Nausea and Vomiting
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Introduction
They can exist separately.
aspiration
electrolyte abnormalities and
bleeding:
The Case of...
Differential Diagnosis
gastrointestinal
endocrine/metabolic
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other
drugs
neurological
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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
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
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
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
- dimenhydrinate
- scopolamine
dopamine agonists trigger the CTZ and the vomiting centre.
- haldol (central), peripheral
- metochlopramide
- prochloperazine and promethazine
- domperidone (less EPS)
anticholinergic
- scopolamine
seritonergic
- ondansetron (Zofran)
corticosteroids: central acting
- dexamethasone
anxiolytic: for anticipatory n/v
Pathophysiology
nucleus of solitary tract
gag reflex is CN IX and X
area postrema responds to blood-borne agents
Stomach, LES relaxes
Resources and References
Topic Development
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