- 1.AN APPROACH TO A CASE OF VOMITING
2. CASE: A 5 Years old male child presented in ER with: Vomiting
-7 to 8 episodes/day for 2 days. The child was in his usual state
of good health 2 days back when he developed acute onset of
non-projectile vomiting, contained nondigested food particles. It
was non-bilious and not blood stained. There were episodes of
colicky, non-radiating abdominal pain. The child had no fever but
was passing stools of loose consistency,5-6 episodes. The feeding
decreased since the illness.There were no respiratory or urinary
symptoms. No irritability, altered sensorium, drowsiness, neck
stiffness, headache. 3. No known medical illnesses s/o inborn
errors of metabolism, cerebral palsy, downs syndrome, neurological
deficits.No h/o any drugs/allergy to any drugs/food Birth was
uneventful There was no h/o travelling. The child had taken water
outside and his friend was also suffering from similar illness. 4.
O/E: GCS:15/15, lethargic T-98, HR-128, RR-56, BP-90/50 Jaundice-
absent, dehydration- some signs+ No signs of meningeal
irritationThe remainder of the examinations were normal Inv:
TC-15,500 Na-143, K-3.2, urea/creat-N Urine-N 5. The child was
managed conservatively with IV fluids and electrolytes, IV
antibiotics and symptomatic management was done. 6. Nausea: The
unpleasant sensation of the imminent need to vomit, usually
referred to the throat or epigastrium; a sensation that may or may
not ultimately lead to the act of vomitingVomiting: Vomiting is the
means by which the upper gastrointestinal tract rids itself of its
contents when almost any part of the upper tract becomes
excessively irritated, over distended, or even over
excitableRegurgitation: The act by which food is brought back into
the mouth without the abdominal and diaphragmatic muscular activity
that characterizes vomiting. 7. PHYSIOLOGY OF VOMITING: The sensory
signals from the pharynx, esophagus, stomach and upper portions of
the small intestines.the nerve impulses are transmitted by both
vagal and sympathetic afferent nerve fibers to multiple distributed
nuclei in the brain stem that all together are called the vomiting
centermotor impulses that cause the actual vomiting are transmitted
from the vomiting center by way of the 5th,7th, 9th,10th,and 12th
cranial nerves to the upper gastrointestinal tract, through vagal
and sympathetic nerves to the lower tract, and through spinal
nerves to the diaphragm and abdominal muscles 8. Act of vomiting: a
deep breath raising of the hyoid bone and larynx to pull the upper
esophageal sphincter open closing of the glottis to prevent vomitus
flow into the lungs lifting of the soft palate to close the
posterior nares strong downward contraction of the diaphragm along
with simultaneous contraction of all the abdominal wall muscles.
This squeezes the stomach between the diaphragm and the abdominal
muscles, building the intragastric pressure to a high level.
Finally, the lower esophageal sphincter relaxes completely,
allowing expulsion of the gastric contents upward through the
esophagus. 9. Causes of vomiting: Neonatal period: Bilious
vomiting:Non-bilious vomiting:AtresiasFeeding excessive
volumeMidgut volvulusMilk(human or formula intoleranceAnnular
pancreasDecreased motilityHirschprungs diseaseprematurityAberrant
sup. Mes. Arteryantenatal exposure to MgSO4 or narcoticsPreduodenal
portal veinsepsis (meningitis)with ileus,NECPeritoneal bandsCNS
lesionPersistent omphalomesenteric ductLesion above ampulla of
VaterDuodenal duplicationpyloric stenosisMeconium plugupper
duodenal stenosis Annular pancreas GER, inborn errors of metabolism
10. Causes in infancy: Medical causes:Surgical causes:GER
gastroenteritisCHPSCNS infectionsVolvulusUTIInborn errors of
metabolism Uremia Cow milk protein allergyOver feeding Faulty
feeding techniqueMalrotaion IntussusceptionICSOL Peritonitis
HydrocephalusSubdural hematoma 11. Causes in childhood: Medical
causes:Surgical causes:GER gastroenteritis CNS infections UTI
Inborn errors of metabolism Uremia, toxins Cow milk protein allergy
Over feeding Faulty feeding technique Post nasal dripping DKA
Psychogenic Hepatitis, pneumoniaIntestinal obstruction Appendicitis
