Approach To The Vomitting Child Flashcards
What is the most common cause of vomiting in babies?
Benign gastro-oesophageal reflux.
What proportion of neonatal emergency department visits are due to vomiting?
Up to one-third
What are the key aspects to assess in the history of a vomiting child?
Timing, nature, and color of the vomiting
What are common causes of vomiting in neonates?
Congenital anomalies and sepsis.
What are common causes of vomiting in older children?
Functional and infective causes.
What are some common congenital GIT causes of vomiting?
• Oesophageal atresia
• Duodenal atresia
• Annular pancreas
• Malrotation
• Jejunal atresia
• Ileal atresia
• Meconium ileus
• Imperforate anus
• Hirschsprung’s disease
What are some rarer congenital GIT causes of vomiting?
• Oesophageal stricture, congenital antral web or diaphragm
• Duodenal web
• Meconium plug syndrome
• Colon atresia
• Meconium peritonitis
• Small-left-colon syndrome
• Megacystis - microcolon syndrome
• Duplications
• Mesenteric defect - hernia
• Persistent omphalomesenteric band
What are some common acquired causes of vomiting due to obstruction?
• Pyloric stenosis
• Intussusception
• Incarcerated hernia
• Adhesions
• Bezoars
• Ingested foreign bodies
• Tumours
• Malrotation with midgut volvulus
What are some common acquired causes of vomiting due to inflammation?
• Oesophageal stricture
• Appendicitis
• Crohn’s disease
• Ulcerative colitis
• Perforations
• Primary peritonitis
• Necrotizing enterocolitis
• Intra-abdominal abscess
• Pancreatitis
• Cholecystitis
What are some common acquired causes of vomiting due to trauma?
• Bowel injury
• Mesenteric injury
• Retroperitoneal bleeding
• Pancreatic injury
• Head injury
What are some other common acquired causes of vomiting?
• Gastroesophageal reflux
• Postoperative/septic paralytic ileus
• Intra-cranial pathology
• Metabolic derangements
• Non-GIT infections
What is the number one diagnosis to exclude when an infant or child is vomiting bile?
The number one diagnosis to exclude is midgut volvulus, which is a lethal condition requiring emergency management.
What are the characteristics of vomit that suggest a possible midgut volvulus?
Pure, canary yellow vomit is suggestive of a volvulus.
What does darker, more faeculent looking green vomitus indicate?
It suggests a possible lower gastrointestinal (GIT) obstruction.
What should be assessed when an infant or child is vomiting bile?
• Other signs of bowel obstruction such as abdominal distension, visible bowel loops, and failure to pass stool.
• Hernia sites, such as checking for inguinal hernias.
• Nasogastric tube passage to:
• Relieve pain from gastric distension
• Relieve pressure on the diaphragm (important for neonates who are diaphragmatic breathers)
• Allow measurement and intravenous fluid replacement of gastrointestinal losses
• Reduce vomiting and associated risk of aspiration
What should be done if an infant or child is vomiting blood?
See the approach to gastrointestinal (GIT) bleeding.
What differential diagnoses should be considered for abdominal pain with tenderness/peritonitis at different ages?
• In younger children, intussusception is a common pathology.
• In older children, appendicitis is more common.
Why should the groin and scrotum be checked during an abdominal exam?
Testicular torsion in a boy may present with vomiting and abdominal pain, so it is important to check the groin and scrotum.
What should be done if an abdominal mass is found?
• Palpate for a “sausage-shaped” mobile mass in children aged 3 months to 3 years, which may indicate idiopathic intussusception.
• An upper abdominal mass may be associated with early satiety.
• If a deformable mass extends to the pelvis, consider faecaloma first, and perform a digital rectal examination and/or abdominal x-ray to confirm.
• If malignancy is suspected (e.g., lymphoma), ultrasound should be performed as lymphoma may double in size within 48 hours, requiring urgent referral.
What signs should be looked for in cases of sepsis in neonates and young infants?
• Signs of sepsis can be subtle and include temperature instability (hypothermia or pyrexia), lethargy, irritability, and feed intolerance.
• Always look for signs of meningitis, pharyngitis, middle ear infection, and check the urine dipstick for urinary tract infection (UTI).
What is the most common cause of dehydration in children?
The most common cause of dehydration in children is acute gastroenteritis.
How can bowel obstruction lead to significant fluid deficits?
Bowel obstruction can lead to fluid deficits due to:
• Sepsis, if associated with bacterial translocation, necrotic gut, or perforation.
• Vomiting and nasogastric losses.
• Inability to take in fluids orally.
• Fluid sequestration in the obstructed bowel lumen.
• Oedema of the congested, obstructed bowel wall.
How is dehydration managed in children?
Dehydration is managed by monitoring the response after each 10ml/kg isotonic crystalloid bolus (e.g., Ringer’s lactate), ensuring replacement of ongoing losses, and providing glucose-containing maintenance fluid.
What is protracted vomiting, and what conditions can cause it in infants?
Protracted vomiting refers to long-standing vomiting with progressive worsening. It can be caused by:
• Hypertrophic pyloric stenosis (HPS) in infants, characterized by projectile vomiting.
• Gastro-oesophageal reflux causing protracted milk vomiting and failure to thrive.
• Mallory-Weiss oesophageal mucosal tear due to repeated forceful vomiting, causing upper gastrointestinal bleeding.
What should be considered when an infant is failing to thrive with protracted vomiting?
When failure to thrive occurs with protracted vomiting, consider the need for imaging:
• Ultrasound to assess for hypertrophic pyloric stenosis (HPS).
• Contrast meal with duodenal C-loop follow-through to assess for malrotation with intermittent midgut volvulus, even if the clinical examination is normal.
What electrolyte disturbances are common in infants with vomiting?
Common electrolyte disturbances in vomiting infants include:
• Hypokalaemic, hyponatraemic, hypochloraemic metabolic alkalosis, commonly seen in gastric outlet obstruction from infantile hypertrophic pyloric stenosis (HPS).
What are the common causes of bowel obstruction in neonates?
Common causes of bowel obstruction in neonates include:
• Atresia
• Hirschsprung’s disease
• Meconium disease
• Midgut volvulus
• Inguinal hernia
What are the common causes of bowel obstruction in infants and toddlers?
Common causes of bowel obstruction in infants and toddlers include:
• Hypertrophic pyloric stenosis
• Intussusception
• Inguinal hernia
What are the common causes of bowel obstruction in older children?
Common causes of bowel obstruction in older children include:
• Ascaris worms
• Adhesions (especially after previous surgery; look for subtle laparoscopic port site scars)
• Mimic: acute appendicitis with perforation (septic ileus)
