Gastroenterology Book

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Vomiting Causes in Children

Aka: Vomiting Causes in Children, Bilious Emesis in Children
  1. See Also
    1. Vomiting in Children
    2. Triage of Children with Vomiting
    3. Vomiting Management in Children
    4. Pediatric Diarrhea
    5. Pediatric Dehydration
  2. 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. 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
  3. 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
  4. 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)
  5. 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
  6. Causes: Common
    1. Gastroesophageal Reflux
    2. Infectious Gastroenteritis
    3. Urinary Tract Infection
    4. Foodborne Illness
  7. Causes: Increased Intracranial Pressure
    1. See Brain Lesion in Children
    2. Meningitis
    3. Pseudotumor Cerebri
    4. Hydrocephalus
    5. Abusive Head Trauma of Infancy (previously Shaken Baby Syndrome)
    6. Metabolic Encephalopathy
    7. Brain Abscess
  8. Causes: Metabolic
    1. See Inborn Errors of Metabolism
    2. Galactosemia
    3. High ammonia
    4. Congenital Adrenal Hyperplasia
    5. Phenylketonuria
    6. Organic acidemia
    7. Hypokalemia
    8. Hypermagnesemia
    9. Hypercalcemia
  9. Causes: Medications and Toxins
    1. See Unknown Ingestion
    2. Aspirin
    3. Alcohol
    4. Erythromycin
    5. Theophylline
    6. Opiates
    7. Iron
    8. Furadantin
  10. Causes: Infectious
    1. Otitis Media
    2. Pneumonia
    3. Sepsis
    4. Pertussis
  11. 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
  12. 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
  13. References
    1. (2017) Crit Dec Emerg Med 31(4): 19-25

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