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?
  3. Systemic Symptoms and Signs
    1. Fever
    2. Malaise or Fatigue
    3. Weight loss (red flag)
  4. 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 (e.g. Small Bowel Obstruction from mid-gut Volvulus in infants)
  5. 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
  6. 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
  7. Associated Conditions
    1. Pharyngitis
    2. Otalgia
    3. Dysuria
  8. Neurologic Symptoms and Signs
    1. Altered Level of Consciousness (GCS, mental status)
      1. Consider Non-accidental Trauma

V. History: Red Flags

  1. Weight loss or failure to gain weight
  2. Projectile Emesis in the young infant
    1. Evaluate for Pyloric Stenosis
  3. Bilious Emesis in newborn
    1. Evaluate for malrotation and Volvulus (emergent management needed)
  4. Bloody stools, Abdominal Distention and Emesis in a newborn
    1. Evaluate for necrotizing entercolitis
  5. Refractory Vomiting in a benign Abdomen, possible Altered Level of Consciousness
    1. Evaluate for Non-accidental Trauma, brain mass

VI. Examination

  1. Observe for Dehydration
    1. Weight loss since prior exam
    2. Decreased skin turgur
    3. Dry mucus membranes (or not making tears in children)
    4. Sinus Tachycardia
    5. Orthostatic Hypotension
    6. Decreased Capillary Refill
  2. Other systemic signs of serious illness
    1. Tachypnea (Sepsis, Metabolic Acidosis)
  3. Abdominal examination
    1. Abdominal Distention
    2. Abdominal wall Hernia
    3. Peritoneal signs (abdominal guarding, Rebound Tenderness)
    4. Abdominal Trauma (e.g. Bruising)
    5. Abdominal tenderness to palpation
      1. Right lower quadrant pain: Appendicitis (esp. with Psoas Sign, Rosving's sign)
      2. Flank Pain: Pyelonephritis or Uretolithiasis
    6. Bowel sounds
      1. Hyperactive suggests Gastroenteritis
      2. High pitched suggests Small Bowel Obstruction
      3. Absent or decreased suggests ileus
  4. Genitourinary exam
    1. Inguinal Hernia
    2. Testicular Torsion (testicular tenderness, swelling, absent Cremasteric Reflex)
    3. Ovarian Torsion
  5. Neurologic Examination
    1. Altered Level of Consciousness
  6. 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
    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
  6. Additional labs to consider in Sepsis
    1. Blood Culture
    2. Lactic Acid
  7. Additional labs/measures to consider in newborns
    1. Ammonia (Inborn Errors of Metabolism)
    2. Attempt passage of oral Gastric Tube

X. Imaging

  1. Abdominal Ultrasound
    1. Pyloric Stenosis
    2. Intussusception
    3. Appendicitis
    4. Cholecystitis
    5. Hydronephrosis
  2. Abdominal XRay (flat and upright, or in infants, a left lateral decubitus image)
    1. Malrotation
    2. Small Bowel Obstruction
  3. Chest XRay
    1. Abdominal free air
    2. Pneumonia

XI. Management

  1. See Vomiting Management in Children
  2. Always consider Nonaccidental Trauma
    1. See Pediatric Nonaccidental Trauma Screening (SPUTOVAMO-R2 Checklist)
    2. See Nonaccidental Trauma and TEN-4 Rule
  3. Urgent surgical Consultation indications
    1. Bilious Emesis
    2. Pyloric Stenosis
    3. Intussusception
    4. Appendicitis
    5. Volvulus (esp. Intestinal Malrotation)
  4. Empiric Management
    1. See Vomiting Management in Children
    2. Treat Pediatric Dehydration as needed
    3. Antiemetic followed by oral liquid trial
      1. Ondansetron 0.15 mg/kg up to 4-8 mg (age >6 months)
      2. Avoid Promethazine (Phenergan) in children (FDA black box warning)

XII. References

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

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