The document discusses the causes, diagnosis, and management of emesis (vomiting) in pediatric patients, highlighting differential diagnoses such as pyloric stenosis and acute appendicitis. It emphasizes the significance of recognizing gastrointestinal symptoms in children undergoing cancer treatment, with a focus on chemotherapy-induced nausea and vomiting (CINV). Additionally, it explores the efficacy of olanzapine as a preventive measure for CINV compared to traditional antiemetics, indicating its potential benefits for patient quality of life during treatment.

1. B Y D R T A N V E E R A L A M
S K M C H . R C
Emesis /CINV

2. Key points
 Definition
 How to approach a child with emesis
 Causes
 Excluding possible causes
 Investigation
 Management
 CINV
 Studies done

3. introduction
 Nausea: The unpleasant sensation of the imminent need to
vomit, usually referred to the throat or epigastrium; a sensation
that may or may not ultimately lead to the act of vomiting.
 Vomiting: Forceful oral expulsion of gastric contents
associated with contraction of the abdominal and chest wall
musculature.
 Regurgitation: The act by which food is brought back
into the mouth without the abdominal and diaphragmatic
muscular activity that characterizes vomiting.

5. Differential diagnosis
Clues on physical examination
— Certain physical findings may offer diagnostic clues that can aid in
narrowing the differential diagnosis:
 Gastroparesis /gastroenteritis.
 Constipation :
 Meningitis :
 A tense, bulging fontanels in neonates ,headache ,neck stiffness projectile vomiting level
of suspicion for meningitis.
 Pyloric stenosis:
 Projectile vomiting in an infant three to six weeks of age suggests pyloric
stenosis as a diagnosis.
 Acute appendicitis : Alvarado scoring(apgar scoring)
 CINV

6. •Metabolic cause:
An unusual odor emanating from the patient should be
investigated for metabolic causes of vomiting.
•Obstruction
Marked distension, visible bowel loops, absent bowel sounds,
bile staining in the vomitus
•Trauma related
Vomiting in association with trauma should leads to imaging
studies to rule out intracranial or intraabdominal injury.
•Miscellaneous causes:
 Cholecystitis , uti ,motion sickness,pregnancyetc, sepsis,
 excessive feeding volume, pneumonia ,etc

7. How Vomitus helps in diagnosis

8. Clinical Approach

9. Referrels
Patients should be referred to a pediatric gastroenterologist or
other appropriate specialist (eg, pediatric surgeon,
neurologist) when there are symptoms or physical findings
that are of particular concern.
 These include an abnormal neurologic exam,
peritoneal signs on abdominal examination, severe
abdominal pain, gastrointestinal bleeding, or
significant weight loss.
 Immediate pediatric surgical consultation is warranted if
appendicitis, bowel obstruction, or bowel
perforation are suspected.

10. Laboratory Investigations

11. management
 Examination
 Vitals
 diagnosis
 IV fluids bolus (NS +R/L +dextrose)
 Antiemetic
 (dimenhydrinate ,metoclopramide, (ondansetron,
granisetron,palonosetron Serotonin (5-HT3) aprepitant ,corticosteroide
,domperidone
 Reassess ( vitals + exam +oral trial)
 Treat the cause

14. CINV: types & Definitions
 Acute (post-treatment)
Occurs within first 24 hours after administration of cancer chemotherapy
 Delayed
CINV that begins after first 24 hours
May last for 120 hours
 Anticipatory
Learned or conditioned response from poorly controlled nausea and
vomiting associated with previous chemotherapy
 Breakthrough
CINV that occurs despite prophylaxis and requires rescue
 Refractory
Occurs during subsequent treatment cycles when prophylaxis and/or
rescue has failed in previous cycles

15. Emetogenic Potential of Single Antineoplastic
Agents
HIGH Risk in nearly all patients (> 90%)
MODERATE Risk in 30% to 90% of patients
LOW Risk in 10% to 30% of patients
MINIMAL Fewer than 10% at risk

