Pediatric Vomiting Flashcards
1
Q
Nausea
A
Unpleasant sensation in the upper abd and pharynx
Associated w/ the feeling of the need to vomit
2
Q
Vomiting
A
Active, forceful process using thoracic and abdominal muscles w/ expulsion of gastric contents
3
Q
Vomiting
Pathophysiology
A
-
Vomiting triggers:
- ⊕ of vomiting center (VC) in the medulla
- ⊕ of chemoreceptor trigger zone (CTZ) near 4th ventricle
- 2° ⊕ of VC from middle ear to vestibulocerebral system
-
Toxins ⊕ 5-HT enterochromatic cells of intestine
- 5-HT → ⊕ VC & vagal nerves in the intestines
- ↑ Non-peristaltic contractions in small intestine + gallbladder contracts
- Some duodenal contents regurgitate into the stomach
- Retrograde peristaltic wave in small intestines + contraction of inspiratory and abdominal muscles + diaphragm relaxes
- Gastric contents are expelled
4
Q
Non-Bilious vs Bilious
Emesis
A
Non-bilious ⇒ proximal to Ampulla of Vater
Bilious ⇒ distal obstruction past the Ampulla of Vater (more concerning)
5
Q
Non-bilious Vomiting
Differential Dx
A
- Gastroesophageal Reflux
- Rumination
- Infantile Hypertrophic Pyloric Stenosis
- Congenital Obstructive Lesions
- Infections
- Metabolic/Endocrine
- Neurologic
- Milk Protein Intolerance
- Celiac Disease
- Renal Disease
- Renal Tubular Acidosis
- Intermittent ureteropelvic junction obstruction
- Psychologic
- Stress
- Bulimia
- Pregnancy
- Meds/Drugs/Toxins
- Child Abuse/Shaken Baby Impact Syndrome
- Abdominal Migraine
- Inflammatory bowel disease
- Porphyria
6
Q
Gastroesophageal Reflux
(GER)
A
Expulsion of food from the stomach secondary to the transient relaxation of LES
- Not true vomiting
- 50% of infants < 1 y/o have GER > 1x/day
- Complications: esophagitis, pain, Sandifer’s Syndrome (spasmodic torsional dystonia), apnea, aspiration, wheezing, failure to thrive, brief resolved unexplained event (BRUE)
- Diagnosis: clinically, UGI, pH probe
- Treatment: non-medical vs. medical vs. surgical (Nissin Fundoplication)
7
Q
Rumination
A
Regurgitation of food to the mouth where it is re-chewed and re-swallowed.
- Usually occurs between 3-6 m/o in infants who lack interaction from caregiver
- Self-stimulating behavior
- Can have failure to thrive, metabolic complications
8
Q
Infantile Hypertrophic Pyloric Stenosis
A
- Progressive vomiting which becomes projectile
- Usually 4-6 weeks of age
- M:F 5:1
- Hypokalemic, hypochloremic Metabolic Alkalosis due to vomiting
-
Diagnosis: Palpate Olive, visual peristalsis
- U/S shows Pyloris > 4mm
- Treatment is Pyloromyomotemy
9
Q
Congenital Obstructive Lesions
A
-
Differential includes:
-
Atresias
- Esophageal ⇒ nonbilious vomiting
- Duodenal ⇒ bilious vomiting
- Annular Pancreas ⇒ pancreas wraps around esophagus
- Webs
-
Atresias
- Consider Ingestions such as Lactobeazor, coins, etc.
- Diagnosis: UGI, Flat Plate x-ray
- Treatment: Surgery
10
Q
Infectious Causes
A
-
Acute Gastroenteritis
- Viral infections: Rotavirus, Norovirus, Adenovirus, Astrovirus
- Usually not as sick
- Bacterial infections: Salmonella, Shigella, Camplobacter, Yersinia, E. Coli (HUS), C. diff
- Bloody emesis, fever
- Protozoan infections: Giardia, Lamblia, Cryptosporidium
- Other infectious causes of vomiting include: Labrynthitis, Pancreatitis, UTIs/Pyelonephritis, H. Pylori, PNA, sinusitis, otitis media, meningitis
- Post-tussive vomiting
11
Q
Metabolic/Endocrine
Causes
A
-
Inborn Errors of Metabolism
- Carbohydrate and metabolism defects
- Galactosemia
- Fructose Intolerance
- Pompe Disease
- Urea Cycle defects
- Amino Acidemias
- Lysosomal Storage Diseases
- Peroxisomal Disorders
- Fatty Acid Oxidation Defects
- Clinical manifestations include:
- Coarse facial features
- Developmental delays
- Hepatomegaly
- Hypoglycemia
- Seizures
- ± Consanguinity in Fhx
- Diagnosis: newborn screen, organic acids, amino acids, lactate, pyruvate, ammonia
- Carbohydrate and metabolism defects
- Diabetes
- Congenital Adrenal Hyperplasia
- Addison’s Disease
12
Q
Neurologic
Emesis
A
-
↑ Intracranial Pressure
- Pseudotumor cerebri
- Hydrocephalus
- Arnold Chiari malformations
- Tumors
- Shaken baby syndrome
- Meningitis (bacterial, viral, fungal, ricketsettial)
- Encephalitis (toxins, viral, drug induced, cat scratch disease)
-
Cyclic Vomiting
- Onset usually 3 y/o
- Progresses to abdominal migraines then cephalad migraines
13
Q
Bilious Vomiting
Differential Dx
A
- Structural causes
- Hirschsprung’s Disease
- Intussusception
- Necrotizing Enterocolitis
14
Q
Bilious Vomiting
Structural Causes
A
-
Duodenal or Jejunal atresia
- Usu. 2nd portion of duodenum
- Failture of recanalization of intestines during early gestation
-
Malrotation w/ or w/o Volvulus
- Malrotation: inappropriate rotation of the intestines during gestation
- Volvulus: lack of proper mesenteric anchoring to the retroperitoneum
- Diagnosis: UGI, flat plate x-ray
- Treatment: Surgery
15
Q
Hirschsprung’s Disease
A
- Congenital absence of ganglion cells in submucosal and myenteric plexuses of distal intestines, usually rectosigmoid
- Transition zone seen on x-ray
- Clinical manifestations: abdominal distention, vomiting, constipation
- Most kids ]dx w/in first 6 weeks of life
- Can have bilious vomiting right after birth or no BM in the first 2 days
- Diagnosis: barium enema, suction biopsy
- Treatment: Pull through surgery
16
Q
Intussusception
A
- Folding of part of intestine (usually ileocecal) into itself ⇒ compression of intestinal vasculature and ischemia
- Usually presents at 6 months to 2 yrs (↑ of Peyer Patches w/ viral infection)
-
Clinical manifestations:
- Every 20 minutes w/ severe colic, then lethargy
- Currant jelly stools (bloody mucous)
- Feels like a sausage in the abd
- Dx/Tx: Air contrast barium enema is both diagnostic and therapeutic
