A 5-year-old boy presented with vomiting 7-8 times per day for 2 days. On examination, he had some signs of dehydration. Investigations showed normal results. He was managed conservatively with IV fluids, electrolytes, antibiotics, and symptomatic treatment. The summary provides the key details about the patient's presentation and management in 3 sentences.
2. CASE:
A 5 Years old male child presented in ER with:
Vomiting -7 to 8 episodes/day for 2 days.
The child was in his usual state of good health 2 days back when he
developed acute onset of non-projectile vomiting, contained nondigested food particles. It was non-bilious and not blood stained. There
were episodes of colicky, non-radiating abdominal pain. The child had
no fever but was passing stools of loose consistency,5-6 episodes. The
feeding decreased since the illness.
There were no respiratory or urinary symptoms. No irritability, altered
sensorium, drowsiness, neck stiffness, headache.
3. No known medical illnesses s/o inborn errors of metabolism,
cerebral palsy, down’s syndrome, neurological deficits.
No h/o any drugs/allergy to any drugs/food
Birth was uneventful
There was no h/o travelling. The child had taken water
outside and his friend was also suffering from similar illness.
4. O/E:
GCS:15/15, lethargic
T-98, HR-128, RR-56, BP-90/50
Jaundice- absent, dehydration- some signs+
No signs of meningeal irritation
The remainder of the examinations were normal
Inv: TC-15,500 Na-143, K-3.2, urea/creat-N
Urine-N
5. The child was managed conservatively with IV fluids and
electrolytes, IV antibiotics and symptomatic management
was done.
6.
Nausea: The unpleasant sensation of the imminent need to vomit,
usually referred to the throat or epigastrium; a sensation that may or
may not ultimately lead to the act of vomiting
Vomiting: Vomiting is the means by which the upper gastrointestinal
tract rids itself of its contents when almost any part of the upper
tract becomes excessively irritated, over distended, or even over
excitable
Regurgitation: The act by which food is brought back into the mouth
without the abdominal and diaphragmatic muscular activity that
characterizes vomiting.
7. PHYSIOLOGY OF VOMITING:
The sensory signals from the pharynx,
esophagus, stomach and upper portions of the
small intestines.
the nerve impulses are transmitted by both
vagal and sympathetic afferent nerve fibers to
multiple distributed nuclei in the brain stem that
all together are called the “vomiting center”
motor impulses that cause the actual vomiting
are transmitted from the vomiting center by
way of the 5th,7th, 9th,10th,and 12th cranial
nerves to the upper gastrointestinal tract,
through vagal and sympathetic nerves to the
lower tract, and through spinal nerves to the
diaphragm and abdominal muscles
8. Act of vomiting:
a deep breath raising of the hyoid bone and
larynx to pull the upper esophageal sphincter
open
closing of the glottis to prevent vomitus flow
into the lungs
lifting of the soft palate to close the posterior
nares
strong downward contraction of the
diaphragm along with simultaneous
contraction of all the abdominal wall
muscles.
This squeezes the stomach between the
diaphragm and the abdominal muscles,
building the intragastric pressure to a high
level. Finally, the lower esophageal sphincter
relaxes completely, allowing expulsion of the
gastric contents upward through the
esophagus.
9. Causes of vomiting:
Neonatal period:
Bilious vomiting:
Non-bilious vomiting:
Atresias
Feeding excessive volume
Midgut volvulus
Milk(human or formula intolerance
Annular pancreas
Decreased motility
Hirschprungs disease
prematurity
Aberrant sup. Mes. Artery
antenatal exposure to MgSO4 or
narcotics
Preduodenal portal vein
sepsis (meningitis)with ileus,NEC
Peritoneal bands
CNS lesion
Persistent omphalomesenteric duct
Lesion above ampulla of Vater
Duodenal duplication
pyloric stenosis
Meconium plug
upper duodenal stenosis
Annular pancreas
GER, inborn errors of metabolism
10. Causes in infancy:
Medical causes:
Surgical causes:
GER
gastroenteritis
CHPS
CNS infections
Volvulus
UTI
Inborn errors of metabolism
Uremia
Cow milk protein allergy
Over feeding
Faulty feeding technique
Malrotaion
Intussusception
ICSOL
Peritonitis
Hydrocephalus
Subdural hematoma
11. Causes in childhood:
Medical causes:
Surgical causes:
GER
gastroenteritis
CNS infections
UTI
Inborn errors of metabolism
Uremia, toxins
Cow milk protein allergy
Over feeding
Faulty feeding technique
Post nasal dripping
DKA
Psychogenic
Hepatitis, pneumonia
Intestinal obstruction
Appendicitis
ICSOL
Peritonitis
Hydrocephalus
Subdural hematoma
12. History:
Age of the patient
Duration /Frequency
Onset
Associated with food intake
Color and contents
Non digested food :proximal
obstruction
Semi digested food : distal
obstruction
instantly : esophageal
obstruction
Bilious content
: distal to 2nd
part of duodenum
After a while : stomach
or duodenal obstruction
Fecal material
: obstruction
at the large intestine
Nature (projectile / non
projectile)
Associated symptoms
Fever / Abdominal Pain /Diarrhea
/constipation/ dysphagia.
13. • Respiratory – cough, chest discomfort
• Urinary – dysuria, hematuria
• CNS – irritability, altered sensorium, drowsy, neck stiffness, headache, visual
disturbance
• Past medical history
Any known medical illness such as metabolic inborn error, cerebral palsy,
down syndrome, neurological deficit
• Drug and allergy history
• Birth history
• Nutritional history
Recently change into cow milk/ food allergy/ type of food
• Other relevant history
Recent eating outside, recent travelling, family member or friends in
school have similar illness
14. Physical Examination
General condition
Comparison of patient’s weight before and after onset of illness
Conscious level- GCS
Hydration status
Sunken fontanel
Eyes sunken and tearless
Dry mucous membrane
Prolonged capillary refill time
Reduced skin turgor
Tachycardia, tachypnea
15. Look for any evidence of any specific disorder/ disease based on history
Abdominal Examination
Distension/ Visible peristalsis
Tenderness/ hepatospelnomegaly
abdominal masses
Bowel sounds
CNS Examination
Power, Tone, reflexes
Changes in vision
Respiratory Examination
Ear examination by otoscopy
Fundoscopy
20. Management:
Asses
the severity of dehydration
Rehydrate accordingly
Correct electrolyte imbalances
Encourage oral intake
Treat according to the underlying cause
Treat cause:
23. APPROACH:
VOMITING
AGE, otitis media,
hepatitis, CNS and other
infections
fever
abnormal neurologic
examination
CNS infection,
SOL
pyloric stenosis,
intussusception,
adhesions, appendicitis,
hernia
projectile vomiting
recurrent vomiting or
poor growth or weight
loss
signs of intestinal
obstruction
diarrhea
psychogenic
migraine
Renal, metabolic
disease
medications
toxins,
drugs
gastroenteritis,
food poisoning
24. Cyclical vomiting syndrome:
Numerous episodes of vomiting interspersed with well
intervals
Onset between 2 to 5 years of age
Usually occur in the early morning or upon awakening
Tend to start about the same time of day, same length of
time and present the same symptoms at the same level of
intensity
Theories: migraine- related mechanism, mitochondrial
disorders, autoimmune dysfunction.
29. Key messages:
Differentiate
vomiting, nausea and regurgitation
Sort
out the cause for vomiting by history, examination
and investigations
r/o
surgical causes
Manage
Prevent
with IV fluids,antiemetics and treat the cause
and manage complications