Transcript Vomiting In Children Reassurance, Red Flag, or Referral?

Vomiting In Children
Salma Elkhabier
Morehouse School of Medicine
Pediatrics Residency Program-PGY3
Physiology of Vomiting
Classification of Vomiting
• According to nature:
1. Projectile---------- ↑ ICP or pyloric stenosis
2. Non Projectile------ GER or any other causes.
• According to quality
1. Bilious ( dark green)----------- Always pathological and
indicate obstruction beyond the ampulla of vater.
2. Bloody: red blood----- Upper GI or massive lower GI
bleed, coffee ground----- old upper GI or lower GI
bleeding
3. Non bloody, non bilious: usually clear or yellowish with
remnants of previously ingested food--------most types of
vomiting.
Differential diagnosis of vomiting
Age
Common
Causes
Type of Vomiting Comment/Associ
ated Features
Newborn
1.
1. Bilious, depending
on level of lesion
2. Bilious
3. Bilious or nonbilious
4. Bilious or nonbilious
5. Bilious or nonbilious
6. Nonbilious
Intestinal
atresia/webs
2.
Meconium
ileus
3. Hirschsprung
disease
4. Necrotizing
Enterocolitis
5. Inborn irrors of
metabolism
1. May occur at level of
esophagus,
Duodenum or jejunum
2. Strongly associated e CF
3. History of non-passage
of stools
in nursery suggestive;
suction
rectal biopsy may
demonstrate
lack of ganglion cells.
4. Plain films of abdomen
may
reveal intestinal
pneumatoses
5. May have acidosis or
Hypoglycemia
Differential diagnosis of vomiting
Age
Common Causes
Type of vomiting
Comment/Associated
features
O to 3 months
1.
Pyloric stenosis
2. Malrotation with
midgut volvulus
3. Inborn errors of
Metabolism
4. Milk/soy protein
allergy
5. Gastroesophageal
Reflux
6. Child abuse
7. infections/sepsis
1.
2.
3.
1. Hypochloremic metabolic
Alkalosis
2. Abdominal distention
may be present, plain X
rays may show air fluid
levels & paucity of distal
bowel gas.
3. Newborn metabolic
screen may
be abnormal; acidosis or
hypoglycemia may be
present
4. may have gross or occult
blood h/o extreme
fussiness,fecal occult blood
testing of stools may be
positive
5. may have gross
or occult blood
Emesis usually within 30
minutes
of feeding; symptoms
worse in
supine flat position
4.
5.
6.
Nonbilious
Bilious
Bilious or
nonbilious
Bilious or
nonbilious
Nonbilious
Nonbilious
Differential diagnosis of vomiting
Age
Common Causes
Type of Vomiting
Comment/Associated
features
3 to 12 Months
1. AGE
1.
1. Stool studies may help
establish
offending pathogen
2. Abdomen distention may
be
present; plain radiographs
may
show air-fluid levels and
paucity of distal bowel gas;
stools may be grossly
bloody
with “currant jelly”
Appearance
3. AF fullness may
be present; CNS imaging
studies may reveal acute or
subacute bleeding
4. AF fullness may
be present; CNS imaging
studies and LP diagnostic
5. Exam likely suggest dx.
2. Intussusception
3. Child abuse
4. Intacranial mass or
meningitis
5. Non specific causes
like infections (
UTI/ OM)
2.
3.
4.
5.
Nonbilious
initially; may
progress to
bilious
Bilious
Nonbilious
Nonbilious/
projectile
Nonbilious
Infantile Hypertrophic Pyloric Stenosis
•
•
•
•
•
3 in 1000 livebirths
Ist born males
2-6 weeks
Projectile /nonbilious emesis
Unclear etiology but some cases attributed to deficiencies in
neuropeptidergic innervation and nitric oxide.
• Erythromycin in 1st 2 weeks of birth should be avoided ( eight
times fold inc in PS due to interaction with intestinal motilin
receptors)
Infantile Hypertrophic Pyloric Stenosis
• Diagnosis mainly by typical history and exam findings.
• May or may not see prestaltic waves
• Palpable olive strongely support diagnosis.
• Hyperchloremic hypokalemic metabolic alkalosis is classic
• Abdominal US is diagnostic
• Surgical pyloromytomy after correction of electrolytes is the preferred
mode of management.
Infantile Hypertrophic Pyloric Stenosis
Pyloric muscle thickness of 4
mm or more and muscle length
of 14 mm or more are
diagnostic of pyloric stenosis
Malrotation with Midgut Volvulus
•
Stages of intestinal develpment:
1.
Rapid growth of the midgut outside the abdominal cavity through
a herniation of the umbilical orifice.
2.
The midgut returns to the abdominal cavity, rotating 180 degrees
and pushing the hindgut to the left.
3.
Retroperitonealization of portions of the right colon, left colon,
duodenum, and intestinal mesentery, helping them serve as
anchors for the bowel.
Disruption of this normal development in 2nd or 3rd stage may lead
to an aberrant return or anchoring of the midgut within the
abdominal cavity.
•
Malrotation with Midgut Volvulus
• Typically presnent in 1st week of life
• May go for years undetected if not associated with volvulus.
•
The midgut twists in a clockwise direction around the superior
mesenteric vessels, leading to obstruction of vascular supply to
most of the small and large intestine.
• Clinical presentation starts with bilious vomiting and can proceed
quickly to a shock like state with hemodynamic instability and
metabolic acidosis if bowel ischemia occurs---- if not emergently
surgically treated will lead to bowel perforation, sepsis and death
• If bowel ischemia is prolonged, loss of bowel and resultant short gut
syndrome may occur.
