7. Vomiting

Question 1

What stimulates the vomiting centres?

Answer 1

Enteric pathogens
Intestinal inflammation
Metabolic derangement
Infection
Head injury
Visual stimuli
Middle ear stimuli

Question 2

What are the different types of vomit?

Answer 2

Vomiting with Retching
Projectile vomiting
Bilious vomiting
Effortless vomiting

Question 3

What are the stages of vomiting?

Answer 3

Pre ejection phase- pallor, nausea, tachycardia
Ejection phase- retch, vomit
Post ejection phase

Question 4

What different condition do we think about when a child vomits?

Answer 4

GORD
Pyloric stenosis
Over feeding
Infection
Congenital

Question 5

What are the signs of pyloric stenosis?

Answer 5

Olive tumour
Visible gastric peristalsis 
Projection of non bilious vomiting 
Low posttasium
Low chlorine
Metabolic alkalosis
On USS, long thicknened pylorus

Question 6

How do you manage pyloric stenosis?

Answer 6

Manage imbalance with fluid resuscitation

Refer to surgeons and give laparoscopic pyloromectomy

Question 7

What is key to know about vomiting?

Answer 7

Is it bilious vomiting! Better to see it or get photo
Indicates bowel obstruction e.g. biliary atresia, vulvolis
Is green/yellow in colour

Question 8

What are your differentials for bilious vomiting?

Answer 8

Intestinal atresia (in newborn babies only)
Malrotation +/- volvulus  
Intussusception  
Ileus  
Crohn’s disease with strictures

Question 9

What is your management of bilious vomiting?

Answer 9

Abdominal x-ray
Consider contrast meal
Surgical opinion re exploratory laparotomy

Question 10

Differentials for effortless vomiting

Answer 10

Almost always GORD
very common in infants
Self limiting and resolves spontaneously in the majority of cases
It may in rare cases indicate 
Cerebral palsy
Progressive neurological problems 
Oesophageal atresia
Generalised GI problem

Question 11

What are the presenting symptoms of GORD?

Answer 11

Vomiting
Haematmesis
Feeding problems
Failure to thrive
Apnea, cough, wheeze, chest infection
Sandifer’s syndrome (neurological syndrome, hypotonia, back arching, reflux)

Question 12

How do you treat GORD?

Answer 12

History and exam
Resassure
If persistent/red flags then Investigate:
Video fluoroscopy, barium swallow
pH study
Oesophageal impedance monitoring
Endoscopy (severe symptoms or persisting throughout life)

Question 13

What are the benefits and disadvantages of videofluoroscopy and barium meals?

Answer 13

May detect aspiration

Detect anatomy well

Question 14

What are the benefits and disadvantages of a pH study?

Answer 14

Defects acid reflex detected by barium

Only detects acid reflux, may be unpleasant for children

Question 15

What is are the advantages and disadvantages of an endoscopy

Answer 15

Best test for oseophagitis
Can be combined with pH study

Needs anesthetic

Question 16

What is the feeding advice for GORD?

Answer 16

Thicken the feed- parobil
Ween early
Prevent oral aversion by treating the reflex
Feed at 45 degrees, keep head raised

Question 17

What is the nutritional support for GORD?

Answer 17

Calorie supplements
Exclusions diet (milk free for 4 weeks)
Nasogastric tube
Gastrostomy

Question 18

What are the medical treatments of GORD?

Answer 18

Feed thickener- gaviscon, thick and easy
Pro kinetic drugs
Acid suppressing drugs (H2 receptors, PPI inhibitors)

Question 19

When would you do surgery for GORD?

Answer 19

Persistant
Failure to thrive
aspiration
Oseophagitis
Vomiting without complications is NOT an indication

Question 20

Child presents with acute infection and vomiting what could this be?

Answer 20

Gastroenteritis
Respiratory infection
UTI

Question 21

What are the advantages and disadvantages of a trial of feeding

Answer 21

Mostly physiological test, may be best discriminator if child needs surgery

NG tube required, needs 2-3 days in hospital