II. Pathophysiology

  1. See Vomiting (includes definitions)

III. Causes

IV. History

  1. See Vomiting History for clinical clues (geared toward adults)
  2. Prenatal and Birth History
    1. Prenatal conditions
    2. Did infant pass meconium and how long after birth (Hirschsprung's Disease)?
    3. Congenital disorders
      1. Inborn Errors of Metabolism (e.g. abnormal Newborn Screening)
  3. Recent exposures
    1. Travel history
    2. Spoiled food intakes
    3. Contagious contacts
    4. Possible toxin exposures or Unknown Ingestions
  4. Systemic Symptoms and Signs
    1. Fever
    2. Malaise or Fatigue
    3. Weight loss (red flag)
  5. Emesis Characteristics
    1. Onset of Vomiting
    2. Timing between food or milk and Emesis
    3. Projectile Emesis
      1. Evaluate for Pyloric Stenosis in the young infant
    4. Emesis appearance or color
      1. Undigested food or milk or yellow color (Stomach contents)
      2. Hematemesis (Upper GI Bleeding)
      3. Bilious Emesis
        1. Evaluate for obstruction (e.g. Small Bowel Obstruction from mid-gut Volvulus in infants)
  6. Gastrointestinal Symptoms or Signs
    1. Abdominal Pain before Vomiting (red flag)
    2. Gastrointestinal Bleeding (Hematemesis, Melana)
    3. Dysphagia
    4. Constipation
    5. Diarrhea
      1. Diarrhea that follows Vomiting is consistent with Gastroenteritis
      2. Vomiting that follows Diarrhea is consistent with enteritis (or Urinary Tract Infection in girls, women)
    6. Jaundice
  7. Genitourinary Symptoms
    1. Urine Output
      1. At least three times daily in infants and twice daily in children and older
    2. Dysuria
    3. Urgency or frequency
    4. Hematuria
  8. Endocrine Symptoms
    1. Polyuria, Polydypsia, polyphagia
  9. Associated Conditions
    1. Pharyngitis
    2. Otalgia
  10. Neurologic Symptoms and Signs
    1. Altered Level of Consciousness (GCS, mental status)
      1. Consider Non-accidental Trauma
    2. Focal neurologic changes
    3. Ataxia

V. History: Red Flags

  1. Weight loss or failure to gain weight
  2. Dehydration
    1. Urinating <3 times daily in age <1 year and <2 times daily in older children
    2. Tachycardia for age, lethargy, dry mucous membranes
  3. Projectile Emesis in the young infant
    1. Evaluate for Pyloric Stenosis
  4. Bilious Emesis
    1. Evaluate for Intestinal Obstruction
    2. Newborn
      1. Evaluate for malrotation and Volvulus (emergent management needed, 20-40% mortality)
      2. Midgut Volvulus is responsible for 20% of Bilious Emesis cases in the first 72 hours of life
  5. Bloody stools, Abdominal Distention and Emesis in a newborn
    1. Evaluate for necrotizing entercolitis
  6. Increased Intracranial Pressure
    1. Refractory Vomiting in a benign Abdomen with Altered Level of Consciousness, neurologic changes
    2. Evaluate for Non-accidental Trauma, Brain Mass, Hydrocephalus

VI. Examination

  1. General observation
    1. Irritability or discomfort at rest (observed from doorway)
    2. Consolability
  2. Observe for Dehydration
    1. Weight loss since prior exam
    2. Decreased skin turgur
    3. Dry mucus membranes (or not making tears in children)
    4. Sunken Fontanelles (age <15 months)
    5. Sinus Tachycardia
    6. Orthostatic Hypotension
    7. Decreased Capillary Refill
  3. Other systemic signs of serious illness
    1. Tachypnea (Sepsis, Metabolic Acidosis)
  4. Abdominal examination
    1. Abdominal Distention
    2. Abdominal wall Hernia
    3. Peritoneal signs (abdominal guarding, Rebound Tenderness)
    4. Abdominal Trauma (e.g. Bruising)
    5. Costovertebral Angle Tenderness
    6. Abdominal tenderness to palpation
      1. Right lower quadrant pain: Appendicitis (esp. with Psoas Sign, Rosving's sign)
      2. Flank Pain: Pyelonephritis or Uretolithiasis
    7. Bowel sounds
      1. Hyperactive suggests Gastroenteritis
      2. High pitched suggests Small Bowel Obstruction
      3. Absent or decreased suggests ileus
  5. Genitourinary exam
    1. Inguinal Hernia
    2. Testicular Torsion (testicular tenderness, swelling, absent Cremasteric Reflex)
    3. Ovarian Torsion
  6. Neurologic Examination
    1. Altered Level of Consciousness
    2. Neurologic Exam appropriate for age
    3. Bulging Fontanelles (age <15 months)
    4. Ataxia on gait exam
  7. Skin
    1. Jaundice

VII. Differential Diagnosis

  1. See Vomiting Causes
  2. Ptyalism (Excessive Salivation)
  3. Gastroesophageal Reflux Disease (Acid Reflux) or Spitting Up in an infant
  4. Forceful Coughing
    1. Post-nasal drainage
    2. Asthma, Bronchitis or Bronchiolitis
    3. Pneumonia
  5. Undigested Food Regurgitation
    1. Esophageal Obstruction
    2. Esophageal Diverticulum
    3. Overfilled Stomach
    4. Delayed Gastric Emptying or Gastroparesis

