Self-limiting infections and food poisoning are the most common causes of acute vomiting.4 It is important to assess the degree of dehydration as accurately as possi- ble. Dehydration is classifi ed as mild (3–5% body weight loss), moderate (5–10%), and severe (⬎10%) based on signs and symptoms as outlined in Table 2–6. The four most useful clinical signs in assessing dehydration are general appearance, eyes, tears, and mucous mem- branes.5 Patients with moderate to severe dehydration may need intravenous fl uid replacement. Children pre- senting with vomiting accompanied by abdominal dis- tension, bilious vomiting, or severe abdominal pain need an abdominal X-ray series and prompt surgical consultation. In infants presenting with vomiting, sep- sis, urinary tract infections, meningitis, and child abuse all need to be considered in the differential diagnosis.
Hypertrophic pyloric stenosis commonly presents between 3 and 8 weeks of life with projectile, nonbilious emesis. An ultrasound of the pylorus demonstrates an elongated channel in an infant (Figure 2–3). In adoles- cents presenting with vomiting, pregnancy, drug abuse, and eating disorders need to be considered.
The location of abdominal pain may help to dif- ferentiate the potential causes of vomiting. The most common causes of epigastric pain associated with vom- iting are eosinophilic esophagitis (EoE), gastritis, and Helicobacter pylori associated with peptic ulcer disease.6 Sending the stool for H. pylori and a 2–4-week trial of proton pump inhibitors (PPI) may be helpful.7 If the symptoms persist, endoscopy may be warranted.
Esophageal furrows, edema, and white exudate are commonly seen in patients with EoE (see Figure 17–2).
Features Differentiating Vomiting from Regurgitation
Feature Regurgitation Vomiting
Event Effortless expulsion Forceful expulsion of gastric contents
Prodrome None Pallor, salivation, tachycardia + retching
Cause(s) Gastroesophageal refl ux, rumination Many disorders
Complications Uncommon Esophagitis, hematemesis
Implications Few Post-Nissen retching syndrome
Reproduced with permission from Kleinman, Goulet, Mieli-Vergani, Sanderson, Sherman, Shneider (eds): Walker’s Pediatric Gastrointestinal Disease, Fifth Edition, © 2008
Table 2–2.
Red Flags that Need Further Evaluation in Children with Vomiting Symptoms
Projectile Bilious Blood
Severe or persistent abdominal pain Headache, neck pain, weakness Polydipsia
Dysuria
Causes
Pyloric stenosis, gastric outlet obstruction, malrotation
Obstruction distal to the ampulla of Vater, cyclic vomiting syndrome Prolapse gastropathy, peptic injury, esophageal varices
Intussception, pancreatitis, peptic ulcer, cholelithiasis, appendicitis Space-occupying lesion, Chiari malformation, migraine
Diabetic ketoacidosis
Urinary tract infection, renal stones Signs
Bulging anterior fontanelle (infants) Nuchal rigidity
Papilledema
Hyperrefl exia or hypertonia
Meningitis, hydrocephalus, subdural hemorrhage (child abuse) Meningitis, intracranial hemorrhage
Increased intracranial pressure (pseudotumor cerebri) Metabolic problems, upper motor lesion
Table 2–4.
Differential Diagnosis of Vomiting by Age and Pathology
Gastrointestinal Tract Neonate Infant Childhood Adolescent
Luminal (within the lumen)
Gastroesophageal refl ux Esophageal atresia Antral web
Malrotation with volvulus Incarcerated inguinal hernia
Gastroesophageal refl ux Pyloric stenosis Intussception
Malrotation with volvulus Incarcerated inguinal
hernia
Malrotation with volvulus Intussception Incarcerated inguinal
hernia
Malrotation with volvulus
Superior mesenteric artery syndrome
Mucosal infl ammation (intestinal surface)
Gastroesophageal refl ux disease Formula protein allergy Necrotizing enterocolitis
Gastroesophageal refl ux disease
Formula protein allergy Gastroenteritis
Gastroenteritis Eosinophilic
esophagitis (EoE) H. pylori gastritis Peptic ulcer disease
Gastroenteritis EoE
Peptic ulcer disease Infl ammatory bowel
disease Appendicitis Muscle/nerve (GI wall) Achalasia
Hirschsprung’s disease Feeding intolerance (cardiac,
renal, pulmonary)
Pseudo-obstruction Gastroparesis Cyclic vomiting
syndrome (CVS)
Gastroparesis CVS
Rumination Irritable bowel
syndrome
Hepatobiliary/pancreas Hepatitis Hepatitis Hepatitis
Pancreatitis
Gallstones Pancreatitis Pancreas divisum Genitourinary system Sepsis/UTI UTI, hydronephrosis Hydronephrosis RTA Renal failure CNS/vestibular Posthemorrhagic
hydrocephalus Chiari malformation
Subdural hemorrhage (SDH)
Hydrocephalus
Space-occupying lesion (SOL) SDH
Chiari malformation
Bulimia/psychogenic Drug abuse Motion sickness Ménière’s disease Metabolic/endocrine Congenital adrenal hyperplasia
Inborn errors of metabolism (galactosemia, organic academia, urea cycle defects)
Addison’s disease Fatty acid oxidation
disorder
Addison’s disease DKA
Fatty acid oxidation disorder
Pregnancy Addison’s disease Porphyria Drug abuse Diabetes mellitus Abbreviations: UTI = urinary tract infection; EoE = eosinophilic esophagitis.
