Vomiting (Pediatric patient)

Vomiting is a reflex resulting in emptying of the stomach contents through the mouth, accompanied by contraction of the abdominal muscles and diaphragm. It is an important defensive reflex that protects the body from the effects of some potential toxins. Vomiting itself can be preceded by nausea , which is a subjectively perceived feeling of discomfort, sometimes becoming very intense. There are gastrointestinal and also non-gastrointestinal causes of vomiting. It is important to recognize early warning signs that indicate the need for urgent intervention (eg, the presence of blood or bile in the vomit, abdominal distension, headache, abnormal neurological findings, etc.).

Differential diagnosis of vomiting in children

Acute vomiting

• Acute abdomen (general alteration of the condition, abnormal finding on the abdomen, signs of peritoneal irritation):
  • GIT obstruction (vomiting, possibly biliary vomiting, gas and stool arrest, general alteration, abdominal distension), appendicitis, renal or biliary colic, invagination, volvulus.
• Acute gastroenteritis (vomiting + diarrhea + fever + spread of the infection);
• Infections – sepsis, pyelonephritis, otitis, sinusitis, pneumonia etc. (fever);
• Pankreatitis (vomiting + acute abdominal pain);
• food poisoning, intoxication (anamnesis);
• type 1 diabetes mellitus (polyuria, polydypsy, Kussmaul breathing, glucosuria, high ketone levels in urine);
• central cause – acute meningoencephalitis, bleeding etc. (impaired consciousness, headache, fever, petechiae);
• drug side effects (some antibiotics).

Repeated vomiting in newborns and infants

• pylorostenosis (arc-shaped vomiting in an infant up to 6 weeks of age, general alteration of the condition);
• Congenital adrenal hyperplasia (hyponatremia, hyperkalemia, hypoglycemia, virilization of the external genitalia in girls);
• GIT obstruction – meconium ileus, volvulus, invagination, malrotation, Hirschprung's disease (ileus, gas and stool arrest, general alteration, abdominal distension);
• neurological causes, metabolic defects, etc. (apathy, prolonged jaundice, perinatal risk history, abnormal neurological findings);
• constipation;
• cows' milk allergy;
• slight vomiting – Gastroesophageal reflux disease (GERD).

Repeated vomiting in toddlers and older children

• cyclic vomiting or acetonemic vomiting (episodes of high-intensity profuse vomiting and resting period, pallor, flush, fever, lethargy, salivation, diarrhea, family or personal history of migraine);
• central cause (delayed psychomotor development, myopathy, anisocoria, hypotension, hypertension, risk perinatal history);
• type 1 diabetes mellitus
• congenital adrenal hyperplasia;
• metabolic causes – aminoaciduria, organic aciduria, hypercalcemia, renal insufficiency;
• chronic inflammatory bowel disease (abdominal pain, diarrhea);
• severe constipation;
• medications (antiepileptics, digoxin, cytostatics, vitamin A intoxication);
• pregnancy;
• eating disorders;
• rarely celiac disease, cows' milk allergy, lactose intolerance.

Hematemesis

• in breastfed children ragade on the mother's breast;
• gastroenteritis, bad diet (repeated vomiting and blood only in the last portions of vomiting);
• nose bleeding;
• chronic lung disease, chronic cough (coughing up blood);
• colored stomach contents by eating / drinking red foods / beverages;
• reflux esophagitis (burning behind the sternum, heartburn);
• foreign object swallowing, dysphagia;
• gastroduodenal ulcer, H. pylori infection (epigastric or periumbilical pain, often food-related, non-steroidal anti-inflammatory drugs);
• portal hypertension, bleeding from esophageal varices (liver disease, splenomegaly, anemia, leukopenia, thrombocytopenia);
• prehepatic portal hypertension based on thrombosis of the portal vein, bleeding from esophageal varices (history of navel cannulation).

Differential diagnosis of vomiting according to the age of the child

Newborns and infants

• gastroenteritis
• Gastroesophageal reflux disease (GERD), overfeeding, aerophagia,
• GIT obstruction: pylorostenosis, meconium ileus, volvulus, Malrotation, Hirschprung's disease,
• sepsis, otitis media, pertussis syndrome ,
• rarely: CAH, metabolic defect, tumor, intracranial hypertension, subdural hemorrhage, alimentary intoxication, rumination, renal tubular acidosis, withdrawal syndrome (child of a drug addicted mother).

