Vomiting Child

Question 1

What differentials should be considered in a vomiting infant?

Answer 1

GOR, feeding problems, infections (gastroenteritis, pertussis, UTI, meningitis), food allergy, intestinal obstruction and metabolic or renal problems.

Question 2

What differentials should be considered in vomiting young children?

Answer 2

Infections (gastroenteritis, pertussis, UTI, meningitis), appendicitis, intestinal obstruction, increased ICP, coaeliac disease, torsion of testis and metabolic/renal.

Question 3

What differentials should be considered in vomiting adolescents?

Answer 3

Infections (gastroenteritis, pyelonephritis, UTI, meningitis and sepsis), peptic ulceration, appendicitis, migraine, raised ICP, DKA, Alcohol/drugs, cyclical vomiting, bulimia/anorexia and pregnancy.

Question 4

What is hypertrophic pyloric stenosis?

Answer 4

Narrowing of the pylorus of the stomach due to hypertrophy of the stomach muscles.

Question 5

What are the risk factors for pyloric stenosis?

Answer 5

First born male
FHx of pyloric stenosis
Prematurity
Early exposure to erythromycin either as baby or to mother

Question 6

What are the clinical features of a child with pyloric stenosis?

Answer 6

Presents at 2-8 weeks with vomiting after feeds
M:F 4:1
Projectile type vomiting and vomit directly after feeds
Non bile vomit
No diarrhoea but constipation is likely
Always hungry after vomits

Left to right RUQ peristalsis
Deranged electrolytes - hypochloraemic, hypokalaemic metabolic alkalosis
Failure to thrive

Question 7

How should suspected pyloric stenosis be investigated?

Answer 7

Us and Es and USS

Question 8

How is pyloric stenosis managed?

Answer 8

Correct electrolyte disturbance, fluids and Surgery - Rundstedt’s pyloromyotomy

Question 9

What is intussusception?

Answer 9

Telescoping of the bowel, most commonly ileum passing into the caecum through the ileo-caecal valve. Usually no underlying problem, can be following viral infection leading to enlargement of lymph tissue such as Peyer’s patches.

Question 10

What are the risk factors for intussusception?

Answer 10

Typically 3-24 months
Male 3:1 female
Cystic fibrosis
HSP
Nephritic syndrome

Question 11

How does intussusception usually present?

Answer 11

Episodic intermittent inconsolable crying
Colicky abdominal pain and drawing the legs up – paroxysmal abdominal colic
Vomiting (bilious)
PR blood (late sign indicating necrosis)
Can have a long history especially if over 4 years of age
Lethargy
Shock

Question 12

How should suspected intussusception be investigated?

Answer 12

USS – gold standard
AXR
Diagnostic enema
CT

Image may show a leading enlarged lymph node (peyer’s patch), pathological lead point and target sign

Question 13

How is intussusception managed?

Answer 13

Acute management
Obstructed – Resuscitation fluids and NG tube
Group and save + cross match

Air reduction (contrast enema reduction) guided by US
Failing this laparoscopy or laparotomy with removal of necrotic bowel
Broad spectrum antibiotics

Question 14

How does gastro-oesophageal reflux present in children?

Answer 14

Vomiting/regurgitation following feeds
Onset from birth typically before 8weeks
Most resolve by 12months
Most will and gain weight

Question 15

What complications can occur from gastro-oesophageal reflux

Answer 15

Faltering growth
Oesophagitis
Aspiration 
Frequent otitis media 
Dental erosion

Question 16

How is gastro-oesophageal reflux managed?

Answer 16

Parental reassurance, safe guarding and feeding assessment.
Advice regarding position – 30-degree head-up
Sleep on their backs
Ensure infant not being overfed
Trial Feed thickeners
Trial Gastric acid suppression e.g. Gaviscon but not at same time as thickeners and no PPI or histamine receptor antagonists
Consider other diagnosis

If severe and failure to thrive then fundoplication – surgery

Question 17

What are the two most common risk factors for GOR?

Answer 17

Preterm delivery

Neurological disorders

Question 18

If vomiting is bilious what is the likely cause?

Answer 18

Intestinal obstruction

Question 19

If vomiting is projectile in a 3-6 week infant what is the likely cause?

Answer 19

Pyloric stenosis

Question 20

If vomiting contains blood what is the likely cause?

Answer 20

Oesophagitis, gastritis or peptic ulcer

Question 21

If vomiting is in the early morning what is the likely cause?

Answer 21

Raised intracranial pressure

Question 22

If vomiting is periodic what is the likely cause?

Answer 22

Inborn error of metabolism, cyclic vomiting syndrome

Question 23

If vomiting is prolonged what is the likely cause?

Answer 23

Prolonged (>12 hours in a neonate or >24 hours in children younger than 2 years or >48 hours in older children) – surgical abdomen, inborn error of metabolism or cyclic vomiting