Vomiting, Pediatric

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Vomiting, Pediatric

Basics

Description

A careful and complete physical examination can often contribute to determining the cause of vomiting in children:

- Endocrine - Diabetes - Diabetic ketoacidosis - Diabetic gastroparesis

Vomiting accompanied by hematemesis, intestinal obstruction (bilious vomiting), dehydration, neurologic dysfunction, or an acute abdomen should be treated as a medical emergency, and hospitalization should be considered.

• Vomiting is the forceful expulsion of gastric contents through the mouth.Vomiting is a prominent feature of many disorders of infancy and childhood.It is often the only presenting symptom of many diseases.
• Regurgitation is defined as small, effortless mouthfuls of food or stomach contents.
• Retching is contraction of the abdominal musculature against a closed glottis, restricting expulsion of stomach contents (also referred to as "dry heaves " ).

• Vomiting is a prominent feature of many disorders of infancy and childhood.
• It is often the only presenting symptom of many diseases.

Pathophysiology

• Vomiting can be:A defense mechanism to expel ingested toxinsAn abnormality of, or damage to, the postrema area of the brain (a.k.a. the chemoreceptor trigger zone or vomiting center), which is located at the base of the fourth ventricleA result of intestinal obstruction or anatomic abnormalitiesDue to chronic gastrointestinal mucosal diseaseThe result of a generalized metabolic diseaseA result of increased intracranial pressure

• A defense mechanism to expel ingested toxins
• An abnormality of, or damage to, the postrema area of the brain (a.k.a. the chemoreceptor trigger zone or vomiting center), which is located at the base of the fourth ventricle
• A result of intestinal obstruction or anatomic abnormalities
• Due to chronic gastrointestinal mucosal disease
• The result of a generalized metabolic disease
• A result of increased intracranial pressure

Diagnosis

History

• A full history should include medication and drug use, trauma, family history of migraines and chronic gastrointestinal diseases, and travel history.
• Special attention should be directed to the timing of the emesis, relationship to meals, position and time of day, as well as to the chronicity of symptoms.
• Fever: may suggest an infectious etiology
• Abdominal pain and frequent, forceful, or bilious emesisOften associated with anatomic or obstructive intestinal disorderFor example, obstruction of a lumen (i.e., common bile duct stone or ureteropelvic junction [UPJ] obstruction) can present as vomiting.
• Age of patientSome etiologies of vomiting may be aged-based.For example, pyloric stenosis or inborn errors of metabolism should be considered in infants with vomiting, dehydration, and biochemical abnormalities.In adolescents, disordered eating patterns (bulimia) and the possibility of pregnancy should be considered.
• Mental retardation, pica, and patchy baldness: indicate foreign body or hair ingestion and the development of a gastric bezoar
• Nausea and epigastric pain related to meals: often indicate gastritis, gastric emptying delay, or gallbladder disease
• Symptoms alleviated by meals: may signify gastroesophageal reflux or gastric ulcer
• Alternating vomiting and lethargy: may indicate intussusception
• Chronic headaches, fatigue, weakness, weight loss, and early morning vomiting: neurologic causes of vomiting secondary to increased intracranial pressure
• Right- or left-sided abdominal pain: may indicate renal disease
• Recurrent, intermittent episodes of vomiting interspersed with periods of wellness may suggest cyclic vomiting syndrome (CVS).
• Recurrent vomiting and other gastrointestinal symptoms are commonly seen with mucosal diseases such as celiac disease, eosinophilic esophagitis, and inflammatory bowel disease.

• Often associated with anatomic or obstructive intestinal disorder
• For example, obstruction of a lumen (i.e., common bile duct stone or ureteropelvic junction [UPJ] obstruction) can present as vomiting.

• Some etiologies of vomiting may be aged-based.
• For example, pyloric stenosis or inborn errors of metabolism should be considered in infants with vomiting, dehydration, and biochemical abnormalities.
• In adolescents, disordered eating patterns (bulimia) and the possibility of pregnancy should be considered.

