Vomiting

1. Vomiting J. DeVito

2. Definition • Complex reflex behavioral response to variety of stimuli • 3 phases • Prodromal period—Nausea/autonomic sx’s • Retching • Forceful expulsion of stomach contents through oral cavity

3. Vomiting vs Regurgitation • Regurgitation—effortless reflux into esophagus • Not preceded by prodrome • No retching • Gastric contents are not forcibly expelled

4. No single “Vomiting center”

5. 3 Temporal Patterns • Acute-Most common • Chronic recurrent-70% of recurrent • Cyclic recurrent-30% of recurrent

6. Case • 3 week male • Previously feeding well • Increasing irritability x 3 days • Feeds decreasing over this time • Afebrile • Emesis, initially non bilious, progressing to bilious • + guiac stool

7. Malrotation with Volvulus—Note “corkscrew” in Proximal Jejunum

8. Malrotation w/o Volvulus

9. Acute • Moderate-severe acuity • +/- dehydration • Sx’s-fever/diarrhea • Recurrence rate—No • Stereotypy—Unique • **If child has had 3 similar episodes, consider cyclic pattern -Viral illness most common cause

10. DDx Acute Vomiting • Infectious • AGE-most common • OM-very common • Strep pharyngitis • Sinusitis • Hepatitis • Pyelo • Meningitis

11. DDx Acute Vomiting • GI • Inguinal Hernia • Intussusception • Malrotation w/ volvulus • Appy • Cholecystitis • Pancreatitis • Distal intestinal obstruction syndrome

12. DDx Acute Vomiting • GU-Pyelo, UPJ obstruction • Endocrine-DKA • Neuro-Concussion, subdural • Other-Toxic ingestion • Food poisoning

13. Evaluation of Acute Vomiting • Screening • CMP • UA • Definitive • Rota • Giardia • Abd rads • Surgical consult if necessary

14. Complications of acute vomiting • Dehydration w/ electrolye derangement • Usually resolves w/ IVF • Lose Gastric HCL, Pancreatic HCO3, GI NaCl • Hypochloremic/hypokalemic alkalosis—PS • Higher risk—AA, female,longer illness, more severe dehydration • Hematemesis from Prolapse gastropathy or MW tear • PG-repeated severe trauma from herniation of cardia through GE junction

15. Case • 10 yr female • Low grade vomiting, usually daily • Dysphagia • Wt loss • Complains of food stuck in chest, helps to sip fluids after to get bolus down • Wakes up coughing most mornings, often will vomit after

16. UGI -Air fluid level at thoracic inlet -Distal segment narrowing -Barium trickling into stomach

17. Achalasia

18. Chronic vs Cyclic Recurrent Chronic Recurrent Cyclic Recurrent 70% Not acutely ill/dehydrated 1-2 emesis/hr at peak >2 episodes per week No stereotypy Daytime onset Abd pain/diarrhea 15% FHx Migraines GI:Non GI, 7:1 30% Severe/dehydrated 6 emesis/hr at peak <2 episodes per week + sterotypy Early AM onset Pallor/leth/nausea/abd pain 80% FHx Migraines GI:Non GI, 1:5

19. Acute vs Chronic vs Cyclic

20. DDx Chronic Recurrent Vomiting • Infectious • H. Pylori-common • Giardiasis-common • Sinusitis-common

21. DDx Chronic Recurrent Vomiting • GI • Anatomic obstruction • GERD +/- esophagitis-common • EE-common • Gastritis-common • Duodenitis--common • Achalasia • SMA syndrome • GB dyskinesia

22. DDx Chronic Recurrent Vomiting • GU-Pyelo, Pregnancy, uremia • Endocrine-Adrenal Hyperplasia • Neuro-Arnold-Chiari Malformation, neoplasm • Other-Rumination, bulemia, psychogenic

23. Evaluation of Chronic Recurrent Vomiting • Screening • CBC • ESR • CMP • Amylase • GGT • UA • Giardia • Can start H2 blocker or PPi to proceed more definitive testing • Definitive • Endoscopy • Sinus CT • UGI/SBFT • Abd US

24. Case • 8 yr female • Severe vomiting starts in early morning, can last 2-3 days • Headache associated • Mild abd pain, no diarrhea, but appears ill to parents • Misses school a few days every month • 3 ER visits in last 6 weeks for IVF and antiemetics