ICSOL Peritonitis Hydrocephalus Subdural hematoma 12. History: Age
of the patientDuration /Frequency Onset Associated with food
intakeColor and contents Non digested food :proximal obstruction
Semi digested food : distal obstructioninstantly : esophageal
obstructionBilious content : distal to 2nd part of duodenumAfter a
while : stomach or duodenal obstructionFecal material : obstruction
at the large intestineNature (projectile / non
projectile)Associated symptoms Fever / Abdominal Pain /Diarrhea
/constipation/ dysphagia. 13. Respiratory cough, chest discomfort
Urinary dysuria, hematuria CNS irritability, altered sensorium,
drowsy, neck stiffness, headache, visual disturbance Past medical
history Any 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 allergy/ type of food Other relevant history
Recent eating outside, recent travelling, family member or friends
in school have similar illness 14. Physical Examination General
condition Comparison of patients weight before and after onset of
illness Conscious level- GCSHydration status Sunken fontanel Eyes
sunken and tearless Dry mucous membraneProlonged capillary refill
time Reduced skin turgor Tachycardia, tachypnea 15. 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 visionRespiratory ExaminationEar
examination by otoscopyFundoscopy 16. Complications: Metabolic:
dehydration, hypokalemic hypochloremic alkalosis,
hyponatremiaMalnutritionMallory Weiss
tearEsophagitisAspirationShockPnemomediastinum,
pneumothoraxPetechiae, retinal hemorrhages 17. Investigations:
Blood Investigations Full Blood Count-Leukocyctosis (infection)
BUN/ creatinine/electrolytes -Effects of vomiting on electrolytes (
hypokalemia), Renal insufficiency Blood glucose Levels - exclude
DKA Blood gases-Acidosis :organic acidemia, Alkalosis: pyloric
stenosisUrine RE/ME, Urine C/SImaging CXR, Plain Abdominal X-ray,
Barium meal, Barium follow through, Cranial CT, Upper GI endoscopy
18. Management: Assesthe severity of dehydration Rehydrate
accordingly Correct electrolyte imbalances Encourage oral intake
Treat according to the underlying cause Treat cause: 19.
Reflux/gastroparesis: dopamine antagonist(metoclopramide)
Chemotherapy:metoclopramide, ondensetron, prochlorperazine,
chlorpromazine Post-operative:ondensetron, phenothiazine
Motionsickness/ vestibular disorders: dimenhydrinate, scopolamine
Adrenalcrisis: cortisol 20. APPROACH: VOMITING AGE, otitis media,
hepatitis, CNS and other infectionsfever abnormal neurologic
examinationCNS infection, SOLpyloric stenosis, intussusception,
adhesions, appendicitis, herniaprojectile vomitingrecurrent
vomiting or poor growth or weight losssigns of intestinal
obstructiondiarrhea psychogenic migraineRenal, metabolic disease
medicationstoxins, drugs gastroenteritis, food poisoning 21.
Cyclical vomiting syndrome: Numerous episodes of vomiting
interspersed with well intervalsOnset between 2 to 5 years of
ageUsually occur in the early morning or upon awakeningTend to
start about the same time of day, same length of time and present
the same symptoms at the same level of intensityTheories: migraine-
related mechanism, mitochondrial disorders, autoimmune dysfunction.
22. D/D:GI anomalies(malrotation, duplication cysts, choledochal
cysts, recurrent intussusceptions), CNS disorders(neoplasm,
epilepsy, vestibular pathology), nephrolithiasis, cholelithiasis,
hydronephrosis, metabolic endocrine disorders(urea cycle,
fatty-acid metabolism, Addison disease, porphyria, hereditary
angioedema), chronic appendicitis and inflammatory bowel disease
23. s/s: nausea, pallor, intolerance of noise and light, lethargy,
headache, epigastric pain, abdominal pain, diarrhea and fever.Inv:
endoscopy, contrast GI radiography, brain MRI, metabolic
studies(lactate, organic acids, ammonia) 24. Treatment:enough rest
and sleep, hydration, antiemetics (ondensetron)
Prevention:lifestyle changes, prophylactic
medications(cyproheptadine, propranolol, amitriptyline,
phenobarbital) 25. Key messages: Differentiatevomiting, nausea and
regurgitation Sortout the cause for vomiting by history,
examination and investigations r/osurgical causes Manage
Preventwith IV fluids,antiemetics and treat the causeand manage
complications 26. THANK-YOU
