Approach to vomiting (pediatrics): Clinical sciences

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Introduction 0:00–0:37

Vomiting refers to the forceful expulsion of the stomach contents that is usually related to gastrointestinal illness. But it can also be a manifestation of other systemic conditions.
Vomiting can be acute occurring over hours to days. Chronic, persisting for days to weeks or episodic, which is characterized by a pattern of acute episodes separated by asymptomatic periods.
When a pediatric patient presents with vomiting first, perform an ABCD E assessment to determine if they are stable or unstable.

Unstable patients 0:37–1:38

If unstable, stabilize the airway breathing and circulation, obtain IV access and begin IV fluids. You might also need to keep your patient NP and insert a nasogastric tube.
Finally, if needed. Put your patient on continuous vital sign monitoring and provide supplemental oxygen and antibiotics.
Next. Perform a focused history and physical examination and assess for signs and symptoms suggesting diabetic ketoacidosis or DKA.
These include polydipsia, polyuria, polyphagia, weight loss, fruity breath, dry mucous membranes and kool respirations or a rapid deep pattern of breathing.
If any of these signs and symptoms are present. Consider DKA and order labs including a basic metabolic panel, venous blood gas, urine dipstick and a serum beta hydroxybutyrate.

DKA 1:38–2:16

If the blood glucose is greater than 200 mg per deciliter ph is less than 7.3 or bicarbonate levels are less than 15 milli equivalents per liter.
The urine ketones are positive and beta hydroxybutyrate is three millimoles per liter or higher diagnosed DKA. On the other hand, if signs and symptoms of DKA are absent, consider acute surgical abdomen.

Acute abdomen 2:16–2:52

These include a sudden onset of severe acute abdominal pain with abdominal tenderness rebound and guarding. Also, you might notice a rigid abdomen.
These findings suggest peritoneal inflammation and indicate an acute or surgical abdomen. This commonly occurs as a result of appendicitis but also intussusception and incarcerated hernia.
Ok. Now, let's return to the ABCD E assessment and talk about stable patients starting with acute onset vomiting if your patient reports acute vomiting.

Stable patients 2:52–3:00

The first step is to assess for bilious emesis if present, consider intestinal obstruction and assess the underlying condition, which is often seen in the superior Mesenteric artery syndrome or pancreatitis.

Acute vomiting – bilious 3:00–3:24

First, let's focus on the superior mesenteric artery or Sma syndrome. In Sma syndrome.

SMA 3:24–4:34

The third part of the duodenum becomes compressed between the superior mesenteric artery and the aorta. This might occur due to weight loss and depletion of the mesenteric fat pad history typically reveals adolescents with early satiety, severe post prandial emesis and recent weight loss.
Remember that these individuals will typically report abdominal pain relieved by a prone or knee to chest position and the physical exam will show abdominal tenderness at this point.
Consider Sma syndrome, then obtain an upper gi series. If you see a sharp cut off sign with dilation of the first two portions of the duodenum and compression of the third with the to and fro motion of the contrast column.
Obtain an abdominal ct scan, decreased aortomesenteric angle confirms the diagnosis of Sma syndrome. Next, let's look at pancreatitis.
In this case, history will reveal no weight loss before the onset of symptoms and abdominal pain that decreases when sitting upright and worsens.

Pancreatitis 4:34–5:32

While supine patients often describe boring, sharp and knifelike epigastric pain with fever. And the physical exam typically shows epigastric tenderness with these findings.
Consider pancreatitis be sure to order labs primarily amylase and lipase levels and obtain an abdominal ultrasound. If amylase and lipase levels are elevated, usually three times normal levels and the ultrasound shows pancreatic enlargement with or without a surrounding fluid collection, diagnosed pancreatitis.
Ok. Now, let's go back and focus on Children with no bilious emesis.

Acute vomiting – not bilious 5:32–5:42

In this case, your first step is to assess for diarrhea if present, consider infectious gastroenteritis which is usually associated with fever, crampy, abdominal pain and possibly sick contacts or recent travel.

Infectious gastroenteritis 5:42–7:29

The physical exam typically demonstrates abdominal tenderness without rebound or guarding but often in combination with signs of dehydration like reduced skin turgor and dry mucous membranes.
Next, obtain stool viral antigen testing or stool culture with a microscopic examination. If you identify the causative pathogen diagnose infectious gastroenteritis on the other hand, if diarrhea is absent, assess for non gastrointestinal symptoms, the presence of urinary symptoms should make you consider a urinary tract infection.
Or uti Children with uti often have a fever and those under two months of age might have foul smelling urine and irritability.
Older infants and Children typically have dysuria, urgency and frequent urination. The physical exam often reveals body temperature above 38 °C, possibly in combination with suprapubic tenderness or costovertebral angle tenderness.
Next, obtain a urinalysis and urine culture. If the urinalysis is positive for leukocyte esterase and nitrites and the culture grows more than 50,000 colony forming units per milliliter, diagnose urinary tract infection.
Finally, let's discuss patients with acute vomiting and sore throat. In this case, consider group a streptococcal pharyngitis.

Strep pharyngitis 7:29–8:21

If your patient reports fever, headache and sore throat and their exam shows pharyngeal erythema, possibly with tonsillar exudates in cervical lymphadenopathy, then perform a rapid strep test.
A positive test confirms group a streptococcal pharyngitis. Here is a clinical pearl.
Other infections like acute hepatitis and pneumonia can also cause vomiting. Many Children with respiratory infections also have posttussive emesis which is triggered by forceful coughing.
Ok. Now, let's take a look at patients with chronic vomiting to narrow your differential start by assessing for a change in bowel habits.

