Vomiting

CHAPTER 29 Vomiting



Martha S. Wright, MD



1 What is the pathophysiology of vomiting?


True vomiting is the forceful elimination of gastrointestinal contents through the mouth or nose. Vomiting is caused by coordinated diaphragmatic and abdominal contractions in conjunction with pyloric constriction and gastroesophageal relaxation. This motor activity occurs in response to stimulation of the medullary “vomiting center” by impulses from a variety of anatomic locations. Sources of these impulses include the pelvic and abdominal viscera, the heart, the peritoneum, the labyrinth, and the “chemoreceptor trigger zone,” an area on the floor of the fourth ventricle that is sensitive to circulating drugs, toxins, and metabolic derangements.



2 What is the clinical difference between vomiting and “spitting up”?


It is important to differentiate vomiting from “spitting up” because the causes of spitting up are rarely serious while vomiting may indicate a potentially life-threatening condition. Spitting up is characterized by effortless regurgitation of stomach or esophageal contents and in most infants and children is due to gastroesophageal reflux or overfeeding. Vomiting, on the other hand, is forceful, may be accompanied by retching, and is frequently associated with autonomic symptoms, such as salivation, pallor, sweating, tachycardia, and mydriasis.



KEY POINTS: FORCEFUL VOMITING




1 Effortless regurgitation is usually caused by non–life-threatening conditions.


2 Forceful vomiting may be associated with more serious conditions, such as gastrointestinal obstruction, metabolic disease, or toxic ingestions.



3 What is the differential diagnosis of vomiting in the pediatric patient?


Vomiting may be caused by abnormalities in a variety of organ systems. When preschool-aged patients report “vomicking,” they help us to remember the wide-ranging differential diagnosis with the following mnemonic:



image V = Vestibular: labyrinthine disorders, otitis media


image O = Obstruction: malrotation, volvulus, adhesions, intussusception, obstipation, pyloric stenosis, incarcerated hernia, intestinal atresias, annular pancreas, duodenal hematoma


image M = Metabolic: diabetic ketoacidosis, inborn errors of metabolism (e.g., urea cycle defects, carbohydrate or amino acid metabolic defects), congenital adrenal hyperplasia, Reye’s syndrome


image I = Infection/Inflammation: gastrointestinal (appendicitis, hepatitis, pancreatitis, cholecystitis, gastroenteritis, gastritis, necrotizing enterocolitis) or extragastrointestinal (upper respiratory tract infections, sinusitis, pharyngitis, pneumonia, sepsis, cystitis, asthma)


image C = Central nervous system disease: increased intracranial pressure (brain tumor, intracranial hematoma, cerebral edema), hydrocephalus, meningitis, pseudotumor cerebri, concussion, migraine, ventriculoperitoneal shunt malfunction


image K = Kidney disease: acute renal failure, chronic renal failure, pyelonephritis, renal calculi, renal tubular acidosis, obstructive uropathy


image I = Intentional: eating disorders, rumination


image N = Nasty drugs/poisons: chemotherapeutics, ipecac, iron, salicylates, organophosphates, theophylline, alcohols, lead and other heavy metals, poisonous mushrooms


image G = Other GI/GU/GYN causes (GI [gastrointestinal]: gastroesophageal reflux, formula intolerance, peptic ulcer disease, cyclic vomiting syndrome; GU [genitourinary]: testicular torsion, epididymitis; GYN [gynecologic]: dysmenorrhea, ovarian torsion, pregnancy, pelvic inflammatory disease)


Furnival RA: Vomiting. In Harwood-Nuss A, Linden CH, Luten RC, et al (eds): The Clinical Practice of Emergency Medicine, 2nd ed. Philadelphia, Lippincott-Raven, 1996, pp 1265–1267.



4 The differential diagnosis for vomiting depends on the age of the pediatric patient. What are the life-threatening causes of vomiting in the different pediatric age groups?


See Table 29-1.


Table 29-1 Life-Threatening Causes of Vomiting by Age















Age Cause
Neonate GI obstruction

image Congenital intestinal obstruction


image Atresias


image Malrotation with volvulus


Renal



image Obstructive uropathy


image Uremia


Trauma



image Shaken baby syndrome with subdural hematoma


image Abdominal trauma


Metabolic



image Inborn metabolic errors


image Congenital adrenal hyperplasia


Infectious



image Sepsis


image Meningitis


image Severe gastroenteritis


image Necrotizing enterocolitis


Neurologic



image Hydrocephalus

Older infant/toddler GI obstruction

image Pyloric stenosis


image Intussusception


image Incarcerated hernia


image Malrotation with volvulus


Renal



image Uremia


Trauma



image Shaken baby syndrome with subdural hematoma


image Abdominal trauma


Infectious



image Sepsis


image Meningitis


image Severe gastroenteritis


Neurologic



image Hydrocephalus


image Mass lesion


Toxic ingestions

Older child/adolescent

GI obstruction



image Malrotation with volvulus


image Small bowel obstruction


Renal



image Uremia


Infectious



image Meningitis


Metabolic



image Diabetic ketoacidosis


image Reye’s syndrome


Neurologic



image Intracranial mass lesion (e.g. tumor, hematoma)

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Sep 1, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Vomiting

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