Older children

• gastroenteritis, gastritis,
• systemic infection, sinusitis, otitis media, pertussis syndrome,
• poisoning,
• medication,
• food intolerance, celiac disease,
• rarely: Reye's syndrome, peptic ulcer, GERD, pancreatitis, CNS tumor, intracranial hypertension, chemotherapy, achalasia, cyclic vomiting, esophageal stricture, metabolic defect, diabetic ketoacidosis, GIT obstruction.

Teenagers

• gastroenteritis, infection, poisoning, gastritis, sinusitis, IBD, appendicitis, migraine, pregnancy, medication, bulimia, psychogenic vomiting
• rarely: Reye's syndrome, hepatitis, peptic ulcer, GERD, pancreatitis, CNS tumor, intracranial hypertension, chemotherapy, cyclic vomiting, gallbladder colic, renal colic, DKA, GIT obstruction.

Differential diagnosis of vomiting according to pathophysiology

• supramedular stimulation - psychogenic vomiting,
  • CNS hypertension,
  • seizures (children have a lower threshold for seizures),
  • vestibular (kinetosis) - to small children we can give anise candy, anise tea (Kinedryl should not be given to infants!),
• chemoreceptor stimulation,
  • drugs, toxins ( digoxin , ipeca, anticonvulsants , opiates ),
  • metabolic products - diabetes mellitus , Lactacidosis , PKU , renal tubular acidosis , tyrosinemia , hypervalinémie , lysinurie , hyperglycinemia , maple syrup disease , methylmalonic aciduria (most) propionic aciduria , Reye's syndrome , defects of urease cycle , uremia , fructose intolerance , galactosemia , Diabetes insipidus , adrenal insufficiency ,hypercalcemia ,
• peripheral receptor stimulation or GIT obstruction,
  • pharynx – vomiting reflex,
  • esophagus – reflux, achalasia, dysmotility, atresia,
  • stomach – peptic lesion, pylorostenosis,
  • hepatitis, cholecystitis,
  • cardiac ischemia.

Examination

• FW, CRP, blood count;
• serum levels of sodium, potassium, chloride, calcium, urea, creatinine, glycaemia, hepatic transaminases, amylase;
• acid-base balance;
• chemical and microscopic examination of urine, including cultivation;
• parasitological and culture examination of stool;
• toxicological screening (especially in older children);
• metabolic testing (especially in hypoglycaemia) to rule out fatty acid beta-oxidation disorder (MCAD deficiency).
• Abdominal ultrasound (especially imaging of the kidneys, liver, pancreas and gallbladder) event. X-ray native abdominal image.

• Screening for inherited metabolic disorders: plasma levels of ammonia and lactate, possibly determination of organic aminoaciduria and the spectrum of amino acids, pyruvate and carnitine in serum.
• In postmenarcheal girls, hCG-s examination.
• X-ray contrast examination: swallowing act and passage of the GIT with a contrast agent.
• ORL, psychological and neurological examination, if necessary, X-ray or CT of the paranasal sinuses, CT or better MRI of the brain to rule out extraintestinal causes of vomiting.

• Examination of celiac disease (EMA, AGA, AGG, aTTG),
• non-specific intestinal inflammations (ANCA, ASCA antibodies, intestinal USG, enteroclysis),
• porphyria (δ-ALA, porphobilinogen),
• endocrine active tumors (urinary catecholamines, vanillic acid and homovanillic acid),
• endocrinopathies (plasma cortisol and other hormones).
• Upper GIT fibroscopy combined with biopsy and sampling for Helicobacter pylori or enterobiopsy.
• Gastrointestinal motility studies, abdominal CT examination, vestibular apparatus examination, audiological examination, VEP - visual evoked potentials (children with periodic syndrome and children with other types of headache can be distinguished).

Slight vomiting

• =leaking small amounts of food from the mouth, manifestation of esophageal reflux,
• in infants it is very common, usually it does not negatively affect well-being (happy spitter),
• it is considered to be normal and disappears within 12-18 months.

Rumination

• =regurgitation of a small amount of food from the stomach to the mouth, the food is chewed again and swallowed again with a feeling of satisfaction,
• it is usually caused by manipulation of the fingers in the mouth or movements of the tongue,
• it is rare in neuropathic and mentally handicapped children.