Physical Exam

• Visible bowel loops: obstruction
• Palpation for bowel loops and tenderness and auscultation for evidence of absent bowel sounds or borborygmi (rumbling bowel sounds): intestinal obstruction
• Rectal examination: testing the stool for occult blood
• Discoloration of skin and sclera: jaundice (liver/gallbladder or metabolic disease)
• Orange tint of sclera or skin: hypervitaminosis A
• Unusual odor: metabolic disease, diabetic ketoacidosis
• Chronic vomiting: evidence of neurologic dysfunction, including nystagmus, head tilt, papilledema, abnormal reflexes, and weakness
• Tense anterior fontanelle: may indicate meningitis, hydrocephalus, or vitamin A toxicity
• Enlarged parotid glands and hypersalivation: bulimia and other feeding disorders
• Pelvic examination: pregnancy, pelvic inflammatory disease, or ovarian disease

Diagnostic Tests & Interpretation

• CBCAnemia and iron deficiency can occur with gastritis/esophagitis, inflammatory bowel disease, celiac disease, and ulcer disease.
• Blood chemistryElectrolyte abnormalities are found in pyloric stenosis and metabolic disease.An elevated alanine aminotransferase, conjugated bilirubin, and gamma-glutamyl transferase (GGT) can indicate liver, gallbladder, or metabolic disease.
• Urinalysis: pyelonephritis, nephrolithiasis
• Lipase/amylase: pancreatitis
• BUN/creatinine: Elevated levels can occur with renal disease.
• Urine culture: UTI
• Stool studies: occult blood, infection, Helicobacter pylori antigen
• If chronic vomiting historyTissue transglutaminase IgA, endomysial antibody, or deamidated gliadin IgA and serum IgA (celiac disease)Erythrocyte sedimentation rate and/or C-reactive protein (inflammatory bowel disease but can also be elevated in acute infection/illness)

• Anemia and iron deficiency can occur with gastritis/esophagitis, inflammatory bowel disease, celiac disease, and ulcer disease.

• Electrolyte abnormalities are found in pyloric stenosis and metabolic disease.
• An elevated alanine aminotransferase, conjugated bilirubin, and gamma-glutamyl transferase (GGT) can indicate liver, gallbladder, or metabolic disease.

• Tissue transglutaminase IgA, endomysial antibody, or deamidated gliadin IgA and serum IgA (celiac disease)
• Erythrocyte sedimentation rate and/or C-reactive protein (inflammatory bowel disease but can also be elevated in acute infection/illness)

• Plain abdominal radiographic studyCan detect ileus and/or obstructionMay also need upright or left lateral decubitus films
• Abdominal ultrasoundLiver, gallbladder, renal, pancreatic, ovarian, or uterine diseaseIn infants, abdominal ultrasound is the test of choice for pyloric stenosis.Useful when considering abdominal abscess and appendicitisCan detect intussusception
• Contrast radiographyIntestinal anatomic abnormalities (e.g., malrotation, intussusception, volvulus, hiatal hernia), gastric bezoar, achalasia
• Gastric scintigraphy (gastric emptying study)Evaluate rate of gastric emptying; assess for gastroparesis.
• Abdominal CTNot generally indicated for evaluation of vomiting, although it is an effective tool when more anatomic abdominal detail is required (abscess, tumor).
• Head CTCan be helpful in evaluation of acute neurologic causes of vomiting (i.e., cerebrovascular insult; hydrocephalus)
• Brain MRIProvides superior imaging of the brain stem, where the vomiting center is located, without radiation exposureTest of choice if considering intracranial mass

• Can detect ileus and/or obstruction
• May also need upright or left lateral decubitus films

• Liver, gallbladder, renal, pancreatic, ovarian, or uterine disease
• In infants, abdominal ultrasound is the test of choice for pyloric stenosis.
• Useful when considering abdominal abscess and appendicitis
• Can detect intussusception

• Intestinal anatomic abnormalities (e.g., malrotation, intussusception, volvulus, hiatal hernia), gastric bezoar, achalasia

• Evaluate rate of gastric emptying; assess for gastroparesis.

• Not generally indicated for evaluation of vomiting, although it is an effective tool when more anatomic abdominal detail is required (abscess, tumor).

