II. Causes: Newborn (age <1 month)

  1. Vomiting in a newborn is abnormal until serious causes are excluded
  2. Gastrointestinal obstruction (Abdominal Distention, Unconsolable Infant, poor feeding, bilious or Projectile Vomiting)
    1. Intestinal Malrotation with Volvulus
      1. Presents with Bilious Emesis
      2. More than 50% of cases present in the first month of life
    2. Intestinal Atresia (including Duodenal Atresia)
      1. Typically presents while still in newborn nursery
    3. Meconium Ileus (Cystic Fibrosis)
    4. Hirschsprung's Disease
      1. Typically presents in first few days of life with delayed passage of meconium
      2. Delayed presentation may occur with Abdominal Distention, Vomiting, lethargy, Anorexia
      3. May also present with Hirschsprung-Associated Enterocolitis
    5. Pyloric Stenosis
      1. See below
    6. Incarcerated Inguinal Hernia
      1. Consider in both boys and girls
  3. Infection or Sepsis (fever, listless)
    1. Urinary Tract Infection
    2. Meningitis
    3. Bacteremia
  4. Ill appearing without infection
    1. Inborn Errors of Metabolism
    2. Necrotizing Enterocolitis (Premature Infants)
    3. Nonaccidental Trauma
  5. Other benign causes
    1. Pediatric Reflux
      1. See below
    2. Nasal congestion
      1. See below

III. Causes: Infants (age 1 month to 1 year)

  1. Mechanical gastrointestinal obstruction (Abdominal Distention, bilious or Projectile Vomiting)
    1. Incarcerated Hernia
    2. Intestinal Malrotation with Volvulus
    3. Pyloric Stenosis
      1. Age 3-6 week old (nearly always by 3 months), esp. in boys
      2. Nonbilious, projectile Emesis within minutes of feeding
    4. Intussusception
      1. Age 3 months to 3 years
      2. Paroxysms of intermittent severe Abdominal Pain (child may draw legs to Abdomen) and inconsolable
      3. Interspersed periods of pain resolution
      4. Associated with intractable Vomiting, lethargy
  2. Infection
    1. Viral Gastroenteritis
      1. See below
    2. Bacterial enteritis
    3. Acute Otitis Media
    4. Urinary Tract Infection
  3. Other serious causes
    1. Nonaccidental Trauma with abusive Head Injury
    2. Unknown Ingestion
  4. Other non-serious causes
    1. Pediatric Reflux
      1. Most common cause of Vomiting in infants
      2. Consider pathologic reflux if weight loss, food aversion, persistent fussiness
    2. Nasal congestion
      1. Infants are obligate nose breathers
      2. May result in Emesis and Choking episodes
      3. Treat with frequent Nasal Saline and suctioning

IV. Causes: Children (age >1 year)

  1. Infection
    1. Viral Gastroenteritis (see comments above)
      1. Diagnosis of exclusion, unless Vomiting followed by Diarrhea (often with exposure history)
      2. Consider alternative diagnosis with fever, significant Abdominal Pain, lethargy, toxicity
      3. Most common cause of Vomiting in Children over age 1 year
    2. Appendicitis (guarding, Rebound Tenderness, Rosving Sign, Psoas Sign)
    3. Urinary Tract Infection
  2. Other serious causes
    1. Diabetic Ketoacidosis
      1. New onset Type 1 Diabetes Mellitus may present as intractable Vomiting, Dehydration
      2. Higher risk as presenting finding in age <4 years, lower socioeconomic status
      3. Presents with Vomiting, Abdominal Pain, weight loss, Polyuria, polydipsia, Tachycardia, Hypotension
    2. Testicular Torsion
    3. Ovarian Torsion
    4. Foreign Body Ingestion
    5. Nonaccidental Trauma
    6. Pediatric Blunt Abdominal Trauma
    7. Intussusception
      1. See Above
    8. Superior Mesenteric Artery Syndrome
      1. Duodenum constricted between superior Mesenteric Artery and abdominal aorta
      2. Rare, but increased risk in slender patients with weight loss (e.g. Anorexia Nervosa, Gastroenteritis)
      3. Presents as proximal Small Bowel Obstruction with Bilious Emesis, upper Abdominal Pain, early satiety
  3. Other causes
    1. Migraine Headaches
      1. Exclude intracranial cause (thorough history and exam) when Migraine diagnosis has not been established
    2. Cyclical Vomiting Syndrome
      1. Recurrent Emesis episodes lasting hours to days in school age children
      2. Associated with Migraine Headaches and responds to Migraine Headache Management
    3. Gastroparesis
      1. Postprandial Nausea, Vomiting, distention, early satiety and Epigastric Pain
      2. Consider following viral illness (esp. Rotavirus), Anticholinergic or Opioid medications
      3. Consider in Diabetes Mellitus and neuromuscular disorders (e.g. Cerebral Palsy, Muscular Dystrophy)

V. Causes: Teens

  1. See Vomiting Causes
  2. See causes above
  3. Pancreatitis
    1. Consider Medication Causes of Pancreatitis
    2. Consider Infections (e.g. mumps, Mycoplasma pneumonia)
    3. Consider Pediatric Blunt Abdominal Trauma
  4. Cholecystitis
    1. Consider young presentations in Celiac Disease, Sickle Cell Anemia, spherocytosis, prolonged Parenteral nutrition
  5. Pregnancy
  6. Peptic Ulcer Disease
  7. Gastroesophageal Reflux disease or Esophagitis
  8. Unknown Ingestion

VII. Causes: Increased Intracranial Pressure

X. Causes: Infectious

XI. Causes: Anatomic malformation

  1. Pyloric Stenosis
  2. Intussusception
  3. Malrotation
  4. Volvulus
  5. Inguinal Hernia
  6. Intestinal adhesions
  7. Gastric web
  8. Esophageal atresia
  9. Intestinal Atresia
  10. Hirschsprung's Disease
  11. Annular Pancreas
  12. Imperforate anus
  13. Meconium ileus
  14. Small left colon
  15. Gastroschisis
  16. Omphalocele
  17. Prostaglandin-induced antral hypertrophy
  18. Gastroparesis

XII. Causes: Miscellaneous

  1. Obstructive uropathy
  2. Vascular anomaly
  3. Small Bowel Obstruction (esp. prior abdominal surgery, Inguinal Hernia)
  4. Necrotizing Enterocolitis (NEC)
  5. Protein-sensitive enterocolitis
  6. Peptic Ulcer Disease (Gastric or Duodenal Ulcer)
  7. Gastritis
  8. Esophagitis
  9. Appendicitis
  10. Meckel's Diverticulum
  11. Pseudo-obstruction
  12. Pregnancy (teens)
  13. Foreign Body Ingestion
  14. Ureterolithiasis

XIII. References

  1. (2017) Crit Dec Emerg Med 31(4): 19-25

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