Basics
Description
- 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 " ).
Pathophysiology
- Vomiting can be:
- 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 emesis
- 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.
- Age of patient
- 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.
- 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.
Physical Exam
A careful and complete physical examination can often contribute to determining the cause of vomiting in children:
- 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
Lab
- CBC
- Anemia and iron deficiency can occur with gastritis/esophagitis, inflammatory bowel disease, celiac disease, and ulcer disease.
- Blood chemistry
- 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.
- 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 history
- 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)
Imaging
- Plain abdominal radiographic study
- Can detect ileus and/or obstruction
- May also need upright or left lateral decubitus films
- Abdominal ultrasound
- 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
- Contrast radiography
- Intestinal 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 CT
- Not generally indicated for evaluation of vomiting, although it is an effective tool when more anatomic abdominal detail is required (abscess, tumor).
- Head CT
- Can be helpful in evaluation of acute neurologic causes of vomiting (i.e., cerebrovascular insult; hydrocephalus)
- Brain MRI
- Provides superior imaging of the brain stem, where the vomiting center is located, without radiation exposure
- Test of choice if considering intracranial mass
Diagnostic Procedures/Other
- Upper endoscopy
- 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)
- Gastroesophageal and antroduodenal manometry: can be used to evaluate for primary or secondary motility disorders, evaluation of suspected rumination syndrome
Differential Diagnosis
- Disorders of gastrointestinal tract:
- Anatomic
- Esophageal: stricture, web, ring, atresia
- Stomach: pyloric stenosis, web, hiatal hernia
- Intestine: duodenal atresia, malrotation, duplication
- Colon: Hirschsprung disease, imperforate anus
- Motility
- Achalasia
- Gastroesophageal reflux
- Intestinal pseudoobstruction
- Gastroparesis
- Ileus
- Obstruction
- Foreign body/bezoar
- Intussusception
- Stricturing Crohn disease
- Volvulus
- Incarcerated hernia
- Eosinophilic esophagitis
- Hepatobiliary disease
- Appendicitis
- Necrotizing enterocolitis
- Peritonitis
- Celiac disease
- Peptic ulcer
- Trauma
- Duodenal hematoma
- Pancreatitis (pseudocyst)
- Neurologic
- Intracranial mass lesions:
- Tumor
- Cyst
- Subdural hematoma
- Cerebral edema
- Hydrocephalus
- Pseudotumor cerebri
- Arnold-Chiari malformation
- Migraine (head, abdominal)
- Seizures
- Postconcussion syndrome
- Renal
- Obstructive uropathy
- UPJ obstruction
- Hydronephrosis
- Nephrolithiasis
- Renal insufficiency
- Glomerulonephritis
- Renal tubular acidosis
- Metabolic
- Inborn errors of metabolism:
- Galactosemia
- Fructose intolerance
- Hereditary fructose intolerance
- Amino acid or organic acid metabolism
- Urea cycle defects
- Fatty acid oxidation disorders
- Lactic acidosis
- Infection
- Sepsis
- Meningitis
- UTI
- H. pylori
- Parasites
- Giardia
- Viral/bacterial gastroenteritis
- Viral hepatitis (A, B, C)
- Pneumonia
- Bordetella pertussis
- Streptococcal pharyngitis
- Endocrine
- Diabetes
- Diabetic ketoacidosis
- Diabetic gastroparesis
- Adrenal insufficiency
- Respiratory
- Immunologic
- Food allergy
- Anaphylaxis
- Graft-versus-host disease
- Chronic granulomatous disease
- Other:
- Pregnancy
- Rumination
- Bulimia
- Motion sickness
- CVS
- Overfeeding
- Pain
- Cannabinoid hyperemesis
- Medications:
- Drugs (chemotherapy)
- Vitamin toxicity
- Vascular (superior mesenteric artery syndrome)
- Porphyria
- Familial dysautonomia
Alert
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.
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.