Gastroesophageal reflux disease

• = regurgitation of gastric contents into the esophagus,
• if pyloric reflux is added, pancreatic juice and bile can also be regurgitated in the esophagus,
• gastroesophageal reflux disease (GERD) can be acidic or basic,
• it is to some extent a physiological phenomenon that recedes with age
  • in infants it manifests as or vomiting,
  • in older children such as heartburn,
• 60% of children regulate GER spontaneously within 18 months, 30% have manifestations of GER within 4 years,
• if left untreated, about 10% can have various complications.

True vomiting

• =strenuous emptying of most of the stomach contents at one time,
• Ask about:
  • character
  • whether or not it is preceded by nausea (cerebral vomiting),
  • whether it starts immediately after a meal or not
• previous susceptibility to vomiting, amount of vomiting, odor (intoxication, acetone),
• bile admixture indicates duodenogastric reflux,
• vomiting is a common manifestation of various diseases,
• it is often accompanied by acidosis and ketonemia from lipolysis,
• causes - in the GIT: malformations and obstruction ( hiatal hernia , pylorostenosis , volvulus , atresia , meconium ileus , Hirschprung's disease , peptic ulcer …),
  • food allergy (cow's milk protein allergy, celiac disease , other),
  • functional and psychogenic disorders ( pylorospasm , rumination , acetonemic vomiting , anorexia nervosa , bulimia ),
  • infections: gastroenteritis, food poisoning, stomatitis, urinary tract infections (incl. hydronephrosis ), respiratory infections (including otitis), appendicitis.
  • neurological diseases: meningitis, encephalitis, intracranial birth trauma, migraine , kinetosis ,
  • intracranial hypertension: hydrocephalus , subdural hematoma , tumors,
  • toxic and metabolic causes: adrenal hyperplasia (arcuate), PCU , galactosemia , hypercalcemia , uremia, drugs, DM…,
  • liver disease: hepatitis, Reye's syndrome ,
  • cardiac failure,
• laboratory examination:
  • urine – chemically and sediment,
  • blood – sodium , potassium , chlorides , calcium , phosphorus , ABB, glycemia , amylase , urea , creatinine , liver tests , ammonia ,
  • x-ray - native image of the abdomen,
  • endoscopy - gastroscopy (especially in hematemesis),
  • psychological examination - after excluding an organic cause, with signs of behavioral disorders, with anorexia.

Cyclic vomiting syndrome (acetonemic vomiting)

• characterized by variously frequent attacks of repeated vomiting (on average there is one attack per month, the episode lasts on average 24 hours);
• episodes are of varying severity and may cause rapid dehydration, hypoglycaemia, ionic imbalance and metabolic acidosis, especially in young children;
• episodes are usually stereotyped in terms of onset, course, duration and intensity
• mainly affects children (most often between the ages of 2 and 7);
• the etiopathogenesis remains unclear (the relationship with migraine and adrenergic autonomic dysfunction is often discussed);
• course: low carbohydrates → glycogen depletion → lipolysis → acidosis and ketosis;
• diagnosis by exclusion after exclusion of organic causes.

According to the Roman Criteria II, it is a functional disorder of the GI tract defined by the occurrence of three or more episodes of intense sudden nausea and repeated vomiting, which last for hours to days, there are completely asymptomatic intervals lasting weeks to months between episodes. At the same time, no metabolic, neurological or GI diseases of a structural or biochemical nature are present (Rasquin-Weber A, Hyman PE, Cucchiara S, et al. Childhood functional gastrointestinal disorders. Gut, 1999, 45, Suppl. II, pp. II60 – II68. ).

• Prophylaxis (prevention of further episodes): elimination of triggering factors, ev. long-term medication with antimigraine drugs, neuroleptics, prokinetics, antiepileptics, beta-blockers.
• Abortive therapy in the prodromal phase: regimen measures (calm, silence, gloom, sleep, paracetamol analgesia for headache or abdominal pain or benzodiazepines to relieve anxiety and nausea), prokinetics, antiemetics.
• Symptomatic treatment: oral replacement of water, glucose and ions, ev. parenteral rehydration with correction of ion losses (solutions with glucose, sodium and potassium).

Links

• BENEŠ, Jiří. Studijní materiály [online]. ©-. [cit. 10.07.2009]. <http://jirben.wz.cz>.

Bibliography

• HRODEK, Otto – VAVŘINEC, Jan. Pediatrie. 1. edition. Praha : Galén, 2002. - pp. ISBN 80-7262-178-5.

• ŠAŠINKA, Miroslav – ŠAGÁT, Tibor – KOVÁCS, László. Pediatria. 2. edition. Bratislava : Herba, 2007. - pp. ISBN 978-80-89171-49-1.