of GER is easy to observe in an infant who spits up.

In older children, the

refluxate

is usually kept down by

reswallowing

, but GER may be suspected by associated symptoms, such as heartburn, cough,

epigastric

abdominal pain,

dysphagia

, wheezing, aspiration pneumonia, hoarse voice, failure to thrive, and recurrent hiccoughs or belching.

In severe cases of

esophagitis

, there may be laboratory evidence of

anemia

and

hypoalbuminemia

secondary to

esophageal

bleeding and inflammation.

When

esophagitis

develops as a result of acid reflux,

esophageal

motility and LES function are impaired further, creating a cycle of reflux and

esophageal

injury

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Laboratory and Imaging Studies

A clinical diagnosis is often sufficient in children with classic effortless regurgitation and no complications.

Diagnostic studies are indicated if there are persistent symptoms or complications or if other symptoms suggest the possibility of GER in the absence of regurgitation.

A child with recurrent pneumonia, chronic cough, or

apneic

spells without overt emesis may have occult GER.

A

barium upper gastrointestinal (GI) series helps to rule out

gastric outlet obstruction,

malrotation

, or other anatomical contributors to GER.

Because of the brief nature of the examination, a negative barium study does

not rule out GER, nor does it rule it in as it is normal to have some reflux

into the

esophagus

many times per day.

A

24-hour

esophageal

pH probe monitoring uses a pH electrode placed

transnasally

into the distal

esophagus

, with continuous recording of

esophageal

pH.

Data typically are gathered for 24 hours and analyzed for the number and temporal pattern of acid reflux events.

Esophageal

impedance monitoring records the migration

of electrolyte-rich gastric fluid in the

esophagus

.

Endoscopy is useful to

evaluate for

esophagitis

,

esophageal

stricture, and anatomical abnormalities.

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Treatment

In otherwise healthy young infants, no treatment is necessary.

For infants with complications of GER, an H2 blocker or proton-pump inhibitor may be offered ,but these have shown little benefit in infants with uncomplicated GER and/or fussiness.

Prokinetic

drugs, such as

metoclopramide

, occasionally are helpful by enhancing gastric emptying and increasing LES tone, but they are seldom effective and may lead to complications.

When severe symptoms persist despite medication, or if

lifethreatening

aspiration is present, surgical intervention may be required.

Fundoplication

procedures, such as the

Nissen

operation, are designed to enhance the

antireflux

anatomy of the LES.

In children with a severe neurological defect who cannot tolerate oral or gastric tube feedings, placement of a feeding

jejunostomy

may be considered as an alternative to

fundoplication

.

In older children, lifestyle changes should be discussed, including cessation of smoking, weight loss, not eating before bed or exercise, and limiting intake of caffeine, carbonation, and high-fat foods.

However, proton pump inhibitor therapy is more effective in reducing symptoms and supports healing.

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Cyclic Vomiting Syndrome

Etiology

and Epidemiology

Cyclic vomiting syndrome (CVS) presents with intermittent episodes

of

prolonged nausea and vomiting with periods of health in between.

It can occur at any age but is diagnosed most frequently in preschool to school-age children.

It is thought to be a migraine variant; many patients have a positive family history of migraines, and some with CVS will eventually develop migraine headaches.

Triggers to an episode often include viral illnesses, lack of sleep, stressful or exciting events (holidays, birthdays, vacations), physical exhaustion, and menses

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Clinical Manifestations

Episodes can start at any time but will often start in the early morning hours.

Episodes are similar to each other in timing and duration.

Repetitive vomiting can last hours to days.

Patients can also have abdominal pain,

diarrhea

, and headaches.

Those affected are typically pale, listless, and prefer to be left alone.

They may have photo- or

phonophobia

.

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Laboratory and Imaging Studies

There are no specific tests for CVS, which is diagnosed based on the history and the exclusion of other disorders.

Diagnoses that should be considered include

malrotation

with intermittent

volvulus

,

uteropelvic

junction (UPJ) obstruction,

EoE

, intracranial mass lesions, and metabolic disorders.

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Rome III Criteria

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Treatment

For the acute episode, supportive treatment includes hydration; dark, quiet environment; and

antiemetics

such as

ondansetron

.

In addition, abortive therapy using

antimigraine

medications such as NSAIDs and

triptans

can be used.

For those with frequent or prolonged episodes, prophylactic therapy can be used, such as

cyproheptadine

,

tricyclic

antidepressants, beta

blockers, or

topiramate

.

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