Nausea
The unpleasant sensation of the imminent need to vomit,Usually referred to the throat or epigastriumA sensation that may or may not ultimately lead to the act of vomiting.
Retching
muscular activity of the abdomen and thorax, often voluntarilyleading to forced inspiration against a closed mouth and glottis without oral discharge of gastric contents
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.
Rumination
Food that is regurgitated in the postprandial period, re-chewed and then re-swallowed (psychological)
NEUROPHYSIOLOGY
There are four major pathways by which nausea and vomiting are induced,
Vagal afferents
Abdominal vagal afferents are involved in the emetic response. Can be evoked by either mechanical or chemo-sensory sensations. Examples of sensations that trigger this pathway include over distension, food poisoning, mucosal irritation, cytotoxic drugs, and radiation.
Area postrema
Chemotrigger receptor zone
Vestibular system
It involved in the emetic response to motion Exacerbated by visual sensations, Irritation or labyrinthine inflammation.
Amygdala
ETIOLOGY OF VOMITTING
Central
Vestibular - motion sickness and vertigo
Infectious - gastroenteritis, septicemia, non-GI infections
Cortical - pain, strong emotions, smell, taste
Drugs - chemotherapy, opiates
Metabolic - acidosis, uremia, hyperthyroidism, hypercalcemia, adrenal disorders
Peripheral
Pharyngeal stimulation
Gastric mucosal irritation
Gastric and intestinal obstruction/dilation
INTRODUCTION TO APPROACH
A standardized approach is not recommended
Vomiting may be caused by many pathologic states involving several systems including
Gastrointestinal, Neurologic, Renal, and Psychiatric
The best course of action should be dictated by the medical history.
History of presenting illnessCharacteristics of vomitus
Smell Quantity Colour Blood - Bright red/dark red/coffee-ground BiliousTiming - Onset, Duration, Frequency and Time of day
Triggers / Associated symptoms
Diarrhoea Fever Abdominal pain/distension Anorexia Stool frequency Urinary output Headache Vertigo Lethargy Stiff neck Cough Sore throat
Past medical history
Chronic illnesses like Diabetes
Travel history (infectious gastroenteritis)
Recent head trauma
Toxin exposure
Medications
Allergies
Few important interpretations of history
Undigested Achalasia
Bilious Post ampullary obstruction
Blood or coffee ground Gastritis , Ulcer
Bloody after forceful vomiting Mallory wiess tear
Malodorous Stasis with bacterial overgrowth
Feculent Obstruction
Force of vomiting
Forceless Regurgitation , gastroesophagial reflux
Projectile Pyloric stenosis, obstruction, metabolic disease
Temporal associations of chronic or recurrent vomitting
Temporal associations Diagnosis
Time of day
Early morning increased ICP, sinusitis with postnasal mucous, pregnancy, uremia(headache, papilledema, sinus tenderness, secondary amenorrhea)
During or after meals peptic ulcer disease, reflux(epigastric pain, heart burn)for specific foods(Heredetary fructose intolerance, galactocemia, metabolic inborn error, cows milk intolerance, etc.,
After fasting food vomitted gastric obstructionfood not vomitted metabolic disease
Other precipitants
Cough posttussive
Infections metabolic, reccurent gastroenteritis
Vestibular stimulation motion sickness, menetrriers disease
Hyperhydration uretropelvic junction obstruction
Menses dysmenorrhea associated vomitting, acute intermittent porphyria
Medications and toxins medication side effects – pancreatitis, hepatitis, AIPsteroid withdrawal – Addisons diseasepoisonings – NSAIDS
Episodic / cyclic
Abdominal migraine, abdominal epilepsy, pheochromocytoma, pophyria, familial dysautonomia, metabolic inborn error, FMF, self induced, cyclical vomitting
Food associations
Cow milk, soy, gluten - Protein intolerance
Multiple food exacerbants - Esinophilic gastroenteritis, fructose intolerance
Periodicity of vomiting
Paroxysmal, cyclic
- cyclic vomiting syndrome, porphyria, carcinoid, pheochromocytoma, familial dysautonomia
Neurological symptoms
Headache, vertigo, visual changes - Metabolic, toxin, CNS disease
Fundoscopic evidence of increased ICP - CNS mass
Others
Lack of nausea CNS mass
Esophagial pain Esophagitis
Diarrhea Infectious enteritis
Abdominal peristaltis Obstruction, pyloric stenosis
Peritoneal signs Surgical abdomen, perforated appendicitis
Jaundice Hepatobiliary etiology or urinary tract infection in a neonate
Surgical scars Obstruction secondaryto adhesions
Early morning vomiting Pregnancy and CNS mass
Vomiting with meals Peptic ulcer disease, Psychogenic disease, Disproportionate hypotention, Hyperkalemia, Adrenal crisis
Prolonged vomiting
>12 hours in a neonate,
>24 hours in children younger than two years of age, or
>48 hours in older children should not be ignored.
