Recurrent vomiting

Anshu SrivastavaDepartment of Paediatric Gastroenterology

SGPGIMS, Lucknow

Regurgitation and vomiting often confused in children

APT 2011;34:263-73/ GCNA 32 (2003) 997–1019

Cyclic↑intensity, ↓frequency

Chronic↓Intensity, ↑frequency

Recent years: Increase in cases with nausea and vomiting and gastroparesis

Regurgitation: Effortless return of food from stomach, no nausea/retchingVomiting: forceful expulsion of gastric/intestinal contents, often associated with nausea & retching Rumination: effortless regurgitation of recently ingested food with subsequent re-mastication/ re-swallowing or spitting

Vomiting: acute vs recurrent ( chronic vs cyclic)

triggers of vomiting in the blood or CSF

input from the GI tract

motion sickness and labyrinthine disorders

stress-induced, behavioural or psychiatric disorders

Chronic/ recurrent

ChronicGastrointestinal•Gastroesophageal reflux disease •Food allergy•Eosinophilic esophagitis•Achalasia cardia*•Gastritis•Gastroparesis•GOO: hypertrophic pyloric stenosis, peptic ulcer, pancreatitis, mass lesion•Small bowel obstruction: duodenal stenosis, annular pancreas, superior mesenteric artery syndrome•Rumination syndromeNon Gastrointestinal•Raised intracranial tension: SOL •Chronic sinusitis•Uraemia•Overfeeding

RecurrentGastrointestinal•Cyclic vomiting syndrome•Abdominal migraine•Malrotation with volvulusNon Gastrointestinal•Metabolic: Mitochondrial cytopathy (FAOD respiratory chain disorders etc) Urea cycle defects•DKA•Addison’s disease•Acute hydronephrosis due to PUJ obstruction (Dietl’s crisis)

Clues in historyNature of vomitus Non bilious • esophageal, gastric, D1• pseudo vomiting in achalasia cardia, ± dysphagia • stale food and large volume: GOO/ gastroparesisassociated with epigastric fullness, early satiety, succussion splash and visible distensionBilious vomiting • obstruction distal to second part of duodneum, • after repeated episodes of vomiting, • patients with gastro jejunostomyFeculent ( distal intestinal obstruction, gastro-colic fistula): abdominal pain, distension, gola formation

Clues in history

Pattern of vomiting; cyclical or chronic

Associated symptoms: pain, jaundice, fever, urinary symptoms, headache etc

Drug intake especially chemotherapeutics, radiation

Precipitants: specific food, stress, menstrual cycles, febrile illness etc

Previous surgery

Family history: migraine, CVS

Vomiting: acute or chronic

Clues on examination

Complete general and systemic examinationGrowth failureRecent significant weight loss (SMA syndrome)Signs of nutrient deficiency (malabsorption)HypertensionOral cavity; dental erosions, halitosis (GERD/ rumination)Eczema, reactive airway disease; (food allergy)Fundus/ neurologic abn (CNS)Abdominal: lumps, visible peristalsis, abdominal tenderness, surgical scar (SAIO/ pseudoobstruction)Hypotonia, developmental delay, cardiomyopathy; (mitochondrial cytopathy)

InvestigationsBlood• CBC with differential, ESR• Electrolytes, glucose, renal

functions• Liver and pancreatic enzymes• Lactate, pyruvate, ammonia,

carnitineUrine• Urine analysis• Organic acids, amino acids• Porphyrin screenStool• Occult blood

Imaging• UGI and SBFT• Ultrasound/ CT abdomen

abdomen• MRI brainEndoscopy and motility studies• Upper gastrointestinal endoscopy

with biopsies• 24 hours esophageal pH and

impedance • Esophageal manometry• Antroduodenal manometry• Gastric emptying study• Small bowel transit and colonic

transit

Current Gastroenterology Reports 2001, 3:248–256

Based on lik

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Case 1 - 6 year old boy

Vomiting daily (not large volume/ non bilious, never contains stale food)

Occurs at any time No relationship to meals Sometimes wakes up at night with symptoms Once had small amount of blood in vomitus

Symptomatic for past 10 months

No weight loss, hematemesis, dysphagia, abdominal pain, respiratory symptomsNo history of drug intake like NSAID

Examination: normal growth, no positive finding

Investigations

• Outside: normal UGI endoscopy, no erosions, no hiatus hernia

• Diagnosis?• Was esophageal biopsy taken? no• What next??

