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

Approach to the Child
with Nausea and
Vomiting
by Dr.Ryan Al.Ghanemi
Introduction
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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.
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Vomiting:Forceful oral expulsion of gastric contents associated with contraction of
the abdominal and chest wall musculature.
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Regurgitation:The act by which food is brought back into the mouth without the
abdominal and diaphragmatic muscular activity that characterizes vomiting.
Introduction
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A standardized approach is not recommended because it may be caused by many
pathologic states involving several systems (including gastrointestinal, neurologic,
renal, and psychiatric).
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The best course of action should be dictated by the medical history.
Neurophysiology
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Nausea and vomiting are innate responses that induce a learned and conditioned
aversion to ingested toxins
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There are four major pathways by which nausea and vomiting are induced.
Vagal afferents
Area postrema
Vestibular system
Amygdala
Vagal Afferents
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Abdominal vagal afferents are involved in the emetic response.
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Can be evoked by either mechanical or chemo-sensory sensations.
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Examples of sensations that trigger this pathway include overdistension, food
poisoning, mucosal irritation, cytotoxic drugs, and radiation.
Area Postrema
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It’s a chemoreceptor trigger zone.
Anatomically, this region is located at the
caudal extremity of the floor of the fourth
ventricle.
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It’s a permeable blood-brain barrier region
in which systemic chemicals act to induce
emesis can reach
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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.
Vestibular System
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It involved in the emetic response to motion
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Exacerbated by visual sensations, Irritation or labyrinthine inflammation.
Somatomotor Events
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The diaphragm descends and the
intercostal muscles contract while the
glottis is closed.
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The abdominal muscles contract and the
gastric contents are forced into upper
gastric vault and lower esophagus.
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The abdominal muscle relaxes and the
esophageal refluxate empties back into
the gastric vault.
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Several cycles of retching, each more
rhythmical and forceful in nature, occur,
with shorter intervals in between.
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Abdominal contraction associated with
elevation of diaphragms results in forceful
expulsion of gastric contents.
Diagnosis by Age
Diagnosis by Age
Neonates & Young Infants
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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).
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The most frequent diagnostic considerations are gastroesophageal reflux, pyloric
stenosis, and intestinal obstruction.
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& it may be sepsis, excessive feeding volume, or increased intracranial
pressure.
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Although much less common, inborn errors of metabolism also can present with
vomiting.
Neonates & Young Infants
Gastroesophgeal Reflux
Disease
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Physiologic reflux in newborns and infants is common, and is characterized by
effortless regurgitation in an othewise healthy infant (a "happy spitter").
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A minority of infants who regurgitate have pathological gastroesophageal reflux.
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No features definitively identify these infants, but they may have recurrent fussiness
or irritability and feeding aversion.
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These symptoms are thought to result from pain caused by esophageal acid
exposure.
Gastroesophgeal Reflux
Disease
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Bradycardia or cyanotic episodes also may occur, particularly in preterm or
neurologically impaired infants.
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Poor weight gain despite an adequate intake of calories should prompt evaluation for
causes of vomiting and weight loss other than GERD.
Milk protein Induced
Enteritis
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Intolerance of dietary proteins (most commonly milk protein) typically manifest as
colitis, presenting with bloody stools.
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However, in some infants the dietary protein causes an enteritis, with or without
associated colitis, and affected infants may present with vomiting.
Intestinal Obstruction
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Causes of intestinal obstruction that present during early infancy include:
Malrotation with or without volvulus
Hirschsprung disease.
Intussusception
Intestinal atresia
Pyloric stenosis
Intestinal Obstruction
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Intestinal obstruction frequently causes bile staining in the vomitus.
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Bile-stained vomitus should be treated as a life-threatening emergency, although it
can be seen occasionally in infants without bowel obstruction.
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Vomiting that is not bile-stained may be caused by proximal obstruction, such as
pyloric stenosis, upper duodenal stenosis, gastric volvulus, or annular pancreas.
Intestinal Obstruction
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If intestinal obstruction is suspected, the specific diagnosis often can be suggested by
the patient's history and with appropriate radiologic imaging.
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Plain radiographs of the abdomen generally provide a rapid assessment of possible
bowel obstruction with relatively little radiation exposure.
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Abdominal ultrasound provides high sensitivity and specificity for detecting
intussusception.
Pyloric Stenosis
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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.
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It occurs in approximately 3 in 1,000 live births.
