Vomiting
Vomiting: Excerpt from Pediatric Complaints and Diagnostic Dilemmas
James P. Cavanagh
Approach to the Patient with Vomiting
I. Definition of the Complaint
Vomiting is defined as the forceful contraction of abdominal muscles and the
diaphragm in a coordinated fashion that expels the gastric contents through an
open gastric cardia into the esophagus and out of the mouth. The medullary
vomiting center coordinates this process of vomiting via efferent pathways of
the vagus and phrenic nerves. Stimulation of the medullary vomiting center
occurs either directly or through the chemoreceptor trigger zone (CTZ). Direct
stimulation may occur through afferent vagal signals from the gastrointestinal
tract or other sites including, but not limited to, the vestibular system, the
cerebral cortex, and the hypothalamus. The CTZ in the area postrema of the
fourth ventricle can be activated by noxious sights and smells or by chemical
stimuli in the blood secondary to medications, metabolic abnormalities, or
certain toxins.
Gastroesophageal reflux (GER) is not vomiting but rather regurgitation. Although
GER can be projectile at times, it is an effortless return of gastric contents
into the mouth without nausea or coordinated muscular contractions.
II. Complaints by Cause and Frequency
Vomiting is not a diagnosis but rather a symptom of an underlying pathologic
process that requires a thorough evaluation. The causes of vomiting can be
grouped according to age at presentation (Table 3-1) or according to etiology
(Table 3-2): (a) obstructive gastrointestinal lesions, (b) nonobstructive
gastrointestinal disorders, (c) neurologic causes, (d) metabolic causes, (e)
renal causes, (f) pulmonary causes, (g) toxicologic causes, and (h)
miscellaneous causes.
III. Clarifying Questions
Thorough history taking is imperative for formulating an accurate differential
diagnosis and eventually discovering the correct etiology of vomiting.
Consideration of the vomiting duration and pattern, the content of the emesis,
and associated symptoms provides a framework for creating a differential
diagnosis. The following questions may help provide clues to the correct
diagnosis:
• What is the duration of vomiting?
— Acute episodes of vomiting, chronic vomiting, and cyclic vomiting carry very
different differential diagnoses. Acute vomiting is mostly caused by transient,
self-limited infectious or metabolic conditions. Chronic vomiting tends to have
a gastrointestinal origin and may be caused by a partial mechanical obstruction
(e.g., hiatal hernia, achalasia, duplications, webs). Other conditions causing
prolonged vomiting include peptic and duodenal ulcers, dysmotility syndromes,
increased intracranial pressure, psychogenic disturbance, pregnancy, and lead
poisoning. Cyclic vomiting tends to be extraintestinal and is usually caused by
migraine or migraine equivalents, cardiac arrhythmias, or ureteropelvic
junction (UPJ) obstruction.
• Is there any timing pattern to the vomiting?
— Episodes of vomiting that occur with a regular diurnal pattern also provide
helpful clues. Early-morning vomiting can be very ominous if it is caused by
increased intracranial pressure, but it could also occur secondary to morning
sickness from pregnancy. Vomiting after eating of specific foods may be the
result of a food allergy. Vomiting patterns may also become apparent if
secondary gain is achieved (e.g., absence from school or tests), or vomiting
may be associated with school phobia. Vomiting that occurs shortly after eating
is consistent with psychogenic vomiting as well as gastric outlet obstruction
or peptic ulcer disease.
• Is the vomiting effortless?
— GER occurs in almost all newborns, but by 6 months of age fewer than 5% of
children are symptomatic. GER tends to be effortless and is not associated with
pain or morbidity. Rarely, reflux is severe enough to cause discomfort and
arching, Sandifer syndrome, or poor weight gain, at which point medical therapy
may be necessary. True vomiting tends to be a more noxious event, often causing
pain and retching.
• Is there bilious emesis?
— The presence of bilious emesis suggests an obstruction distal to the ampulla of
Vater but may also be present in nonobstructed patients after prolonged
episodes of vomiting due to a relaxed pylorus. Bilious vomiting in a newborn
infant should be treated as a surgical emergency until proved otherwise.
