VOMITING

Atan Baas Sinuhaji

Sub Division of Pediatrics Gastroentero-Hepatology

Department of ChildHealth,School of Medicine

University of Sumatera Utara /Adam Malik Hospital

Medan

Vomiting

overt reflux

passage of gastric contents into

the mouth

Reflux

Movement of gastric contents retrogradeInto esophagus or more proximalInto esophagus or more proximal

Food/Drink

Gases Gastric Acid

REFLUX

OVERT SILENT

INTO THE MOUTH INTO THEESOPHAGUS

TO RESP. TRACT

VOMITING LARYNGITIS PNEUMONIAASPIRATION

REFLUX

GASTRIC PRESS. = ESOPH. PRESS.

FUNCTION HIATALHERNIA

GASTRIC PRESS. > ESOPH. PRESS.

OBSTRUCTION RETROGADEPERISTA LSIS

Lower Esophageal IN OUT

Lower Esophageal Sphincter (LES)RELAXATION

GastricOutlet

Obstruc.

Pyloric Stenosis

AbdomInal Tumor

LES RELAXATION

TRANSIENT CONTINOUS

“Gastroesophageal

reflux”Chalasia

HIATALHERNIA

=

SLIDING HIATUSHERNIA

PARTIALTHORACICSTOMACH

PARAESOPHAGEALHERNIA = ROLLING

REFLUX

GASTRIC ACID= ACID REFLUX

FOOD/DRINK GASES

ERUCTATION HICCUP= SINGULTUS

= “CEKUKAN”

HEARTBURN= PYROSIS= “SENDAWA”

MetaplasiaEpithel ofesophagus

= “CEKUKAN”

Barrett’sesophagus

ULCUS

stricturebleeding

ADENO CA

CONSEQUENCES OF REFLUX

1.- SINGULTUS- ERUCTATION

2. HEART BURN = “SENDAWA”3. ESOPHAGITIS & BARRET’S ESOPHAGUS4. CHRONIC PNEUMONIA ASPIRATION4. CHRONIC PNEUMONIA ASPIRATION5. FAILURE TO THRIVE (FTT)6. LARYNGITIS7. RUMINATION8. SANDIFER’S SYNDROME9. FOOD REFUSAL

VOMITING

RETURN OF FOOD/DRINKFROM THE STOMACH TO THE MOUTH

TRUEVOMITING

REGURGITATION

= SPITTING= SPITTING= “MINTAR”= “GUMOH”

PHYSIOLOGICPATHOLOGIC

COMPLICATION (GASTROESOPHAGEAL DISEASE = GER Disease)

GER

Gastroesophageal reflux (GER)

Physiologic passage of gastric

content to esophagus

Transient LES relaxation

Gastroesophageal reflux

- 50% of infant 0-3 months of age

- 25% of infant 3-6 months of age

- 5% of infant 10-12 months of age- 5% of infant 10-12 months of age

Resolving in most by 12 months and

nearly all by 24 months

Gastro Gastro –– Esophageal Reflux DiseaseEsophageal Reflux Disease

(GERD) (GERD)

GER that causes symptoms or complications that GER that causes symptoms or complications that GER that causes symptoms or complications that GER that causes symptoms or complications that

effect quality of lifeeffect quality of life

GERD GERD ≠ ≠ VOMITINGVOMITING

-- Not all vomiting are GERDNot all vomiting are GERD-- Not all vomiting are GERDNot all vomiting are GERD

-- Many GERD children do not vomitMany GERD children do not vomit

TRUE VOMITING

�� NAUSEANAUSEA

�� RETCHINGRETCHING

�� FORCEFUL GASTRIC CONTENTS/ FORCEFUL GASTRIC CONTENTS/ �� FORCEFUL GASTRIC CONTENTS/ FORCEFUL GASTRIC CONTENTS/

INTRA ABDOMINAL PRESSURE INTRA ABDOMINAL PRESSURE ↑↑↑↑

�� SYMPTOMS OF AUTONOMIC SYMPTOMS OF AUTONOMIC

NERVUS SYSTEM (+)NERVUS SYSTEM (+)

REGURGITATION

�� THE YOUNG BABYTHE YOUNG BABY

�� NOT MATURE NOT MATURE L.E.S.L.E.S.

�� NAUSEA (NAUSEA (--))

�� NOT FORCEFULNOT FORCEFUL

�� SYMPTOMS OF ANS (SYMPTOMS OF ANS (--))

RUMINATION

- RETURN OF FOODS INTO THE MOUTH- FOODS RECHEWED- FOODS REINGESTED

NAUSEA

- UNPLEASANT SENSATION & OFTEN

CULMINATING IN VOMITINGCULMINATING IN VOMITING

- CONTRACTION OF PYLORIC

ANTRAL

- SYMPTOMS OF ANS (+)

VOMITING IN INCREASE

INTRACRANIAL PRESSURE

- PROJECTILE

- NAUSEA (-)- NAUSEA (-)

- RETCHING (-)

DIAGNOSIS GER

1. History

2. Body weight ���� poor weight gain ?

3. Diagnostic Test

- Upper GI series ���� rule out anatomical - Upper GI series ���� rule out anatomical

abnormalities

- pH probe (12-24 hours) ���� GOLD STANDARD

- Scintigraphy

- Endoscopy ���� complication

TREATMENT GER

1. Conservative therapy

2. Pharmacotherapy2. Pharmacotherapy

3. Surgery ���� Nissen Fundoplication

THE NISSEN FUNDOPLICATION

A. The lower esophagus is mobilized,allowing the fundus of the stomach to be pulled up and

around the lower esophagus

B and C .The fundic wrap has sutures placed to form a collar around the lower esophagus