• Can be helpful in evaluation of acute neurologic causes of vomiting (i.e., cerebrovascular insult; hydrocephalus)

• Provides superior imaging of the brain stem, where the vomiting center is located, without radiation exposure
• Test of choice if considering intracranial mass

• Upper endoscopyCan identify esophageal, gastric, and duodenal inflammation (reflux esophagitis, eosinophilic esophagitis, gastritis, ulcer disease, celiac disease)Provides means to obtain biopsies or cultures for infections (H. pylori, duodenal Giardia, cytomegalovirus gastritis)
• Gastroesophageal and antroduodenal manometry: can be used to evaluate for primary or secondary motility disorders, evaluation of suspected rumination syndrome

• Can identify esophageal, gastric, and duodenal inflammation (reflux esophagitis, eosinophilic esophagitis, gastritis, ulcer disease, celiac disease)
• Provides means to obtain biopsies or cultures for infections (H. pylori, duodenal Giardia, cytomegalovirus gastritis)

Differential Diagnosis

• Disorders of gastrointestinal tract:AnatomicEsophageal: stricture, web, ring, atresiaStomach: pyloric stenosis, web, hiatal herniaIntestine: duodenal atresia, malrotation, duplicationColon: Hirschsprung disease, imperforate anusMotilityAchalasiaGastroesophageal refluxIntestinal pseudoobstructionGastroparesisIleusObstructionForeign body/bezoarIntussusceptionStricturing Crohn diseaseVolvulusIncarcerated herniaEosinophilic esophagitisHepatobiliary diseaseAppendicitisNecrotizing enterocolitisPeritonitisCeliac diseasePeptic ulcerTraumaDuodenal hematomaPancreatitis (pseudocyst)
• NeurologicIntracranial mass lesions:TumorCystSubdural hematomaCerebral edemaHydrocephalusPseudotumor cerebriArnold-Chiari malformationMigraine (head, abdominal)SeizuresPostconcussion syndrome
• RenalObstructive uropathyUPJ obstructionHydronephrosisNephrolithiasisRenal insufficiencyGlomerulonephritisRenal tubular acidosis
• MetabolicInborn errors of metabolism:GalactosemiaFructose intoleranceHereditary fructose intoleranceAmino acid or organic acid metabolismUrea cycle defectsFatty acid oxidation disordersLactic acidosis
• InfectionSepsisMeningitisUTIH. pyloriParasitesGiardiaViral/bacterial gastroenteritisViral hepatitis (A, B, C)PneumoniaBordetella pertussisStreptococcal pharyngitis
• EndocrineDiabetesDiabetic ketoacidosisDiabetic gastroparesisAdrenal insufficiency
• RespiratorySinusitisLaryngitis
• ImmunologicFood allergyAnaphylaxisGraft-versus-host diseaseChronic granulomatous disease
• Other:PregnancyRuminationBulimiaMotion sicknessCVSOverfeedingPainCannabinoid hyperemesisMedications:Drugs (chemotherapy)Vitamin toxicityVascular (superior mesenteric artery syndrome)PorphyriaFamilial dysautonomia

• AnatomicEsophageal: stricture, web, ring, atresiaStomach: pyloric stenosis, web, hiatal herniaIntestine: duodenal atresia, malrotation, duplicationColon: Hirschsprung disease, imperforate anus
• MotilityAchalasiaGastroesophageal refluxIntestinal pseudoobstructionGastroparesisIleus
• ObstructionForeign body/bezoarIntussusceptionStricturing Crohn diseaseVolvulusIncarcerated hernia
• Eosinophilic esophagitis
• Hepatobiliary disease
• Appendicitis
• Necrotizing enterocolitis
• Peritonitis
• Celiac disease
• Peptic ulcer
• TraumaDuodenal hematomaPancreatitis (pseudocyst)

• Esophageal: stricture, web, ring, atresia
• Stomach: pyloric stenosis, web, hiatal hernia
• Intestine: duodenal atresia, malrotation, duplication
• Colon: Hirschsprung disease, imperforate anus

• Achalasia
• Gastroesophageal reflux
• Intestinal pseudoobstruction
• Gastroparesis
• Ileus

• Foreign body/bezoar
• Intussusception
• Stricturing Crohn disease
• Volvulus
• Incarcerated hernia

• Duodenal hematoma
• Pancreatitis (pseudocyst)

• Intracranial mass lesions:TumorCystSubdural hematoma
• Cerebral edema
• Hydrocephalus
• Pseudotumor cerebri
• Arnold-Chiari malformation
• Migraine (head, abdominal)
• Seizures
• Postconcussion syndrome

• Tumor
• Cyst
• Subdural hematoma

• Obstructive uropathyUPJ obstructionHydronephrosisNephrolithiasis
• Renal insufficiency
• Glomerulonephritis
• Renal tubular acidosis