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More commonly in males (4:1 to 6:1).
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Approximately 30 percent of cases occur in firstborn children.
Pyloric Stenosis
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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").
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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.
Pyloric Stenosis
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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.
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The diagnosis is made by ultrasound
examination of the abdomen.
Hirschsprung Disease
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Usualy diagnosed in the neonatal
period.
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Patients present with symptoms of
distal intestinal obstruction: bilious
emesis, abdominal distension, and
failure to pass stool.
Hirschsprung Disease
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The diagnosis can be suggested by a
delay in passage of the first
meconium (greater than 48 hours of
age).
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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.
Older Infants & Children
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By far, the most common is gastroenteritis.
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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.
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Adrenal crisis and anaphylaxis should be considered in children with disproportionate
hypotension and/or predisposing factors.
Older Infants & Children
Gasteroparesis
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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.
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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.
Gasteroparesis
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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, pseudoobstruction and muscular dystrophy
Viral illness (postviral gastroparesis)
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In most cases, the symptoms resolve spontaneously within 6 to 24 months.
Intussusception
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It is the most common cause of intestinal obstruction in infants between 6 and 36
months of age.
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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.
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The episodes become more frequent and more severe over time.
Intussusception
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Vomiting may follow episodes of
abdominal pain. Initially emesis is
non-bilious, but it may become
bilious as the obstruction progresses.
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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.
Intussusception
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In up to 70 percent of cases, the stool
contains gross or occult blood.
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In infants, intussusception may present as
lethargy, with or without vomiting or rectal
bleeding.
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In young infants, intussusception is more often
caused by a pathological lead point, such as
Meckel diverticulum or a duplication cyst.
Infections
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Pharyngitis (particularly streptococcal pharyngitis).
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Urinary tract infections frequently present with nausea and/or vomiting.
Intracranial Hypertension
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Brain tumors and other intracranial masses can cause nausea, vomiting, or both, by
increasing the intracranial pressure at the area postrema of the medulla.
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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 headache or focal neurologic deficit; these signs and symptoms
may be subtle.
Intracranial Hypertension
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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.
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The clinical manifestations of idiopathic intracranial hypertension vary with age.
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Younger children, for example, who cannot complain of headache or visual
impairment, may present with irritability, sleep, or behavior disturbance.
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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.
Munchausen Syndrome by
Proxy
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Also known as factitious disorder by proxy, Meadow syndrome, and proxy factitia
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It’s consists of fabricating or inducing illness in a child in order to get attention.
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The patient may have a history of frequent recurrent illnesses without a clear etiology
Adolescents
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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.
Clinical Approach
Clinical Approach
Clinical Approach
Clinical Approach
Clinical Approach
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A detailed history and astute clinical acumen are necessary to narrow down the
diagnostic possibilities.
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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.
Clinical Approach
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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.
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
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
Laboratory Investigations
Referrals
• When to refer the patient?
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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.
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These include an abnormal neurologic exam, peritoneal signs on abdominal
examination, severe abdominal pain, gastrointestinal bleeding, or significant
weight loss.
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Immediate pediatric surgical consultation is warranted if appendicitis, bowel
obstruction, or bowel perforation are suspected.
Treatment
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Treatment should be directed toward the underlying etiology.
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Electrolyte abnormalities, metabolic abnormalities, or nutritional deficiencies should
be corrected.
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Cognitive-behavioral interventions are useful for vomiting associated with functional
dyspepsia, adolescent rumination syndrome, and bulimia.
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Prokinetic medications such as metoclopramide, domperidone (where available), and
erythromycin are beneficial when there are abnormalities in esophago-gastric motility.
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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 .
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Likewise, they are not indicated for anatomic abnormalities or surgical abdomen.
Treatment
Clinical Approach
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Instead, antiemetics are most useful for motion sickness, postoperative vomiting,
cyclic vomiting syndrome, and gastrointestinal motility disorders .
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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.
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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.
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These include neurokinin 1 receptor antagonists that likely mediate nausea and
vomiting triggered by chemotherapeutic agents, motion, gastric irritants, and other
stimuli .
Alternative Medicine
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There is some evidence for efficacy of some nutraceuticals, such as ginger for
functional dyspepsia and other motility disorders.
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Hypnotherapy is often helpful for treatment of anticipatory nausea and vomiting (eg,
prior to chemotherapy).
THANKS A LOT!
DR. Ryan Al.Ghanemi