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Vomi%ng

in

Infant

Pediatrics,May2012

HugoSousaRafaelaParreira

SlviaFarraposo

Ta5anaQueirs

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Pediatrics

Summary

Defini5ons

Clinicalhistory&Physicalexamina5on

Mainpathologies

Conclusion

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Pediatrics

Defini%ons

Encompassesallretrogradeejec5onofgastrointes5nal,oresophageal,contentsfromthemouth

Subdividedaccordingtoitsforcefulness

None Esophagealemptying

Minimal Regurgita5on

Moderate Vomi5ng

Severe Projec5levomi5ngwithretching

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Vomi%nginInfant

ClinicalHistoryPhysical

Examina%onHospitaliza%on

Pediatrics

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Howoldistheinfant?

Howisthegeneralhealth?

Whatisthevomi%nglike? Volume Frequency Content Periodoftheday Temporalassocia5ons Procedurestoreducevomi

5ng

Arethereassociatedsymptoms?

ClinicalHistory

Pediatrics

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Vmitosnolactente

PhysicalExamina%on

Generalexamin

a%on

Fever Cardiacrythm Respira5on Fundi

Abdominalexamina%

on

Pain Tende

rness

Disten5on Signsofdehydr

a%on

Althoughvomi5ngisagastrointes5nalsymptom,itcan

beamanifesta5onofdiseaseinmul5plesystemsofthe

body

Pediatrics

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Vmitosnolactente

CriteriaforHospitalarAdmission

Severedehydra5on

Uncontrollablevom

i5ng

Refusetofeed Intolerancetor

ehydra5on

Vomi5ngethiology

Socialenvironment

Pediatrics

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Pediatrics

Complica%onsofVomi%ng

Metabolic

Aspira5on

Nutri5onal Shock

Esophagi5s

Mallory-Weisstear

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Pediatrics

Differen%alDiagnosisofVomi%ng

MainCauses

Physiologicreflux/GERD

Gastroenteri5s

Malrota5on/Midgutvolvulus/Intussuscep5on

Obstruc5on/Pyloricstenosis

Metabolicdisorders

UTI

Dietaryproteinintolerance

Increasedintracranialpressure

Hepatobiliarydisease

Pancrea55s

Rumina5on

Munchausensyndromebyproxy

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Surgical Gastrointes%nal Infec%ous

Neurologic

Neurosurgery Metabolic

Pathologies

Vomi%nginInfant

Pediatrics

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Surgical Gastrointes%nal Infec%ous

Neurologic

Neurosurgery Metabolic

Pathologies

Vomi%nginInfant

Pediatrics

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SurgicalPathologyHypertrophicpyloricstenosis

Narrowed(stenosed)pyloricsphincter

Junc%onofstomachandduodenum

Pediatrics

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SurgicalPathologyHypertrophicpyloricstenosis

Whites

NorthernEurope

Males

First-borns

Bloodgroup

TypesB,O

FamilyHistory

MotherwhohadHPS

TEFHypoplasia/agenesisILF

Pediatrics

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SurgicalPathologyHypertrophicpyloricstenosis

Usuallynotpresentatbirth

Moreconcordantin

monozygo5ctwinsMuscleinnerva5on

Infanthypergastrinemia

Nitricoxide

Prostaglandins

Pediatrics

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SurgicalPathologyHypertrophicpyloricstenosis

Hypochloremicmetabolicalkalosis

Chronicmalnutri%on

Severedehydra%on

AQer3weeksofage

1stweekthmonth

Mayfolloweachfeeding

Intermient

Progressive

Imediatelyaerfeeding

Nonbiliousvomi5ng

Pediatrics

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SurgicalPathologyHypertrophicpyloricstenosis

Palpatepyloricmass Gastricperistal5cwave Ultrasound Contraststudies

Oliveshaped

2cminlength

Midepigastrum

Sensi5vityof9%

Pyloricthickness>4mm

Pyloriclenght>14mm

Elongatedpyloricchannel

Shouldersign

DoubletractsignThediagnosiscanbeestablishedclinically60-80ofthe%mebyan

experiencedexaminer

Pediatrics

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SurgicalPathologyHypertrophicpyloricstenosis

Intravenousfluidtherapy

Rehidrated

[HCO3-]

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SurgicalPathologyIntes%nalobstruc%on

BiliousemesisNonbiliousvomi5ng

Proximalobstruc%on

Duodenalobstruc5on

Anularpancreas

Distalobstruc%on

Malrota%on/volvulus

Intussuscep5on

Intes5nalatresia

Hirschsprungdisease

Pediatrics

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SurgicalPathologyMalrota%on/volvulus

Midgutvolvulus

Duodenalobstruc%on

Duringfetaldevelopment

Cecum

Pediatrics

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SurgicalPathologyMalrota%on/volvulus

Pa%entsofanyagewitharota%onalanomalycandevelopacutebowel

threateningvolvuluswithoutpre-exis%ngsymptoms

Biliousemesis Abdominalpain1styearoflife

Pediatrics

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SurgicalPathologyMalrota%on/volvulus

