Vomiting In Children Salma Elkhabier Morehouse School of

Vomiting In Children Salma Elkhabier Morehouse School of Medicine Pediatrics Residency Program-PGY 3

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. Bilious, depending on level of lesion 2. Bilious 3. Bilious or nonbilious 4. Bilious or nonbilious 5. Bilious or nonbilious 6. Nonbilious 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 Intestinal atresia/webs 2. Meconium ileus 3. Hirschsprung disease 4. Necrotizing Enterocolitis 5. Inborn irrors of metabolism

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 or nonbilious Nonbilious

Differential diagnosis of vomiting Age Common Causes Type of Vomiting Comment/Associated features 3 to 12 Months 1. AGE 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/ 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 1 st 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 2 nd or 3 rd stage may lead to an aberrant return or anchoring of the midgut within the abdominal cavity. •

Malrotation with Midgut Volvulus • Typically presnent in 1 st 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 1 st 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.