Newborn infants with bilious emesis may have intestinal obstruction associated
with duodenal atresia or intestinal malrotation and midgut volvulus. The
absence of bilious emesis is also important, because in that case any
obstruction that was present would be located proximal to the ampulla of Vater
(e.g., pyloric stenosis).
• Is there any blood in the vomitus?
— The presence of blood in emesis must first be confirmed by either a Gastroccult
or a Hematest test. If blood is present, then hematemesis must be distinguished
from hemoptysis. The blood in hematemesis ranges in color from bright red to
coffee-ground, depending on its length of time in contact with gastric
contents, but compared with hemoptysis it tends to be darker red, acidic, and
associated with retching or gastrointestinal complaints. The blood in
hemoptysis is bright red, frothy, alkaline, and associated with respiratory
symptoms. Hematemesis may be a result of peptic ulcers, Mallory-Weiss tears,
esophagitis, esophageal varices, acute iron ingestion, gastritis, bleeding
diathesis, or vascular malformations.
• Is undigested food present in the vomitus?
— The presence of undigested food material is very common in children with GER
who present with episodes of effortless, postprandial regurgitation. Other
conditions that predispose to undigested food in emesis include esophageal
atresia or strictures, esophageal or pharyngeal (Zenker
's) diverticulum, and achalasia. Old food present in the emesis may signify a
gastric outlet obstruction or a gastric motility disorder.
• Is fecal material present in the emesis?
— The presence of fecal material in the emesis suggests a distal intestinal
obstruction, peritonitis, a gastrocolic fistula, or bacterial overgrowth in the
stomach or small intestine.
• Is diarrhea occurring with the vomiting?
— The presence of diarrhea and vomiting suggests a gastrointestinal disorder, of
which an infectious gastroenteritis is the most common. Isolated vomiting tends
to have a far greater differential, involving many other organ systems.
Isolated vomiting may occur in serious conditions such as increased
intracranial pressure, lower-lobe pneumonias, ingestions, and diabetic
ketoacidosis.
• Is there any abdominal pain?
— When vomiting is associated with abdominal pain, the location of the abdominal
pain and the descriptive nature of the pain can be clues as to the etiology.
Pain in the right lower quadrant may be caused by an acute appendicitis,
whereas right upper quadrant pain is more likely to be of gall bladder or
hepatic in origin. The most common cause of diffuse abdominal pain is
constipation. Colicky pain tends to occur with an obstructed hollow viscous,
whereas well-localized, sharp pain tends to occur when parietal peritoneum is
inflamed. Flank or lateral pain signifies a renal etiology. Pain from peptic
ulcer disease is often alleviated by vomiting, whereas pain secondary to
pancreatitis or biliary tract disease is not improved with vomiting.
• Is fever present?
— The presence of fever in a patient with vomiting is very common. It may signify
an infectious gastrointestinal process, such as acute viral gastroenteritis,
bacterial enteritis, appendicitis, hepatitis, pancreatitis, peritonitis, or an
acute extraintestinal infection, such as sepsis, meningitis, acute otitis
media, pharyngitis, or urinary tract infection. Other causes of fever include
inflammatory conditions such as inflammatory bowel disease.
• Are any associated symptoms present?
— Other information that may help in narrowing the differential includes the
presence of weight loss, headache, lethargy, poor school performance, or
environmental or infectious exposures.
The following cases present less common causes of vomiting in children.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
More About Cyclic vomiting syndrome
More Medical Textbooks Online about Cyclic vomiting syndrome
Review other book chapters online related to Cyclic vomiting syndrome:
Medical Books Excerpts
- Vomiting
- "In A Page: Pediatric Signs and Symptoms" (2007)
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- Nausea
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Vomiting
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Hematemesis
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Nausea
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Vomiting
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Nausea and Vomiting
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- Hematemesis
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Vomiting
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Hematemesis
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Nausea
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Vomiting
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Nausea
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
- Vomiting
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
- Vomiting
- "Pediatric Complaints and Diagnostic Dilemmas" (2003)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Vomiting - Case 3-1: 7-Week-Old Boy (Pediatric Complaints and Diagnostic Dilemmas)
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