Vomiting in Childhood

Question 1

What are the different classes of vomiting (4)?

Answer 1

• vomiting with retching
• projectile vomiting
• bilious vomiting (red flag)
• effortless vomiting

Question 2

What are features of vomiting with retching?

Answer 2

• pre-ejection phase (pallor, nausea, tachycardia)
• ejection phase (retch, vomit)
• post-ejection phase (pale and limp)

Question 3

What can stimulate the vomiting centre?

Answer 3

• Enteric pathogens (tummy bug)
• Intestinal inflammation
• Metabolic derangement
• Infection anywhere in the body. E.g. meningitis, UTI, encephalitis, otitis media, chest infection, sepsis.
• Head injury (raised ICP)
• Visual stimuli
• Middle ear stimuli

Question 4

What is pyloric stenosis?

Answer 4

congenital narrowing of the pyloric sphincter

Question 5

How can pyloric stenosis present?

Answer 5

-young infant (4-12 weeks)
-non-bilious projectile vomiting (usually after feed)
-not gaining weight adequately
-dehydration
electrolyte disturbance (metabolic alkalosis, hypochloraemia, hypokalaemia)

Question 6

How can you diagnose pyloric stenosis?

Answer 6

• do test feed and see visible gastric peristalsis (‘olive tumour’)
• US detection of long, thickened pylorus
• ABG - alkalosis

Question 7

How can you manage pyloric stenosis?

Answer 7

• fluid resuscitation if dehydrated

- refer to surgeons (Ramstedts pyloromyotomy)

Question 8

What colour is bile?

Answer 8

GREEN!!! (not yellow)

Question 9

What is gastro-oesophageal reflux?

Answer 9

movement of gastric contents into oesophagus

Question 10

How does GORD present?

Answer 10

• infants
• effortless vomiting (almost always caused by GORD)
• may be haematemesis
• feeding problems
• FTT
• respiratory symptoms because of aspiration
• neurological (Sandifer’s syndrome - abnormal movement of body to try and alleviate discomfort from GORD)

Question 11

How should you assess a child you suspect to have GORD?

Answer 11

• history and examination often sufficient
• radiological investigations e.g. video fluoroscopy, barium swallow
• pH study combined with oesophageal impedance monitoring (gold standard)
• endoscopy (chid >2years or have symptoms of pain or difficulty swallowing)

Question 12

Why would we consider a barium swallow to identify GORD?

Answer 12

may show:

• dysmotility
• hiatus hernia
• reflux
• gastric emptying
• strictures

Question 13

What treatment can be offered for GORD?

Answer 13

• feeding advice - thicken the feed (as can help keep the feed down-may use gaviscon or ‘thick and easy’) and position baby at 45 degrees while feeding and prop up baby to sleep at 45 degrees
• nutritional support (some may require NG tube if continue to have large vomits), calorie supplements, exclusion diet (milk free) if not getting better
• medical treatment e.g. PPIs, H2 receptor blockers
• surgery - fundoplication

Question 14

What are indications for surgery for GORD?

Answer 14

• FTT
• aspiration pneumonia
• oesophagitis

Question 15

What can cause bilious vomiting?

Answer 15

• intestinal atresia (In newborn babies only)
• malrotation with or without volvulus
• intussusception (toddlers)
• ileus (older child)
• Crohn’s disease with strictures (older child)

Question 16

What investigations should be done in to bilious vomiting?

Answer 16

• surgical opinion!!!
• abdo. x-ray
• consider contrast meal

Question 17

What is ileus?

Answer 17

lack of movement somewhere in the intestines that leads to a buildup and potential blockage of food material. An ileus can lead to an intestinal obstruction. This means no food material, gas, or liquids can get through.

Question 18

What is intussusception?

Answer 18

condition in which a part of the intestine folds into the section next to it. It typically involves the small bowel and less commonly the large bowel. Symptoms include abdominal pain which may come and go, vomiting, abdominal bloating, and bloody stool.

Question 19

What is volvulus?

Answer 19

when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool.