Regurgitation and Vomiting
Regurgitation and Vomiting: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics
Regurgitation is the nonforceful expulsionof contents from esophagus or stomach, whereas vomiting is the forcefulexpulsion of gastric contents through the mouth. The first partof this chapter is concerned with regurgitation and the second withvomiting.
Principal Causes of Regurgitation
- Normalvariations
- Gastroesophageal reflux
- Esophageal disorders
- Congenitalanomalies
- Esophagealatresia with or without tracheoesophageal fistula
- Esophageal stenosis
- Esophageal web
- Duplication
- Foreign body
- Stricture
- Hiatal hernia
- Rumination
Clinical Features and Diagnosis: Regurgitation
Normal Variations
In infants,milk may flow from mouth during or after feeding with little effortor distress.Common causes include overfeeding,air swallowed during feeding, crying, or coughing.Physical exam is normal and weightgain is adequate. History and physical exam are diagnostic. Gastroesophageal Reflux
Is the spontaneouspassage of stomach contents into esophagus.Common finding in many infants. Maybegin by a few weeks of age and usually resolves by 8–12mos of age. Infant is otherwise asymptomatic and has normal weightgain. No testing is required in this clinical circumstance.Gastroesophageal reflux disease refersto infants with regurgitation and vomiting associated with poorweight gain; respiratory symptoms (e.g., wheezing, hoarseness, orapnea); or esophagitis. Upper GI series is valuable to exclude anyanatomic abnormality. Esophageal pH probe study can quantitate frequencyand duration of acid reflux episodes. Endoscopy with biopsy shouldbe performed if esophagitis is suspected. Esophageal Disorders
Congenital Anomalies
Esophageal Atresia with or without Tracheoesophageal Fistula
Esophagealatresia usually exists with distal tracheoesophageal fistula. Uppersegment of esophagus ends in blind pouch and lower segment communicateswith trachea.Maternal history of polyhydramniosis common.Drooling, choking, and regurgitationoccur with first feeding.Opaque nasal catheter that fails topass into stomach and remains curled up in proximal esophagus establishesdiagnosis. Air in stomach on chest radiograph indicates presenceof tracheoesophageal fistula. If diagnosis is uncertain, injectionof small amount of contrast material into upper esophagus with fluoroscopyis confirmatory. Esophageal Stenosis
Usuallyoccurs in middle third of esophagus.Regurgitation and poor weight gainare prominent symptoms.Contrast esophagram is diagnostic. Esophageal Web
Mucosalmembrane that usually occurs in upper esophagus or at junction between middleand lower third of esophagus.Obstruction may be complete and causeregurgitation soon after birth.Diagnosis may be confirmed by esophagramor endoscopy. Duplication
Duplicationsof esophagus are cystic or tubular structures that can compressesophagus, causing regurgitation. Some duplications contain gastricmucosa, which may produce GI bleeding.Combination of tests, including chestradiography, upper GI radiographic series, and chest CT or MRI,is diagnostic. Foreign Body
Esophagealforeign bodies usually cause obstruction at level of cricopharyngeusmuscle or just above lower esophageal sphincter.Choking, coughing, dysphagia, regurgitation,and vomiting may occur. If foreign body is radiopaque, it may beseen on chest radiograph. Otherwise, filling defect is usually seenon esophagram.Diagnosis may be confirmed by endoscopy. Stricture
Usuallydue to long-standing reflux esophagitis but also may be due to causticingestion.Usual manifestations are dysphagia,regurgitation, and vomiting.Contrast esophagraphy or endoscopyis diagnostic. Hiatal Hernia
Herniationof portion of stomach into thorax.Usually is congenital and often isassociated with gastroesophageal reflux.Although regurgitation, vomiting, andepigastric pain may occur, it can be asymptomatic.Upper GI radiographic series is diagnostic. Rumination
Regurgitationof already ingested food from stomach and esophagus into mouth, whereit is rechewed and swallowed or spit out.Primarily occurs in 2 populations:developmentally impaired young children as self-stimulation behaviorand adolescents with significant psychological stress. Younger childrenhave minimal vomiting, whereas adolescents have significant vomiting.pH probe shows resolution of esophagealacidification during sleep. Diagnostic Approach: Regurgitation
