3. INTRODUCTI
ON
Common symptom of disorders ranging from self limiting to life
threatening illness
Recognize serious conditions requiring immediate interventions
4. Definition
s
Vomiting(emesis): Forceful oral expulsion of gastric contents
associated with contraction of abdominal and chest wall
musculature(retrograde)
Nausea: Unpleasant,vaguely epigastric or abdominal sensation
accompanied by variety of autonomic changes that may precede
vomiting but may be present in a child who does not vomit
Regurgitation: Effortless passage of gastric contents into mouth.
*Nelsons Textbook of Pediatric symptom based Diagnosis
5. Definitions
(cont)
Prolonged Vomiting:
Vomiting > 12hours in a neonate,
>24hours in children younger than 2 years of age
> 48 hours in older children
Recurrent Vomiting : At least 3 episodes occurring over 3 months
Chronic vomiting : Low grade frequent vomiting episodes
(>2episode/week)
Episodic / Cyclic vomiting: Discrete episodes of high intensity
vomiting that occur sporadically in between asymptomatic intervals
*Indian Journal of pediatrics(April 2013)
6. Sitophobia: An extreme avulsion to eating or to food
Retching: It is the effort to vomit, short of expulsion of gastric
contents
Rumination: Repeated regurgitation of stomach contents which are
often rechewed and reswallowed
*Nelsons Textbook of Pediatric symptom based Diagnosis
Definitions (cont)
14. Red Flag signs of vomiting
1. Persistent or severe vomiting and Failure to thrive
2. Guarding / Rigidity or abdominal distension
3. Lethargy / Altered sensorium
4. Inconsolability and Bulging fontanelle in infant
15. 5. Nuchal rigidity, Photophobia and fever in older child
6. Toxic/septic/apprehensive look
7. Bilious /bloody vomiting
8. Signs of severe dehydration or symptomatic hypoglycemia
Red Flag signs of vomiting
26. Clinical Clues
● Bile stained Vomitus: Intestinal obstruction distal to ampulla of vater
● Acute change in stool pattern:Constipation (intestinal obstruction ),
Diarrhea (Intestinal infection)
● High colored urine: Hepatitis or concentrated urine in dehydration
(Oliguria fluid resuscitation)
● Failure to thrive (Chronic cases: IEM)
● Cyclical Vomiting and Vomiting due to migraine: Asymptomatic
between interval period
● Drug induced Vomiting: Metallic taste ,undesirable taste, gastritis or
hepatitis
27.
28. Clinical Clues(Cont.)
● Skin pigmentation with long standing vomiting – Addison’s
disease
● Lethargy disproportionate to severity of vomiting , Abdominal pain
(Right hypochondrial tenderness) Hepatitis, DKA, increased
ICP
● Abdominal lump, Constipation, Bilious vomiting ,abdominal
distension, hyperperistalsis and not passing stools: Intestinal
obstruction
● Abdominal pain, tenderness, guarding and rigidity (with or without
29.
30. Clinical Clues(Cont.)
● Toxic child ,effortless vomiting, projectile, non bilious,Early morning –
extrabdominal cause (Intracranial)
● Nausea ,Dizziness ,Vertigo ,Nystagmus vestibular dysfunction
● Well appearing child with No clinical findings migraine ,cyclical
vomiting & psychogenic vomiting
31. Evaluation of Vomiting
● ASK:
1)Age
2)Timing : Onset Duration Time of day
Frequency Triggers
3)Associated symptoms:
Diarrhea: Stool pattern Urine: oliguria
Abdominal pain /distension Fever, Headache
Anorexia, Failure to thrive Periodicity
Drug history(Digoxin) Relation to travel
Back pain (Pyelonephritis)
32. ● Look:
Sick or well , Lethargy, Abdominal distension , Tenderness,
Guarding, Rigidity, Hepatosplenomegaly, Signs of raised ICP ,
meningeal signs, skin pigmentation , Fundus examination,
Nystagmus, vertigo , Sore throat /cough, No abnormal signs
found
33. Laboratory investigation
● Investigations not required :
1. Well appearing infant with typical regurgitant reflex
2. Well child with suspected gastritis or GER
3. Brief episode of vomiting with no dehydration and clear
etiology like gastroenteritis
4. Chronic vomiting where acid peptic disease is suspected
34. Laboratory investigation(Cont.)
● Investigation generally done include:
1. Blood investigations: children with red flag signs and with dehydration
features
2. Serum electrolytes with Blood gas:
● Infant with projectile vomiting from pyloric stenosis: Hypochloremic
Hypokalemic Metabolic alkalosis
● Congenital adrenal hyperplasia: Hyperkalemia and hyponatremia
● Alcohols,salicylates, uremia,Metabolic defects: Lactic acidosis with
elevated anion gap
35. Laboratory investigation(Cont.)
● Renal Tubular Acidosis: Metabolic acidosis with normal anion gap
● Renal or Prerenal Failure : Elevated creatinine
● Hepatic enzymes & Pancreatic enzymes: Elevated in liver and
pancreatic disease
● Urinanalysis: Presence of Glucose & KetonesDKA
■ RBC Renal cause(Nephritis,UTI,Calculi,Trauma)
■ WBC/Nitrites (UTI)
36. Radiological investigation
Plain Xray abdomen (Erect):
-Distended bowel loop with air fluid levels: Intestinal obstruction
-Dilated stomach : Pyloric stenosis
-Free air under diaphragm: Hollow viscus perforation
-Abnormal calcification: Renal /biliary stones or Fecoliths
-Basilar infiltrates: Lower lobe pneumonias
37.
