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Persistent Vomiting
Vomiting is defined as the forceful expulsion of gastric contents through the mouth. Vomiting can be caused by a benign, self-limited process or it may be indicative of a serious underlying disorder persistent vomiting, spitting up, throwing up.
Vomiting is usually preceded by nausea, increased salivation, and retching. It is distinct from regurgitation, which is characterized by passive movement of gastric contents into the
Projectile vomiting results from intense gastric peristaltic waves, usually secondary to gastric outlet obstruction caused by hypertrophic pyloric stenosis or pylorospasm.
Retching often precedes vomiting, and it is characterized by spasmodic contraction of the expiratory muscles with simultaneous abdominal contraction.
Nausea is an imminent desire to vomit, usually induced by visceral stimuli.
Etiology of Vomiting by Age
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Newborn
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Infant
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Older Child
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Obstruction
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Malrotation of bowel
Volvulus
Intestinal atresia
Intestinal stenosis
Meconium ileus
Meconium plug
Hirschsprung disease
Imperforate anus
Incarcerated hernia
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Pyloric stenosis
Foreign bodies
Malrotation (volvulus)
Duplication of alimentary tract
Intussusception
Meckel diverticulum
Hirschsprung disease
Incarcerated hernia
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Intussusception
Foreign bodies
Malrotation (volvulus)
Meckel diverticulum
Hirschsprung disease
Incarcerated hernia
Adhesions
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Gastrointestinal disorders (infectious/inflammatory)
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Necrotizing enterocolitis
Gastroesophageal reflux
Paralytic ileus
Peritonitis
Milk allergy
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Gastroenteritis
Gastroesophageal reflux
Pancreatitis
Appendicitis
Celiac disease
Paralytic ileus
Peritonitis
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Gastroenteritis
Peptic ulcer disease
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Infectious disorders (nongastrointestinal)
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Sepsis
Meningitis
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Sepsis
Meningitis
Otitis media
Pneumonia
Pertussis
Hepatitis
Urinary tract infection
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Meningitis
Otitis media
Pharyngitis
Pneumonia
Hepatitis
Urinary tract infection
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Neurologic disorders
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Hydrocephalus
Kernicterus
Subdural hematoma
Cerebral edema
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Hydrocephalus
Subdural hematoma
Intracranial hemorrhage
Mass lesion (abscess, tumor)
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Subdural hematoma
Intracranial hemorrhage
Brain tumor
Other mass-occupying lesion
Migraine
Motion sickness
Hypertensive encephalopathy
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Metabolic and endocrine disorders
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Inborn errors of metabolism: Urea cycle defects, galactosemia, disorders of organic acid metabolism
Congenital adrenal hyperplasia
Neonatal tetany
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Inborn errors of metabolism
Fructose intolerance
Adrenal insufficiency
Metabolic acidosis
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Adrenal insufficiency
Diabetic ketoacidosis
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Renal disorders
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Obstructive uropathy
Renal insufficiency
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Obstructive uropathy
Renal insufficiency
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Obstructive uropathy
Renal insufficiency
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Toxins
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Digoxin
Iron
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Digoxin
Iron
Lead
Food poisoning
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Other
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Pregnancy
Anorexia nervosa
Bulimia
Psychogenic etiology
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Clinical Evaluation of Vomiting in the Neonate
Bilious Vomiting
Bilious vomiting, at any age, suggests intestinal obstruction or systemic infection.
Anatomic abnormalities of the gastrointestinal tract that may present in the first week of life with bilious vomiting and abdominal distention include malrotation, volvulus, duplications of the bowel, bowel atresia, meconium plug, meconium ileus, incarcerated hernia, and aganglionosis (Hirschsprung disease).
Necrotizing Enterocolitis
NEC is the most common inflammatory condition of the intestinal tract in the neonate. Symptoms of NEC include abdominal distention, bilious vomiting, and blood in the stool.
Metabolic Disorders
Inborn errors of metabolism should be considered in any acute neonatal illness, including persistent vomiting. Factors that suggest a metabolic disorder include early or unexplained death of a sibling, multiple spontaneous maternal abortions, or history of consanguinity.
Neurologic Disorders. Central nervous system abnormalities, such as intracranial hemorrhage, hydrocephalus and cerebral edema, should be suspected in the neonate who has
Clinical Evaluation of Vomiting in Infancy
Pyloric Stenosis
Pyloric stenosis is a major consideration in infants. Hypertrophy of the pylorus causes gastric
Gastroesophageal Reflux
Gastroesophageal reflux (GER) is defined as retrograde movement of gastric contents into the esophagus. GER occurs in 65% of infants and is caused by inappropriate relaxation of the
Gastrointestinal Allergy
Cow milk allergy is rare in infancy and early childhood and generally resolves by 2 to 3 years
Clinical Evaluation of Vomiting in Childhood
Peptic Ulcer
Peptic ulcer disease in early childhood is often associated with vomiting. Primary ulcer disease more often presents with epigastric pain in children by 11 years of age. Peptic ulcer
Pancreatitis
Pancreatitis is a relatively rare cause of vomiting, but should be considered in the child who has sustained abdominal trauma. Patients usually complain of epigastric pain, which may
Central Nervous System Disorders
Persistent vomiting without other gastrointestinal or systemic complaints suggests an intracranial tumor or other lesions that increase intracranial pressure.
Subtle neurologic findings (eg, ataxia, head tilt) should be assessed and a
Physical Examination of the Child with Persistent Vomiting
Volume depletion often results from vomiting, manifesting as sunken fontanelles, decreased skin turgor, dry mouth, absence of tears, and decreased urine output.
Peritoneal irritation often causes the child to keep his knees drawn up or to bend over. Abdominal distension, visible peristalsis, and increased bowel sounds are consistent with
Abnormal masses, enlarged organs, guarding, or tenderness should be sought. A hypertrophic pylorus
Intussusception is often associated with a tender, sausage-shaped mass in the right upper quadrant and
Digital Rectal Exam. Decreased anal sphincter tone and large amounts of hard fecal material in the ampulla suggests fecal impaction. Constipation, increased rectal sphincter tone, and an empty rectal
Treatment
Initial therapy should correct hypovolemia and electrolyte abnormalities. In acute diarrheal illnesses
Bilious vomiting and suspected intestinal obstruction is managing by giving nothing by mouth,
Pharmacologic Therapy
Antiemetic agents usually are not required because most instances of acute vomiting are caused by self-limited, infectious gastrointestinal illnesses. Conditions where effective
Diphenhydramine and dimenhydrinate are useful in treating the symptoms of motion sickness or vestibulitis. Anticholinergics, such as the scopolamine patch, also are
Prochlorperazine and chlorpromazine have anticholinergic and antihistaminic properties. These drugs also decrease dopamine transmission in the
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