Nausea and Vomiting

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Introduction

They can exist separately.

dehydration

aspiration

electrolyte abnormalities and

bleeding:

 

 

The Case of...

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Differential Diagnosis

gastrointestinal

  • viral gastroenteritis
  • bacterial gastroenteritis
  • obstruction (intussusception, volvulus)
  • appendicitis
  • hepatitis
  • ulcers
  • pancreatitis
  • cholecystitis
  • inflammatory/IBD
  • impaired motility
  • gastroperesis
  • gastroesophageal reflux (very common in infants)
  • foreign body
  • food allergy
  • celiac disease

 

endocrine/metabolic

  • pregnancy
  • Addison's
  • DKA
  • hypercalcemia
  • uremia
  • acidosis
  • hyperparathyroidism

other

  • UTI, pyelonephritis
  • nephrolithiasis
  • otitis media
  • pneumonia
  • bulemia
  • psychgenic (rumination syndrome)

 

drugs

  • antibiotics (esp erythromycin)
  • opioids
  • chemotherapy
  • toxins (lead)
  • digoxin
  • theophylline

neurological

  • labyrinthitis
  • Meniere's Disease
  • meningitis
  • neoplasm
  • migraines
  • glaucoma

 

Neonatal vomiting

pyloric stenosis (incidence 1:500)

malrotation of the intestine (incidence 1:500)

tracheoesophageal fistula (incidence 1:3000-4500)

duodenal atresia (incidence 1:10,000): can be bilious; air-fluid levels on AXR

 

Pediatric

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History and Physical Exam

  • history
  • physical exam

History

HPI:

  • onset, duration, severity
    • early morning - pregnancy, uremia, raised ICP
  • associated symptoms: fever, abdominal pain, diarrhea, headaches, coughing
  • contents: bloody, bilious, food

 

Ask about sick contacts

 

Pediatric

  • age of onset

Physical Exam

vitals

abdominal exam: tenderness, distention, masses

hydration status (pediatrics)

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Investigations

  • lab investigations
  • diagnostic imaging

Lab Investigations

bloodwork

  • CBC
  • electrolytes
  • BUN, creatinine
  • ESR
  • blood gases
  • amylase, lipase
  • urine, blood, stool C&S

Diagnostic Imaging

Imaging should be guided by clinical suspicion.

 

barium swallow (upper GI series): malrotation, other causes of obstruction, reflux

endoscopy: GI bleed

Abdominal X Ray

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Management

Rehydration - Replace fluid and electrolytes.

Treat the cause of vomiting while you also treat the symptoms and complications.

 

Replace

If it is drug-induced, stop it if possible.

 

Medications

Anti-histamine/anticholinergic agents: target the vestibular apparatus, and are helpful for movement

dopamine agonists trigger the CTZ and the vomiting centre.

anticholinergic

seritonergic

corticosteroids: central acting

anxiolytic: for anticipatory n/v

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Pathophysiology

nucleus of solitary tract

gag reflex is CN IX and X

area postrema responds to blood-borne agents

Stomach, LES relaxes 

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Resources and References

 

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Topic Development

authors:

reviewers:

 

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