GER Eosinophilic esophagitis

Normal esophagus

Esophageal Histology: useful

Small number of intraepithelial eosinophilsBasal cell thickeningLengthening of stromal papillae

24 hour pH metryCriteria measured Test result “normal” ranges

Reflux index 11% 6 %

Number of episodes >30s 38 25

Episodes >5 min 1 3

Longest epsiode 27 min 9.2min

Abnormal pH studyDiagnosis : GERD

Onset of symptoms

Omeprazole 20 mg ODLifestyle changes

Treatment and follow up

Asymptomatic

Symptoms resolved after 3 weeks Ongoing therapy

Clinical Presentation

• Infant– Regurgitation– Irritability– Feeding problem– FTT– Apnoea

• Child– Regurgitation/vomiting– Heartburn– Epigastric pain– Retro-sternal pain– Dysphagia– Extra-esophageal

• Pulmonary• ENT

Who is at risk for severe GERD

• Esophageal atresia• Neurologic impairment• Obesity• Hiatus hernia• Cystic fibrosis• Family history GERD/ GERD complications

Scand J Gastroenterol. 2010;45(2):139-46/ Can J Gastroenterol. 2010;24(5):312-6.J Pediatr Gastroenterol Nutr. 2010;50(2):161-6/ C ochrane Database Syst. 2007;Rev(1): CD006151.

Pyloric stenosis Malrotation

Diagnosis : Barium contrast radiography

Detection of anatomic abnormalitiesNeither sensitive nor specific for diagnosing GERD

-Brief duration produces false-negatives-Frequent occurrence of non-pathological reflux during the examination produces false-positives

11 year old boy with chest pain

24 hours pH studyReflux index: % time pH<4, GOLD standard

Symptom correlation

pH 7

pH 4

pH 0

Chest pain

Symptom correlationPeriod of 2 minutes before event is considered

Association: acidic reflux and chest pain

Time Two minutes time period

Combined pH and impedance

Advantages: Ability to detect all GER episodes and with a pH sensor classify them as acid and non-acid GER Differentiate between liquid, gas or mixed GER Differentiate swallows (antegrade flow) from GER (retrograde flow). No dietary restrictions required Measure accurately the height of the refluxate and the proximal extent of the GER episode The mechanisms of bolus and acid clearance can be studied

JPGN 2009: 48;2–12

Different substances have a different Impedance

Air (high) 5000 .. 10.000 OhmBasal oesophageal impedance 1500 .. 2000 OhmLiquid (low) 200 .. 500 Ohm

AirBaseline

Liquid

Ohm

600030000

Gastric reflux

/ \ shaped waveformLiquid swallow \ \ shaped waveform

Case 2- 13 year old girl

Symptomatic for the past 6 months Vomits 2 to 4 hours after a meal Large volume, non bilious Stale food vomiting Early satiety Feeling of upper abdominal fullness and distension Has lost 3 kgs in the last 6 months

No pain abdomen, systemic symptomsno corrosive/ drug intake

Examination and Investigation

Examination • O/E 37 kg ht 155 cm• BP 110/76 , PR 94/m RR 24• Afebrile • General physical – normal• Systemic exam – normal• Body image –normal• No abnormal feeding habits

Investigations • Blood sugar 96 mg/dl• Thyroid function normal• ABG pH 7.43 HCO3 23, Lactate <

2 mmol/L, • Urine ketones – negative• Hemogram, LFT, KFT, serum

electrolytes normal• TTG negative• Fundus exam – no papilledema• BMFT, USG abd – normal• UGIE – normal, Biopsy no GERD

Diagnosis??

Gastric emptying: methodology

Tc99mStandard meal• 237 Kcal • 75% carbohydrate • 16% protein• 8% fat

25g rice

25g pulses25g flour

6 hours fastingMeal consumed in 10-15min

Dynamic acquisition60 sec frames first 60 min

Static acquisition 2, 3 and 4 hours

Gastric emptying study: Percent gastric retention

1 h: 100% 2 h: 80%

3 h: 60%

4 h: 40%

1h : normal < 96%2h : normal < 71%3h : normal < 44%4h : normal < 22%

Diagnosis: Gastroparesis (idiopathic)

No difference between girls and boysSame across 5-18years of ageEmptying slower in children as compared to adults.

Assessment of gastric emptying in children: Establishment of normative data. Manuscript submitted for publication

Treatment and follow up

Started on Itopride 25mg TID 1 hour before meals.

Small frequent liquid/ semsolid mealsAvoid high fat, high fibre diet

Significant improvement in symptomsImproved appetiteWeight gain

Gastroparesis WorkupExclude mechanical obstruction UGIE/ Barium UGI series/ USG/CT scanEvaluate gastric emptying Solid phase gastric emptying time- scintigraphy

(GOLD STANDARD)Determine the etiology: Blood count, glucose, K, Ca, albumin,TSH, free T4, HbA1C, ANA, histology, antroduodenal manometry

etc

Gastroenterology 2004;127:1592–1622Neurogastroenterol Motil (2010) 22, 113–133

Antroduodenal Manometry

Fasting state : MMC

Fed state

Gastroenterology 2004;127:1592–1622Neurogastroenterol Motil (2010) 22, 113–133

Case 3:13 yr boy

1y 4y 9 y 13y

Bilious vomiting with ‘gola’ formation, Pain abdomen and borborygmi, constipation during that period