Conservative Therapy

1. Prone position and upright position :

- The infant is awake and observed

SIDS

2. Small frequent feeding

3. Thickening of formula

Pharmacotherapy

1. Acid Neutralization : Antacids

2. Antisecretory ( Cimetidine, Ranitidine,

Omeprazole, etc)

3. Prokinetic

- Metoclopramide ���� Extrapyramidal - Metoclopramide ���� Extrapyramidal

Symptoms

- Bethanechole ���� Bronchospasme

- Cisapride : 0,2 mg/kg/dose 3 or 4 x daily

Arrythmia

VOMITING

SURVIVAL VALUE

DEFENSE- UNDERLYING

- COMPLICATION

THREATENINGTOXIC

COMPLICATION OF TRUE VOMITING

1. Body Fluids Imbalance- dehydration- hyponatremia- hypokalemia- hypochloremia- hypocalcemia ==> tetany- hypocalcemia ==> tetany- metabolic alkalosis

2. Mallory Weiss Syndrome3. Pneumonia aspiration4. Intake - hypoglicemia

- starvation- Failure To Thrive- Metabolic acidosis

VOMITING

Na+

WaterCl-H+ K+

Hyponatremia

Met. Alk.

dehydration Hypo-

chloremiaHypokalemia

hypovolemia

RBF

Renin

Aldosteron ↑↑↑↑

Retention of Na+ & Water

Loss of K+Loss of H+

hypocalcemia

HYPOKALEMIA

LOSS OF K+

METABOLIC ALKALOSIS HYPOKALEMIAIN VOMITING

METABOLIC ALKALOSIS

ALDOSTERON

METABOLIC

ALKALOSIS

LOSS OF H+

HYPOKALEMIAALKALOSISIN VOMITING

HYPOKALEMIA

ALDOSTERON

VOMITING

METABOLIC ALKALOSISMETABOLICACIDOSIS

-ADRENAL INSUFF

> > >

-ADRENAL INSUFF- INBORN ERROR- RENAL FAILURE- STARVATION

DIARRHOEA

MET. ACIDOSIS METAB. ALKALOSIS METAB. ALKALOSIS

> > > Congenital Chloridorrhea

VOMITING

DIGESTIVE TRACTOUTSIDE

Surgery Medical

- obstruction- inflammation- perforation

- gastritis- peptic ulcer- Gastroenteritis

- psychogenic- neurogenic:

int.cran. press.↑↑↑↑- systemic:sepsis- hemodynamic

MANAGEMENT

1. STABILIZATION OF GENERAL CONDITION

Body Fluids Imbalance

2. PROTECTION AGAINST ASPIRATION

3. CAUSAL ABDOMINAL EMERGENCY

4. CALORI/ PROTEIN

5. COMPLICATIONS

6. ANTIEMETIC DRUGS

PNEUMONIA ASP.

CEREBRAL EDEMA

NO RECOMMENDED

ANTI EMETIC

1. DOPAMINE receptor antagonist

- metoclopramide- domperidone

2. Cannabinoid (dronabinol)

3. Anticholinergic (Scopolamine)3. Anticholinergic (Scopolamine)4. 5HT3 receptor antagonist

- ondansetron5. Phenothiazine dan anti histamin

- phenergan, benadryl- largactil

6. Corticosteroid

CTZ

PERUBAHAN KIMIA DARAH

(OBAT, TOKSIN, METABOLIK)

BBB KORTEKS

-PSIKOGENIK

-VASKULAR

-TIK

-SEIZURE

VESTIBULARN .VIII

PERIFERN .X

AFF. SIMFATISN. FRENIKUS

VOMITING CENTRE

35

-SAL.CERNA

-SAL.NAFAS

-HEPATOBILIAR

-PANKREAS

-JANTUNG

-GINJAL

-KONTRAKSI DIAFRAGMA

-KONTRAKSI OTOT DINDING PERUT

-KONTRAKSI USUS

-PERNAFASAN TERTAHAN

N. FRENIKUS

N. SPINALIS

N. VAGUS

BOWEL

COMPLETE INVAGINATION

BOWEL OBSTRUCTI0N

PYLORIC STENOSIS

INCOMPLETE

INVAGINATION = INTUSSUSCEPTION

PROXIMAL BOWEL(INTUSSUSCEPTUM)

DISTAL BOWEL(INTUSSUSCIPIENS)(INTUSSUSCIPIENS)

SPONTANEUS REDUCTION

CONTINUING

3 months - 3 years

TYPE OF INVAGINATION

- ILEOCOLIC > > >- ILEOILEIC- CECOCOLIC

- COLICOCOLIC- COLICOCOLIC- ILEOILEOCOLIC

SIGNS & SYMPTOMS- SUDDEN ONSET

- PAROXYSMAL PAIN

- VOMITING

- BLEEDING PERANUM

- TUMOR

- SIGNE de DANCE

- ABDOMINAL DISTENTION - ABDOMINAL DISTENTION

- DEFECATION & FLATUS (-)

- WATER & ELECTROLYTES- HYDROSTATIC- OPERATIVE

Th / :

DIAGNOSTIC

CLINIC

PLAIN OF ABDOMINAL

PHOTO

SIGN OF

RADIOLOGIC

SIGN OF

OBSTRUCTION

BARIUM ENEMA

- CUPPING

- COIL SPRING