18. 1st Generation 5HT3 RAs
Are Therapeutically Equivalent
Pts receiving MEC* (N=1,085)
80% of pts received prophylactic steroids
*Cyclophosphamide 500 - 1200 mg/m2, carboplatin
≥300 mg/m2
59.0 60.0
71.0
58.0 58.0
72.0
Total Nausea Emesis
Oral granisetron 2 mg
IV ondansetron 32 mg
CompleteControl(%)
• Highest Level Evidence &
Not Debated
• MASCC 2004
• NCCN 2009
• ASCO 2006
• 1st Generation Agents are
Therapeutically Equivalent
• Dolasetron
• Ondansetron
• Granisetron
• 1st Generation oral and IV
doses equally effective
Perez et al. J Clin Oncol 1998;16:754

19. 1st vs 2nd generation 5-HT3 antagonist
• Pharmacologic differences from older 5-HT3 antagonists
• prolonged half-life (~40 hours)
• enhanced receptor binding affinity (30-fold)
• Comparable tolerability
• 1st Generation Oral 5HT3 RAs Not Effective for Delayed
CINV

20. Palonosetron vs. 1st gen 5HT-3:
Complete Response on Day of Chemo & Beyond
Palonosetron 0.25 mg (n=378)
Ondansetron/Dolasetron 32/100 mg (n=376)
46.8
42.0
*
57.7
*
64.0
*
72.0
60.6
0
20
40
60
80
100
Time (hr)
Acute: 0-24
(Day 1)
Delayed: 24-120
(Days 2-5)
Overall: 0-120
(Days 1-5)
CompleteResponse(CR)
(%ofPatients)
*p<0.025 for pairwise difference (2-sided Fisher’s exact test) between palonosetron and ondansetron/dolasetron.
Gralla R et al. Ann Oncol. 2003; Eisenberg P et al. Cancer. 2003.
Rubenstein EB et al. Proc Am Soc Clin Oncol. 2003. Abstract 2932.
CR = no emetic episodes or use of rescue medications

21. A JOURNAL OF PAKISTAN PAEDIATRIC ASSOCIATION
ABSTRACT
Objectives: The objective of the study is to evaluate gastrointestinal
problems in cancer patients during treatment.
Patients and methods: In a sample of 150 children having different
childhood malignancies, the frequency, pattern and risk factors of
gastrointestinal (GIT) symptoms were analyzed.
Results: Almost 30% of pediatric cancer patients experienced one or
more episode of GIT problems. Overall prevalence of anticipatory
vomiting was 12%, acute vomiting was 51.33%; delayed vomiting was
26% that was highest on day 2 with 18% experiencing vomiting and
decreased to 8% by day 5. Expectancy of nausea was found to be a
strong predictor of subsequent occurrence of nausea and vomiting
(P=0.047) as well as the chemotherapeutic regimen potentiality that
significantly affected delayed vomiting (P=0.02).

22. continue
•Other predictive factors
•as age, gender, did not affect various forms of vomiting
•40 %of the enrolled patient suffered from mucositis, ranging from grade 1
to 3
•Clinical features of oral candidiasis werepresent in 10% of patients
•. 28% of the enrolled patients had attacks of
•diarrhea
•while 11.33% experienced constipation mostly due to vincristine
• opioids, 18% had altered perception of taste or smell.
Conclusion: The gastrointestinal symptoms are common in cancer
patients. Early recognition of GIT symptoms is essential for early
intervention and guide nutritional support.

23. Clinical research of Olanzapine for prevention of
chemotherapy-induced nausea and vomiting
by journal of experimental & clinical research
background
This study was designed to mainly evaluate the activity and safety of olanzapine
compared with 5-hydroxytryptamine3(5-HT3) receptor antagonists for prevention of
(CINV) + QOL
Methods
229 patients receiving highly or moderately emetogenic chemotherapy were
randomly assigned to the test group [olanzapine(O) 10 mg p.o. plus azasetron (A) 10
mg i.v. and dexamethasone (D) 10 mg i.v. on day 1;
Results
In summary, this study demonstrated that olanzapine has obtained the better
efficacy on being safely used for preventing the CINV. Olanzapine can improve the
complete response of delayed nausea and vomiting in patients receiving the highly or
moderately emetogenic chemotherapy comparing with the standard therapy of
antiemesis, as well as improve the QoL of the cancer patients during chemotherapy.
Olanzapine is a safe and efficient drug for prevention of CINV. Further study should
be done to compare the efficacy of olanzapine with aprepitant or palonosetron on
prevention of CINV through large sample study
Pub med