[08.10] PED - Vomiting in Children V2.1.pdf

Vomiting

What is defined as the coordinated reflex mechanism by which the upper gastrointestinal tract rids itself of contents when excessively irritated, overdistended, or overexcitable?

Antiperistalsis

What intestinal motility pattern moves bowel contents proximally through the pyloric sphincter into the stomach prior to vomiting?

Deep breath

What is the initial respiratory event that begins the mechanical vomiting act?

Hyoid bone and larynx

Which anatomical structures raise during the vomiting act to allow the upper esophageal sphincter to open?

Glottis

Which respiratory structure closes during vomiting to prevent vomitus from flowing into the lungs?

Soft palate

Which oral structure lifts during vomiting to close the posterior nares?

Downward contraction of diaphragm and contraction of abdominal muscles

Which simultaneous muscular contractions dramatically increase intragastric pressure during vomiting?

Lower esophageal sphincter (LES)

Which gastrointestinal sphincter relaxes to allow active, forceful expulsion of gastric contents into the esophagus?

Floor of the fourth ventricle

Where is the chemoreceptor trigger zone (CTZ) anatomically located within the medulla / area postrema?

Morphine and digitalis

Which specific medications directly stimulate the chemoreceptor trigger zone to induce vomiting?

Vestibular labyrinth of the inner ear

Which sensory apparatus detects rapid changes in direction or rhythm of motion to initiate motion sickness?

Vestibular nuclei in the cerebellum

Where do sensory signals from the inner ear travel before reaching the chemoreceptor trigger zone during motion sickness?

Vagal and sympathetic afferents

Which neural afferent pathways transmit signals from the vomiting center to execute the vomiting act?

Nausea

What is defined as the unpleasant, subjective sensation of impending or imminent vomiting with an epigastric sensation?

Epigastrium

In which abdominal region is the subjective sensation of nausea primarily localized?

Conscious recognition of subconscious excitation in the vomiting center

What central neural mechanism produces the subjective experience of nausea?

Regurgitation

What term describes the effortless movement of stomach contents into the esophagus and mouth without retching?

Incompetent or immature lower esophageal sphincter

What physiological factor causes frequent, non-pathologic regurgitation in infants during the first year of life?

Bilious vomitus

What color of vomitus (green or bright yellow) indicates an intestinal obstruction distal to the ampulla of Vater?

Second part of the duodenum

Where is the ampulla of Vater located relative to duodenal anatomy?

Projectile vomitus

Which forceful pattern of vomiting is characteristic of hypertrophic pyloric stenosis in infants under 12 weeks of age?

Increased intracranial pressure

What central nervous system condition can cause non-bilious projectile vomiting in older infants and children?

Hematemesis

What term refers to the vomiting of blood, ranging from mild mucosal tears to severe variceal bleeding?

Severe esophageal varices bleeding

What underlying vascular pathology is suggested by large-volume, bright red hematemesis?

Mallory-Weiss tear

What mucosal lesion at the gastroesophageal junction causes mild hematemesis after repeated forceful retching or vomiting?

Prolapse gastropathy

What gastric mucosal injury resulting from recurrent vomiting can cause mild hematemesis?

Feculent vomitus

What dark, foul-smelling type of vomitus indicates a lower gastrointestinal tract obstruction?

Saliva and mucus

What are the normal fluid components of clear vomitus?

Digested bile

What substance imparts a yellow color to vomitus?

Undigested bile

What substance imparts a green color to vomitus?

Partially digested food

What component gives vomitus an orange color?

Small amounts of fresh blood

What causes pink-colored vomitus?

Large amounts of fresh blood

What causes bright red vomitus, signaling a medical emergency?

Old, partially digested blood or feces

What causes brown vomitus, signaling a medical emergency?

Old, partially digested blood

What causes "coffee grounds" vomitus, signaling a medical emergency?

Old, digested blood

What causes black vomitus, signaling a medical emergency?

Infectious gastroenteritis

What diagnosis is suggested when acute-onset vomiting is accompanied by diarrhea or fever?

Post-infectious gastroparesis

What motility disorder should be suspected when nausea and vomiting persist following an acute infectious illness?

Inborn errors of metabolism and cyclic vomiting syndrome

Which two conditions present with recurrent or periodic episodes of vomiting?

Early morning

At what specific time of day does vomiting typically occur in patients with increased intracranial pressure, pregnancy, or cyclic vomiting syndrome?