• UPJ obstruction
• Hydronephrosis
• Nephrolithiasis

• Inborn errors of metabolism:GalactosemiaFructose intoleranceHereditary fructose intoleranceAmino acid or organic acid metabolismUrea cycle defectsFatty acid oxidation disordersLactic acidosis

• Galactosemia
• Fructose intolerance
• Hereditary fructose intolerance
• Amino acid or organic acid metabolism
• Urea cycle defects
• Fatty acid oxidation disorders
• Lactic acidosis

• Sepsis
• Meningitis
• UTI
• H. pylori
• Parasites
• Giardia
• Viral/bacterial gastroenteritis
• Viral hepatitis (A, B, C)
• Pneumonia
• Bordetella pertussis
• Streptococcal pharyngitis

• DiabetesDiabetic ketoacidosisDiabetic gastroparesis
• Adrenal insufficiency

• Diabetic ketoacidosis
• Diabetic gastroparesis

• Sinusitis
• Laryngitis

• Food allergy
• Anaphylaxis
• Graft-versus-host disease
• Chronic granulomatous disease

• Pregnancy
• Rumination
• Bulimia
• Motion sickness
• CVS
• Overfeeding
• Pain
• Cannabinoid hyperemesis
• Medications:Drugs (chemotherapy)Vitamin toxicity
• Vascular (superior mesenteric artery syndrome)
• Porphyria
• Familial dysautonomia

• Drugs (chemotherapy)
• Vitamin toxicity

Treatment

• Potential therapeutic interventions are broad, and therapy should be directed toward the underlying etiology.
• Historically, empiric antiemetic medications were contraindicated in cases of acute vomiting, although more recent studies suggest ondansetron may reduce frequency of admission.
• Oral rehydration therapy is typically the first line of treatment. IV fluids are appropriate if oral rehydration therapy fails or are contraindicated.
• Neurotransmitters involved in vomiting include dopamine, acetylcholine, histamine, endorphins, serotonin, and neurokinins. The mechanism of many antiemetic medications is blockade of these neurotransmitters.

Issues for Referral

• Chronic vomiting (2 " “3 weeks)
• Weight loss
• Severe abdominal pain or irritability
• Gastrointestinal bleeding
• Bilious emesis
• Evidence of intestinal obstruction
• Serum electrolyte abnormalities
• Abnormal neurologic examination
• Dehydration
• Signs of acute abdomen
• Lethargy

Additional Reading

• Fedorowicz ‚ Z, Jagannath ‚ VA, Carter ‚ B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2011;(9):CD005506. ‚ [View Abstract]
• Freedman ‚ SB, Adler ‚ M, Seshadri ‚ R, et al. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med. 2006;354(16):1698 " “1705. ‚ [View Abstract]
• Li ‚ B, Misiewicz ‚ L. Cyclic vomiting syndrome: a brain-gut disorder. Gastroenterol Clin North Am. 2003;32(3):997 " “1019. ‚ [View Abstract]
• Li ‚ BK, Sunku ‚ BK. Vomiting and nausea. In: Wyllie ‚ R, Hyams ‚ JS, eds. Pediatric Gastrointestinal and Liver Disease. 4th ed. Philadelphia: Saunders; 2011.

Codes

ICD09

• 787.03 Vomiting alone
• 779.33 Other vomiting in newborn

ICD10

• R11.10 Vomiting, unspecified
• P92.1 Regurgitation and rumination of newborn

SNOMED

• 422400008 Vomiting (disorder)
• 55331005 Newborn regurgitation of food (finding)
• 84480002 Retching (finding)

FAQ

• Q: What are the most common causes of nonbilious vomiting in an infant?
• A: Gastroesophageal reflux and milk protein allergy, although hypertrophic pyloric stenosis, sepsis, and malrotation must be considered.
• Q: What is appropriate management of a 6-month-old presenting with an episode of bilious emesis and lethargy?
• A: Referral for emergent abdominal ultrasound and surgical consult for possible intussusception
• Q: Is bilious emesis always associated with small bowel obstruction?
• A: Repeated episodes of vomiting can cause duodenal contents to reflux into the stomach resulting in bile-stained emesis without small bowel obstruction. Nevertheless, evaluation should include high suspicion and workup for possible obstruction.