Each episode last 2-3 days, multiple episodes, needs admission and IV fluids

Poor weight gain, normal appetite

episodic symptoms, once every 2-3 months,Asymptomatic in between

No fever or systemic

symptoms

Appearing well

Differential diagnosis for bilious vomiting

Surgical causes

beyond D2

MalrotationDuodenal webs, stenosisIntussusceptionVolvulus, adhesions etc

MalrotationDJ not crossed to left sideJejunal loops on the right sidePaucity of bowel loops in left side

Management:surgery

Suspect:1. Early symptoms in life2. Episodic bilious vomiting3. Features of obstruction

Case 4 : 6 year old boy

Recurrent vomiting past 3 ½ years Episodes: 2-3 times/year and lasts for 2-4 days Starts with nausea – retching At its peak, he vomits 8-10 times/hour, occ bilious Symptoms start at any time, mostly early morning No significant abdominal pain, abdominal

distension Frequently requires admission and IV fluids No triggers could be identified

• In the interim he is a normal playful child, does well in school • Growth and development normal• Examination: general and systemic is normal

Diagnosis received elsewhere• Malrotation of gut• Appendicitis• GI tuberculosis: ATT given• Brain tumor

2y 4 y 3 y 5 y 6 y

E E EEE E EE

Last episode• Taken up for exploratory laparotomy• Parents refused at the last minute• Anxious & worried parents

Upper GI endoscopy Barium meal follow through CT head Hmg, RFT, LFT, ABG, urine USG abdomen

All normal

SGPGI

8 admissions, 3-5 days each Iv fluids, antiemetic and antibioticsOnset of symptoms

Diagnosis?

NASPGHAN (pediatric)• Min 5 episodes or 3 attacks in 6mo time• Episodic intense nausea and vomiting, lasts 1hr to

10days, separated by ≥ 1 week• Stereotypical• Vomiting> 4times/hr, for ≥ 1hr• Return to baseline health b/w episodes• Not attributed to other etiology

JPGN 2008;47:379-93

Cyclic vomiting syndrome

Acute onset

Intense nausea and

vomiting

Return to baseline health

Symptom free interval

Cyclical pattern

Stereotypical

“Switch turned

on-off ” !!

Trigger

Management Counseling patient and parents Lifestyle changes• Avoid fasting/ over exertion• Ensure adequate sleep• Avoid triggers/excitement TreatmentAbortive therapy : Dark quiet environment, IV fluids• Ondansetron 0.3–0.4mg/kg/dose IV q 4–6 h• Lorazepam 0.05–0.1mg kg/dose IV q6 hProphylaxis: Amitryptiline was started at 0.25mg/kg/QHS and increased to 0.5 mg/kg HS after baseline EKGEpisodes reduced in severity and frequency

Child with stereotypical cyclical pattern of vomitingage 2-18years; 85-90% have CVS, ~10-15% other etiology

Age <2years- high chances of metabolic and GI causes

Do BMFT for malrotation, electrolytes (Na, K, chloride, bicarbonate), blood glucose, Bun and creatinine, ±USG abdomen in all cases

Check: Age <2 years or Presence of alarm features

No: manage as CVS yes: investigate further

Alarm symptoms: suspect something else…

Bilious vomiting, abdominal tenderness, severe pain, distension Conversion to continuous pattern ...... GI: volvulus, adhesions,

pancreatitis, biliary, UPJ obstruction etiology. • Amylase, lipase, LFT• USG/ SBFT/ CT / UGI endoscopy /24h esophageal pH study• Gastric emptying scan/ Antroduodenal manometry

Attacks precipitated by fasting, high protein meal, intercurrent illness..... Hypoglycemia , high anion gap metabolic acidosis with ketosis, respiratory

alkalosis, persistent Hyponatremia Acute encephalopathy (lethargy, severe irritability, confusion, psychosis or

rapidly changing/unstable mental status)Metabolic :FAOD, urea cycle disorder, organic acidemia, mitochondrial• ABG, lactate, Urine ketones, Urine for PBG, urine organic acids, • serum amino acids, blood ammonia, plasma cortisol, carnitine and acyl

carnitine, etc

Alarm symptoms: suspect something else…

Abnormal neurological examination - altered mentation, abnormal eye movements, ataxia, - focal neurological signs, papilledema, development regression or stagnation, - recent changes in personality

CNS etiology: posterior fossa or hypothalamic tumor, Chiari malformation, hydrocephalus, or subdural hematoma *(more often chronic), complex partial seizures (rare)• MRI head • Fundus examination• EEG when indicated

Conclusions• Vomiting may be the presenting symptom of many

diseases, ranging from self-limited to life-threatening and GI to non GI

• Detailed history along with pattern (cyclic vs chronic) important to differentiate etiologies

• Bilious emesis at any age is suggestive of intestinal obstruction and needs immediate attention.

• Disorders like GERD, CVS, gastroparesis, rumination are increasing and awareness with high index of suspicion helps in making timely diagnosis

• Investigations should be targeted to the likely differential diagnosis

Thanks