Lack of associated nausea and positional triggers

Which two clinical features of vomiting strongly point toward increased intracranial pressure rather than a primary GI cause?

Acute gastroenteritis, appendicitis, inflammatory bowel disease, and Hirschsprung-associated enterocolitis

Which four pediatric gastrointestinal conditions present with both vomiting and diarrhea?

Intussusception, infectious colitis, and inflammatory bowel disease

Which three conditions cause hematochezia (rectal bleeding) alongside vomiting?

Acute gastroenteritis, urinary tract infection, and inflammatory bowel disease

Which three conditions present with fever alongside vomiting?

Immunodeficiency syndromes

What underlying condition should be evaluated in a child presenting with vomiting and a history of recurrent systemic infections?

Migraine headaches and increased intracranial pressure

Which two central conditions present with prominent headache accompanying vomiting?

Congenital anatomical, motility, or immunologic anomalies

What category of underlying defects should be investigated in infants with recurrent structural vomiting?

Newborn screening

Which routine neonatal test result must always be reviewed when assessing a child for inborn errors of metabolism?

Cholecystitis

What pathology is suggested by physical exam tenderness localized to the Right Upper Quadrant (RUQ)?

Pyelonephritis or urinary tract infection

What diagnosis is suggested by Costovertebral Angle (CVA) tenderness on physical examination?

Esophagitis, gastritis, peptic ulcer disease, and pancreatitis

Which four conditions produce focal tenderness in the epigastrium?

Hepatitis, metabolic disorders, or inborn errors of metabolism

Which three conditions cause organomegaly on abdominal palpation?

Toxic ingestion, diabetic ketoacidosis, intracranial mass, or inborn errors of metabolism

Which four conditions present with altered consciousness, seizures, or focal neurologic deficits alongside vomiting?

Hydrocephalus or meningitis

Which two conditions should be suspected in an infant presenting with vomiting and an open or bulging fontanelle?

Vestibular neuronitis or cerebellar mass

Which two central pathologies cause ataxia, dizziness, or nystagmus accompanying vomiting?

Congenital adrenal hyperplasia

What endocrine diagnosis is indicated by ambiguous genitalia in an infant with recurrent vomiting?

Inborn errors of metabolism

What diagnostic category is suggested by unusual body or urine odors in a vomiting infant?

Bulimia nervosa

What eating disorder should be suspected in an adolescent presenting with vomiting and enlarged parotid glands?

Greater than 12 hours

What duration of vomiting in a neonate constitutes a red flag for fluid and electrolyte abnormalities?

Greater than 24 hours

What duration of vomiting in a child under 2 years old constitutes a red flag requiring investigation?

Greater than 48 hours

What duration of vomiting in an older child constitutes a red flag for systemic or metabolic disease?

Systemic or metabolic disorder

What type of underlying illness is suggested by prolonged vomiting, profound lethargy, or significant weight loss?

Surgical abdomen (e.g., appendicitis or mechanical obstruction)

What underlying category of disease is indicated by marked abdominal distention or peritoneal signs?

Subdural hematoma or duodenal hematoma

Which central or intra-abdominal lesions should be suspected when vomiting follows physical trauma?

Adrenal crisis

What acute endocrinologic emergency is indicated by hypotension disproportionate to illness accompanied by hyponatremia and hyperkalemia?

Gastroenteritis, gastroesophageal reflux, overfeeding, anatomic obstruction, systemic infection, pertussis, and otitis media

What are the most common causes of emesis in infants?

Adrenogenital syndrome, inborn errors of metabolism, brain tumor, subdural hemorrhage, food poisoning, rumination, renal tubular acidosis, UPJ obstruction, and pseudoobstruction

What are rare causes of emesis in infants?

Gastroenteritis, systemic infection, gastritis, toxic ingestion/poisoning, pertussis, medications, GERD, sinusitis, otitis media, anatomic obstruction, and eosinophilic esophagitis

What are common causes of emesis in children?

Reye syndrome, hepatitis, peptic ulcer, pancreatitis, brain tumor, increased ICP, middle ear disease/labyrinthitis, chemotherapy, achalasia, cyclic vomiting, esophageal stricture, duodenal hematoma, IEM, pseudoobstruction, gastroparesis

What are rare causes of emesis in children?

