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Recurrent vomiting
Anshu SrivastavaDepartment of Paediatric Gastroenterology
SGPGIMS, Lucknow
Regurgitation and vomiting often confused in children
APT 2011;34:263-73/ GCNA 32 (2003) 997–1019
Cyclic↑intensity, ↓frequency
Chronic↓Intensity, ↑frequency
Recent years: Increase in cases with nausea and vomiting and gastroparesis
Regurgitation: Effortless return of food from stomach, no nausea/retchingVomiting: forceful expulsion of gastric/intestinal contents, often associated with nausea & retching Rumination: effortless regurgitation of recently ingested food with subsequent re-mastication/ re-swallowing or spitting
Vomiting: acute vs recurrent ( chronic vs cyclic)
triggers of vomiting in the blood or CSF
input from the GI tract
motion sickness and labyrinthine disorders
stress-induced, behavioural or psychiatric disorders
Chronic/ recurrent
ChronicGastrointestinal•Gastroesophageal reflux disease •Food allergy•Eosinophilic esophagitis•Achalasia cardia*•Gastritis•Gastroparesis•GOO: hypertrophic pyloric stenosis, peptic ulcer, pancreatitis, mass lesion•Small bowel obstruction: duodenal stenosis, annular pancreas, superior mesenteric artery syndrome•Rumination syndromeNon Gastrointestinal•Raised intracranial tension: SOL •Chronic sinusitis•Uraemia•Overfeeding
RecurrentGastrointestinal•Cyclic vomiting syndrome•Abdominal migraine•Malrotation with volvulusNon Gastrointestinal•Metabolic: Mitochondrial cytopathy (FAOD respiratory chain disorders etc) Urea cycle defects•DKA•Addison’s disease•Acute hydronephrosis due to PUJ obstruction (Dietl’s crisis)
Clues in historyNature of vomitus Non bilious • esophageal, gastric, D1• pseudo vomiting in achalasia cardia, ± dysphagia • stale food and large volume: GOO/ gastroparesisassociated with epigastric fullness, early satiety, succussion splash and visible distensionBilious vomiting • obstruction distal to second part of duodneum, • after repeated episodes of vomiting, • patients with gastro jejunostomyFeculent ( distal intestinal obstruction, gastro-colic fistula): abdominal pain, distension, gola formation
Clues in history
Pattern of vomiting; cyclical or chronic
Associated symptoms: pain, jaundice, fever, urinary symptoms, headache etc
Drug intake especially chemotherapeutics, radiation
Precipitants: specific food, stress, menstrual cycles, febrile illness etc
Previous surgery
Family history: migraine, CVS
Vomiting: acute or chronic
Clues on examination
Complete general and systemic examinationGrowth failureRecent significant weight loss (SMA syndrome)Signs of nutrient deficiency (malabsorption)HypertensionOral cavity; dental erosions, halitosis (GERD/ rumination)Eczema, reactive airway disease; (food allergy)Fundus/ neurologic abn (CNS)Abdominal: lumps, visible peristalsis, abdominal tenderness, surgical scar (SAIO/ pseudoobstruction)Hypotonia, developmental delay, cardiomyopathy; (mitochondrial cytopathy)
InvestigationsBlood• CBC with differential, ESR• Electrolytes, glucose, renal
functions• Liver and pancreatic enzymes• Lactate, pyruvate, ammonia,
carnitineUrine• Urine analysis• Organic acids, amino acids• Porphyrin screenStool• Occult blood
Imaging• UGI and SBFT• Ultrasound/ CT abdomen
abdomen• MRI brainEndoscopy and motility studies• Upper gastrointestinal endoscopy
with biopsies• 24 hours esophageal pH and
impedance • Esophageal manometry• Antroduodenal manometry• Gastric emptying study• Small bowel transit and colonic
transit
Current Gastroenterology Reports 2001, 3:248–256
Based on lik
ely diag
nosis
Tailo
r mad
e
Case 1 - 6 year old boy
Vomiting daily (not large volume/ non bilious, never contains stale food)
Occurs at any time No relationship to meals Sometimes wakes up at night with symptoms Once had small amount of blood in vomitus
Symptomatic for past 10 months
No weight loss, hematemesis, dysphagia, abdominal pain, respiratory symptomsNo history of drug intake like NSAID
Examination: normal growth, no positive finding
Investigations
• Outside: normal UGI endoscopy, no erosions, no hiatus hernia
• Diagnosis?• Was esophageal biopsy taken? no• What next??
