SIGNS AND SYMPTOMS 
- General:
- Appearance variable depending on the underlying cause
- Signs of dehydration, including tachycardia, tachypnea, pallor, decreased perfusion, and shock
- Altered mental status may occur secondary to shock, hypoglycemia, or extra-abdominal conditions (sepsis, inborn error of metabolism, increased intracranial pressure, toxicologic poisoning).
- Vomiting characteristics:
- Assess color, composition, onset, progression, and relationship to intake and position.
- Nonbilious emesis is caused by a lesion proximal to the pylorus.
- Bilious (green) emesis indicates obstruction below the duodenal ampulla of Vater; in infants, bilious emesis is associated with a more serious underlying condition (malrotation, volvulus, intussusception, bowel obstruction); may also be due to adynamic ileus or sepsis.
- Bloody emesis (hematemesis) involves a lesion proximal to the ligament of Treitz; bright red bloody emesis has little or no contact with gastric juices due to an active bleeding site at or above cardia.
- "Coffee-grounds" emesis results from reduction of heme by gastric secretions.
- Feculent odor suggests lower obstruction or peritonitis.
- Undigested food in emesis suggests an esophageal lesion or one at or above the cardia.
- GER: Begins shortly after birth, remains relatively constant, usually with normal weight gain.
- Hypertrophic pyloric stenosis: Begins insidiously at 2–6 wk of age and progresses, becoming increasingly forceful (projectile) after feedings.
- Obstruction and/or ischemic bowel (malrotation with midgut volvulus, intussusception, necrotizing enterocolitis): Sudden onset associated with rapid progression to appearing ill out of proportion to the duration of illness; abdomen distended and tender.
- Abdominal:
- Distention suggests obstruction.
- Peritoneal signs suggest inflammation and possible perforation.
- Complications:
- Aspiration
- Mallory–Weiss tear
- Boerhaave syndrome
History
- Constitutional:
- Vomiting characteristics:
- Timing, duration
- Bilious?
- Bloody?
- Associated symptoms:
- PMHx:
- History of similar
- Past surgical history
Physical Exam
- General:
- General appearance, vital signs, hydration status
- Cardiovascular:
- Quality heart tones
- Pulses, perfusion
- Abdominal:
- Tenderness, distention, mass
- Bowel sounds
- Genitourinary:
- Scrotal swelling, tenderness, mass
- Rectal:
- Presence of blood, mass, tenderness
ESSENTIAL WORKUP
Exclude life-threatening causes of vomiting.
DIAGNOSIS TESTS & INTERPRETATION
Lab
- As indicated by history and physical exam and consideration of differential:
- Metabolic assessment (glucose, electrolytes)
- Infection assessment (CBC, culture—urine)
- Pregnancy tests for females of childbearing age
Imaging
- As indicated by differential considerations
- Abdominal radiographs (flat plate, upright, and decubitus) helpful for evaluation of obstruction or perforation
- Pelvic and abdominal US for evaluation of hypertrophic pyloric stenosis, intussusception, appendicitis as well as pelvic or scrotal pathology
- Abdominal CT scan helpful for evaluation of appendicitis, mass/tumor often requiring contrast
Diagnostic Procedures/Surgery
Nasogastric tube:
- Location, character, and severity of gastric bleeding
DIFFERENTIAL DIAGNOSIS
- Neonate/infant:
- GI/mechanical: GER, meconium ileus, necrotizing enterocolitis, hypertrophic pyloric stenosis, intussusception, malrotation with midgut volvulus, Hirschsprung disease, congenital obstructions (atresias, duplications, imperforate anus. stenoses, and webs), hernia, foreign body/bezoar, paralytic ileus
- Metabolic/endocrine: Inborn errors of metabolism (amino acidurias, fatty acid oxidation disorders, urea cycle defects), uremia, congenital adrenal hyperplasia, kernicterus
- Neurologic: CNS bleeding (often due to trauma), tumor, hydrocephalus
- Infectious: Otitis media, UTI, pneumonia, sepsis, pertussis, meningitis/encephalitis
- Feeding problems: Chalasia, improper technique (overfeeding, improper position), milk allergy
- Other: Toxicologic, nonaccidental trauma
- Child/adolescent:
- GI: Gastroenteritis, obstruction (hernia, adhesions, intussusception, foreign body, bezoar), pancreatitis, appendicitis, peptic ulcer, peritonitis, paralytic ileus, trauma (duodenal hematoma)
- Metabolic/endocrine: Diabetic ketoacidosis, uremia, adrenal insufficiency
- Infectious: Gastroenteritis, UTI, sinusitis, upper respiratory infection, sepsis, meningitis, encephalitis, pneumonia, hepatitis
- Neurologic: CNS mass/tumor, CNS bleeding (often due to trauma), cerebral edema, concussion, migraine
- Other: Toxicologic, (nonaccidental) trauma, pregnancy, bulimia
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PRE-HOSPITAL
Not applicable
INITIAL STABILIZATION/THERAPY
- Fluid resuscitation with 0.9% NS IV; caution if concern about increased intracranial pressure.
- Determine bedside fingerstick glucose.
ED TREATMENT/PROCEDURES
- Continue fluid resuscitation and correction of electrolyte imbalance if present.
- Decompress stomach with nasogastric or orogastric tube if abdomen distended or vomiting persistent.
- Continue evaluation for underlying cause.
- Consider antiemetic medications.
- Surgical consultation if acute abdomen; antibiotics if peritonitis or other systemic infection present
MEDICATION
Antiemetics may be helpful once the underlying cause of vomiting has been determined.
First Line
Ondansetron: 4–8 mg (peds: 0.1 mg/kg per dose) IV or PO q6h
Second Line
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DISPOSITION
Admission Criteria
- Unstable vital signs, including persistent tachycardia or other evidence of hypovolemia
- Serious etiologic condition or inability to exclude serious etiologic conditions
- Intractable vomiting or inability to take oral fluids
- Inadequate social situation or follow-up
Discharge Criteria
- Stable; able to tolerate oral fluids
- Benign etiology considered most likely and serious or potentially important etiologies excluded
- Parental understanding of instructions to advance clear liquids slowly and return for continued vomiting, abdominal distention, decreased urination, fever, lethargy, or unusual behavior
Issues for Referral
- Chronic or recurrent episodes of vomiting or abdominal pain:
- Pediatric gastroenterology
FOLLOW-UP RECOMMENDATIONS
PCP in 1–2 days
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