Vomi%ng

in Infant

Hugo Sousa Rafaela Parreira Slvia Farraposo Ta5ana Queirs

Pediatrics, May 2012

 Summary

Deni5ons Clinical history & Physical examina5on Main pathologies Conclusion

Pediatrics

 Deni%ons
Encompasses all retrograde ejec5on of gastrointes5nal, or esophageal , contents from the mouth Subdivided according to its forcefulness
None Minimal Moderate Severe Esophageal emptying Regurgita5on Vomi5ng Projec5le vomi5ng with retching

Pediatrics

 Vomi%ng in Infant

Clinical History

Physical Examina%on

Hospitaliza%on

Pediatrics

 Clinical History

ant? ld is the inf How o ealth? e general h h How is t ng like? the vomi% What is Volume cy Frequen Content d of the day Perio ons ral associa5 i5ng Tempo reduce vom res to Procedu ms? ted sympto associa Are there

Pediatrics

 Physical Eno lactente Vmitos xamina%on

Although vomi5ng is a gastrointes5nal symptom, it can be a manifesta5on of disease in mul5ple systems of the body
n mina%o l exa Genera r Feve rythm iac Card a5on ir Resp i Fund examina%on al bdomin A Pain ness er Tend 5on en on D i st hydra% f de Signs o
Pediatrics

 Criteria for Hospitalar actente Vmitos no l Admission

on hydra5 i5ng re de Seve trollable vom on Unc to feed n f u se ydra5o o reh Re rance t le Into ng ethiology i5 Vom environment al Soci

Pediatrics

 Complica%ons of Vomi%ng

Esophagi5s Nutri5onal Aspira5on Metabolic Mallory- Weiss tear Shock

Pediatrics

 Dieren%al Diagnosis of Vomi%ng

Main Causes Physiologic reux/GERD Gastroenteri5s Malrota5on/Midgut volvulus/Intussuscep5on Obstruc5on/Pyloric stenosis Metabolic disorders UTI Dietary protein intolerance Increased intracranial pressure Hepatobiliary disease Pancrea55s Rumina5on Munchausen syndrome by proxy

Pediatrics

 Vomi%ng in Infant

Pathologies
Neurologic Neurosurgery

Surgical

Gastrointes%nal

Infec%ous

Metabolic

Pediatrics

 Vomi%ng in Infant

Pathologies
Neurologic Neurosurgery

Surgical

Gastrointes%nal

Infec%ous

Metabolic

Pediatrics

Hypertrophic pyloric stenosis

Surgical Pathology

Narrowed (stenosed) pyloric sphincter

Junc%on of stomach and duodenum

Pediatrics

Hypertrophic pyloric stenosis

Surgical Pathology

Whites Northern Europe Males First-borns TEF Hypoplasia/agenesis ILF

Family History Mother who had HPS Blood group Types B, O

Pediatrics

Hypertrophic pyloric stenosis

Surgical Pathology

Usually not present at birth More concordant in monozygo5c twins

Nitric oxide Prostaglandins Muscle innerva5on Infant hypergastrinemia

Pediatrics

Hypertrophic pyloric stenosis

Surgical Pathology

Nonbilious vomi5ng AQer 3 weeks of age 1st week 5th month Progressive Imediately acer feeding May follow each feeding Intermibent

Hypochloremic metabolic alkalosis

Chronic malnutri%on Severe dehydra%on

Pediatrics

Hypertrophic pyloric stenosis

Surgical Pathology

Palpate pyloric mass

Gastric peristal5c wave

Ultrasound

Contrast studies

Olive shaped 2 cm in length

Sensi5vity of 95% Pyloric thickness > 4 mm

Elongated pyloric channel Shoulder sign

Double Pyloric lenght > 14 m the Mid epigastrum The diagnosis can be established clinically 60-80% of m %me by an tract sign

experienced examiner

Pediatrics

Hypertrophic pyloric stenosis

Surgical Pathology

Preopera%ve treatment

Surgical treatment Pyloromyotomy Cura5ve

Intravenous uid therapy Rehidrated [HCO3-] < 30 mEq/dL

Pediatrics

Surgical Pathology
Intes%nal obstruc%on

Nonbilious vomi5ng

Bilious emesis

Proximal obstruc%on Duodenal obstruc5on Anular pancreas

Distal obstruc%on Malrota%on/volvulus Intussuscep5on Intes5nal atresia Hirschsprung disease

Pediatrics

Surgical Pathology
Malrota%on/volvulus

During fetal development Cecum Midgut volvulus Duodenal obstruc%on

Pediatrics

Surgical Pathology
Malrota%on/volvulus

1st year of life

Bilious emesis

Abdominal pain

Pa%ents of any age with a rota%onal anomaly can develop acute bowel threatening volvulus without pre-exis%ng symptoms

Pediatrics

Surgical Pathology
Malrota%on/volvulus

Ultrasound
Inversion of the superior mesenteric artery and vein Malrota%on with volvulus Duodenal obstruc5on Thickened bowel loops to the right of the spine Free peritoneal uid

Contrast studies

Pediatrics

Surgical Pathology
Malrota%on/volvulus

Surgical treatment

Persistent symptoms

Pseudo-obstruc%on-like mo%lity disorder

Regardless of age Immediately if volvulus

Pediatrics

 Vomi%ng in Infant

Pathologies
Neurologic Neurosurgery

Surgical

Gastrointes%nal

Infec%ous

Metabolic

Pediatrics

Gastrointes%nal Pathology
Gastroesophageal reux

Recurrent post-prandial spi\ng and vomi%ng in healthy infants that resolves spontaneously