In infantwith regurgitation who is otherwise well and gaining weight, mostlikely diagnosis is normal variation or mild gastroesophageal reflux.Persistent regurgitation with poorweight gain, respiratory symptoms, or symptoms suggesting esophagitisrequires investigation.Upper GI radiographic series excludesother causes of esophageal obstruction. Most reliable test for gastroesophagealreflux is esophageal pH monitoring. Endoscopy with biopsy can confirmdiagnosis of esophagitis.Other investigations depend on history,physical exam, and results of the above studies. Principal Causes of Vomiting
- Normalvariations
- Infection
- Gastrointestinal disorders
- Anatomic
- Stomach
- Pyloricstenosis
- Antral web
- Duplication
- Bezoar
- Gastric volvulus
- Intestine
- Duodenal atresia, stenosis, or web
- Annular pancreas
- Jejunal atresia and stenosis, and ilealatresia and stenosis
- Volvulus and malrotation
- Colonic atresia or stenosis
- Congenital aganglionic megacolon (Hirschsprungdisease)
- Intestinal duplication
- Intussusception
- Necrotizing enterocolitis
- Incarcerated inguinal hernia
- Meconium ileus and distal intestinalobstruction syndrome
- Intestinal stricture
- Intestinal adhesions
- Meckel diverticulum
- Intramural hematoma
- Superior mesenteric artery syndrome
- Imperforate anus
- Infection/inflammation
- Motility disorders
- Gastroparesis(idiopathic)
- Adynamic ileus
- Chronic intestinal pseudoobstruction
- Neoplasm
- Neurologic disorders
- Migraine
- Increased intracranial pressure
- Renal disorders
- Endocrine disorders
- Diabeticketoacidosis
- Adrenal insufficiency
- Metabolic disorders
- Drugs and toxins
- Motion sickness
- Pregnancy
- Psychologic disorders
- Anxiety
- Bulimia
Clinical Features and Diagnosis: Vomiting
Normal Variations
Frequent causes of occasional vomiting ininfancy are overfeeding, crying or coughing during or followingfeeding, rough handling, and overtiredness. History and physicalexam are diagnostic.
Infection
Vomiting may occur with any acute infection.Common causes are acute otitis media, gastroenteritis, nonspecificviral illness, pneumonia, urinary tract infection, meningitis, septicemia,and hepatitis. These disorders are discussed in other chapters.
Gastrointestinal Disorders
Anatomic
Stomach
Pyloric Stenosis
Hypertrophyof circular musculature of pylorus produces pyloric stenosis.Usual presenting feature is persistentnonbilious vomiting, which usually occurs at 1–12 wks ofage.Physical exam may reveal palpable pyloricmass. If pyloric mass is not palpable, abdominal U/S orupper GI series is diagnostic. Antral Web
Web locatedin antrum just proximal to pylorus may give rise to persistent vomiting.Abdominal radiography shows dilatedstomach with absence of distal bowel gas. Upper GI series, abdominalU/S, or endoscopy can be diagnostic; however, visualizationmay be difficult, especially with upper GI series. Duplication
Persistentvomiting, abdominal pain, and epigastric mass often occur with duplication ofstomach.Gastric ulceration of duplication,particularly at site of communication with stomach, may producebleeding with hematochezia.Combination of abdominal radiographsand abdominal U/S usually establishes diagnosis. Bezoar
Mass ofingested foreign material in stomach.Different types include lactobezoar(milk precipitates), trichobezoar (hair), phytobezoar (vegetablefiber), and gastrolith (concretion of various materials). Lactobezoarsoccur in infants, presumably because of improper mixing of formulawith inadequate amount of water. Trichobezoars are most common inchildhood and are usually due to chronic hair swallowing.Frequent findings are vomiting, abdominaldistension, and palpable epigastric mass. Abdominal radiographsshow intraluminal gastric mass with mottled appearance that mayextend into duodenum and jejunum.Abdominal U/S or upper GIseries is diagnostic. Gastric Volvulus
