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Introduction
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.
Regurgitation:The act by which food is brought back into the mouth without the
abdominal and diaphragmatic muscular activity that characterizes vomiting.
Introduction
Neurophysiology
Nausea and vomiting are innate responses that induce a learned and conditioned
aversion to ingested toxins
There are four major pathways by which nausea and vomiting are induced.
Vagal afferents
Area postrema
Vestibular system
Amygdala
Vagal Afferents
Area Postrema
Vestibular System
Somatomotor Events
Diagnosis by Age
Diagnosis by Age
Forceful and repeated vomiting in newborns is not normal and should be taken
seriously, particularly if there are other signs of illness (eg, fever, weight loss, or
feeding refusal).
Although much less common, inborn errors of metabolism also can present with
vomiting.
Gastroesophgeal Reflux
Disease
No features definitively identify these infants, but they may have recurrent fussiness
or irritability and feeding aversion.
These symptoms are thought to result from pain caused by esophageal acid exposure.
Gastroesophgeal Reflux
Disease
Poor weight gain despite an adequate intake of calories should prompt evaluation for
causes of vomiting and weight loss other than GERD.
However, in some infants the dietary protein causes an enteritis, with or without
associated colitis, and affected infants may present with vomiting.
Intestinal Obstruction
Intestinal Obstruction
Intestinal Obstruction
Pyloric Stenosis
Pyloric Stenosis
Pyloric Stenosis
Hirschsprung Disease
Hirschsprung Disease
Gasteroparesis
It is the condition of impaired emptying of gastric contents into the duodenum in the
absence of a mechanical obstruction; this may cause postprandial vomiting.
In gastroparesis the vomiting usually occurs many hours after ingestion of food, a
characteristic that differentiates this entity from GER or rumination syndrome, in
which the emesis is during or immediately after eating.
Gasteroparesis
Intussusception
The episodes become more frequent and more severe over time.
Intussusception
Intussusception
Infections
Intracranial
Hypertension
Brain tumors and other intracranial masses can cause nausea, vomiting, or both, by
increasing the intracranial pressure at the area postrema of the medulla.
Intracranial
Hypertension
In older children, headache is a more common chief complaint in older children and
frequently is described as being pulsatile, occasionally awakening the child from
sleep. Associated nausea or vomiting may be present, as may neck or retroocular
pain that is worse with eye movement.
Munchausen Syndrome
by Proxy
Also known as factitious disorder by proxy, Meadow syndrome, and proxy factitia
The patient may have a history of frequent recurrent illnesses without a clear etiology
Adolescents
Clinical Approach
Clinical Approach
Clinical Approach
Clinical Approach
Clinical Approach
A detailed history and astute clinical acumen are necessary to narrow down the
diagnostic possibilities.
The appropriate urgency depends on duration of illness, overall clinical status of the
patient (especially hydration, circulatory, and neurologic status) and associated
findings on the physical examination and history.
Clinical Approach
Prolonged vomiting (>12 hours in a neonate, >24 hours in children younger than
two years of age, or >48 hours in older children) should not be ignored. Screening
laboratory tests should include: Additional testing should be based upon the
history and physical examination
complete blood count
electrolytes,
blood urea nitrogen,
amylase, lipase,
liver function tests,
urinalysis, urine culture, and stool studies for occult blood, leukocytes, and
parasites.
Clinical Approach
Clues on physical examinationCertain physical findings may offer diagnostic clues
that can aid in narrowing the differential diagnosis:
A tense, bulging fontanelle in a neonate or young infant should increase the
level of suspicion for meningitis.
Clinical Approach
An unusual odor emanating from the patient should prompt an
investigation for metabolic causes of vomiting.
Marked distension, visible bowel loops, absent bowel sounds, green or
yellow bile, or increased "rumbling" bowel sounds ("borborygmi") should raise
suspicion for intestinal obstruction.
Enlarged parotid glands in an adolescent should raise suspicion for bulimia
Laboratory
Investigations
Referrals
When to refer the patient?
Treatment
Likewise, they are not indicated for anatomic abnormalities or surgical abdomen.
Treatment
Clinical Approach
Instead, antiemetics are most useful for motion sickness, postoperative vomiting,
cyclic vomiting syndrome, and gastrointestinal motility disorders .
In addition, a double-blind study suggests that single dose ondansetron may facilitate
oral rehydration in children with gastroenteritis who are unable to tolerate oral
intake.
During the last two decades, there have been considerable advances in the
development of antiemetics. These include the emergence of 5-hydroxytryptamine 3
receptor antagonists (Ondansetron, Granisetron), which have one primary site of
antagonism and have helped in the treatment of post-operative nausea and vomiting
and chemotherapy-associated emesis.
These include neurokinin 1 receptor antagonists that likely mediate nausea and
vomiting triggered by chemotherapeutic agents, motion, gastric irritants, and other
stimuli .
Alternative Medicine
There is some evidence for efficacy of some nutraceuticals, such as ginger for
functional dyspepsia and other motility disorders.
Hypnotherapy is often helpful for treatment of anticipatory nausea and vomiting (eg,
prior to chemotherapy).
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