Chronic vomiting 8:21–8:40

First, let's discuss conditions characterized by a change in bowel habits like celiac disease and constipation. Starting with celiac disease history typically reveals bloating and diarrhea, sometimes in combination with constipation and steatorrhea.

Celiac disease 8:40–9:40

Your patient might also have an autoimmune condition or a family history of celiac disease. The physical exam might reveal abdominal distension as well as short stature and delayed puberty.
With these findings consider celiac disease. Next, obtain total iga levels and anti TTG IGA and perform an esophagogastroduodenoscopy with biopsies if total IGA levels are normal anti T TGI G A is positive in the biopsy shows villous atrophy crypt hyperplasia and increased intraepithelial lymphocytes diagnose celiac disease.
On the other hand, Children with constipation typically present with infrequent bowel movements, straining during defecation and hard stool consistency.

Constipation 9:40–10:05

The physical exam might show mild abdominal distension, a palpable stool mass or fecal impaction. These findings are suggestive of constipation.
On the flip side. If your patient reports no change in bowel habits, first, assess the association of vomiting with oral intake emesis that immediately follows eating should make you consider eosinophilic esophagitis.

Eosinophilic esophagitis 10:05–10:56

The vomitus will contain undigested food in the history might reveal asthma, allergic rhinitis or eczema. In some cases, patients might report poor weight gain.
Next, perform an upper endoscopy and biopsy. If the endoscopy reveals inflammation of the esophagus and a ringed appearance and the biopsy shows 15 or more eosinophils per high power field diagnose eosinophilic esophagitis.
On the other hand, if your patient has emesis minutes to hours after eating, consider gastroparesis, the history will reveal nausea, early satiety and possibly a recent viral illness.

Gastroparesis 10:56–11:50

The exam usually demonstrates abdominal distension and occasionally tenderness. Next.
Obtain an upper gi series if there is no evidence of mechanical obstruction, perform a scintigraphic gastric emptying scan, delayed gastric emptying confirms the diagnosis of gastroparesis.
Here's one more clinical pearl gastritis is another common cause of chronic vomiting. And patients with ulceration may have coffee ground emesis or Melana.
Finally, let's focus on episodic vomiting in this case, assess for early morning vomiting and if present, assess for signs and symptoms, suggesting increased intracranial pressure.

Episodic vomiting 11:50–12:18

These include headache, diplopia, altered mental status, visual field defects as well as papilledema and focal neurologic deficits.
If you identify any of these findings, consider increased intracranial pressure and obtain a head ct scan. If you see edema, possibly with a mass hemorrhage infarction or ventriculomegaly, diagnose increased intracranial pressure, which typically occurs as a result of meningitis, brain tumor and head trauma.

Increased ICP 12:18–12:45

On the other hand, if your patient has early morning vomiting without signs of increased intracranial pressure, consider cyclic vomiting syndrome.

Cyclic vomiting syndrome 12:45–13:59

These patients have intense acute bouts of vomiting lasting hours to days, but they're symptom free between episodes. Moreover, some patients might report pallor photophobia or headaches during these episodes.
Finally, history might reveal a family history of migraine headaches. The exam might reveal tachy mucous membranes or decreased skin turgor during an acute episode to confirm the diagnosis, assess the Rome four criteria for cyclic vomiting syndrome.
These criteria state that each patient has stereotypical episodes of vomiting as well as three or more discrete episodes of emesis in the past year and two episodes in the past six months occurring at least one week apart.
If the patient meets the criteria, diagnose cyclic vomiting syndrome. On the other hand, if there's no history of early morning vomiting, assess the relation of emesis to your patient's oral intake.

Eating disorder 13:59–14:46

If emesis occurs after binge eating, consider an eating disorder. These patients usually have distress related to both eating and body image and some report recent weight loss or a change in mood.
The physical exam might show parotid gland enlargement, dental caries or scars on the dorsum of the fingers. In this case, continue with a validated screening tool such as the eating disorders, examination, a positive screen confirms an eating disorder.
Now, let's consider vomiting that occurs after fluid consumption. This should make you consider ureteropelvic junction obstruction history usually reveals unilateral flank pain and symptoms that resolve with diuresis.

UPJ obstruction 14:46–15:20

While the exam might show costovertebral angle tenderness. Next, obtain a renal ultrasound.
And if it shows hydronephrosis during an episode, diagnose ureteropelvic junction obstruction. Finally, let's discuss emesis, not related to oral intake.

CHS 15:20–15:58

In this case, assess the patient for possible substance use if they use marijuana daily, consider cannabinoid hyperemesis syndrome.
These patients are usually adolescents who report intense and frequent vomiting as well as a history of hydrophilia, which means their symptoms are relieved by warm showers.
Exam findings are typically normal. These findings are suggestive of cannabinoid hyperemesis syndrome.
All right. As a quick recap.

Review 15:58–16:55

In most cases, patients presenting with vomiting will be stable but sometimes vomiting can also be a manifestation of severe systemic conditions, including diabetic ketoacidosis and acute abdomen.
Now, acute vomiting is often associated with sma syndrome, pancreatitis, infectious gastroenteritis, uti and group A streptococcal pharyngitis.
While chronic vomiting can be related to celiac disease, constipation, eosinophilic esophagitis and gastroparesis. Finally, episodic vomiting can be associated with increased ICP cyclic vomiting syndrome, eating disorders, ureteropelvic junction, obstruction or cannabinoid hyperemesis syndrome.