Usuallyoccurs in neonatal period but can occur in childhood.In mesenteroaxial type, stomach rotateson its mesentery, and abdominal radiographs show air-fluid collectionsin distended stomach. Upper GI series shows typical beak cutoffwith obstruction at either gastroesophageal junction or antrum.In organoaxial type, rotation of stomachoccurs on its cardiopyloric axis. Also may be associated with hiatalhernia. Diagnostic contrast studies show lesser curvature of stomachin inferior location and greater curvature in superior location. Intestine
Duodenal Atresia, Stenosis, or Web
Duodenalatresia presents with nonbilious or bilious vomiting depending onwhether atresia is above or below ampulla. Abdominal radiographsshow air-fluid levels in stomach and duodenum (double bubble sign)with absence of air in distal intestine. Diagnosis is confirmedat surgery.Clinical findings with duodenal stenosisor web depend on how severe narrowing is. Typically, intermittentvomiting occurs. Abdominal radiographs show dilated stomach andduodenum with some gas in distal bowel. Upper GI series is usuallydiagnostic. Annular Pancreas
May be asymptomaticor compress the second portion of duodenum, causing intestinal obstructionand bilious vomiting. Less severe duodenal narrowing gives riseto intermittent vomiting.Radiologic findings are similar tothose found with duodenal atresia or stenosis.Diagnosis is confirmed at surgery.Also may be associated with pancreatitis. Jejunal Atresia and Stenosis, and Ileal Atresia and Stenosis
Atresiasaccount for about 95% of jejunoileal obstructions, whereasstenoses account for remainder. In utero vascular accidents appearto be responsible for these lesions, which usually present withinfirst 24 hrs of life with bilious vomiting, abdominal distension,and failure to pass meconium.Abdominal radiographs show dilatedloops of small bowel with multiple air-fluid levels. The more distalthe obstruction, the greater the number of air-fluid levels anddistended bowel loops.Because jejunal and ileal stenosisare usually severe, clinical and radiologic findings are similarto those found with jejunal and ileal atresia.Upper GI series may be diagnostic.Diagnosis is confirmed at surgery. Volvulus and Malrotation
Volvulusof midgut usually occurs with intestinal malrotation. Failure ofbowel to rotate to normal position during fetal life produces malrotation.Bilious vomiting and abdominal distensionusually occur.Abdominal radiographs may show evidenceof duodenal or lower small bowel obstruction with multiple dilatedair-filled loops of small bowel.Most favored diagnostic test is upperGI radiographic series. Diagnosis is confirmed at surgery. Colonic Atresia or Stenosis
Colon isleast common site for GI atresia or stenosis.Usual findings of colonic obstructionare bilious vomiting, marked abdominal distension, and failure topass meconium.Abdominal radiographs show multipledilated loops of bowel with air-fluid levels.Contrast enema is diagnostic. Congenital Aganglionic Megacolon (Hirschsprung Disease)
Due to absenceof enteric ganglia along variable portion of intestine.Short segment disease involves rectosigmoidcolon and accounts for about 80% of cases. Long segmentdisease involves portion of colon above rectosigmoid and accountsfor 10–15% of cases. Remaining cases involve entirecolon and some portion of small intestine.Neonates may have vomiting, abdominaldistension, and failure of meconium passage within 24 hrs of birth.Another presentation in infancy is enterocolitis with abdominaldistension, bloody diarrhea, fever, and vomiting.Toddlers commonly have history of chronicconstipation, abdominal distension, and poor weight gain.Exam usually reveals empty rectal ampulla.Abdominal radiographs commonly show dilated small and large intestine,which suggests low obstruction. Barium enema may show narrowed transition zonein distal colon, but it may be unreliable in infants.Suction rectal biopsy with acetylcholinesterasestaining can establish diagnosis. Otherwise, full-thickness rectalbiopsy is necessary. Intestinal Duplication
Small intestinalduplications usually occur in area of terminal ileum. Large intestinal duplicationsare rare.Clinical manifestations include biliousvomiting, abdominal distension, palpable abdominal mass, and lowerGI bleeding.Abdominal radiographs may show evidenceof intestinal obstruction or mass.Diagnosis is usually established byabdominal U/S, but it is confirmed at surgery. Intussusception
