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P34 Pediatrics
Gastroenterology
Toronto Notes 2019
Vomiting: forceful expulsion of stomach contents through the mouth
Regurgitation: the return of partially digested food from the stomach to the mouth
Gastroenterology
Vomiting
History
• characteristicofemesis(e.g.projectile,bilious,bloody)
• patternofemesis(e.g.associationwithfeeds,cyclic,morning)
• associated symptoms (e.g. anorexia, diarrhea, etc.)
• red flags: bilious or bloody emesis, projectile vomit, abdominal distension and tenderness, high fever,
signs of dehydration
• notethatvomitingwithoutdiarrheaismostlikelynotgastroenteritis
■ post tussive vomiting is also common with coughing fits in children
• vitalsignstodetermineclinicalstatusandhydrationstate
Pyloric Stenosis 3 Ps
Palpable mass
Peristalsis visible
Projectile vomiting (2-4 wk after birth) Investigations
Physical Findings
• CBC,electrolytes,BUN,Cr,amylase,lipase,glucosedoneroutinely
• insickchild,add:ESR,venousbloodgases,C&S(blood,stool),imaging
Table 15. Common Differential Diagnosis, Associated Findings, and Diagnostic Approach Based on Age
Cause
NEONATES – NON-BILIOUS
Tracheoesophageal Fistula Pyloric stenosis
GERD
Sepsis
Inborn error of metabolism
NEONATES – BILIOUS
Intestinal obstruction – malrotation with volvulus, meconium ileus
Duodenal atresia/stenosis Hirschsprung’s disease
CHILDREN AND ADOLESCENTS
Acute viral gastroenteritis Appendicitis Intussusception
Non-GI infection (e.g. meningitis)
Increased ICP
Toxic ingestion Pregnancy Cyclic vomiting
Suggestive Findings
Vomiting, excessive secretions soon after birth (e.g. drooling, choking, respiratory distress), inability to feed, inability to advance NG tube
Projectile vomiting immediately after feeding, dehydrated, palpable “olive” in RUQ, decreased stools, hunger
Fussiness after feeds, spit ups, arching of back, poor weight gain
Fever, lethargy, tachycardia, tachypnea, widening pulse pressure
Poor feeding, FTT, jaundice, hepatosplenomegaly, cardiomyopathy, dysmorphia, developmental delay
Bilious emesis, abdominal distension, pain, bloody stool, shock
Bilious emesis, abdominal distension, often seen in DS, jaundice, polyhydramnios during pregnancy. Hypokaelmic, hypochloremic metabolic alkalosis.
Bilious emesis, abdominal distension, pain, failure to pass stool
Diarrhea, fever, sick contact, recent travel
Periumbilical discomfort that later localizes to RLQ, fever, anorexia
Colicky progressive abdominal pain, drawing of legs up to chest, lethargy, bloody “red currant jelly” stool (Triad)
Fever, localized findings depending on cause
Nocturnal wakening, progressive recurrent headache worse with Valsalva, nuchal rigidity
Finding possibly varying by substance- toxidrome, often a history of ingestion Amenorrhea, morning sickness, bloating, breast tenderness
At least 3 self-limited episodes of vomiting lasting 12 h, 7 d between episodes, no organic cause of vomiting
Management
Diagnostic Approach
Inability to advance NG tube, CXR, upper GI series with water-soluble contrast
U/S of pylorus, upper GI study (if U/S not diagnostic)
Electrolytes, ABG (hypokalemic, hypochloremic metabolic alkalosis)
Empiric trial of acid suppression, pH monitoring study, upper GI study, endoscopy
CBC, cultures (blood, urine, CSF), CXR
Electrolytes, ABG (hyponatremic, hyperkalemic metabolic acidosis), lactate, ammonia, LFTs, BUN, Cr, serum glucose, bilirubin, PT/PTT, CBC
AXR, upper GI series, contrast enema
AXR, upper GI series (‘double bubble’ sign)
AXR, upper GI series, contrast enema, rectal biopsy
CBC, stool culture Abdominal U/S Abdominal U/S
Cultures (CSF, blood, urine), brain imaging, CXR
Brain CT without contrast
Therapeutic LP in idiopathic intracranial HTN
Qualitative and sometimes quantitative levels (urine, blood) Urine β-hCG
Diagnosis of exclusion
• rehydration(seeFluidsandElectrolytes,P32) • treatunderlyingcause
■ antiemetic drugs can be used in children >2 yr with severe vomiting is severe: promethazine, prochlorperazine, metoclopramide, ondansetron