GER Eosinophilic esophagitis
Normal esophagus
Esophageal Histology: useful
Small number of intraepithelial eosinophilsBasal cell thickeningLengthening of stromal papillae
24 hour pH metryCriteria measured Test result “normal” ranges
Reflux index 11% 6 %
Number of episodes >30s 38 25
Episodes >5 min 1 3
Longest epsiode 27 min 9.2min
Abnormal pH studyDiagnosis : GERD
Onset of symptoms
Omeprazole 20 mg ODLifestyle changes
Treatment and follow up
Asymptomatic
Symptoms resolved after 3 weeks Ongoing therapy
Clinical Presentation
• Infant– Regurgitation– Irritability– Feeding problem– FTT– Apnoea
• Child– Regurgitation/vomiting– Heartburn– Epigastric pain– Retro-sternal pain– Dysphagia– Extra-esophageal
• Pulmonary• ENT
Who is at risk for severe GERD
• Esophageal atresia• Neurologic impairment• Obesity• Hiatus hernia• Cystic fibrosis• Family history GERD/ GERD complications
Scand J Gastroenterol. 2010;45(2):139-46/ Can J Gastroenterol. 2010;24(5):312-6.J Pediatr Gastroenterol Nutr. 2010;50(2):161-6/ C ochrane Database Syst. 2007;Rev(1): CD006151.
Pyloric stenosis Malrotation
Diagnosis : Barium contrast radiography
Detection of anatomic abnormalitiesNeither sensitive nor specific for diagnosing GERD
-Brief duration produces false-negatives-Frequent occurrence of non-pathological reflux during the examination produces false-positives
11 year old boy with chest pain
24 hours pH studyReflux index: % time pH<4, GOLD standard
Symptom correlation
pH 7
pH 4
pH 0
Chest pain
Symptom correlationPeriod of 2 minutes before event is considered
Association: acidic reflux and chest pain
Time Two minutes time period
Combined pH and impedance
Advantages: Ability to detect all GER episodes and with a pH sensor classify them as acid and non-acid GER Differentiate between liquid, gas or mixed GER Differentiate swallows (antegrade flow) from GER (retrograde flow). No dietary restrictions required Measure accurately the height of the refluxate and the proximal extent of the GER episode The mechanisms of bolus and acid clearance can be studied
JPGN 2009: 48;2–12
Different substances have a different Impedance
Air (high) 5000 .. 10.000 OhmBasal oesophageal impedance 1500 .. 2000 OhmLiquid (low) 200 .. 500 Ohm
AirBaseline
Liquid
Ohm
600030000
Gastric reflux
/ \ shaped waveformLiquid swallow \ \ shaped waveform
Case 2- 13 year old girl
Symptomatic for the past 6 months Vomits 2 to 4 hours after a meal Large volume, non bilious Stale food vomiting Early satiety Feeling of upper abdominal fullness and distension Has lost 3 kgs in the last 6 months
No pain abdomen, systemic symptomsno corrosive/ drug intake
Examination and Investigation
Examination • O/E 37 kg ht 155 cm• BP 110/76 , PR 94/m RR 24• Afebrile • General physical – normal• Systemic exam – normal• Body image –normal• No abnormal feeding habits
Investigations • Blood sugar 96 mg/dl• Thyroid function normal• ABG pH 7.43 HCO3 23, Lactate <
2 mmol/L, • Urine ketones – negative• Hemogram, LFT, KFT, serum
electrolytes normal• TTG negative• Fundus exam – no papilledema• BMFT, USG abd – normal• UGIE – normal, Biopsy no GERD
Diagnosis??
Gastric emptying: methodology
Tc99mStandard meal• 237 Kcal • 75% carbohydrate • 16% protein• 8% fat
25g rice
25g pulses25g flour
6 hours fastingMeal consumed in 10-15min
Dynamic acquisition60 sec frames first 60 min
Static acquisition 2, 3 and 4 hours
Gastric emptying study: Percent gastric retention
1 h: 100% 2 h: 80%
3 h: 60%
4 h: 40%
1h : normal < 96%2h : normal < 71%3h : normal < 44%4h : normal < 22%
Diagnosis: Gastroparesis (idiopathic)
No difference between girls and boysSame across 5-18years of ageEmptying slower in children as compared to adults.
Assessment of gastric emptying in children: Establishment of normative data. Manuscript submitted for publication
Treatment and follow up
Started on Itopride 25mg TID 1 hour before meals.