Screening laboratory tests should include
Complete blood count
Electrolytes,
Blood urea nitrogen,
Amylase, lipase,
Liver function tests,
Urinalysis, urine culture, and stool studies for occult bloodLeukocytes, and parasites.
Additional testing should be based upon the history and physical examination
Clues on physical examination
Certain physical findings may offer diagnostic cluesWhich aids in narrowing the differential diagnosis:
A tense, bulging fontanel in a neonate or young infant
Increases the level of suspicion for meningitis.
Projectile vomiting in an infant three to six weeks of age suggests
Pyloric stenosis
Ambiguous genitalia and/or hyperkalemia suggest the possibility of
Adrenal crisis (usually due to congenital adrenal hyperplasia).
An unusual odor emanating from the patient should prompt an investigation for
Metabolic causes of vomiting.
Marked distension, visible bowel loops, absent bowel sounds, green or yellow bile, or increased "rumbling" bowel sounds should raise suspicion for
Intestinal obstruction.
Enlarged parotid glands in an adolescent should raise suspicion for
Bulimia
Vomiting in association with trauma should prompt imaging studies
To rule out intracranial or intra abdominal injury.
Hypotension disproportionate to the apparent illness and/or hyperkalemia suggests
The possibility of adrenal crisis
Headache, positional triggers for vomiting, lack of nausea on awakening should suggests
The possibility of intracranial hypertension
Most common causes of vomiting in Neonates
Physiologic reflux or GERD
Pyloric stenosis
Necrotising enterocolitis
Malrotation with midgut volvulus
Gastroenteritis
Hirshprung disease
Congenital atresias, stenosis, web
Metabolic disorders
Feeding intolerance
Common causes of vomitting in Infants (1 month to 1 year)
Acute
Gastroenteritis Pyloric stenosis Hirschsprung’s disease Acutely evolving surgical abdomen Congenital atresias and stenosis Malrotation Intussusception Sepsis and non-GI infection Metabolic disorders
Chronic
Gastroesophageal reflux disease Food intolerance Congenital atresias and stenosis Malrotation Intussusception
Children and
Adolescents
ACUTE
Gastroenteritis
Appendicitis
Sepsis and non-GI
infection
Metabolic disorders
Toxic ingestion
CHRONIC
Gastroesophageal
reflux disease
Gastritis
Food intolerance
Cyclic vomiting
Intracranial
hypertension
Inborn errors of
metabolism
Eating disorders
COMPLICATIONS OF VOMITTING
Nutrition Adults - weight loss, kids - Failure to gain weight/grow
Cutaneous Petechia, Purpura
Oropharyngeal Dental erosion, sore throat)
Esophageal Esophagitis / hematoma
GE junction M-W tears, rupture of esophagus (Borhaeve’s)
Metabolic Electrolyte, acid-base, water imbalance
Renal Pre-renal azotemia, ATN, hypokalemic nephropathy
Infection Spread of infection to close contacts and caregivers(H. pylori, GI viruses)
TREATMENT
Treatment should be directed towards the underlying etiology.
Electrolyte abnormalities, metabolic abnormalities, and nutritional deficiencies should be corrected.
Cognitive-behavioral interventions are useful for vomiting associated with functional dyspepsia, adolescent rumination syndrome and bulimia.
Prokinetic medications such as metoclopramide, domperidone and erythromycin are beneficial when there are abnormalities in esophago-gastric motility.
Antiemetics, which are useful in persistent vomiting to avoid electrolyte abnormalities or nutritional sequelae, typically have not been recommended in the case of vomiting of unknown etiology. These agents are contraindicated in infants .
Likewise, they are not indicated for anatomic abnormalities or surgical abdomen.
Instead, antiemetics are most useful for motion sickness, postoperative vomiting, cyclic vomiting syndrome, and gastrointestinal motility disorders .
A single dose ondensetran may facilitate oral rehydration in children with gastroenteritiswho are unable to tolerate oral intake.
GUIDELINES FOR SICK DAY MANAGEMENT
Urine ketones Insulin(rapid acting)
Frequency of monitoring
Comments
Negative/small Q2H Q2Hif CBG >250 mg/dl
Check ketones every other void
Moderate to large Q1H Q1Hif CBG >250 mg/dl
Check ketones on each void