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Approach to Vomiting

Protocols

History

History of Presenting Illness

·       Characteristics of vomitus

·       Smell

·       Quantity

·       Colour

·       Blood – bright red/dark red/coffee-ground

·       Bilious

·       Timing

·       Onset

·       Duration

·       Frequency

·       Time of day

·       Triggers

·       Associated Symptoms

·       Diarrhea

·       Fever

·       Abdominal pain/distension

·       Anorexia

·       Stool frequency

·       Urinary Output

·       Headache

·       Vertigo

·       Lethargy

·       Stiff neck

·       Cough

·       Sore throat

Past medical history

·       Chronic illnesses (diabetes)

·       Travel history (infectious gastroenteritis)

·       Sexual history (pregnancy)

·       Ineffective use of birth control

·       Last menstrual period

·       Recent head trauma

·       Toxin exposure

Medications

Allergies

 Differential diagnosis of

Age

Acute

Chronic

Infant 

1 month to 1 year

Gastroenteritis 

Pyloric stenosis

Hirschsprung’s disease

Acutely evolving surgical abdomen

·       Congenital atresias and stenosis

·       Malrotation

·       Intussusception

Sepsis and non-GI infection

Metabolic disorders

Gastroesophageal reflux disease 

Food intolerance

Congenital atresias and stenosis

Malrotation

Intussusception

Children and adolescents

Gastroenteritis 

Appendicitis

Sepsis and non-GI infection

Metabolic disorders

Pregnancy

Toxic ingestion

Gastroesophageal reflux disease 

Gastritis

Food intolerance

Cyclic vomiting

Intracranial hypertension

Inborn errors of metabolism

Eating disorders


Physical Exam Findings

Vitals

  • Fever – sign of infection
  • Hypotension, tachycardia – volume loss

Inspection

  • Consciousness – intracranial hypertension, meningitis, metabolic disorders, toxic ingestion
  • Weight loss – eating disorders, obstruction

Head and Neck

  • Red, bulging tympanic membrane – ear infection
  • Bulging anterior fontanelle  and nuchal rigidity – meningitis
  • Erythematous tonsils – upper respiratory tract infection

Cardiovascular system

  • Tachycardia – infection, dehydration

Abdominal exam

  • Abdominal distention – obstruction, mass, congenital abnormality, organomegaly
  • Bowel sounds – high pitched tinkle (obstruction), absent (ileus)
  • Guarding, rigidity, rebound tenderness – appendicitis, peritoneal inflammation

Skin and extremities

  • Petechiae or purpura – serious infection
  • Skin turgor, capillary refill – dehydration
  • Jaundice – metabolic disorder
  • Rashes – food intolerance, viral infection

Red flags: The following findings are of particular concern:

  • Lethargy and listlessness
  • Inconsolability and bulging fontanelle in an infant
  • Nuchal rigidity, photophobia, and fever in an older child
  • Peritoneal signs or abdominal distention (“surgical” abdomen)
  • Persistent vomiting with poor growth or development

Procedure for Investigation (this will be based on the differential diagnosis)

Condition

History and Physical

Diagnostic approach

Gastroenteritis

Diarrhea (usually), history of infectious contact, fever (sometimes)

Clinical evaluation

GERD

Fussiness after feeding, poor weight gain

Empiric trial of acid suppression

Pyloric stenosis

Recurrent projectile vomiting in neonates aged 3-6 weeks, emaciated and dehydrated

Ultrasound

Congenital atresia or stenosis

Abdominal distension, bilious emesis in first 24-48 hours of life

Abdominal X ray 

Contrast enema

Malrotation

Bilious emesis, abdominal distention, abdominal pain, bloody stool

Abdominal X ray 

Upper GI series with contrast under fluoroscopy

Sepsis

Fever, lethargy, tachycardia, tachypnea, widening pulse pressure, hypotension

CBC, 

Cultures (blood, urine, CSF)

Food intolerance

Abdominal pain, urticarial, eczematous rash

Elimination diet

Metabolic disorders

Poor feeding, failure to thrive, hepatosplenomegaly, jaundice, dysmorphic features, developmental delays, unusual odors

Electrolytes, ammonia, liver function tests, BUN, creatinine, serum glucose, total and direct bilirubin, CBC, PT/PTT 

Further specific tests based on findings

Non-GI infection

Fever, localized findings (sore throat, dysuria, flank pain) depending on source

Clinical evaluation 

Further tests if needed

Serious infection

Meningitis 

·       photophobia, nuchal rigidity, headaches

Pyelonephritis

·       fever, back pain, dysuria

CBC, Cultures (CSF, blood, urine) gram stains 

CBC, Cultures (urine, blood)

Cyclic vomiting

At least 3 self-limited episodes of vomiting lasting 12 h,           7 days between episodes,        no organic cause of vomiting

Diagnosis of exclusion

Intracranial hypertension

Nocturnal wakening, progressive recurrent headache made worse by coughing or Valsalva maneuver, nuchal rigidity, visual changes, weight loss, photophobia

Brain CT (without contrast)

Eating disorders

Body dysmorphism, teeth erosions, skin lesions on hand (Russell’s sign), binge eating behavior

Clinical evaluation

Pregnancy

Amenorrhea, morning sickness, breast tenderness, bloating, history of sexual activity and improper contraception use

Urine pregnancy test

Toxic ingestion

History of ingestion, findings vary depending on substance and pattern of ingestion

Varies depending on substance