Vomiting

  • Vomiting is a prominent feature of many disorders of infancy and childhood and is often the only presenting symptom of many diseases.
  • Vomiting can be:
    • A defense mechanism to expel ingested toxins
    • An abnormality of the vomiting center related to increased intracranial pressure
    • A result of intestinal obstruction or anatomic/mucosal abnormalities
    • The result of a generalized metabolic disease
  • A full history should include medication and drug use, trauma, family history of migraines and, in adolescents, questions regarding feeding disorders (bulimia) and intercourse (pregnancy). Special attention should be directed to the timing of the emesis related to meals or position.

Signs and Symptoms

History

  • Fever: Infectious causes of vomiting are common.
  • Abdominal pain and frequent, forceful, or bilious emesis: Often associated with anatomic or obstructive intestinal disorder
  • Age of patient: Pyloric stenosis and inborn errors of metabolism almost always present in infancy with vomiting, dehydration, and biochemical abnormalities
  • Mental retardation, pica, and patchy baldness: Indicate foreign body or hair ingestion and the development of a gastric bezoar
  • Nausea and epigastric pain related to meals: Often indicate gastritis, gastric emptying delay, or gallbladder disease
  • Alleviated by meals: May signify gastroesophageal reflux and gastric ulcer disease
  • Alternating vomiting and lethargy: May indicate intussusception
  • Chronic headaches, fatigue, weakness, weight loss, and early morning vomiting: Neurologic causes of vomiting secondary to increased intracranial pressure
  • Right- or left-sided abdominal pain: May indicate renal disease, inflammatory bowel disease
  • Chronicity on a monthly basis may suggest a cyclic vomiting syndrome.

Physical Exam
A careful and complete physical examination can often provide excellent clues as to the cause of vomiting in children:
  • Visible bowel loops: Obstruction
  • Palpation for a mass effect and tenderness, and auscultation for evidence of absent bowel sounds or borborygmi (rumbling bowel sounds): Intestinal obstruction
  • Rectal examination: Testing the stool for occult blood
  • Discoloration of skin and sclera: Jaundice (liver/gallbladder or metabolic disease)
  • Orange tint of sclera or skin: Hypervitaminosis A
  • Unusual odor: Metabolic disease
  • Chronic vomiting: Evidence of neurologic dysfunction, including nystagmus, head tilt, papilledema, abnormal reflexes, and weakness
  • Tense anterior fontanelle: May indicate meningitis, hydrocephalus, or vitamin A toxicity
  • Enlarged parotid glands and hypersalivation: Bulimia and other feeding disorders
  • Pelvic examination: Pregnancy, pelvic inflammatory disease, or ovarian disease

Tests

Lab

  • CBC: Anemia and iron deficiency can occur with intestinal duplication and obstruction, gastritis/esophagitis, and ulcer disease.
  • Blood chemistry:
    • Electrolyte abnormalities are found in pyloric stenosis and metabolic abnormalities.
    • An elevated alanine aminotransferase, total bilirubin, and γ-glutamyl transferase can indicate liver, gallbladder, or metabolic disease.
  • Urinalysis: Pyelonephritis, nephrolithiasis
  • Amylase: Pancreatitis
  • BUN/creatinine: If elevated, renal disease
  • Urine culture: UTI

Imaging
  • Plain abdominal radiographic study: Obstruction
  • Abdominal ultrasound:
    • Liver, gallbladder, renal, pancreatic, ovarian, or uterine disease
    • In infants, abdominal ultrasound is the test of choice for pyloric stenosis.
    • Useful when considering abdominal abscess and appendicitis
  • Contrast radiography: Intestinal anatomic abnormalities (malrotation, intussusception, volvulus)
  • Gastric emptying study to evaluate gastric motility
  • Computed tomography: Not generally indicated for evaluation of vomiting, although it is an effective tool when more anatomic abdominal detail is required (abscess, tumor)

Diagnostic Procedures/Surgery
  • Endoscopy: Esophageal, gastric, and duodenal inflammation (esophagitis, gastritis, ulcer disease, celiac disease, eosinophilic enteritis) as well as for obtaining cultures for unusual infections (duodenal Giardia, Helicobacter pylori/cytomegalovirus gastritis)
  • Gastroesophageal manometry to evaluate for primary or secondary motility disorders

Differential Diagnosis

  • Disorders of GI tract:
    • Anatomic:
      • Esophageal: Stricture, web, ring, atresia
      • Stomach: Pyloric stenosis, web, duplication
      • Intestine: Duodenal atresia, malrotation, duplication
      • Colon: Hirschsprung disease, imperforate anus
    • Motility:
      • Achalasia
      • Gastroesophageal reflux
      • Intestinal pseudo-obstruction
    • Obstruction:
      • Foreign body/bezoar
      • Intussusception
      • Volvulus
      • Incarcerated hernia
    • Cholecystitis or cholelithiasis
    • Eosinophilic enteritis
    • Appendicitis
    • Necrotizing enterocolitis
    • Peritonitis
    • Celiac disease
    • Peptic ulcer
    • Trauma:
      • Duodenal hematoma
      • Pancreatitis (pseudocyst)
  • Neurologic:
    • Intracranial mass lesions:
      • Tumor
      • Cyst
      • Subdural hematoma
    • Cerebral edema
    • Hydrocephalus
    • Pseudotumor cerebri
    • Migraine (head, abdominal)
    • Seizures
  • Renal:
    • Obstructive uropathy:
      • Ureteropelvic junction obstruction
      • Hydronephrosis
      • Nephrolithiasis
    • Renal insufficiency
    • Glomerulonephritis
    • Renal tubular acidosis
  • Metabolic:
    • Inborn errors of metabolism:
      • Galactosemia
      • Fructose intolerance
      • Hereditary fructose intolerance
      • Amino acid or organic acid metabolism
      • Urea cycle defects
      • Fatty acid oxidation disorders
      • Lactic acidosis
  • Infection:
    • Sepsis
    • Meningitis
    • UTI
    • Parasites
    • Giardia
    • Ascaris
    • H. pylori
    • Otitis media
    • Viral/Bacterial
    • Gastroenteritis
    • Viral hepatitis (A, B, C)
    • Pneumonia
    • Bordetella pertussis
  • Endocrine:
    • Diabetes:
      • Diabetic ketoacidosis
      • Gastroparesis
    • Adrenal insufficiency
  • Respiratory:
    • Sinusitis
    • Laryngitis
  • Immunologic:
    • Food allergy
    • Graft-versus-host disease
    • Chronic granulomatous disease
  • Other:
    • Pregnancy
    • Rumination
    • Bulimia
    • Psychogenic
    • Cyclic vomiting syndrome
    • Overfeeding
    • Pain
    • Medications:
      • Drugs (chemotherapy)
      • Vitamin toxicity
    • Vascular (superior mesenteric artery syndrome)

ALERT
Evidence of hematemesis, intestinal obstruction (bilious vomiting), dehydration, neurologic dysfunction, or an acute abdomen should be treated as a medical emergency, and hospitalization should be considered.