VIII. Labs

  1. Precautions
    1. Most children will not need lab testing (esp. first 24 hours, without red flag findings)
    2. Labs should be directed by history and exam
  2. Fingerstick Glucose (for Hypoglycemia, DKA)
  3. Complete Blood Count
  4. Comprehensive metabolic panel (Electrolytes, Renal Function tests, Liver Function Tests)
  5. Urinalysis and Urine Culture
  6. Urine Pregnancy Test
    1. Obtain in all biological females of reproductive age
  7. Review Newborn Screen results for Inborn Errors of Metabolism
    1. Typically drawn at 24 to 48 hours of life and results available within the first week of life
  8. Additional labs to consider in Sepsis
    1. Blood Culture
    2. Lactic Acid
    3. Lumbar Puncture
  9. Additional labs/measures to consider in newborns
    1. Ammonia (Inborn Errors of Metabolism)
    2. Attempt passage of oral Gastric Tube
    3. Serum Lipase
    4. Stool testing for enteric organisms and Clostridium difficile (if indicated)

X. Imaging: First-Line Sudies

  1. Abdominal Ultrasound
    1. Primary findings
      1. Pyloric Stenosis
      2. Intussusception
      3. Appendicitis
      4. Cholecystitis
      5. Hydronephrosis
    2. Malrotation and Volvulus may be detected by Ultrasound
      1. Malrotation findings
        1. Position of superior mesenteric vessels (SMA, SMV) and third portion duodenum
      2. Midgut Volvulus
        1. Doppler Whirlpool Sign
          1. Clockwise rotation of SMV and mesentary around the SMA
          2. Test Sensitivity 95% and 89% Test Specificity
      3. References
        1. Zhang (2017) Medicine 96(42): e8287 [PubMed]
  2. Abdominal XRay for Small Bowel Obstruction (preferred initial study in first 2 days of life)
    1. Background
      1. Obtain flat and upright, or in infants, a left lateral decubitus image
      2. Normal XRay does NOT exclude malrotation or Volvulus with incomplete obstruction
    2. Duodenal Obstruction
      1. Double Bubble Sign without distal gas
      2. Newborns
        1. Duodenal Atresia (>90% of cases)
        2. Malrotation with Midgut Volvulus (<10% of cases)
    3. Jejunal Obstruction
      1. Triple bubble signs without distal gas
      2. Newborns
        1. Typically due to jejunal atresia
  3. Chest XRay (if indicated)
    1. Abdominal free air
    2. Pneumonia

XI. Imaging: Second-Line Studies

  1. Fluoroscopic Upper GI Series with Oral Contrast (e.g. 10 ml Iopamidol)
    1. Proximal Small Bowel Obstruction (e.g. Malrotation, Volvulus, Small Bowel atresia)
    2. Identifies malrotation by visualizing the position of the duodenal-jejunal junction (at the ligament of Trietz)
    3. Test Sensitivity 96% for malrotation and 79% for Volvulus
    4. Sizemore (2008) Pediatr Radiol 38(5): 518-28 [PubMed]
  2. Fluoroscopic contrast enema
    1. Distal Small Bowel Obstruction (e.g. Hirschsprung Disease)
  3. CT Head or rapid MRI Brain
    1. Findings suggestive of CNA cause (Increased Intracranial Pressure)

XII. Management

  1. See Vomiting Management in Children
  2. Stabilization
    1. See ABC Management
    2. See Pediatric Dehydration Management (includes oral and IV fluid Resuscitation)
    3. See Oral Rehydration Therapy Protocol in Pediatric Dehydration
    4. See Vomiting Management in Children
  3. Antiemetic followed by oral liquid trial
    1. Ondansetron (Zofran) 0.15 mg/kg up to 4-8 mg (FDA approved for age >6 months)
      1. Give 2 mg orally for weight <15 kg
      2. Give 4 mg orally for weight >15 kg
    2. Avoid Promethazine (Phenergan) in children (FDA black box warning)
  4. Always consider Nonaccidental Trauma
    1. See Pediatric Nonaccidental Trauma Screening (SPUTOVAMO-R2 Checklist)
    2. See Nonaccidental Trauma and TEN-4 Rule
  5. Consider extra-abdominal causes
    1. Neurologic causes
    2. Unknown Ingestion
    3. Diabetic Ketoacidosis
    4. Inborn Errors of Metabolism
  6. Urgent and emergent surgical Consultation indications (early surgical Consultation)
    1. Bilious Emesis
    2. Pyloric Stenosis
    3. Intussusception
    4. Appendicitis
    5. Volvulus (esp. Intestinal Malrotation)
    6. Ectopic Pregnancy
  7. Disposition
    1. Discharge home indications
      1. Tolerating oral fluids
      2. Reassuring Vital Signs without significant Dehydration
      3. No red flags for more serious Pediatric Vomiting causes
    2. Home instructions
      1. Ondansetron (Zofran) prescription (see dosing above)
      2. Review Oral Rehydration Therapy Protocol in Pediatric Dehydration
      3. Review Vomiting Management in Children
    3. Follow-up
      1. Follow-up clinic visit at 24 to 48 hours

XIII. References

  1. (2017) Crit Dec Emerg Med 31(4): 19-25
  2. (2022) Crit Dec Emerg Med 36(1): 3-11
  3. Broder (2023) Crit Dec Emerg Med 37(2): 20-1

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