Malrotation with Midgut Volvulus
Failure of contrast to pass beyond the
second portion of the duodenum in UGI
which is characteristic of malrotation.
Abdominal US may demonstrate
malposition of superior mesenteric
vessels.
Duodenal Atresia
• A congenital obstruction of the second portion of the
duodenum happened due to a failure of recanalization of the
bowel during early gestation.
• 1 per 5,000 to 10,000 live births
• Associated with trisomy 21 in 25% of cases.
• A surgical emergency and typically presents within a few
hours after birth
• Infants present with clinical features of failure to tolerate
feedings and bilious emesis shortly after birth.
• Due to the proximal nature of the obstruction, abdominal
distention usually is not present.
Duodenal Atresia
“Double bubble” sign on
plain radiograph, which
represents air in the
stomach and proximal
duodenum and
indicates duodenal atresia.
Jejunoileal atresias
• More distal obstructions
• Believed to be due to a mesenteric vascular accident at some
point during the course of gestation.
• Occurs in 1 in 3000 live birts
• Present with Bilious vomiting with Abdominal distension in
the 1st 24 hours of life.
• Anatomically, jejunoileal atresias can be classified into four
types: membranous, interrupted, apple-peel, and multiple.
• Abdominal radiography may show dilated loops of small
bowel with air-fluid levels.
• Treatment for all types is urgent surgical correction.
Jejunoileal atresias
Dilated loops of small bowel
with air-fluid levels,
indicative of jejunoileal atresia.
Intussusception
• Is the telescoping of one portion of the bowel into its distal
segment, most commonly, the terminal ileum into the cecum
• Commonly due to lymphatic hypertrophy in the Peyer patches
from a recent viral infection.
• peak incidence occurs between 3 months and 3 years
• A history of intermittent episodes of severe and crampy
abdominal pain with bilious emesis is classic.
• Child may be lethargic between episodes.
• Parents may describe blood tinged “ current jelly “ stools.
Intussusception
• Abdominal examination may be normal or may reveal sausage
shaped mass palpable in the right lower quadrant.
• Urgent surgical consultation is warranted.
• Contrast or air enemas can be diagnostic and theraputic.
• Surgical reduction of the intussusception is indicated when the
contrast enema is not successful.
Intussusception
• Contrast outlining the
lead portion of the
intussusception, giving
the typical “coiled spring”
appearance.
Superior Mesenteric Artery Syndrome
• Is a functional upper intestinal obstructive condition known as
Wilkie or cast syndrome.
• Occurs when the angle between the SMA and the aorta is
narrowed to less than 25 degrees ( normally 45), the
duodenum may become entrapped and compressed.
• Happens usually in patient who have experienced rapid weight
loss, immobilization in a body cast, or surgical correction of
spinal deformities.
• presents with epigastric abdominal pain, early satiety, nausea,
and bilious vomiting. Pain worsens in supine position and
relieved by prone or knee-chest position.
Superior Mesenteric Artery
Syndrome
• Diagnosis usually is
confirmed by upper GI
radiographic series or
computed tomography
scan with dilated stomach
and failure of contrast to
pass beyond the third
portion of the duodenum.
Superior Mesenteric Artery Syndrome
• Conservative management of SMA syndrome
focuses on gastric decompression, followed by
the establishment of adequate nutrition and
proper positioning after meals.
• Placement of an enteral feeding tube distal to
the obstruction or TPN may be needed in
severe cases.
Surgical correction with duodenojejunostomy
is a last resort.
Other Causes of Vomiting
•
Cyclic vomiting:
•
•
•
stereotypic recurrent episodes of nausea and vomiting without an
identifiable organic cause
Idiopathic, happened in early childhood, unknown pathogenesis.
Characterized by
1.
2.
3.
4.
Three or more episodes of recurrent vomiting
Intervals of normal health between episodes
Episodes that are stereotypic with regard to symptom onset and duration
lack of laboratory or radiographic evidence to support an alternative diagnosis
•
•
Treatment is supportive
Amitriptyline and propranolol have been described as effective for
prophylactic therapy
Other Causes of Vomiting
• Abdominal Migraine
•
•
•
•
•
•
episodic attacks of epigastric or periumbilical abdominal pain
Female: male ratio 3:2
Onset between 7 and 12 years.
FH of migraine may be present
believed to share pathophysiologic mechanisms with CVS
Attacks characterized by acute, intense abd pain that interfer with normal
activities and accompanied by anorexia, nausea, vomiting, headache,
photophobia and pallor.
• Periods of normal health between episodes.
• Diagnosis is supported by a favorable response to medications used for
treatment of migraine headaches.
Other Causes of Vomiting
• Rumination
• repeated and painless regurgitation of ingested food into the mouth
beginning soon after food intake, followed by swallowing or spitting up of
food.
• Symptoms do not occur during sleep and do not respond to the standard
treatment of GER.
• To qualify for the diagnosis, symptoms must be present for longer than 8
weeks.
• typically seen in mentally retarded children, neonates during prolonged
hospitalization, and children and infants who have GER, may also
happened in adolescent with bulimia or neglected children.
• The management of rumination involves a multidisciplinary approach, with
a primary focus on behavioral therapy and biofeedback.
Conclusion
• Vomiting is a nonspecific symptom that may accompany a
wide variety of GI and extraintestinal disorders
• Conditions such as mild GER may only necessitate
reassurance, but symptoms of bilious vomiting should prompt
immediate referral to a pediatric surgeon.
• Associated fluid and electrolyte imbalances always must be
considered when assessing a child who has a history of
vomiting.
• Results of the history and physical examination, keeping in
mind the nature of the vomiting and age of the child, may help
you determine the likely cause and the need for emergent
treatment.