Approach to the Child with Nausea and Vomiting

1. Approach to the Child with Nausea and Vomiting by Dr.Ryan Al.Ghanemi

2. Introduction • Nausea: The unpleasant sensation of the imminent need to vomit, usually referred to the throat or epigastrium; a sensation that may or may not ultimately lead to the act of vomiting. • Vomiting:Forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest wall musculature. • Regurgitation:The act by which food is brought back into the mouth without the abdominal and diaphragmatic muscular activity that characterizes vomiting.

3. Introduction • A standardized approach is not recommended because it may be caused by many pathologic states involving several systems (including gastrointestinal, neurologic, renal, and psychiatric). • The best course of action should be dictated by the medical history.

4. Neurophysiology • Nausea and vomiting are innate responses that induce a learned and conditioned aversion to ingested toxins • There are four major pathways by which nausea and vomiting are induced. • Vagal afferents • Area postrema • Vestibular system • Amygdala

5. Vagal Afferents • Abdominal vagal afferents are involved in the emetic response. • Can be evoked by either mechanical or chemo-sensory sensations. • Examples of sensations that trigger this pathway include overdistension, food poisoning, mucosal irritation, cytotoxic drugs, and radiation.

6. Area Postrema • It’s a chemoreceptor trigger zone. Anatomically, this region is located at the caudal extremity of the floor of the fourth ventricle. • It’s a permeable blood-brain barrier region in which systemic chemicals act to induce emesis can reach • This area contains receptors for neuroactive compounds such as dopamine, morphine, acetylcholine, endorphin, and many others A diagram summarizing the pathways involved in emesis. Rache: Nucleus Rache, AP: area postrema, IV: 4 th ventricle, 5-HT: 5-hydroxytryptamine (serotonin), EC: enterochromaffin cell, GI: gastrointestinal.

7. Vestibular System • It involved in the emetic response to motion • Exacerbated by visual sensations, Irritation or labyrinthine inflammation.

8. Somatomotor Events • The diaphragm descends and the intercostal muscles contract while the glottis is closed. • The abdominal muscles contract and the gastric contents are forced into upper gastric vault and lower esophagus. • The abdominal muscle relaxes and the esophageal refluxate empties back into the gastric vault. • Several cycles of retching, each more rhythmical and forceful in nature, occur, with shorter intervals in between. • Abdominal contraction associated with elevation of diaphragms results in forceful expulsion of gastric contents.

9. Diagnosis by Age

10. Diagnosis by Age

11. Neonates & Young Infants • Forceful and repeated vomiting in newborns is not normal and should be taken seriously, particularly if there are other signs of illness (eg, fever, weight loss, or feeding refusal). • The most frequent diagnostic considerations are gastroesophageal reflux, pyloric stenosis, and intestinal obstruction. • & it may be sepsis, excessive feeding volume, or increased intracranial pressure. • Although much less common, inborn errors of metabolism also can present with vomiting.

12. Neonates & Young Infants

13. Gastroesophgeal Reflux Disease • Physiologic reflux in newborns and infants is common, and is characterized by effortless regurgitation in an othewise healthy infant (a "happy spitter"). • A minority of infants who regurgitate have pathological gastroesophageal reflux. • No features definitively identify these infants, but they may have recurrent fussiness or irritability and feeding aversion. • These symptoms are thought to result from pain caused by esophageal acid exposure.

14. Gastroesophgeal Reflux Disease • Bradycardia or cyanotic episodes also may occur, particularly in preterm or neurologically impaired infants. • Poor weight gain despite an adequate intake of calories should prompt evaluation for causes of vomiting and weight loss other than GERD.

15. Milk protein Induced Enteritis • Intolerance of dietary proteins (most commonly milk protein) typically manifest as colitis, presenting with bloody stools. • However, in some infants the dietary protein causes an enteritis, with or without associated colitis, and affected infants may present with vomiting.

16. Intestinal Obstruction • Causes of intestinal obstruction that present during early infancy include: • Malrotation with or without volvulus • Hirschsprung disease. • Intussusception • Intestinal atresia • Pyloric stenosis

17. Intestinal Obstruction • Intestinal obstruction frequently causes bile staining in the vomitus. • Bile-stained vomitus should be treated as a life-threatening emergency, although it can be seen occasionally in infants without bowel obstruction. • Vomiting that is not bile-stained may be caused by proximal obstruction, such as pyloric stenosis, upper duodenal stenosis, gastric volvulus, or annular pancreas.

18. Intestinal Obstruction • If intestinal obstruction is suspected, the specific diagnosis often can be suggested by the patient's history and with appropriate radiologic imaging. • Plain radiographs of the abdomen generally provide a rapid assessment of possible bowel obstruction with relatively little radiation exposure. • Abdominal ultrasound provides high sensitivity and specificity for detecting intussusception.