Table 2–3.
This is in contrast to distal esophageal erosions seen in patients with severe gastroesophageal refl ux disease (GERD). Patients with pancreatitis present with epigastric to left-quadrant abdominal pain radiating to the back. Right lower quadrant pain suggests appendici- tis or mesenteric lymphadenitis following a viral infec- tion. Intestinal obstruction presents with bilious emesis, cramping abdominal pain, abdominal distension, and hyperactive bowel sounds. A characteristic upper gas- trointestinal radiograph demonstrates malrotation, with absence of the ligament Treitz (duodenal–jejunal
junction) normally found to the left of the midline (Figure 2–4). Hirschsprung’s disease should be consid- ered in the differential diagnosis in infants presenting with vomiting, constipation, and abdominal distension, especially with a history of failure to pass meconium within 48 hours of birth. An unprepped barium enema showing the transition zone in an infant with Hirschsprung’s disease is shown in see Figure 19–6A. If the patient is well hydrated and there are no red fl ag symptoms as outlined in Table 2–4, patient can be safely discharged home. If the child presents with Differential Diagnosis, Approach, and Key Elements in History in Children with Vomiting
Differential Diagnosis Management
Pattern
Abrupt Gastroenteritis (fever, diarrhea, sick contacts) Pancreatitis (epigastric pain following URI, trauma) Cholelithiasis/hepatitis (RUQ pain radiating to back,
fever, jaundice—Murphy’s sign) Intestinal obstruction (bilious vomiting)
Stool rotazyme, culture and sensitivity, ova and parasites Amylase, lipase, CT abdomen ALT, GGT, ultrasound abdomen KUB, UGI, surgical consultation Contents
Bilious Malrotation with volvulus (abdominal distension, hyperactive bowel sounds)
Intussception
Hirschsprung’s (failure to pass meconium within 48 hours of birth)
KUB, surgical consultation Ultrasound abdomen
Unprepped barium enema, rectal biopsy, surgical consultation
Blood Prolapse gastropathy
Mallory–Weiss tear (heartburn) Gastritis (epigastric abdominal pain) H. pylori
EGD EGD EGD
Stool for H. pylori, EGD Undigested food Achalasia (nighttime coughing, dysphagia)
Gastroparesis (postviral, post-Nissen)
UGI, motility study Gastric emptying scan Timing
Early morning ↑ Intracranial pressure (SOL, SDH)—headache, blurred vision Sinusitis (postnasal drip)
Pregnancy (LMP)
Cyclic vomiting syndrome (stereotypical pattern, normal between episodes)
MRI/CT brain CT sinus HCG GI referral After starvation/illness
After meals
Inborn errors of metabolism (FTT, lethargy, seizures) Peptic ulcer (epigastric pain)
Gastroparesis
Eating disorder (food stashing) Rumination (within 1 hour of eating)
Metabolic specialist referral PPI trial for 2 weeks, EGD Gastric emptying scan Counseling
Diaphragmatic breathing Post-tussive
Weight loss
Asthma, allergy, foreign body
Superior mesenteric artery (SMA) syndrome Infl ammatory bowel disease
CXR, albuterol
UGI, nasojejunal feeding Endoscopy
Urinary symptoms Vertigo, tinnitus Previous surgery
UTI, hydronephrosis Vestibular disease Adhesions
Urine culture and ultrasound ENT referral
UGI/SBF, surgical consultation Abbreviations: ALT ⫽ alanine aminotransferase; GGT ⫽ gamma-glutamyl transpeptidase; SOL ⫽ space-occupying lesion; SDH ⫽ subdural hemorrhage;
FTT ⫽ failure to thrive; EGD ⫽ esophagogastroduodenoscoy; PPI ⫽ proton pump inhibitor.
Table 2–5.
moderate to severe abdominal pain, with or without jaundice, complete blood count (CBC), liver transami- nases, lipase, urinalysis, and imaging studies may be needed to rule out pancreatitis, cholelithiasis, and other causes of visceral pain. Acute episodes of cyclic vomit- ing syndrome (CVS) may mimic gastroenteritis, but CVS patients tend to look more ill, because of the asso- ciated severe pallor and lethargy that can mimic shock or semi-coma.