Author:
Rajender K.Gattu
Description
- Forceful, coordinated act of expelling gastric contents through the mouth; characterized by nausea, retching, and emesis, resulting from sustained contraction of abdominal muscles, diaphragm, pylorus, and antrum
- Emesis results from activation of CTZ (chemosensitive trigger zone) which is located in the midbrain
Etiology
The causes of vomiting vary with age and range from very benign to serious life-threatening conditions:
- Neonatal period (<2 mo):
- GI causes include:
- Feeding problems such as overfeeding, chalasia, sucking and swallowing difficulties, improper technique or position
- Gastroesophageal reflux disease (GERD)
- Other serious GI conditions include:
- Meconium ileus, NEC, hypertrophic pyloric stenosis, malrotation with midgut volvulus, Hirschsprung disease, congenital obstructions (atresias, stenoses, and webs), incarcerated hernia
- Non-GI causes:
- Neurologic: CNS bleeding (often due to birth trauma), hydrocephalus, birth asphyxia
- Infectious: Acute pyelonephritis, pneumonia, sepsis, gastroenteritis, meningitis/encephalitis, intrauterine infections (TORCHES)
- Metabolic/endocrine: Inborn errors of metabolism (amino acidurias, galactosemia, fatty acid oxidation disorders, urea cycle defects), congenital adrenal hyperplasia, kernicterus
- Infancy (2 mo-2 yr):
- GI causes:
- GERD, milk intolerance or milk allergy, posttussive emesis, viral gastritis or gastroenteritis, food poisoning
- GI obstruction-pyloric stenosis, intussusception, malrotation with midgut volvulus and incarcerated hernia, foreign body/bezoar, trauma
- Non-GI causes:
- Metabolic/endocrine: Inborn errors of metabolism (amino acidurias, fatty acid oxidation disorders, urea cycle defects)
- Neurologic: Increased intracranial pressure (ICP) from subdural hematoma, closed head injury, nonaccidental injury, hydrocephalus
- Infections: Acute gastroenteritis, UTI, pneumonia, otitis media. Potentially serious infections such as sepsis, meningitis, or encephalitis
- Chronic organ disease: Hepatobiliary disease, chronic renal disease, pancreatitis,
- Other: Toxic ingestion
- Childhood (3-12 yr):
- GI causes:
- Acute gastroenteritis, GERD. Serious causes include, foreign body in esophagus, eosinophilic esophagitis, and intestinal obstruction, e.g., intussusception, malrotation with midgut volvulus, adhesions from previous abdominal surgeries, incarcerated inguinal hernia, paralytic ileus, trauma
- Non-GI causes:
- Posttussive emesis from hyperreactive airway disease, pyelonephritis, strep pharyngitis, otitis media, and upper respiratory infections
- Metabolic: Diabetic ketoacidosis (DKA)
- Neurologic: Increased ICP from tumor, pseudotumor cerebri, subdural hematomas, severe head injury
- Toxic ingestions: Accidental or intentional overdose
- Cyclic vomiting
- Other: Postchemotherapy
- Adolescence (13-18 yr):
- GI causes:
- Non-GI causes:
- Pregnancy, pseudotumor, substance abuse/withdrawal, eating disorders, psychogenic,
- Underlying chronic organ diseases (chronic pancreatitis, end stage renal disease, hepatobiliary disease)
- Substance abuse, drug induced, toxins, or overdose
Signs and Symptoms
- General:
- Appearance variable depending on the underlying cause
- Signs of dehydration, including tachycardia, tachypnea, pallor, decreased perfusion, and shock
- Warning signs and symptoms that indicate serious illnesses include
- Vomiting characteristics:
- 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
- Nonbilious emesis is caused by lesion proximal to the pylorus
- 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
- Undigested food in emesis suggests an esophageal lesion or one at or above the cardia
- Feculent odor suggests lower obstruction or peritonitis
- Neurologic symptoms:
- Persistent severe headache or, nuchal rigidity or bulging fontanelle may occur secondary to increased ICP from tumor, shaken baby syndrome, hemorrhage, and meningitis/encephalitis
- Altered mental status may be seen with intussusception or toxicologic poisoning or other intracranial pathology such as bleeding or tumor or meningitis/encephalitis
- Abdominal:
- Sudden onset with severe persistent abdominal pain and distension suggests intestinal obstruction, ischemic bowel, or ileus
- Rapid progression to appearing ill out of proportion to the duration of illness
- Abdomen distended and tender is associated with malrotation with midgut volvulus, intussusception, necrotizing enterocolitis
- Peritoneal signs suggest inflammation and possible perforation
- Hypertrophic pyloric stenosis begins insidiously at 2-6 wk of age and progresses, becoming increasingly forceful (projectile) after feedings
- Rectal bleeding and episodic abdominal pain is associated with intussusception. May also have altered mental status
- High fever and toxic appearance: Pneumonia, pyelonephritis, meningitis
- Complications:
- Aspiration
- Mallory-Weiss tear
- Boerhaave syndrome
History
- Constitutional:
- Vomiting characteristics: Assess color, composition, onset, progression, frequency
- Timing, duration
- Character of episodes - projectile, posttussive, persistent, or protracted
- Pattern - after feeding, early morning
- Bilious?
