Acute Vomiting Flashcards
Vomiting reflex:
What are 2 unique characteristics of vomiting?
- active abdominal contractions
- contains bile
What is acute vomiting? What 2 differentiations need to be made?
<10 days (7-14d)
- life-threatening vs. self-limiting
- systemic vs. GI disease
What are 7 important parts of a history in patients that are vomiting?
- duration and frequency of vomiting
- timing of vomiting in relation to eating or time of day
- contents
- dietary indiscretion
- appetite
- drug administration
- other clinical signs
What are 5 signs on physical examination seen in patients that are vomiting?
- dehydration - delayed CRT, tacky MM, skin tent, sunken eyes
- abdominal pain
- abnormal abdominal palpation - FB, mass, thickened stomach or intestines, organomegaly, fluid wave
- oral examination - string FB under tongue
- presence of systemic disease - icterus, encephalopathy, uremic breath, peripheral lymphadenopathy, bradycardia
What is acute gastritis? What are some possible causes?
sudden onset of vomiting related to gastric mucosal insult or inflammation
- dietary indiscretion or intolerance
- FB
- drugs and toxins - NSAIDs, corticosteroids, heavy metals, antibiotics, plants, cleaners, bleach
- systemic disease - uremia, liver disease, Addison’s
- parasites - Ollulanus, Physaloptera
- bacteria - toxins, Helicobacter
- viruses
What are the 3 major GI differentials for vomiting?
- gastritis - dietary indiscretion (FB, table scraps, recent changes in diet), toxins (plants, chemicals), FB injures or irritates mucosa, drugs (antibiotics, NSAIDs)
- gastric FB
- hemorrhagic gastroenteritis
What are 6 major systemic differentials for vomiting?
- acute pancreatitis
- parvovirus
- renal failure
- endocrinopathies - Addison’s, DM, hyperthyroidism
- hepatobiliary disease
- toxins - grapes, raisins, xylitol, ethylene glycol
What are 4 findings that point to GI disease as a cause of acute vomiting? 2 systemic findings?
GI - masses or thickening palpated in GIT, significant diarrhea, otherwise normal, in association to eating
SYSTEMIC - ill prior, signs of systemic disease
What is the minimum database used for diagnosing self-limiting vomiting? What 2 things can be added?
PCV/TS - looking for signs of dehydration
- abdominal radiographs - r/o FB
- CBC/chem - r/o systemic disease and electrolyte/acid-base derangements
What are 3 parts to the minimum database for life-threatening vomiting?
- CBC/chem +/- UA
- abdominal radiographs and ultrasounds - look for FB, intestinal tract abnormalities, pancreatitis, GBM, organomegaly
- specific tests for systemic disease - PLI, basal cortisol
What are the most common biochemistry changes associated with acute vomiting? What else is seen?
hyponatremia + acidosis (decreased TCO2/HCO3) - typically mild, self-limiting, and due to dehydration
- hypochloremia - loss of HCl
- hypokalemia
- alkalosis - increased TCO2/HCO3, severe loss of HCl, pyloric outflow tract obstruction
How can vomiting result in metabolic acidosis and alkalosis?
ACIDOSIS - dehydration, hypovolemia, increased lactic acid, loss of duodenal bicarbonate
ALKALOSIS - loss of H+ from stomach increases plasma HCO3, gastric outflow or proximal duodenal obstruction, hyponatremia, hypokalemia, hypochloremia (sever, persistent vomiting)
What biochemical changes are seen with possible systemic disease leading to vomiting?
- renal disease = increased BUN/creatinine, inappropriate USG, acidosis
- liver disease = increased ALT, ALP, Tbili
- DM/DKA = hyperglycemia, glucosuria, ketonuria, acidosis
- hypoadrenocorticism = hyponatremia, hyperkalemia, acidosis
What is the purpose of diagnostic imaging in cases of acute vomiting? What 2 are most commonly performed?
see if causes require surgery vs. supportive care
- abdominal radiographs - obstruction, radiopaque FB, peritoneal effusion
- abdominal U/S - FB, obstruction, intussusception, GBM, gastroenteritis, pancreatitis
How do patients with self-limiting vomiting most commonly present?
- appear systemically healthy - BAR
- minimal to no dehydration
- cause likely to resolve without intervention
(gastroenteritis)
How do patients with life-threatening vomiting most commonly present?
- depressed
- moderate to severe dehydration
- persistent and severe vomiting
- hematemesis
- cause unlikely to resolve without aggressive supportive therapies
What are 4 parts to treatment of life-threatening vomiting?
- IV fluid therapy
- antiemetics - Cerenia, Onsandestron +/- PPIs
- NPO - withhold food and water until vomiting decreases or stops
- remove FB via endoscopy or surgery
What rates are recommended for hydrating patients with life-threatening vomiting?
- estimated % dehydration (clinically detectable at 5%)
- losses due to on going vomiting (estimate volume of vomitus)
- maintenance - 60 mL/kg/day
What electrolytes should be added to fluid therapy in patients presenting with life-threatening vomiting? How can acid-base derangement be treated?
potassium chloride (20 mEq/L) + isotonic crystalloids - LRS, 0.9% NaCl
if acidotic - LRS, alkalotic -.9% NaCl
What 4 treatments are recommended for self-limiting vomiting?
- SQ fluids - LRS, 10-20 mL/kg/site
- NPO for 12 hours
- small frequent meals - highly digestible EN, i/d, RC GI (after resolution for 2-3 days add in usual diet over 3-5 days)
- antiemetics - r/o obstruction first!
Dehydration:
A patient with a history of acute vomiting over 4 days presents with the following CBC. What does this mean?
increased PCV/HCT = hemoconcentration, dehydration from vomiting
A patient with a history of acute vomiting over 4 days presents with the following biochemistry panel. What does this mean?
- high albumin - hemoconcentration
- hyponatremia, hypokalemia, hypochloremia, high CO2 (equivalent to HCO3) = metabolic alkalosis - fluid pools in stomach due to gastric or duodenal outflow tract obstructions (FB?)
What is occurring in this radiograph?
- BLUE = FB in high duodenum
- ORANGE = distended proximal duodenum
- YELLOW = pylorus distended with fluid
- caudal displacement of intestines