19. Pyloric Stenosis • Infantile hypertrophic pyloric stenosis (IHPS) is a condition of hypertrophy of the pylorus, with elongation and thickening, eventually progressing to near-complete obstruction, of the gastric outlet. • It occurs in approximately 3 in 1,000 live births. • More commonly in males (4:1 to 6:1). • Approximately 30 percent of cases occur in firstborn children.

20. Pyloric Stenosis • The classic presentation of IHPS is the three- to six-week-old baby who develops immediate postprandial, non-bilious, often projectile vomiting and demands to be re-fed soon afterwards(a "hungry vomiter"). • In the past, patients were classically described as being emaciated and dehydrated with a palpable "olive-like" mass at the lateral edge of the rectus abdominus muscle in the right upper quadrant of the abdomen.

21. Pyloric Stenosis • Laboratory evaluation classically showed a hypochloremic, metabolic alkalosis resulting from the loss of large amounts of gastric hydrochloric acid, the severity of which depended upon the duration of symptoms prior to initial evaluation. • The diagnosis is made by ultrasound examination of the abdomen.

22. Hirschsprung Disease • Usualy diagnosed in the neonatal period. • Patients present with symptoms of distal intestinal obstruction: bilious emesis, abdominal distension, and failure to pass stool.

23. Hirschsprung Disease • The diagnosis can be suggested by a delay in passage of the first meconium (greater than 48 hours of age). • Affected children may also present initially with enterocolitis, a potentially life threatening illness in which patients have a sepsis-like picture with fever, vomiting, diarrhea, and abdominal distension, which can progress to toxic megacolon.

24. Older Infants & Children • By far, the most common is gastroenteritis. • However, GERD, gastroparesis, mechanical obstruction, anaphylaxis, Munchausen syndrome by proxy (factitious disorder by proxy), intracranial masses, peptic ulcer disease, and cyclic vomiting also may be diagnostic considerations. • Adrenal crisis and anaphylaxis should be considered in children with disproportionate hypotension and/or predisposing factors.

25. Older Infants & Children

26. Gasteroparesis • It is the condition of impaired emptying of gastric contents into the duodenum in the absence of a mechanical obstruction; this may cause postprandial vomiting. • In gastroparesis the vomiting usually occurs many hours after ingestion of food, a characteristic that differentiates this entity from GER or rumination syndrome, in which the emesis is during or immediately after eating.

27. Gasteroparesis • The following conditions may cause gastroparesis: • Surgery with vagus nerve damage (eg, fundoplication) • Use of drugs such as opioids or anticholinergics • Metabolic disturbances such as hypokalemia, acidosis, or hypothyroidism • Eosinophilic gastroenteropathy • Neuromuscular disorders such as cerebral palsy, diabetes mellitus, pseudo-obstruction and muscular dystrophy • Viral illness (postviral gastroparesis) • In most cases, the symptoms resolve spontaneously within 6 to 24 months.

28. Intussusception • It is the most common cause of intestinal obstruction in infants between 6 and 36 months of age. • typically patients develop the sudden onset of intermittent, severe, crampy, progressive abdominal pain, accompanied by inconsolable crying and drawing up of the legs toward the abdomen. • The episodes become more frequent and more severe over time.

29. Intussusception • Vomiting may follow episodes of abdominal pain. Initially emesis is non-bilious, but it may become bilious as the obstruction progresses. • A sausage-shaped abdominal mass may be felt in the right side of abdomen. As symptoms progress, increasing lethargy develops, which can be mistaken for meningoencephalitis.

30. Intussusception • In up to 70 percent of cases, the stool contains gross or occult blood. • In infants, intussusception may present as lethargy, with or without vomiting or rectal bleeding. • In young infants, intussusception is more often caused by a pathological lead point, such as Meckel diverticulum or a duplication cyst.

31. Infections • Pharyngitis (particularly streptococcal pharyngitis). • Urinary tract infections frequently present with nausea and/or vomiting.

32. Intracranial Hypertension • Brain tumors and other intracranial masses can cause nausea, vomiting, or both, by increasing the intracranial pressure at the area postrema of the medulla. • Several characteristics suggest tumor-associated emesis, such as triggering emesis by an abrupt change in body position, neurogenic nausea and other neurologic symptoms such as headacheorfocal neurologic deficit; these signs and symptoms may be subtle.

33. Intracranial Hypertension • Idiopathic intracranial hypertension refers to increased intracranial pressure (ICP) with normal cerebrospinal fluid (CSF) content, normal neuroimaging, the absence of neurologic signs except cranial nerve VI palsy, and no known cause. • The clinical manifestations of idiopathic intracranial hypertension vary with age. • Younger children, for example, who cannot complain of headache or visualimpairment, may present with irritability, sleep, or behavior disturbance. • In older children, headache is a more common chief complaint in older children and frequently is described as being pulsatile, occasionally awakening the child from sleep. Associated nausea or vomiting may be present, as may neck or retroocular pain that is worse with eye movement.

