Vomiting

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CHAPTER 29 Vomiting

Martha S. Wright, MD

1 What is the pathophysiology of vomiting?

True vomiting is the forceful elimination of gastrointestinal contents through the mouth or nose. Vomiting is caused by coordinated diaphragmatic and abdominal contractions in conjunction with pyloric constriction and gastroesophageal relaxation. This motor activity occurs in response to stimulation of the medullary “vomiting center” by impulses from a variety of anatomic locations. Sources of these impulses include the pelvic and abdominal viscera, the heart, the peritoneum, the labyrinth, and the “chemoreceptor trigger zone,” an area on the floor of the fourth ventricle that is sensitive to circulating drugs, toxins, and metabolic derangements.

2 What is the clinical difference between vomiting and “spitting up”?

It is important to differentiate vomiting from “spitting up” because the causes of spitting up are rarely serious while vomiting may indicate a potentially life-threatening condition. Spitting up is characterized by effortless regurgitation of stomach or esophageal contents and in most infants and children is due to gastroesophageal reflux or overfeeding. Vomiting, on the other hand, is forceful, may be accompanied by retching, and is frequently associated with autonomic symptoms, such as salivation, pallor, sweating, tachycardia, and mydriasis.

KEY POINTS: FORCEFUL VOMITING

1 Effortless regurgitation is usually caused by non–life-threatening conditions.

2 Forceful vomiting may be associated with more serious conditions, such as gastrointestinal obstruction, metabolic disease, or toxic ingestions.

3 What is the differential diagnosis of vomiting in the pediatric patient?

Vomiting may be caused by abnormalities in a variety of organ systems. When preschool-aged patients report “vomicking,” they help us to remember the wide-ranging differential diagnosis with the following mnemonic:

image V = Vestibular: labyrinthine disorders, otitis media

image O = Obstruction: malrotation, volvulus, adhesions, intussusception, obstipation, pyloric stenosis, incarcerated hernia, intestinal atresias, annular pancreas, duodenal hematoma

image M = Metabolic: diabetic ketoacidosis, inborn errors of metabolism (e.g., urea cycle defects, carbohydrate or amino acid metabolic defects), congenital adrenal hyperplasia, Reye’s syndrome

image I = Infection/Inflammation: gastrointestinal (appendicitis, hepatitis, pancreatitis, cholecystitis, gastroenteritis, gastritis, necrotizing enterocolitis) or extragastrointestinal (upper respiratory tract infections, sinusitis, pharyngitis, pneumonia, sepsis, cystitis, asthma)

image C = Central nervous system disease: increased intracranial pressure (brain tumor, intracranial hematoma, cerebral edema), hydrocephalus, meningitis, pseudotumor cerebri, concussion, migraine, ventriculoperitoneal shunt malfunction

image K = Kidney disease: acute renal failure, chronic renal failure, pyelonephritis, renal calculi, renal tubular acidosis, obstructive uropathy

image I = Intentional: eating disorders, rumination

image N = Nasty drugs/poisons: chemotherapeutics, ipecac, iron, salicylates, organophosphates, theophylline, alcohols, lead and other heavy metals, poisonous mushrooms

image G = Other GI/GU/GYN causes (GI [gastrointestinal]: gastroesophageal reflux, formula intolerance, peptic ulcer disease, cyclic vomiting syndrome; GU [genitourinary]: testicular torsion, epididymitis; GYN [gynecologic]: dysmenorrhea, ovarian torsion, pregnancy, pelvic inflammatory disease)

Furnival RA: Vomiting. In Harwood-Nuss A, Linden CH, Luten RC, et al (eds): The Clinical Practice of Emergency Medicine, 2nd ed. Philadelphia, Lippincott-Raven, 1996, pp 1265–1267.

4 The differential diagnosis for vomiting depends on the age of the pediatric patient. What are the life-threatening causes of vomiting in the different pediatric age groups?

See Table 29-1.

Table 29-1 Life-Threatening Causes of Vomiting by Age

Age Cause
Neonate GI obstruction

image Congenital intestinal obstruction

image Atresias

image Malrotation with volvulus

Renal

image Obstructive uropathy

image Uremia

Trauma

image Shaken baby syndrome with subdural hematoma

image Abdominal trauma

Metabolic

image Inborn metabolic errors

image Congenital adrenal hyperplasia

Infectious

image Sepsis

image Meningitis

image Severe gastroenteritis

image Necrotizing enterocolitis

Neurologic

image Hydrocephalus

Older infant/toddler GI obstruction

image Pyloric stenosis

image Intussusception

image Incarcerated hernia

image Malrotation with volvulus

Renal

image Uremia

Trauma

image Shaken baby syndrome with subdural hematoma

image Abdominal trauma

Infectious

image Sepsis

image Meningitis

image Severe gastroenteritis

Neurologic

image Hydrocephalus

image Mass lesion

Toxic ingestions

Older child/adolescent

GI obstruction

image Malrotation with volvulus

image Small bowel obstruction

Renal

image Uremia

Infectious

image Meningitis

Metabolic

image Diabetic ketoacidosis

image Reye’s syndrome

Neurologic

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