Child with persistent vomitting

Child with vomitingSubtopicsTerms/DefinitionsPhysiology of EmesisApproachEvaluationDisease basedReferencesOthers essential readingTermsVomit: Forced ORAL expulsion of GI contentContraction of abdominal and chest wallNausea:Unpleasant sensation on the need to vomit/imminent vomittingVomitNauseaNausea>Vomit

Regurgitation: effortless and not preceded by nausea. without the abdominal and diaphragmatic muscular activity (immature LES)Rumination: effortless regurgitationand/orre-swallowing of foodRetching: Spasmodic respiration against a closed glottis+ contractions of muscle without expulsion of any gastric contentsPhysiology1. Neurological Pathwayvagal afferents (1), the area postrema *CTZ* (2), the vestibular system (3), and the amygdala (4)2. Neurotransmitter1)5-HT32)M1, D2, 5-HT3, NK-13)H14)M1, D2, H1, 5-HT3, NK-1 + Emotion/olfactory

APPROACHHistoryPhysical ExaminationInvestigations DiagnosisTargeted treatmentDiagnosisDifferential Diagnosis Risk FactorsComplications-hydration assessment

RED FLAGS1)Nonspecific symptoms (severity)Surgical GIT (obstruction)Neurologic/Systemic (raised ICP, recurrent)(Nonspecific symptomsProlonged vomitingProfound lethargySignificant weight loss

Symptoms of gastrointestinal obstruction or diseaseBilious vomitingProjectile vomiting in an infant three to six weeks of ageHematemesisHematochezia (rectal bleeding)Marked abdominal distension and tenderness

Symptoms or signs suggesting neurologic or systemic diseaseBulging fontanelle in a neonate or young infantHeadache, positional triggers for vomiting or vomiting on awakening,and/orlack of nauseaAltered consciousness, seizures, or focal neurologic abnormalitiesHistory of head traumaHypotension disproportionate to the apparent illness,and/orhyponatremia and hyperkalemia

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EVALUATIONConcerning SignsHistory and Physical ExaminationInvestigationsHistoryVomit vs regurgitation (presence of effort)Triggers?(lactose/fructose/onset minutesto hours of food intake+ cutaneous+ respiratory symptoms)Projectile/absence of nauseaPeriodic episodes? (IEM, migraine, cyclic)Time (early morning+positional triggers)Duration Infective cause (contacts, febrile, associated diarrhea)Content-billious/blood/undigested/feculent/surgical cause of vomitting.Determinant for intervention.Physical examinationGeneral examinationWell vs toxic, signs of dehydration, Abdominal examinationPain, Distension , Vomiting, ObstipationVisible bowel loops/absent vs borborygmiSurgical cause by tenderness site (appendix, gall bladder, pancreas, renal, epigastric) organomegalyNeurologic examinationConscious level (CNS lesion, IEM, toxic, severe dehydration)Raised ICP signs/ localizing signsOthersUnusual odour, enlarged parotids, abnormal external genitalia

Laboratory investigationsHydration assessmentNo clinically detectable dehydration (10%)Mnemonic ( Head (4)/ Thorax (4)/ Limbs (4)/ Genitalia (1) = 13 signsIllustrated textbook of pediatric 4th edition, pg. 2304 in the HeadGeneral appearance/ GCSEye (sunken/with or without tear)FontanelleMucous membrane

Using oral mucosa to assess for dehydration-Nursingtimesjournal http://www.nursingtimes.net/Journals/2014/01/22/c/s/u/080114-Using-oral-mucosa-to-assess-for-dehydration.pdf

4 in the thoraxSkin colorBreathing rate (tachypnea)Tissue turgorWeight*

4 in the limbsCold peripheriesCapillary refill timeIncrease pulse rate (tachycardia)/ weak pulseBlood poressure (hypotension in decompensated shocl)

Those in red is at risk of progression to shockGERDis a normal physiologic process occurring several times per day in healthy infants, children, and adults. Last