34. Munchausen Syndrome by Proxy • Also known as factitious disorder by proxy, Meadow syndrome, and proxy factitia • It’s consists of fabricating or inducing illness in a child in order to get attention. • The patient may have a history of frequent recurrent illnesses without a clear etiology

35. Adolescents • In addition to the disorders affecting children listed above, some of the more common causes include gastroenteritis, appendicitis, inflammatory bowel disease, pregnancy, and toxic ingestions.

36. Clinical Approach

37. Clinical Approach

38. Clinical Approach

39. Clinical Approach

40. Clinical Approach • A detailed history and astute clinical acumen are necessary to narrow down the diagnostic possibilities. • The appropriate urgency depends on duration of illness, overall clinical status of the patient (especially hydration, circulatory, and neurologic status) and associated findings on the physical examination and history.

41. Clinical Approach • Prolonged vomiting (>12 hours in a neonate, >24 hours in children younger than two years of age, or >48 hours in older children) should not be ignored. Screening laboratory tests should include: Additional testing should be based upon the history and physical examination • complete blood count • electrolytes, • blood urea nitrogen, • amylase, lipase, • liver function tests, • urinalysis, urine culture, and stool studies for occult blood, leukocytes, and parasites.

42. Clinical Approach Clues on physical examination — Certain physical findings may offer diagnostic clues that can aid in narrowing the differential diagnosis: • A tense, bulging fontanelle in a neonate or young infant should increase the level of suspicion for meningitis. • Projectile vomiting in an infant three to six weeks of age suggests pyloric stenosis as a diagnosis. • Ambiguous genitalia and/or hyperkalemia suggest the possibility of adrenal crisis (usually due to congenital adrenal hyperplasia),. • Headache, positional triggers for vomiting, lack of nausea, and/or vomiting on awakening should suggest the possibility of intracranial hypertension

43. Clinical Approach • An unusual odor emanating from the patient should prompt an investigation for metabolic causes of vomiting. • Marked distension, visible bowel loops, absent bowel sounds, green or yellow bile, or increased "rumbling" bowel sounds ("borborygmi") should raise suspicion for intestinal obstruction. • Enlarged parotid glands in an adolescent should raise suspicion for bulimia • Vomiting in association with trauma should prompt imaging studies to rule out intracranial or intraabdominal injury. • Hypotension disproportionate to the apparent illness and/or hyperkalemia suggests the possibility of adrenal crisis

44. Laboratory Investigations

45. Referrals • When to refer the patient? • Patients should be referred to a pediatric gastroenterologist or other appropriate specialist (eg, pediatric surgeon, neurologist) when there are symptoms or physical findings that are of particular concern. • These include an abnormal neurologic exam, peritoneal signs on abdominal examination, severe abdominal pain, gastrointestinal bleeding, or significant weight loss. • Immediate pediatric surgical consultation is warranted if appendicitis, bowel obstruction, or bowel perforation are suspected.

46. Treatment • Treatment should be directed toward the underlying etiology. • Electrolyte abnormalities, metabolic abnormalities, or nutritional deficiencies should be corrected. • Cognitive-behavioral interventions are useful for vomiting associated with functional dyspepsia, adolescent rumination syndrome, and bulimia. • Prokinetic medications such as metoclopramide, domperidone (where available), and erythromycin are beneficial when there are abnormalities in esophago-gastric motility. • Antiemetics, which are useful in persistent vomiting to avoid electrolyte abnormalities or nutritional sequelae, typically have not been recommended in the case of vomiting of unknown etiology. These agents are contraindicated in infants . • Likewise, they are not indicated for anatomic abnormalities or surgical abdomen.

47. Treatment

48. Clinical Approach • Instead, antiemetics are most useful for motion sickness, postoperative vomiting, cyclic vomiting syndrome, and gastrointestinal motility disorders . • In addition, a double-blind study suggests that single dose ondansetron may facilitate oral rehydration in children with gastroenteritis who are unable to tolerate oral intake. • During the last two decades, there have been considerable advances in the development of antiemetics. These include the emergence of 5-hydroxytryptamine 3 receptor antagonists (Ondansetron, Granisetron), which have one primary site of antagonism and have helped in the treatment of post-operative nausea and vomiting and chemotherapy-associated emesis. • These include neurokinin 1 receptor antagonists that likely mediate nausea and vomiting triggered by chemotherapeutic agents, motion, gastric irritants, and other stimuli .

49. Alternative Medicine • There is some evidence for efficacy of some nutraceuticals, such as ginger for functional dyspepsia and other motility disorders. • Hypnotherapy is often helpful for treatment of anticipatory nausea and vomiting (eg, prior to chemotherapy).

50. THANKS A LOT! DR. Ryan Al.Ghanemi