Vomiting Flashcards
What is nausea?
Unpleasant painless subjective feeling that one will imminently vomit
Features of nausea?
- Often vague and epigastric/abdominal, but not always
- Associated with autonomic changes:
- Salivation, cold sweating, peripheral vasoconstriction, proximal gastric relaxation, retrograde movement of intestinal contents, changes in respiratory rhythm and quality, mydriasis
What is retching?
Strong, involuntary reverse movements (retroperistalsis) of the stomach and esophagus without vomiting
Features of retching?
- Accompanied by spasmodic contractions of the diaphragm and abdominal wall, closing of the glottis, and relaxation of lower esophageal sphincter
- Gastric material may be moved into the esophagus in preparation of vomiting
What is vomiting?
Retrograde ejection of gastrointestinal (or esophageal) contents from the mouth
Features of vomiting?
- Forceful (unable to keep contents in the mouth) and involuntary
- Associated with relaxation of the diaphragm and upper esophageal sphincter and reversal of intrathoracic pressure from negative to positive
What is regurgitation?
The spitting up of food from the esophagus or stomach, typically without nausea or forceful contractions of the abdominal muscles
Features of regurgitation?
Apparently effortless and typically caused by lower esophageal sphincter dysfunction:
1. High tone of the lower esophageal sphincter may lead to simple esophageal emptying (think achalasia)
2. Low tone of the lower esophageal sphincter may lead to reflux when the gastric musculature contracts
What is rumination?
Regurgitating undigested or partially digested food from the stomach, rechewing it, and then either re-swallowing it or spitting it out
Features of rumination?
- Again effortless
- Psychological or behavioral problems are considered the cause, although considered behavioral or involuntary
- Often occurs in association with dyspepsia and digestive problems
Differential diagnoses of vomiting in a neonate?
- Reflux +/- overfeeding if bottle/cup feeding
- Swallowed amniotic fluid which may cause irritation/discomfort
- Swallowed maternal blood which may cause irritation (swallowed maternal during delivery in first 2d or mother has cracked nipples)
- Obstruction (malrotation, esophageal/intestinal atresia, meconium ileus or plug, Hirschsprung, etc.)
- Necrotizing enterocolitis (10% occur in full term babies)
- Inborn error of metabolism
- Sepsis/meningitis/UTI
- Non-accidental Trauma
Features of esophageal atresia?
- Prenatal history of polyhydramnios and intolerance of initial feeding
- Accompanied distal tracheoesophageal fistula in 85% of cases (see below)
- Associated with other anomalies in 15-50% of patients (especially VACTERL)
Diagnosis of esophageal atresia?
plain films after passage of an opaque rubber catheter, which coils in the upper pouch
Features of pyloric stenosis?
- Non-bilious projectile vomiting
- Beginning at 2-3 weeks of age and increasing during the next month
- Often in a firstborn male child
Clinical manifestation of pyloric stenosis?
- Propulsive gastric waves can be seen on the abdominal wall and a palpable “olive” in the epigastrium (felt best during or after feeding) represents the hypertrophied pyloric muscle
- Dehydration
- poor weight gain
- hypochloremic metabolic alkalosis
Diagnosis of pyloric stenosis?
Contrast study: “string sign” and ultrasound w/ hypertrophied tissue
Treatment of pyloric stenosis?
Surgical pyloromyotomy
Features of duodenal atresia?
- Bilious vomiting
- Associated prematurity (and polyhydramnios)
- Anomalies, including renal, cardiac, and vertebral defects, occur in approximately 75% of infants
- Trisomy 21 is seen in about 50%
Diagnosis of duodenal atresia?
Radiographic “double-bubble” sign
Differential diagnosis of nausea and vomiting in toddlers?
