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APPROACH TO VOMITING IN CHILDREN

APPROACH TO VOMITING IN CHILDREN. Maria Naval C. Rivas, M.D. Department of Pediatrics The Medical City. APPROACH TO VOMITING IN CHILDREN. VOMITING

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APPROACH TO VOMITING IN CHILDREN

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  1. APPROACH TO VOMITING IN CHILDREN Maria Naval C. Rivas, M.D. Department of Pediatrics The Medical City

  2. APPROACH TO VOMITING IN CHILDREN VOMITING - forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest wall musculature. This process is coordinated in the medullary vomiting center. NAUSEA - sensation of impending emesis and is frequently accompanied by autonomic changes, such as increased heart rate and salivation

  3. PATHOPHYSIOLOGY afferent neural pathways from digestive organs afferent neural pathways from non-digestive organs chemoreceptor trigger zone in the area postrema on the floor of 4th ventricle CNS centers (brainstem and vestibular systems) activation of the emetic center of the medulla

  4. ETIOLOGY • Infants / Neonates Acute viral gastroenteritis Gastroesophageal reflux disease Pyloric stenosis Intestinal obstruction (eg, meconium ileus, volvulus, intestinal atresia, stenosis) Intussusception (should be considered in an older infant ≥ 3 mo) Others: sepsis, food intolerance, metabolic disorders

  5. ETIOLOGY • Older Children Acute viral gastroenteritis Serious infections: meningitis, acute pyelonephritis Acute abdomen Increased intracranial pressure 2’ space-occupying lesion Cyclic vomiting

  6. CYCLIC VOMITING - syndrome with numerous episodes of vomiting interspersed with well intervals - onset: 3-5 years of age - duration of vomiting: 2-3 days - frequency: 4 or more episodes per hour - prodrome: nausea, lethargy, headache, fever - precipitants: stress and excitement - Idiopathic type: migraine variant - Tx: rectal antiemetics

  7. ETIOLOGY • Adolescents Acute viral gastroenteritis Pregnancy Eating disorders: Bulimia Toxic ingestions

  8. BULIMIA - defined in DSM-IV as: 1. recurrent episodes of binge eating 2. during the binges, a fear of not being able to stop eating 3. regularly engaging in self-induced vomiting, use of laxatives, rigorous dieting to counteract the effects of binge eating 4. minimum of 2 binge eatings per week for 3 mos. 5. self-evaluation is unduly influenced by body weight and shape - Tx: psychotherapy, behavior modification, nutritional rehabilitation, anti-depressants

  9. Toxic Ingestion Cholinergic Syndromes confusion GI cramping CNS depression vomiting weakness diaphoresis salivation muscle fasciculations lacrimation miosis urinary/fecal incontinence Causes: organophosphate & carbamate insecticides physostigmine, edrophonium, mushrooms

  10. EVALUATION OF A CHILD WITH VOMITING • Assessment of severity Presence of dehydration Surgical Life-threatening disorder • Identification of cause

  11. EVALUATION OF A CHILD WITH VOMITING History of Present Illness onset frequency character ( projectile, bilious, amount) pattern of vomiting ( after feeding? only with certain type of food? in the mornings? recurrent, cyclic episodes?) assoc s/sx (diarrhea, fever, abdominal pain)

  12. Review of Systems Metabolic disorder: failure to thrive, poor suck, weakness Intestinal obtsruction: delay in passage of meconium, abdominal distention, lethargy Intracranial disorder: headache, nuchal rigidity, vision change

  13. Review of Systems Eating disorder: food bingeing or signs of distorted body image Pregnancy: missed periods and breast swelling Rash: eczematous: food intolerance petechial: infection, CNS infection urticarial: food allergy Meningitis, Pyelonephritis or Appendicitis: fever with headache, back pain, or abdominal pain

  14. Past Medical History Acute Gastroenteritis: history of travel Intracranial Pathology: recent head trauma Pregnancy: unprotected intercourse

  15. DIAGNOSTIC APPROACH TO A CHILD WITH VOMITING Clinical Fecalysis Stool culture Empiric trial of acid suppression Esophageal & Upper GI contrast study

  16. Ultrasonography of pylorus Upper GI contrast study Abdominal x-ray Upper GI study or contrast enema

  17. Abdominal ultrasonography Rectal manometry Rectal biopsy Abdominal UTZ Contrast studies

  18. CBC blood, urine, CSF cultures Chest x-ray if pulmonary symptoms Elimination diet

  19. Ultrasonography Brain CT without contrast

  20. Consequences of vomiting 1. Metabolic: potassium deficiency alkalosis sodium depletion 2. Nutritional 3. Mechanical injuries to esophagus and stomach - Mallory Weiss, Boerhaave’s syndrome 4. Dental erosions and caries 5. Purpura

  21. Management 1. management of complications - fluid and electrolytes - nutrition - decompression 2. management of etiology - non-pharmaceutical - pharmaceutical - surgical

  22. THANK YOU

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