Vomiting in Children

Posted by e-Medical PPT
Vomiting is a symptom, presenting complaint in multitude of disorders
 Range from gastrointestinal pathology to disease in distant organ (otitis media or intracranial lesion)
In children, especially infants, must distinguish from regurgitation – effortless expulsion of gastric contents
Integrated response to noxious stimuli, coordinated by central nervous system

Centres responsible for vomiting
Vomiting centre
Nucleus solitarius and series of nuclei in brainstem medulla
Stimulation results in
 integrated motor responses involved in vomiting
 associated vasomotor activity (pallor, flushing), salivation, bulbar responses
Afferent input arises from
 posterior pharynx, GIT, brain

Chemoreceptor trigger zone
 Stimulated by humoral stimuli such as opiates, cytotoxins, ketones, ammonia
 Lies in area postrema – floor of 4th ventricle, outside blood-brain barrier
 Processes most of afferent input for the vomiting centre
Receptors and neurotransmitters involved   
 Dopamine (D2), histamine (H1), serotonin (5-HT3), vasopressin, substance P

Diagnostic evaluation
Before finding cause of vomiting, in any child should first
 Assess hydration status, attend to life-threatening complications
 Ascertain whether
  Bilious – suggests gastrointestinal obstruction
  Blood is present – diagnosis and management different
  If non-bilious and non-bloody, 2 important variables => temporal pattern and age of patient

Recurrent vomiting
Ongoing underlying pathology, therefore may be more worrying
Numerous causes
 GIT
  Infections – H. pylori, Giardia, oesophageal candidiasis
  Hepatitis, pancreatitis, partial intestinal obstruction
 Metabolic, neurologic, renal

Cyclic Vomiting Syndrome (CVS)
Paroxysmal, especially severe, recurrent vomiting disorder
Mysterious disorder, unknown aetiology, and pathophysiology
Substantial increase in interest and understanding of disease in past decade
Previously considered rare, may be 2nd only to GORD as cause of recurrent vomiting in children

Under-recognised
 No specific laboratory, radiographic or endoscopic markers for CVS
 Typically misdiagnosed for years – viral GE, food poisoning, GORD, psychogenic vomiting => leads to inappropriate therapy
  Surgery
  Psychiatric hospitalisation
  Very distressing to patients and families
Prevalence
Being diagnosed with increasing frequency, but actual prevalence remains unknown
0.04-2% among school-aged children
Overdiagnosed sometimes, and often underdiagnosed

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