- Incr. intracranial pressure or intracranial lesion
- Food issues (anaphylaxis, food poisoning, protein intolerance)
- Gastritis/gastroparesis (non-infectious) or PUD
- Infection (gastroenteritis, cholecystitis, appendicitis, UTI, PNA, flu/covid, pharyngitis, hepatitis, malaria, AOM)
- Renal causes (renal tubular acidosis, renal failure, UPJ obstruction)
- Electrolyte derangement/acidosis
- Malrotation w/ volvulus, intussusception, ileus/obstruction
- Pancreatitis
- Rumination
- Torsion (ovarian or testicular)
- Adrenal insufficiency
- Constipation
- Trauma: head injury, NAT, abdominal trauma w/ duodenal hematoma
Causes of peptic ulcer disease?
- H. pyloriinfections
- bile reflux gastritis
- nonsteroidal anti-inflammatory agents
- rare gastrin-secreting tumors (Zollinger-Ellison syndrome)
- Stress ulcers in sepsis, burns, surgery, head trauma, and severe acute illness
Diagnosis of PUD?
- History mostly with empiric treatment
- Endoscopy (evaluation forH. pylori)
Treatment of PUD?
- Acid suppression
- Treat H. pylori: double or triple antibiotics PLUS acid suppression drugs
Features of appendicitis?
Periumbilical pain is followed by vomiting and anorexia
Clinical features of appendicitis?
- fever
- leukocytosis with left shift
- rebound tenderness
- RLQ tenderness
- migration of pain from periumbilical to RLQ tenderness
Features of perforation in appendicitis?
After perforation:
1. may initially feel relief
2. progresses to signs of peritonitis with frequent vomiting
3. fever
4. flexed right hip
Differential diagnosis of nausea and vomiting in adolescents?
- Drugs (prescribed or illicit)- Direct consequences or side effects including cannabinoid hyperemesis syndrome
- Cyclic vomiting syndrome/abd migraine
- Inflammatory Bowel Disease
- Eating disorder (including bulimia)
- Pregnancy
- Diabetic Ketoacidosis
Complications of vomiting?
- metabolic
- nutritional
- Mallory-Weiss tear
- esophagitis
- aspiration
- shock
Metabolic complications of vomiting?
- HCl loss in emesis
- alkalosis, hypochloremia - Na, K loss in emesis
- hyponatremia, hypokalemia - Alkalosis > K into cells
Nutritional complications of vomiting?
- emesis of calories and nutrients
- anorexia for calories and nutrients
- malnutrition
- failure to thrive
Mallory-Weiss tear as a complication of vomiting?
- retching > tear at lesser curve of gastroesophageal junction
- forceful emesis > hematemesis
Features of Esophagitis as a complication vomiting?
- chronic vomiting > esophageal acid exposure
- heart burn
- hemocult in stool
Aspiration as a complication of vomiting?
aspiration of vomitus, especially in context of obtundation
- pneumonia
- neurologic dysfunction
Shock as a complication of vomiting?
- severe fluid loss in emesis or in accompanying diarrhea
- severe blood loss in hematemesis
- dehydration
- blood volume depletion
Causes of Effortless vomiting?
- gastroesophageal reflux
- rumination
Causes of projectile vomiting?
upper GI tract obstruction
e.g. pyloric stenosis
Causes of billous vomiting?
- post ampullary obstruction
- severe/persistent emesis
Causes of bloody vomiting?
- Gastritis/esophagitis/PUD
- Cirrhosis w/ varices
- Mallory-Weiss injury
- Bleeding disorders
- Swallowed blood
Vomitus containing undigested food is caused by?
- achalasia
- rumination
Maladorous vomiting causes?
- H. pylori
- giardiasis
- sinusitis
- small bowel bacterial overgrowth
- colonic obstruction
Surgical scars with vomiting are associated with?
surgical adhesions with obstruction
Succussion splash with vomiting is associated with?
Gastric outlet obstruction with gastric distention
Bowel sound changes with vomiting are associated with?
- Decreased: paralytic ileus
- increased: mechanical obstruction
Severe abdominal tenderness with rebound and vomiting is associated with?
Perforated viscera and peritonitis
Abdominal mass WITH vomiting is associated with?
- Pyloric stenosis
- ovarian cyst
- pregnancy
- abdominal neoplasm
Worsening of vomiting with sitting up is associated with?
Vestibular disease/component of nausea/vomiting
Papilledema, bulging fontanelle with vomiting is associated with?
increased ICP
