a child with vomiting (problem based approach)
TRANSCRIPT
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Sariu Ali:
A Vomiting Child
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Introduction
• Vomiting is a symptom, presenting complaint in multitude of disorders– Range from gastrointestinal pathology to
disease in distant organ (otitis media or intracranial lesion)
• In children, especially infants, must distinguish from regurgitation – effortless expulsion of gastric contents
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Vomiting is an active process , composed of 3 linked activities : Nausea , retching, active propulsion of stomach contents
Control of vomiting by 2 anatomic centers in the mudulla
Chemoreceptor trigger zone CTZcentral vomiting center.
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Physiology
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Common causes of vomiting
Infants Child Adolescent
GastroenteritisGastroesophageal refluxOverfeedingAnatomic obstructionSystemic infectionPertussis syndromeOtitis media
GastroenteritisGastritisToxic ingestionReflux (GERD)MedicationSystemic infectionPertussis syndromeSinusitisOtitis media
GastroenteritisGERDGastritisInflammatory bowel diseaseAppendicitisToxic ingestionSystemic infectionSinusitisMigrainePregnancyMedication
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Infants Child Adolescent
•CAH
•Inborn error of metabolism
•Brain tumor (increased intracranial pressure)
•Subdural hemorrhage
•Food poisoning•Renal tubular acidosis
•Reye syndrome•Hepatitis•Peptic ulcer•Pancreatitis•Brain tumor•Increased ICP•Middle ear disease•Chemotherapy•Achalasia•Cyclic vomiting (migraine)•Esophageal stricture•Duodenal hematoma•Inborn error of metabolism
•Reye syndrome•Hepatitis•Peptic ulcer•Pancreatitis•Brain tumor•Increased ICP•Middle ear disease•Chemotherapy•Cyclic vomiting (migraine)•Biliary colic•Renal colic
Rare causes of vomiting
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Gastrointestinal Causes Infection
GasteroenteritisPeritonitisAppendicitsHepatitis
Motility disordersAchalasiaPseudoobstructionHirschsprung diseaseGastroparesis
Mechanical obstruction
Congential anomalies Malrotation +volvulusIntussusceptionForeign bodiesMeconium ileusIncarcerated hernia
InflammationGERIntrinsic outlet inflammationGastric outlet inflammationDuodenal ulcersEosinophilic gastroenteritisFood allergy /intoleranceCeliac diseasePancreatitis
Causes of Vomiting by systems
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Causes of Vomiting by systems
CNS Incresed ICP, Hydrocapahlus, Brain tumors , drugs ( chemotherapy)
Infections Meningitis , UTI, pneumonia, otitis media, sepsis
Metabolic DKA, Urea cycle disorders, galactosemia
Endocrine adrenal insufficiency
Intoxication alcohol, aspirin, PCM
Renal obstructive uropathy , renal failure , renal tubular acidosis
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Age of the patient Duration /Frequency Onset Associated with food intake
instantly : esophageal obstruction After a while : stomach or duodenal obstruction
Nature (projectile / non projectile) Color and contents
Non digested food :proximal obstruction Semi digested food : distal obstruction Billous content : distal to 2nd part of duodenum Fecal material : obstruction at the large intestine
Associated symptoms Fever / Abdominal Pain /Diarrhea /constipation/
dysphagia.
History
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History Respiratory – cough, chest discomfort Urinary – dysuria,hematuria CNS – irritability, altered sensorium,drowsy, neck stiffness,
headache, visual disturbance
Past medical historyAny known medical illness such as metabolic inborn error,
cerebral palsy, down syndrome, neurological deficit Drug and allergy history Birth history Nutritional history
Recently change into cow milk/ food allerrgy/ type of food Other relevant history
Recent eating outside, recent travelling, family member or friends in school have similar illness
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Physical ExaminationGeneral condition
Comparison of patient’s weight before and after onset of illness
Concious level- GCS Hydration status
Sunken frontanelle Eyes sunken and tearless Dry mucous membrane Prolonged capillary refill time Reduced skin turgor Tachycardia, tacypnea
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Look for any evidence of any specific disorder/ disease based on history
Abdominal Examination• Distension/ Visible peristalsis• Tenderness/ hepatospelnomegaly • abdominal masses • Bowel soundsCNS Examination• Power, Tone, reflexes • Changes in vision
Physical Examination
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• Respiratory Examination• Ear examination by otoscopy• Fundoscopy
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Imaging
CXRPlain Abdominal XrayBarium meanBarium follow throughCranial CTUpper GI endoscopy
Urine
UFEMEUrine C/S
Investigations
Full Blood Count Leukocyctosis (infection )
BUSE/ creatinine Effects of vomiting on electrolytes ( hypokalemia), Renal insufficiency
Blood glucose Levels exclude DKA
Blood gases Acidosis :organic acidemia, Alkalosis: pyloric stenosis
Blood Investigations
Guided by history/ PE
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• Asses the severity of dehydration• Rehydrate accordingly• Correct electrolyte imbalances • Encourage oral intake• Treat according to the underlying cause
Management
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• Nelson Text book of Peadiatrics 17th edition• Hand book of Hospital peadiatrics 2nd edition• Illustrated text book of paediatrics 3rd edition
References
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Thank You
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Disease/condition Therapy-drug class
Reflux Dopamine antagonist: metoclopramide (Reglan) ( 0.1-0.2 mg/kg qid PO/IV)Peripheral dopamine antagonist: domperidone (Motilium) ( 0.2-0.6 mg/kg tid-qid PO)
Gastroparesis Metoclopramide, domperidoneMotilin agonist: erythromycin ( 2-4 mg/kg tid-qid PO/IV)
Intestinal pseudoobstruction
Octreotide ( sandostatin)
Chemotherapy MetoclopramideSerotoninergic 5-HT3 antagonist; ondansetron ( zofran)Phenothiazines; prochlorperazine (compazine)Steroids: dexamethasone ( decadron)Cannabiniods: nabilone
Postoperative Ondansetron, phenothiazine
Motion sickness; vestibular disorder
Antihistamine: dimenhydrinate ( dramamine)Anticholinergic: scopolamine ( transderm scop)
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