25. DDx Cyclic Recurrent Vomiting • Infectious-Chronic sinusitis-common • GI-Malrotation w/ volvulus • GU-Acute hydronephrosis due to UPJ obstruction

26. Cyclic DDx Recurrent Vomiting • Endocrine • DKA • Addison’s • MCAD deficiency • Partial OTC deficiency • MELAS syndrome • Acute intermittent porphyria

27. Cyclic DDx Recurrent Vomiting • Neuro • Abdominal migraine • Migraines • Arnold-Chiari malformation • Neoplasm

28. Cyclic DDx Recurrent Vomiting • Other • Cyclic Vomiting Syndrome—common • Munchausen-by-proxy

29. Diagnosis Clues • Systemic manifestation • Temporal pattern • Daily • Postprandial • Diet relationship • Early Am • High intensity • Stereotypical • Rapid onset/resolve • Character of emesis • Bloody • Bilious • Effortless • projectile • Mucous • Undigested food • Clear/large volume • malodorous

30. Diagnosis Clues • GI • Nausea • Abd pain • Diarrhea • Constipation • Dysphagia • Visible peristalsis • Surgical scars • Bowel sounds • Severe tenderness/rebound • mass • Neuro • Headache • PND • Vertigo • SZ • Muscle tone • Fundoscopic exam FHX PUD-PUD/Hpylori Migraines-Abd migraine/CVS Contaminated water-parasites Travel

31. Cyclic Vomiting Syndrome • 2% of 5-15y in one study 1995 • Pattern is starting point for eval, the “Syndrome”—the idiopathic cases with negative diagnostic w/u • Some overlap with Abdominal Migraine • Functional GI d/o

32. Cyclic Vomiting Syndrome-Typical Patient • 5-8 yr female • Severe (15 episodes) once Q2-4 weeks • Normal between episodes • “cyclic” but only 50% have regular intervals • Start @ 0200-0700 • 1.5h prodrome • Last 24h • Require IVF 60% of time • 15 missed school days /yr

33. Cyclic Vomiting Syndrome-Typical Patient • Pallor/lethargy/anorexia/nausea/retching/abd pain—70% • Can identify stressor (birthday/holiday), illness (URI), or food 75% • Migraine sx’s (headaches, photophobia) ONLY 30% • Often resolves in teen yrs—replaced by migraine HA’s

34. CVS vs Abd Migraine CVS Abd Migraine Recurrent stereotypical VOMITING episodes hrs-days Pallor/leth/anorex/n/retching/abd pain FHX migraines Neg labs, rads, scopes Most respond to migraine therapy Recurrent stereotypical midline ABD PAIN >2h Pallor/leth/anorex/n/v FHx migraine Neg labs, rads, scopes Positive response to migraine therapy

35. CVS • Diagnosis of exclusion • TX-antiemetics, antimigraine meds, supportive therapy (D10 IVF to terminate ketosis) • Use Zofran (0.3 mg/kg, or 8 mg for older kids) onset of sx’s, rtc until improved • Amitriptyline QHS • <6y 10-30 mg/d • 6-12 50-100 mg/d • >12 100-200 Mg/d

36. CVS-other treatments • Low estrogen OCP’s—blunting estrogen decline in menstrual migraines in teens • May use abortive therapies (Triptans)

37. Evaluation of Cyclic Vomiting • Screening • Blood (During episode) • CBC • Glucose-DM elevated, FAO decreased • Lytes-Low Na Addisons, AG/low Bicarb-Organic acidemias • Liver/pancrease function • Ammonia-Urea cycle d/o • Lactate-mitochondriopathy • Carnitine-FAO • AA’s-aminoacidemias • Urine • UA-r/o infection/stone • Organic Acids-organic aciduria • d-ALA-FAO • Porphobilinogen-Acute intporphyria • carnitine

38. Evaluation of Cyclic Vomiting • UGI/SBFT-anatomic lesions • Endoscopy-mucosal inflammation • Sinus CT • Head MRI-subtentorial region • Abd US—esp to eval for hydronephrosis/UPJ obstruction, also GB/pancreatic/ovarian lesions • Definitive Metabolic testing

39. “You Can’t Really Dust For Vomit”