Vomiting

Question 1

Common causes of vomiting

Answer 1

• Gastro-oesophageal reflux (common)
• Feeding problems
  
  • Force-feeding
  • Over feeding
• Infection (fever)
  
  • Viral gastroenteritis (diarrhoea)
  • Respiratory tract (cough, runny nose)
    
    • Whooping cough (pertussis)
  • Urinary tract
  • Meningitis
• Dietary protein intolerances
• Intestinal obstruction
  
  • Pyloric stenosis (projectile at 2-7 weeks)
  • Atresia (duodenal) - Congenital absence or narrowing
  • Intussusception
  • Malrotation
  • Volvulus
  • Strangulated inguinal hernia

Question 2

Red flag symptoms of vomiting

Answer 2

• Bile stained vomit
  
  • Intestinal obstruction
• Haematemesis (red/coffee-grounds?)
  
  • Oesophagitis
  • Peptic ulceration
  • Oral/nasal bleeding
• Projectile vomiting (in first few weeks of life)
  
  • Pyloric stenosis (hungry after vomiting)
• Vomiting after paroxysmal coughing
  
  • Pertussis
• Abdominal pain
  
  • Surgical abdomen
• Abdominal distension
  
  • Intestinal obstruction (including strangulated inguinal hernia)
• Hepatosplenomegaly
  
  • Chronic liver disease
• Blood in stool
  
  • Intussusception
  • Gastroenteritis (salmonella or camylobacter)
• Severe dehydration / shock
  
  • Severe gastroenteritis
  • Systemic infection (UTI, meningitis)
  • Diabetic ketoacidosis
• Bulging fontanelle or seizures
  
  • Raised intracranial pressure
• Failure to thrive
  
  • Reflux
  • Coeliac
  • Other chronic gastrointestinal conditions

Question 3

Vomiting history

Answer 3

*Start from the head and work down*

• Does the child have a good appetite?
• Vomiting
  
  • How much?
  • Are they hungry afterwards?
  • Is it forceful or effortless?
  • Is it related to feeds?
  • What does it contain? Ask about coffee-grounds or other appearances of the vomit. (Bile-stained vomiting in an infant always indicates obstruction and must be considered as pathological.)
• Does the child suffer from abdominal pain?
• Does the child ever have a bloated abdomen?
• Are there any urinary symptoms?
• Ask about bowel habit—is the child constipated?
• Have there been any frequent or loose stools? Are the stools particularly offensive (suggests malabsorption).
• Is there a relevant FHx (e.g. Coeliac or inflammatory bowel disease)?

Question 4

Vomiting history 2

Answer 4

• Vomit
  
  • Duration
  • Frequency
  • Projectile
  • Bilious/non-bilious
  • Presence of blood
  • Relation to feeds
  • Exacerbated by position (GORD)
• Associated symptoms of infection
  
  • Diarrhoea
  • Fever
  • Abdominal pain
  • Headache (↑ ICP)
  • Cough
  • Urinary symptoms
• Relation to food ingestion
  
  • Cow’s milk (associated with atopy)
  • Egg
  • Diet history
    
    • Breast/bottle
    • Age of weaning
• History of recurrent episodes of severe vomiting with periods of being well in between?
• Contact with illness/travel?