- Bloody?
- Associated symptoms:
- Diarrhea
- Anorexia
- Abdominal pain
- Dysuria
- Inguinal swelling
- Neurologic symptoms (headache, mental status change)
- PMHx:
- History of similar
- Past surgical history
Physical Exam
- General:
- General appearance, vital signs, hydration status
- Cardiovascular:
- Quality heart tones
- Pulses, perfusion
- Abdominal:
- Tenderness, distension, mass
- Bowel sounds
- Signs of peritoneal irritation
- Genitourinary:
- Scrotal swelling, tenderness, mass
- Rectal:
- Presence of blood, mass, tenderness
- Neurologic nuchal rigidity, mental status
Essential Workup
Exclude life-threatening or serious causes of vomiting
Diagnostic 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
- Stool microscopy and occult blood
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 may be helpful for evaluation of appendicitis, mass/tumor often requiring contrast
Diagnostic Procedures/Surgery
- Nasogastric tube:
- Location, character, and severity of gastric bleeding
- Esophagogastroduodenoscopy may be indicated for active upper GI bleeding, removal of foreign body in the esophagus and in special situations like recurrent or persistent vomiting of unknown etiology
Differential Diagnosis
- Neonate/infant:
- GERD presents with effortless vomiting;
- Protein-induced enteropathy may present with failure to thrive, vomiting and bloody stools; pyloric stenosis presents at 2-6 wk of age with vomiting increasingly projectile after the feeds
- Intestinal obstruction - presents with bilious vomiting and abdominal distension
- Inborn errors of metabolism including organic acidemias presents with lethargy, poor feeding, vomiting, and metabolic acidosis
- Foreign body obstruction of esophagus presents with vomiting after feeds, sometimes associated with drooling and difficulty swallowing
- intussusception presents between 6-36 mo of age with episodic crying, vomiting, and sometimes associated with bloody stools or altered mental status
- Child/adolescent:
- Acute appendicitis presents with vomiting accompanied by right lower quadrant abdominal pain and peritoneal signs on abdominal examination
- Pregnancy
- Migraine
- Cyclic vomiting
- Eating disorders
- Pseudotumor cerebri - vomiting is associated with headache
- Chemotherapy-induced emesis
- Postoperative emesis
Prehospital
Not applicable, unless needs acute resuscitation for dehydration
Initial Stabilization/Therapy
- Fluid resuscitation with 0.9% NS IV; caution if concern about increased ICP
- 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 for peritonitis or other systemic infections
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/PO q6h
Second Line
- Metoclopramide: 10 mg (peds: 0.1 mg/kg per dose) PO q6h
- Prochlorperazine: 2.5-5 mg (peds: 0.1 mg/kg per dose) IV/IM/PR q6h
- Promethazine: 12.5-25 mg (peds: 0.25 mg/kg per dose) PO/PR/IM q6h
- Consider other 5-HT3 receptor antagonists such as emend (aprepitant) or granisetron for chemotherapy-induced vomiting or postoperative vomiting
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 understand ing of instructions to advance clear liquids slowly and return for continued vomiting, abdominal distension, 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 d