Evident at 1st months of life (peak 4mo) Resolve in most cases by 12mo Pediatrics

Gastrointes%nal Pathology
Gastroesophageal reux

Thickened Feeds

Upright posi5oning acer feeds

Hypoallergenic Diet

Pediatrics

Gastrointes%nal Pathology
Gastroesophageal reux disease

Poor weight gain

Irritability

Feeding refusal

Recurrent stridor Chronic cough Apparent life-threatening event (ALTE)

Pediatrics

Gastrointes%nal Pathology
Gastroesophageal reux disease

Esophageal pH Impedance monitoring

Radiographic studies

Endoscopic studies

Pediatrics

Gastrointes%nal Pathology
Gastroesophageal reux disease

Lifestyle changes

Pharmacotherapy Prokine5c agents H2 receptor antagonists Proton-pum inhibitor

Surgery

Pediatrics

Gastrointes%nal Pathology
Gastroenteri%s

Parasi5c agents

Bacterial agents

Isospora belli Cryptosporidium Giardia

Campylobacter jejuni C. upsaliensis Salmonella strains Escherichia coli

Enteric virus Rotavirus Calicivirus Astrovirus Enteric adenovirus Some picornavirus

Pediatrics

Gastrointes%nal Pathology
Gastroenteri%s

Pediatrics

Gastrointes%nal Pathology
Gastroenteri%s

Pediatrics

Gastrointes%nal Pathology
Gastroenteri%s

Absence of gross blood, mucus and fecal leukocytes Water diarrhea Stool pH <6

Age <2

Virus

Reducing Substances

Pediatrics

Gastrointes%nal Pathology
Gastroenteri%s

Oral/intravenous uid therapy Enteral feeding Zinc supplementa%on Probio%cs

Pediatrics

Gastrointes%nal Pathology
Gastroenteri%s

Pediatrics

 Vomi%ng in Infant

Pathologies
Neurologic Neurosurgery

Surgical

Gastrointes%nal

Infec%ous

Metabolic

Pediatrics

Infec%ous Pathology
Urinary t ract infec%on

Clinical Manifesta5ons Epidemiology 8% of girls and 2% of boys will acquire UTIs in childhood Diagnosis Urinalysis Uroculture E5ology E coli (>85%) Treatment An5bio5c Non specic

Pediatrics

 Vomi%ng in Infant

Pathologies
Neurologic Neurosurgery

Surgical

Gastrointes%nal

Infec%ous

Metabolic

Pediatrics

 Neurologic & Neurosurgical Pathology

Subdural hematoma

Hydrocephalus

Cerebral edema

Pediatrics

 Vomi%ng in Infant

Pathologies
Neurologic Neurosurgery

Surgical

Gastrointes%nal

Infec%ous

Metabolic

Pediatrics

 Metabolic Pathologies

Symptoms Progressive vomi5ng Severe dehydra5on Cyclic vomi5ng Changes in consciousness Neurological signs and symptoms

Diseases Diabe%c ketoacidosis Adrenal insuciency

Galactosemia, fructosemia

Pediatrics

 Conclusion

Vomi5ng
Clinical history Physical examina5on Level of dehydra5on Vomi5ng with symptoms No red ags Fever, diarrhea, respiratory symptoms, ORL, urinary

Isolated vomi5ng Dehydra5on Mild Moderate Frac5onated oral hydra5on Persistent vomi5ng Severe Urinary test Ionogram Renal func5on Fluid therapy

Red ags Shock Bilious emesis Hematemesis Drowsiness Severe abdominal pain/disten5on Acute liver dysfunc5on Respiratory troubles Refusal to feed Malnutri5on Dehydra5on

Frac5onated oral hydra5on Fluid therapy ev Inves5ga5on and focal treatment

 Keep in mind

Vomi5ng and regurgita5on are commonly encountered symptoms in childrens Most commonly vomi5ng is the result of acute, self-resolving ilnesses In some cases, the features of vomi5ng allow to dis5nguish the main causes Hypertrophic pyloric stenosis, gastroenteri5s and EGR are the most common diseases in infants Always keep in mind RED FLAGS!

Pediatrics

 Bibliography
Pediatrics: Current Diagnosis &Ttreatment. William Hay, Myron Levin, Judith Sondheimer and Robin Deterding, 19th Edi5on , Lange LangePaediatrics and Child Health. Mary Rudolf and Malcolm Levene, 2nd Edi5on, Blackwell Publishing 2006 Prac9cal Strategies in Pediatric Diagnosis and Therapy. Larry A. Greenbaum and Patricia S. Lye, 2nd Edi5on, Elsevier Inc. 2004 Kliegman: Nelson Textbook of Pediatrics. Robert M. Kliegman, Richard E. Behrman Hal B. Jenson, Bonita F. Stanton, 18th Edi5on, Elsevier 2007 Urgncia Peditrica Integrada do Porto UPIP. Administrao Regional de Sade do Norte, I.P, 2008 UpToDate in Pediatrics. Sheldon Kaplan et. al, Wolters Klower 2012

Pediatrics

Vomi%ng in Infant

Hugo Sousa Rafaela Parreira Slvia Farraposo Ta5ana Queirs

Pediatrics, May 2012