Is the invaginationof 1 segment of intestine into lumen of more distal part of intestine.In most cases, intussusception is ileo-ileocolic or ileocolic.Pathologic lead points include polyps,Meckel diverticulum, foreign body, duplication, appendiceal inflammation,or tumor.Although intussusception can occurat any age, most occur in children <2 yrs of age. Commonmanifestations are intermittent abdominal pain, vomiting, currantjelly–like stools, and abdominal mass.Abdominal radiographs can be normalor show abdominal mass, usually in right upper quadrant, or abnormalbowel gas pattern.Air-contrast enema can confirm diagnosisand may be therapeutic as well. Contraindications to its use arefree abdominal air, intestinal obstruction with air-fluid levelson abdominal radiographs, and clinical peritonitis. In such cases,surgery should be performed immediately. Necrotizing Enterocolitis
Occurs mostcommonly in premature infants, although it can occur in term newborns. Pathogenesisis not fully known. Terminal ileum and colon are usual involvedareas.Vomiting, abdominal distension, bloodin stool, and temperature instability in ill-appearing infant arefrequent findings.Radiographic findings include persistentdilated bowel loops, gas in bowel wall, and gas in portal vein.Bowel perforation also may occur, with air and fluid in peritonealcavity.Diagnosis is clinical and radiologic. Incarcerated Inguinal Hernia
Can causeintestinal obstruction.Persistent vomiting, abdominal distension,and palpable, tender, nonreducible inguinal hernia indicates intestinalobstruction until proven otherwise.Abdominal radiographs show multipleair-fluid levels and distended small intestine loops. Air-containingloop of bowel may be seen within inguinal canal or scrotum. Meconium Ileus and Distal Intestinal Obstruction Syndrome
In someneonates, thick meconium occludes distal ileum, and persistent vomitingand abdominal distension occur. This condition is almost alwaysdue to cystic fibrosis. Abdominal radiographs show dilated intestinalloops of varying sizes with air-fluid levels and ground glass appearanceof the bowel. Water-soluble contrast enema that shows many small,round, filling defects indicative of meconium is not only diagnosticbut also may be therapeutic. Otherwise surgery is necessary.Older children with cystic fibrosismay develop distal intestinal obstruction syndrome with thick viscousmaterial in bowel. This syndrome was formerly known as meconiumileus equivalent. Vomiting, abdominal pain, and failure to passbowel movements are usual findings. Intestinal obstruction requiringsurgery may occur in some cases. Intestinal Stricture
May follownonoperative necrotizing enterocolitis or any surgery involvingGI tract.Clinical features are those of intestinalobstruction.Radiographic studies show evidenceof obstruction.Diagnosis is confirmed at surgery. Intestinal Adhesions
Can occurduring weeks following surgery or years later.Usual findings are persistent vomitingand abdominal distension.Radiographs show findings of intestinalobstruction with dilated loops of bowel and multiple air-fluid levels.Diagnosis is confirmed at surgery. Meckel Diverticulum
May causeintestinal obstruction by serving as lead point of intussusceptionor by twisting of persistent remnant of vitelline duct.Diagnosis is confirmed at surgery. Intramural Hematoma
Small bowelhematomas are usually caused by blunt abdominal trauma.Duodenal hematoma usually producesepigastric or periumbilical pain and bilious vomiting. Abdominalradiographs may reveal mass that impresses greater curvature ofstomach or displaces transverse colon.Intramural jejunal and ileal hematomascommonly present with partial small intestinal obstruction.Abdominal U/S or upper GIseries is usually diagnostic. Superior Mesenteric Artery Syndrome
Characterizedby persistent vomiting and occurs in individuals who have had recent significantweight loss, who are in body casts, or who have had recent surgeryfor scoliosis. It is thought that superior mesenteric artery iscompressed by spine due to absence of mesenteric fat pad in thisregion.Plain radiographs show dilated stomachand duodenum and upper GI radiographic series shows obstructionof duodenum as it crosses the spine. Imperforate Anus
