| Vomiting | ||
Chris A. Liacouras
| Database Differential Diagnosis Approach to the Patient Data Gathering Physical Examination Laboratory Aids Emergency Care Bibliography |
| DATABASE | ||
DEFINITION
The expulsion of gastric contents through the mouth in varying degrees. Regurgitation is defined as small, effortless mouthfuls of food or stomach contents. Vomiting is usually associated with large, forceful amounts of stomach contents.
| DIFFERENTIAL DIAGNOSIS | ||
DISORDERS OF GASTROINTESTINAL TRACT
NEUROLOGIC
RENAL
METABOLIC
INFECTION
ENDOCRINE
RESPIRATORY
IMMUNOLOGIC
OTHER
| APPROACH TO THE PATIENT | ||
Vomiting is a prominent feature of many disorders of infancy and childhood and is often the only presenting symptom of many diseases. Vomiting can occur as a defense mechanism to expel ingested toxins, as an abnormality of the vomiting center related to increased intracranial pressure, as a result of intestinal obstruction or anatomical/mucosal abnormalities, or as the result of a generalized metabolic disease. A full history should include medication and drug use, trauma, and, in adolescents, questions regarding feeding disorders (bulimia) and intercourse (pregnancy).
| DATA GATHERING | ||
HISTORY
Question: Fever?
Significance: Infectious causes of vomiting
are common.
Question: Abdominal pain and frequent, forceful or bilious
emesis?
Significance: Often associated with anatomic or obstructive
intestinal disorder.
Question: Age of patient?
Significance: Pyloric stenosis and
inborn errors of metabolism almost always present in infancy with vomiting,
dehydration, and biochemical abnormalities.
Question: Mental retardation, pica, and patchy
baldness?
Significance: Foreign body or hair ingestion and the
development of a gastric bezoar.
Question: Nausea and epigastric pain related to
meals?
Significance: Often indicates gastritis, gastric emptying
delay, or gallbladder disease.
Question: Alleviated by meals?
Significance:
Gastroesophageal reflux and gastric ulcer disease
Question: Alternating vomiting and lethargy?
Significance:
Intussusception
Question: Chronic headaches, fatigue, weakness, weight loss, and early
morning vomiting?
Significance: Neurologic causes of vomiting
secondary to increased intracranial pressure
Question: Right- or left-sided abdominal pain?
Significance:
Renal disease, inflammatory bowel disease
| PHYSICAL EXAMINATION | ||
A careful and complete physical examination can often provide excellent clues as to the cause of vomiting in children.
Finding: Visible bowel loops
Significance: Obstruction
Finding: Palpation for a mass effect and tenderness, and auscultation
for evidence of absent bowel sounds or borborygmi (rumbling bowel
sounds)
Significance: Intestinal obstruction
Finding: Rectal examination
Significance: Testing the stool
for occult blood
Finding: Discoloration of skin and sclera
Significance:
Jaundice (liver/gallbladder or metabolic disease)
Finding: Orange tint of sclera or skin
Significance:
Hypervitaminosis A
Finding: Unusual odor
Significance: Metabolic disease
Finding: Chronic vomiting
Significance: Evidence of
neurologic dysfunction, including nystagmus, head tilt, papilledema, abnormal
reflexes, and weakness
Finding: Tense anterior fontanelle
Significance: May
indicate meningitis, hydrocephalus, or vitamin A toxicity
Finding: Enlarged parotid glands and
hypersalivation
Significance: Bulimia and other feeding disorders
Finding: Pelvic examination
Significance: Pregnancy, pelvic
inflammatory disease, or ovarian disease
| LABORATORY AIDS | ||
Test: CBC
Significance: Anemia and iron deficiency can occur
with intestinal duplication and obstruction, gastritis/esophagitis, and ulcer
disease.
Test: Blood chemistry
Significance: Electrolyte
abnormalities are found in pyloric stenosis, metabolic abnormalities, while an
elevated ALT, total bilirubin, and GGT can indicate liver, gallbladder, or
metabolic disease.
Test: Urinalysis
Significance: Pyelonephritis
Test: Amylase
Significance: Pancreatitis
Test: BUN/creatinine
Significance: If elevated—renal
disease
Test: Urine culture
Significance: UTI
Test: Plain abdominal x-ray study
Significance:
Obstruction
Test: Abdominal ultrasound
Significance: 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.
Test: Contrast radiography
Significance: Intestinal anatomic
abnormalities (malrotation, intussusception, volvulus)
Test: Computed tomography
Significance: Not generally
indicated for evaluation of vomiting, although it is an effective tool when more
anatomical abdominal detail is required (abscess, tumor).
Test: Endoscopy
Significance: Esophageal, gastric, and
duodenal inflammation (esophagitis, gastritis, ulcer disease, celiac disease,
eosinophilic enteritis) as well as for obtaining cultures for unusual infections
(duodenal Giardia, Helicobacter pylori/cytomegalovirus
gastritis).
Issues for Referral
| EMERGENCY CARE | ||
Evidence of hematemesis, intestinal obstruction (bilious vomiting), dehydration, neurologic dysfunction, or an acute abdomen should be treated as a medical emergency, and hospitalization should be considered.
| BIBLIOGRAPHY | ||
Piccoli DA. Gastroenterology and nutrition. In: Polin RA, Ditmar MF, eds. Pediatric secrets. St. Louis: CV Mosby, 1989:93–120.
Silverman A, Roy CC, eds. Pediatric clinical gastroenterology, 3rd ed. St. Louis: CV Mosby, 1983.
Sondheimer J. Vomiting and regurgitation. In: Walker WA, Durie PR, Hamilton JR, Walker-Smith JA, Watkins JB, eds. Pediatric gastrointestinal disease. St. Louis: Mosby, 1996:19.
Copyright
© 2000 Lippincott Williams & Wilkins
M. William
Schwartz, Louis M. Bell, Jr., Peter M. Bingham, Esther K. Chung, David F.
Friedman and Andrew E. Mulberg, The 5 Minute Pediatric Consult