Vomiting is the act of disgorging the contents of the stomach through the mouth. It can be a symptom of something as benign as infant overfeeding to as serious and intestinal obstruction (Table 16–1). In the approach to the vomiting pediatric patient, the physician should consider four basic classifications: age, associated symptoms, degree of illness, and etiologies outside the GI tract that can cause vomiting.
As with all pediatric patients the general approach begins with a complete history and precise physical examination (Table 16–2). History should include the age of the patient as well as the onset (duration of illness, relation to feeding, time of day), quantity (number of times), and character of emesis (color, forcefulness, presence of blood, food contents, mucus). Additional history includes travel, ingestions (food and drug), antibiotic use, day care outbreaks, chronic illness, and immunocompetency of the patient. Associated gastrointestinal (GI) symptoms such as fever, abdominal pain, diarrhea, anorexia, and flatulence should be elicited. Signs and symptoms suggestive of etiologies outside the GI tract should be obtained such as headache, neck stiffness, clumsiness, blurred vision, sore throat, rash, cough, chest pain, increased work of breathing, dysuria, urinary frequency, flank pain, vagina discharge, and amenorrhea.
During the physical examination, the overall general appearance should be noted assessing the degree of illness, including responsiveness, mental status, irritability, and vital signs. A head-to-toe examination should be performed making special note of hydration status (mucous membranes, tears, skin turgor, heart rate, pulses, capillary refill, weight), and the abdominal examination (distension; presence, location, and quality of pain; mass; presence of bowel sounds). Note any neurologic, metabolic, cardiac, infectious, gynecologic, renal, and toxic etiologies for vomiting.
The broad differential for the symptom of vomiting makes a prescribed diagnostic set of laboratory tests and radiographs impossible. History, physical, patient’s age, and degree of toxicity should guide the workup.
++ Table Graphic Jump Location Table 16–1.Life-threatening causes of vomiting. ||Download (.pdf) Table 16–1. Life-threatening causes of vomiting.
Neonates (birth-3 mo)
Obstruction: Malrotation, volvulus, Hirschsprung disease, esophageal atresia, pyloric stenosis
Infections: Necrotizing enterocolitis, peritonitis, meningitis, sepsis, gastroenteritis with dehydration
Nongastrointestinal causes: Hydrocephalus, brain tumor, intracranial hematoma, inborn errors of metabolism
Infants and toddlers (3 mo-3 yr)
Obstruction: Volvulus, intussusception, incarcerated hernia, Hirschsprung disease
Infections: Meningitis, sepsis, gastroenteritis with dehydration
Nongastrointestinal causes: Hydrocephalus, brain tumor, intracranial hematoma, cranial abscess, renal tubular acidosis, renal obstruction, hemolytic uremic syndrome, toxins (drugs, lead, iron), myocarditis
Older child and adolescent (3 yr-18 yr)
Obstruction: Volvulus, intussusception
Infections: Meningitis, sepsis, appendicitis
Nongastrointestinal: Brain tumor, intracranial hematoma, uremia, diabetic ketoacidosis, toxins (drugs, lead, iron)
Table Graphic Jump Location Table 16–2.Evaluation of acute vomiting and diarrhea. ||Download (.pdf) Table 16–2. Evaluation of acute vomiting and diarrhea.
Present illness: time of onset, duration and nature of symptoms, associated symptoms (fevers, abdominal pain, myalgias, cephalgia, anorexia, neurological symptoms)