Refers togroup of anomalies in which there is no obvious anal opening.Clinically, these anomalies can bedivided into high and low types depending on whether they end aboveor below puborectal sling of levator ani complex. Anomalies abovethe sling usually have fistulas to bladder or urethra in boys andto vagina or cloaca in girls. Anomalies below the sling usually havefistulas to perineum or urethra in boys and to vulva or vestibulein girls.Evidence of intestinal obstructionmay occur in first few days of life.Diagnosis is made by physical exam.Combination of studies is necessary to define anatomic details.CT and MRI can help establish relationship of the anomaly to levatorani. Water-soluble contrast studies are also helpful to delineateanatomy of the lesion. Infection/Inflammation
Numerous nonobstructive GI disorders areassociated with vomiting. They include gastritis, gastroenteritis,appendicitis, cow milk protein sensitivity, peptic ulcer disease,gluten-sensitive enteropathy, peritonitis, and pancreatitis. Seeother chapters for discussion of these disorders.
Motility Disorders
Gastroparesis (Idiopathic)
Delayed gastric emptying may lead to persistentvomiting and weight loss that can often follow viral infection.
Adynamic Ileus
Usuallytemporary and impairs peristalsis with gas and fluid accumulationin GI tract.Vomiting and abdominal distension aremost prominent manifestations.Predisposing factors include abdominalor spinal surgery, injuries (spinal fractures), septicemia, gastroenteritis,peritonitis, pancreatitis, pneumonia, intestinal ischemia, electrolytedisturbances (hypokalemia, hypercalcemia), and drugs (narcotics,atropine, laxatives, and phenothiazines). Chronic Intestinal Pseudoobstruction
In thistype of motility disorder, recurrent episodes of GI obstructionoccur in absence of mechanical obstruction.Primary causes include visceral myopathyor neuropathy. Secondary causes include diseases of GI smooth muscle(collagen vascular disease, muscular dystrophies), diseases of nervoussystem (primary autonomic dysfunction), endocrine disorders (hypothyroidism,hypoparathyroidism), and drugs (opiates, antidepressants, cathartics,anticholinergics, cytotoxic agents).Vomiting, abdominal pain, diarrhea,constipation, and abdominal distension may occur.Plain radiographs mimic obstruction,hence the term pseudoobstruction. Contrast studies can help distinguishmechanical obstruction and evaluate contractility. Manometric studiesshould be supervised by pediatric gastroenterologist. Neoplasm
Tumors ofintestine are rare but can present with intestinal obstruction.Most common malignant tumor of small intestine in children is lymphoma,which usually arises in ileum.Abdominal U/S, contrast enema,and abdominal CT usually locate and define extent of mass.Histologic diagnosis is definitive. Neurologic Disorders
Migraine
Migraineheadache is often associated with vomiting.Migraine variant called cyclic vomitingis characterized by recurrent episodes of nausea, vomiting, andabdominal pain that may occur with or without headache. These episodesusually evolve into more typical migraine headache pattern. Familyhistory is usually positive for migraine. Increased Intracranial Pressure
Increasein intracranial pressure may cause persistent vomiting.Clinical presentation depends on ageof child. Infants may be irritable with tense or bulging fontanelleand increasing head size. Children and adolescents may have headache,worsening school performance, behavior changes, ataxia, and papilledema.Causes include hydrocephalus, masslesion (e.g., tumor), pseudotumor cerebri, and cerebral edema. Renal Disorders
Persistentvomiting can be feature of renal disorders (e.g., urinary tractinfection, acute and chronic renal failure, nephrotic syndrome,and renal tubular acidosis).Manifestations of renal disease includedysuria, hematuria, proteinuria, edema, hypertension, polyuria,oliguria, and anuria.UA, urine culture, renal profile (serumelectrolytes and creatinine, blood urea nitrogen), and renal U/Scan screen for renal disease. Endocrine Disorders
Diabetic Ketoacidosis
Persistent vomiting may occur with diabeticketoacidosis. See Chap. 47, Polyuriaand Polydipsia, for discussion about diabetesmellitus.