Gastroenteritis, GERD, systemic infection, toxic ingestion/marijuana, gastritis, sinusitis, IBD, appendicitis, migraine, pregnancy, medications, ipecac abuse/bulimia, and concussion

What are common causes of emesis in adolescents?

Biliary colic, renal colic, porphyria, diabetic ketoacidosis, adrenal insufficiency, pseudoobstruction, intestinal tumor, gastroparesis, achalasia, SMA syndrome, and distal intestinal obstruction syndrome

What are rare causes of emesis in adolescents?

Age

What fundamental patient demographic parameter must always guide the differential diagnosis of pediatric vomiting?

Smaller stomach capacity

Why does overfeeding frequently cause regurgitation and vomiting in young infants?

Gastroesophageal reflux (GER)

What term defines the retrograde movement of gastric contents across the lower esophageal sphincter into the esophagus?

3 to 4 months

At what age does physiologic gastroesophageal reflux peak in infants?

Gastroesophageal reflux disease (GERD)

What diagnosis is assigned when gastroesophageal reflux causes troublesome esophagitis or extraesophageal complications?

Transient lower esophageal sphincter relaxations (TLESRs)

What primary physiological mechanism, triggered by gastric distention, causes GERD?

Increased respiratory effort (e.g., coughing, wheezing, pneumonia, URTI)

What pulmonary factor increases intra-abdominal pressure and exacerbates GERD in children?

Sandifer syndrome

What specific condition involves food refusal accompanied by paroxysmal dystonic neck arching and head turning in infants with GERD?

Apnea, stridor, and asthma

What three respiratory manifestations can result from extraesophageal GERD in children?

Bilious emesis, projectile emesis, GI bleeding, lethargy, organomegaly, abdominal distention, dysphagia, odynophagia, micro/macrocephaly, failure to thrive, fever, seizures, and bulging fontanels

What are key alarm signs that rule out simple GERD and require investigation for serious disease?

Clinical history and physical examination

What is the primary method for diagnosing uncomplicated GERD in children?

8-week trial of daily Proton Pump Inhibitor (PPI)

What empirical diagnostic and therapeutic intervention is recommended for children with heartburn or GERD symptoms without alarm signs?

Esophagogastroduodenoscopy (EGD)

What diagnostic procedure should be performed if GERD symptoms recur after discontinuing an empirical 8-week PPI trial?

Diarrhea

What is the primary side effect of magnesium hydroxide antacids?

Constipation

What is the primary side effect of aluminum hydroxide antacids?

Famotidine and cimetidine

Which Histamine-2 Receptor Antagonists (H2RAs) are used for pediatric acid reduction?

Ranitidine

Which H2RA was withdrawn from the market in 2020?

Proton Pump Inhibitors (PPIs)

Which drug class provides the most potent acid blockade and serves as the antacid of choice for pediatric GERD?

Respiratory infections, C. difficile-associated diarrhea (CDAD), osteopenia, hypomagnesemia, B12 deficiency, and kidney damage

What are six potential long-term side effects of chronic PPI therapy in children?

Tardive dyskinesia

What severe extrapyramidal side effect limits the use of metoclopramide as a prokinetic agent?

Fundoplication

What surgical procedure wraps the gastric fundus around the lower esophagus for refractory GERD?

Greater than 15 eosinophils per high-power field (hpf)

What histopathological threshold on esophageal biopsy defines Eosinophilic Esophagitis (EoE)?

Solid food dysphagia

What is the primary gastrointestinal symptom of Eosinophilic Esophagitis in children?

Atopic diseases (asthma, food allergy, allergic rhinitis)

What family or personal medical history is strongly associated with Eosinophilic Esophagitis?

Six-food elimination diet (milk, soy, wheat, egg, peanuts/tree nuts, seafood)

What non-pharmacologic dietary intervention serves as initial therapy for Eosinophilic Esophagitis?

Swallowed topically acting corticosteroids and monoclonal antibodies

What pharmacologic therapies treat Eosinophilic Esophagitis?

Candida albicans, Torulopsis glabrata, Herpes Simplex Virus (HSV), and Cytomegalovirus (CMV)

What are four common infectious etiologies of esophagitis in immunocompromised patients?

Odynophagia, dysphagia, chest pain, fever, nausea, and vomiting

What are the clinical manifestations of infective esophagitis?

Endoscopy with biopsy

What is the definitive diagnostic modality for infective esophagitis?