Inversionofthesuperior

mesentericarteryandvein

Duodenalobstruc5on

Thickenedbowelloopsto

therightofthespine

Freeperitonealfluid

Ultrasound

Contraststudies

Malrota%onwithvolvulus

Pediatrics

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SurgicalPathologyMalrota%on/volvulus

Regardlessofage

Immediatelyifvolvulus

Surgicaltreatment

PersistentsymptomsPseudo-obstruc%on-like

mo%litydisorder

Pediatrics

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Surgical Gastrointes%nal Infec%ousNeurologic

NeurosurgeryMetabolic

Pathologies

Vomi%nginInfant

Pediatrics

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Gastrointes%nalPathologyGastroesophagealreflux

Recurrentpost-prandialspi\ngandvomi%nginhealthyinfantsthatresolvesspontaneously

Evidentat1stmonthsoflife(peak4mo)

Resolveinmostcasesby12mo

Pediatrics

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Gastrointes%nalPathologyGastroesophagealreflux

ThickenedFeedsUprightposi5oning

aerfeedsHypoallergenicDiet

Pediatrics

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Gastrointes%nalPathologyGastroesophagealrefluxdisease

EsophagealpH

ImpedancemonitoringRadiographicstudies Endoscopicstudies

Pediatrics

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Gastrointes%nalPathologyGastroesophagealrefluxdisease

Pediatrics

Pharmacotherapy

Prokine5cagents

H2receptor

antagonists

Proton-puminhibitor

SurgeryLifestylechanges

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Gastrointes%nalPathologyGastroenteri%s

Parasi5cagents

Isosporabelli

Cryptosporidium

Giardia

Bacterialagents

Campylobacterjejuni

C.upsaliensis

Salmonellastrains

Escherichiacoli

Entericvirus

Rotavirus

Calicivirus

Astrovirus

Entericadenovirus

Somepicornavirus

Pediatrics

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Gastrointes%nalPathologyGastroenteri%s

Pediatrics

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Gastrointes%nalPathologyGastroenteri%s

Pediatrics

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Gastrointes%nalPathologyGastroenteri%s

Pediatrics

VirusAge

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Gastrointes%nalPathologyGastroenteri%s

Oral/intravenousfluidtherapy

Pediatrics

Enteralfeeding

Zincsupplementa%on

Probio%cs

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Gastrointes%nalPathologyGastroenteri%s

Pediatrics

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Surgical Gastrointes%nal Infec%ousNeurologic

NeurosurgeryMetabolic

Pathologies

Vomi%nginInfant

Pediatrics

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Infec%ousPathologyUrinarytractinfec%on

E5ology

Ecoli(>8%)

ClinicalManifesta5ons

Nonspecific

Diagnosis

Urinalysis

Uroculture

Pediatrics

Epidemiology

8%ofgirlsand2%ofboyswillacquireUTIsinchildhood

Treatment

An5bio5c

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Surgical Gastrointes%nal Infec%ousNeurologic

NeurosurgeryMetabolic

Pathologies

Vomi%nginInfant

Pediatrics

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Neurologic&NeurosurgicalPathology

HydrocephalusSubduralhematoma Cerebraledema

Pediatrics

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Surgical Gastrointes%nal Infec%ousNeurologic

NeurosurgeryMetabolic

Pathologies

Vomi%nginInfant

Pediatrics

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MetabolicPathologies

Symptoms Diseases

Progressivevomi5ng Diabe%cketoacidosisAdrenalinsufficiencySeveredehydra5on

Cyclicvomi5ng

Galactosemia,fructosemiaChangesinconsciousness

Neurologicalsignsandsymptoms

Pediatrics

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Keepinmind

Pediatrics

Vomi5ngandregurgita5onarecommonlyencounteredsymptomsinchildrens

Mostcommonlyvomi5ngistheresultofacute,self-resolvingilnesses

Insomecases,thefeaturesofvomi5ngallowtodis5nguishthemaincauses

Hypertrophicpyloricstenosis,gastroenteri5sandEGRarethemostcommondiseasesininfants

AlwayskeepinmindREDFLAGS!

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Bibliography

Pediatrics

Pediatrics:CurrentDiagnosis&Ttreatment.WilliamHay,Myron

Levin,JudithSondheimerandRobinDeterding,19thEdi5on,Lange

LangePaediatricsandChildHealth.MaryRudolfandMalcolm

Levene,2ndEdi5on,BlackwellPublishing2006

Prac9calStrategiesinPediatricDiagnosisandTherapy.LarryA.

GreenbaumandPatriciaS.Lye,2ndEdi5on,ElsevierInc.2004

Kliegman:NelsonTextbookofPediatrics.RobertM.Kliegman,

RichardE.BehrmanHalB.Jenson,BonitaF.Stanton,18thEdi5on,

Elsevier2007

UrgnciaPeditricaIntegradadoPortoUPIP.Administrao

RegionaldeSadedoNorte,I.P,2008

UpToDateinPediatrics.SheldonKaplanet.al,WoltersKlower2012

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Vomi%nginInfant

Pediatrics,May2012

HugoSousa

RafaelaParreira

SlviaFarraposo

Ta5anaQueirs