Adrenal Insufficiency
Decreasein adrenal cortisol secretion results in adrenal insufficiency.Causes include adrenal disorders (adrenal aplasia or hypoplasia;congenital adrenal hyperplasia; adrenoleukodystrophy; autoimmunedisease; septicemia, especially meningococcemia; trauma; neoplasm;cessation of long-term corticosteroid therapy), and pituitary orhypothalamic disorders (hypopituitarism, neoplasm).Clinical findings include vomiting,abdominal pain, fever, and hypotension. Chronic illness producesfatigue, generalized weakness, weight loss, and hyperpigmentationof skin and mucous membranes.Presence of hypoglycemia, hyponatremia,hyperkalemia, and metabolic acidosis suggests adrenal insufficiency.Low serum cortisol and elevated serum ACTH occur with primary adrenaldisease. Lack of significant increase in plasma cortisol followingintravenous administration of ACTH also signifies primary adrenaldisease.Abdominal U/S and CT are usefulin identifying mass lesion or hemorrhage. Serum cortisol and ACTHconcentrations are low with primary pituitary disease. Thyroxine,TSH, and growth hormone also should be measured. MRI should be performedto locate any mass lesion affecting the pituitary or hypothalamus. Metabolic Disorders
Persistentvomiting may occur with many metabolic disorders. These includegalactosemia, hereditary fructose intolerance, Reye syndrome, aminoacid disorders, organic acid disorders, urea cycle defects, fattyacid oxidation disorders, and peroxisomal disorders.Certain tests screen for many of thesedisorders: serum electrolytes, glucose, ammonia, lactate, pyruvate,and amino acids; liver function tests; and urine for reducing substances,ketones, and organic acids.See Chap.3, Alteration in Consciousness, and Chap. 13, Developmental Delay,for discussion of many of these disorders. Drugs and Toxins
Many drugsand toxins may produce vomiting. Common ones include erythromycin andtetracycline (usual dosage); digoxin and theophylline (overdosage);cancer chemotherapeutic agents; and ingestions of salicylate, iron,lead, caustics, alcohol, ipecac, or hydrocarbons.History and physical exam may be diagnostic.Drug levels of digoxin, theophylline, salicylate, iron, lead, andalcohol are useful with suspected drug overdosage or ingestion. Motion Sickness
Any prolonged motion (e.g., riding in car,train, bus, boat, or airplane) may result in nausea and vomiting.Stopping motion usually relieves these symptoms.
Pregnancy
Persistentnausea and vomiting may occur during first trimester of pregnancyand even throughout pregnancy. Other associated findings includefatigue, urinary frequency, and breast enlargement. 1 or more missedmenstrual periods is suggestive.Beta human chorionic gonadotropin urinepregnancy tests now in use can detect pregnancy in nearly all patientswithin 9 days of conception. Psychologic Disorders
Anxiety
Any emotional stress may produce anxiety,which in some children is accompanied by acute or chronic vomiting.