38. Radiological investigation(cont.)
1. USG abdomen: Helps in diagnosis of appendicitis ,intussusception,
Pyloric stenosis
2. Upper GI series : Malrotation and upper GIT obstructions
3. CT scan: Useful in imaging of liver and pancreas and in evaluating
mass lesions
4. Upper GI endoscopy: For mucosal pathology
39. ● Metabolic work up:
Children with episodic vomiting or suspected metabolic
disorders, blood and urine screening are positive only during
actual vomiting episodes only
40. ABDOMINAL MIGRAINE
● Episodic attacks of epigastric and periumbilical abdominal pain
● F>M(3:2),Onset 7-12years of age
● Family history positive for migraine headache
● Intense pain lasting for 1 hour or more ;affecting normal activities along with Anorexia,
Nausea, Vomiting, Headache,Phototphobia, Pallor
41. ABDOMINAL MIGRAINE
• Have normal episodes between intervals of migraine
• Diagnosis of exclusion ;usually responsive to drugs used in treating
migraine headaches
• Triggers : Caffeine foods, prolonged fasting, altered sleep, emotional
stress
42. CYCLICAL VOMITING SYNDROME
● Stereotypic recurrent episodes of nausea and vomiting with no
identifiable organic cause
● Idiopathic, begins in early childhood
● Rapid onset ,persisting from hours to days separated by symptom free
intervals from weeks to years
43. CYCLICAL VOMITING SYNDROME
• Diagnosis is made when:
1) ≥ 3 episodes of recurrent vomiting
2) Intervals of normal health between episodes
3) Lack of laboratory and radiologic evidence of alternate diagnosis
• Supportive management i.e dehydration and electrolyte imbalance
correction
• Amitriptyline and propranolol as described as effective in prophylactic
therapy
44. Emergency management
● Treat dehydration
● If bilious vomiting : Stop oral fluids/feeds, Keep NPO and
decompress stomach with NG tube, Start IV fluids, Surgical
opinion
● Antiemetics: ondansetron (preferred)
● Dose of ondansetron: oral : 0.2mg/kg
Parenteral : 0.15mg/kg (max of 4mg)
45. Administration of antiemetics prior to surgical evaluation is
avoided unless in
i. Child not able to take orally due to persistent vomiting
ii. Post operative vomiting
iii. Chemotherapy induced vomiting
iv. Cyclic vomiting syndrome
v. Acute motion sickness
46. Take Home message
● Vomiting is a non specific symptom
● History along with age related common causes helps in
narrowing the differentials
● Important to differentiate serious causes from mild so as
to necessity prompt referral
● Always watch out for RED Flag signs
47. References
● Vomiting in children :Reassurance, red flags , or Referral ?
American Academy pediatrics
● Management of a Child with Vomiting –Indian Journal of
pediatrics
● IAP textbook of RAPID approach to common symptoms
● Nelson textbook of Pediatric symptom based diagnosis
Nausea and vomiting are common sequelae of a multitude of disorders ranging from self limiting to life threatening illness
Hence its important to recognize serious conditions (Intestinal obstruction, Increased ICP etc.) for which immediate intervention is required
Episodes separated not more than 2 mins is considered as single episode
Vomiting is a reflex act. Sensory impulses for vomiting arise from the irritated or distended part of GI tract or other organs and are transmitted to the vomiting center
through vagus and sympathetic afferent fibers. Vomiting center is situated bilaterally in medullaoblongata near the nucleus tractus solitarius.
Motor impulses from the vomiting center are transmitted through V, VII, IX, X and XII cranial nerves to the upper part of GI tract; and through spinal nerves
to diaphragm and abdominal muscles.
1. Antiperistalsis, ileum towards the mouth ,Velocity of antiperistalsis of about 2 to 3 cm/second
2. Deep inspiration followed by temporary cessation of breathing and Closure of glottis
3. Upward and forward movement of larynx and hyoid bone with Elevation of soft palate
4. Contraction of diaphragm and abdominal muscles resulting in elevation of intra-abdominal pressure
5. Compression of the stomach between diaphragm and abdominal wall( intragastric pressure) and Simultaneous relaxation of lower esophageal sphincter, esophagus and upper esophageal sphincter
6. Forceful expulsion of gastric contents (vomitus) through esophagus, pharynx and mouth
Some of the movements play important roles by preventing the entry of vomitus through other routes and thereby prevent the adverse effect of the
vomitus on many structures.
1. Closure of glottis and cessation of breathing prevents entry of vomitus into the lungs
2. Elevation of soft palate prevents entry of vomitus into the nasopharynx
3. Larynx and hyoid bone move upward and forwardand are placed in this position rigidly. This causes the dilatation of throat, which allows free exit of vomitus
Well appearing infant with typical regurgitant reflex (No diarrhoea, fever, nausea and forceful abdominal contractions)
To differentiate from surgical to non surgical causes