Small frequent liquid/ semsolid mealsAvoid high fat, high fibre diet
Significant improvement in symptomsImproved appetiteWeight gain
Gastroparesis WorkupExclude mechanical obstruction UGIE/ Barium UGI series/ USG/CT scanEvaluate gastric emptying Solid phase gastric emptying time- scintigraphy
(GOLD STANDARD)Determine the etiology: Blood count, glucose, K, Ca, albumin,TSH, free T4, HbA1C, ANA, histology, antroduodenal manometry
etc
Gastroenterology 2004;127:1592–1622Neurogastroenterol Motil (2010) 22, 113–133
Antroduodenal Manometry
Fasting state : MMC
Fed state
Gastroenterology 2004;127:1592–1622Neurogastroenterol Motil (2010) 22, 113–133
Case 3:13 yr boy
1y 4y 9 y 13y
Bilious vomiting with ‘gola’ formation, Pain abdomen and borborygmi, constipation during that period
Each episode last 2-3 days, multiple episodes, needs admission and IV fluids
Poor weight gain, normal appetite
episodic symptoms, once every 2-3 months,Asymptomatic in between
No fever or systemic
symptoms
Appearing well
Differential diagnosis for bilious vomiting
Surgical causes
beyond D2
MalrotationDuodenal webs, stenosisIntussusceptionVolvulus, adhesions etc
MalrotationDJ not crossed to left sideJejunal loops on the right sidePaucity of bowel loops in left side
Management:surgery
Suspect:1. Early symptoms in life2. Episodic bilious vomiting3. Features of obstruction
Case 4 : 6 year old boy
Recurrent vomiting past 3 ½ years Episodes: 2-3 times/year and lasts for 2-4 days Starts with nausea – retching At its peak, he vomits 8-10 times/hour, occ bilious Symptoms start at any time, mostly early morning No significant abdominal pain, abdominal
distension Frequently requires admission and IV fluids No triggers could be identified
• In the interim he is a normal playful child, does well in school • Growth and development normal• Examination: general and systemic is normal
Diagnosis received elsewhere• Malrotation of gut• Appendicitis• GI tuberculosis: ATT given• Brain tumor
2y 4 y 3 y 5 y 6 y
E E EEE E EE
Last episode• Taken up for exploratory laparotomy• Parents refused at the last minute• Anxious & worried parents
Upper GI endoscopy Barium meal follow through CT head Hmg, RFT, LFT, ABG, urine USG abdomen
All normal
SGPGI
8 admissions, 3-5 days each Iv fluids, antiemetic and antibioticsOnset of symptoms
Diagnosis?
NASPGHAN (pediatric)• Min 5 episodes or 3 attacks in 6mo time• Episodic intense nausea and vomiting, lasts 1hr to
10days, separated by ≥ 1 week• Stereotypical• Vomiting> 4times/hr, for ≥ 1hr• Return to baseline health b/w episodes• Not attributed to other etiology
JPGN 2008;47:379-93
Cyclic vomiting syndrome
Acute onset
Intense nausea and
vomiting
Return to baseline health
Symptom free interval
Cyclical pattern
Stereotypical
“Switch turned
on-off ” !!
Trigger
Management Counseling patient and parents Lifestyle changes• Avoid fasting/ over exertion• Ensure adequate sleep• Avoid triggers/excitement TreatmentAbortive therapy : Dark quiet environment, IV fluids• Ondansetron 0.3–0.4mg/kg/dose IV q 4–6 h• Lorazepam 0.05–0.1mg kg/dose IV q6 hProphylaxis: Amitryptiline was started at 0.25mg/kg/QHS and increased to 0.5 mg/kg HS after baseline EKGEpisodes reduced in severity and frequency
Child with stereotypical cyclical pattern of vomitingage 2-18years; 85-90% have CVS, ~10-15% other etiology
Age <2years- high chances of metabolic and GI causes
Do BMFT for malrotation, electrolytes (Na, K, chloride, bicarbonate), blood glucose, Bun and creatinine, ±USG abdomen in all cases
Check: Age <2 years or Presence of alarm features
No: manage as CVS yes: investigate further
Alarm symptoms: suspect something else…
Bilious vomiting, abdominal tenderness, severe pain, distension Conversion to continuous pattern ...... GI: volvulus, adhesions,
pancreatitis, biliary, UPJ obstruction etiology. • Amylase, lipase, LFT• USG/ SBFT/ CT / UGI endoscopy /24h esophageal pH study• Gastric emptying scan/ Antroduodenal manometry
Attacks precipitated by fasting, high protein meal, intercurrent illness..... Hypoglycemia , high anion gap metabolic acidosis with ketosis, respiratory
alkalosis, persistent Hyponatremia Acute encephalopathy (lethargy, severe irritability, confusion, psychosis or
rapidly changing/unstable mental status)Metabolic :FAOD, urea cycle disorder, organic acidemia, mitochondrial• ABG, lactate, Urine ketones, Urine for PBG, urine organic acids, • serum amino acids, blood ammonia, plasma cortisol, carnitine and acyl
carnitine, etc
Alarm symptoms: suspect something else…
Abnormal neurological examination - altered mentation, abnormal eye movements, ataxia, - focal neurological signs, papilledema, development regression or stagnation, - recent changes in personality
CNS etiology: posterior fossa or hypothalamic tumor, Chiari malformation, hydrocephalus, or subdural hematoma *(more often chronic), complex partial seizures (rare)• MRI head • Fundus examination• EEG when indicated
Conclusions• Vomiting may be the presenting symptom of many
diseases, ranging from self-limited to life-threatening and GI to non GI
• Detailed history along with pattern (cyclic vs chronic) important to differentiate etiologies
• Bilious emesis at any age is suggestive of intestinal obstruction and needs immediate attention.
• Disorders like GERD, CVS, gastroparesis, rumination are increasing and awareness with high index of suspicion helps in making timely diagnosis
• Investigations should be targeted to the likely differential diagnosis
Thanks
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