Bulimia
Psychologicdisorder that commonly affects adolescent girls. It is separatefrom but may be associated with anorexia nervosa. Onset of bothdisorders often follows stressful event, and underlying fear ofbeing fat underlies both illnesses.Individuals with bulimia have irresistibleurge to overeat. After recurrent episodes of binge eating, theywithdraw and induce vomiting. They also lose weight but usuallynot to same extent as those with anorexia nervosa. Anxiety, depression,and disturbed interpersonal relationships are other manifestations.History and physical exam are diagnostic. Diagnostic Approach: Vomiting
Importantto determine whether regurgitation or vomiting or both are occurring.Distinction is usually based on history and observation of infantor child during feeding.Age of child helps narrow diagnosticpossibilities. In any age group, persistent vomiting, especiallywith impaired weight gain or weight loss, is significant and mustbe investigated. Neonatal Onset
In well-appearingneonate, most common causes of vomiting are excessive air swallowing,overfeeding, and careless or rough handling during or after feeding.In ill-appearing neonate, infectionand mechanical intestinal obstruction are most common causes. Signsof intestinal obstruction include bilious vomiting, abdominal distension,and failure to pass meconium within 48 hrs of birth. Degree of abdominaldistension depends on level of obstruction and pattern of feedingand vomiting. Abdominal distension may be minimal with pyloric stenosisand duodenal atresia. It usually is prominent with more distal intestinalobstruction.Character of vomitus may help localizelevel of obstruction.Undigested food or milk in vomitus suggestsesophageal atresia or pyloric stenosis.Digested food without bile suggestsobstruction proximal to entrance of common bile duct into duodenum.Presence of bile in vomitus usuallyindicates obstruction distal to entrance of common bile duct. Alsomay occur with prolonged vomiting of any cause associated with relaxationof pylorus or in those with septicemia who have ileus.Fecal material in vomitus indicateslarge bowel obstruction.Projectile vomiting may occur withany cause of gastric or duodenal obstruction. In ill neonate or young infant whohas persistent vomiting, certain tests should be considered: CBCwith differential; serum electrolytes, glucose, creatinine, andammonia; blood urea nitrogen; UA; urine culture; urine for reducingsubstances and ketones; and venous pH. When septicemia is suspected,blood, urine, and spinal fluid cultures should be performed.When intestinal obstruction is suspected,chest radiograph and abdominal films should be obtained. Whetherabdominal U/S or radiographic contrast studies are indicateddepends on suspected diagnosis and clinical condition of patient.Neuroimaging should be performed with suspected increased intracranialpressure. Quantitative determination of amino acids in blood andgas chromatography–mass spectrometry analysis for urinaryorganic acids may be performed for suspected amino acid and organic aciddisorders, respectively. Postneonatal Onset
In infancy,normal variations and infection are most common causes of acutevomiting. Presence of persistent vomiting suggests gastroesophagealreflux or intestinal obstruction.In childhood and adolescence, mostcommon causes of vomiting are acute infection, appendicitis, motionsickness, intestinal obstruction, drugs (side effect or overdose),and psychological problems. History and physical exam suggest mostlikely possibilities, and lab investigations are tailored to suspectedcauses. Tests mentioned in previous section should be considered. References
- Altschuler SM, Liacouras CA, eds. Clinicalpediatric gastroenterology. Philadelphia: Churchill Livingstone,1998.
- Kirks DR, ed. Practical pediatric imaging: diagnosticradiology of infants and children, 3rd ed. Philadelphia: Lippincott-Raven,1998.
- Online Mendelian Inheritance in Man (OMIM). McKusick-NathansInstitute for Genetic Medicine, Johns Hopkins University (Baltimore,MD) and National Center for Biotechnology Information, NationalLibrary of Medicine (Bethesda, MD), 2000. World Wide Web URL: http://www.ncbi.nlm.nih.gov/omim.
- Orenstein SR. Gastroesophageal reflux. In: Wyllie RW,Hyams JS, eds. Pediatric gastrointestinal disease, 2nd ed. Philadelphia:WB Saunders, 1999:164–187.
- Rowe MI, et al. Essentials of pediatric surgery. St.Louis: Mosby-Year Book, 1995.
- Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
- Stevens MW, Henretig FN. Vomiting. In: Fleisher GR,Ludwig S, eds. Textbook of pediatric emergency medicine, 4th ed.Philadelphia: Lippincott Williams & Wilkins, 2000:625–633.
- Walker WA, et al., eds. Pediatric gastrointestinaldisease, 3rd ed. Hamilton, Ontario, Canada: BC Decker, 2000.
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Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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