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Vomiting in Children with emphasis on Cyclical Vomiting Syndrome. The patient. 10 year old girl Admitted with acute onset vomiting for 1 day. Started as food, then became yellow/green Abdominal pain Weakness, lethargy Precipitated by “ asthma attack” – used asthma inhaler

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slide1

Vomiting in Children

with emphasis on

Cyclical Vomiting Syndrome

slide2

The patient

  • 10 year old girl
  • Admitted with acute onset vomiting for 1 day. Started as food, then became yellow/green
  • Abdominal pain
  • Weakness, lethargy
  • Precipitated by “ asthma attack” – used asthma inhaler
  • Previous similar episodes
  • No diarrhoea or constipation
slide3

Past medical history

    • Recurrent episodes of vomiting – since infancy
    • Diagnosed with gastro-oesophageal reflux disease as infant
    • Episodes of vomiting more frequent, severe in past 2 years (occur every 1-3 months)
    • Almost always preceded/ precipitated by “asthma attack”. Sometimes even by laughing a lot
    • Frequently resulting in hospital admission – not for bronchospasm but for dehydration and intractable vomiting
slide4

Been extensively investigated (Cape Town) – barium meal, Xrays, gastroscopy, ?others => all negative

    • Apparently given medication in hospital each time admitted, but not on chronic medication other than steroid inhaler and bronchodilator
    • Parents have not been given a diagnosis as yet – very distressed
  • Past surgical history
    • Nil
slide5

Birth history

    • Term, nil of significance
  • Social
    • Recently moved from Cape Town (in past month)
    • Grade 4 at school, doing well, apparently happy
    • 8 year old brother, well
    • Stable, caring family environment
  • Family History
    • Father has asthma (mild)
    • No known history of migraine in family
slide6

Clinical Findings

  • Well–grown child
  • Miserable, lethargic, and uncomfortable due to abdominal pain, but awake and cooperative
  • Haemodynamically stable but looked 5% dehydrated with sunken eyes
  • BP – 104/65mmHg
  • Low-grade fever – 37.5deg
  • Chest – clear
  • CVS – normal
slide7

Abdomen – scaphoid, soft but generally tender. No masses felt, bowel sounds heard. PR not done

  • CNS – Awake, but withdrawn. No meningism, no focal signs. No papilloedema.
  • FBC, urea and electrolytes normal except potassium borderline low (3.1 mmol/l)
  • Urine Dipstix – nil of note. No glycosuria
  • Ultrasound abdomen – normal
  • CT scan brain - normal
slide8

Management

  • Admitted to ward
  • Rehydrated with IV fluids
  • Allowed to take orally as desired
  • Panado, Cyclizine for vomiting
slide9

Progress

  • Still vomiting in ward for about 2 days
  • Temperature settled in ward
  • Did not require nebuliser for bronchospasm
  • Very quiet, withdrawn and miserable for 2 days
  • By third day, was walking around looking better and vomiting had settled
slide10

Vomiting in Children

  • Vomiting is a symptom, presenting complaint in multitude of disorders
    • Range from gastrointestinal pathology to disease in distant organ (otitis media or intracranial lesion)
  • In children, especially infants, must distinguish from regurgitation – effortless expulsion of gastric contents
  • Integrated response to noxious stimuli, coordinated by central nervous system
slide11

Centres responsible for vomiting

  • Vomiting centre
    • Nucleus solitarius and series of nuclei in brainstem medulla
    • Stimulation results in
      • integrated motor responses involved in vomiting
      • associated vasomotor activity (pallor, flushing), salivation, bulbar responses
    • Afferent input arises from
      • posterior pharynx, GIT, brain
slide12

Chemoreceptor trigger zone

    • Stimulated by humoral stimuli such as opiates, cytotoxins, ketones, ammonia
    • Lies in area postrema – floor of 4th ventricle, outside blood-brain barrier
    • Processes most of afferent input for the vomiting centre
  • Receptors and neurotransmitters involved
    • Dopamine (D2), histamine (H1), serotonin (5-HT3), vasopressin, substance P
slide13

Diagnostic evaluation

  • Before finding cause of vomiting, in any child should first
    • Assess hydration status, attend to life-threatening complications
    • Ascertain whether
      • Bilious – suggests gastrointestinal obstruction
      • Blood is present – diagnosis and management different
      • If non-bilious and non-bloody, 2 important variables => temporal pattern and age of patient
slide14

Duration either

    • Acute – short-term episode, abrupt onset
    • Recurrent – at least 3 episodes over 3-month period=> chronic - relatively mild episodes that occur frequently
    • => cyclic – recurrent, intense episodes separated by asymptomatic periods
slide15

Acute Vomiting

  • Neonate/ Infant
    • With fever
      • Sepsis, meningitis, UTI
      • Tonsillitis, otitis media, gastroenteritis
    • If no signs sepsis
      • Pyloric stenosis/ outlet obstruction
      • Metabolic
      • Neurologic
      • Endocrine
  • Child/ adolescents
    • With fever (but otherwise well)
      • Gastroenteritis, esp if also have diarrhoea
    • With lethargy/ altered mental status
      • Neurologic
      • Metabolic
      • Endocrine
      • Drugs, toxins, alcohol
slide16

Investigations for acute vomiting

  • Thorough examination
  • “Septic workup” – blood cultures, urine, FBC, CRP, LP
  • Upper GI radiology – Barium swallow/ meal, AXR, ultrasound abdomen, endoscopy
  • Metabolic investigations – blood gas, ammonia, blood and urine organic acids
slide17

Management

  • Depends on specific cause
  • While investigating/ treating underlying pathology – replace lost fluids, maintain hydration
  • If mild and child able to drink, can try oral rehydration. Intravenous may also be required
  • Pharmacologic agents not usually recommended
    • May mask signs of serious disease
    • Undesirable side-effects in children
slide18

Recurrent vomiting

  • Ongoing underlying pathology, therefore may be more worrying
  • Numerous causes
    • GIT
      • Infections – H. pylori, Giardia, oesophageal candidiasis
      • Hepatitis, pancreatitis, partial intestinal obstruction
    • Metabolic, neurologic, renal
slide19

Recurrent Vomiting

  • Infants
    • GIT – feed intolerance
    • Renal
    • Metabolic – lethargy, poor feeding, failure to thrive, seizures, abnormal tone
    • Neurologic – raised pressure – meningitis, tumour, hydrocephalus
  • Older child/ Adolescent
    • GIT
    • Chronic sinusitis
    • Drug intoxication
    • Migraine
    • Bulimia
    • Pregnancy
slide20

Investigations

  • Guided by history
    • Timing - early morning (or nocturnal) – reflux, peptic ulcer (empty stomach), intracranial mass lesion, pregnancy
    • Relation to eating - worse with food- suggests upper GIT abnormalities.
    • Description –
      • projectile suggests outlet obstruction (stomach, duodenum, more distal intestine)
      • faeculent – colonic obstruction, intestinal stasis, bowel ischaemia
slide21

Examination

    • Jaundice – liver/ gallbladder pathology
    • Neurologic examination important
  • Special investigations
    • Sinus Xrays
    • MRI/CT brain
    • Stool occult blood/ parasites
    • FBC, LFT, U&E, Amylase, ESR
    • Urinalysis and culture
    • Toxicology screen
slide22

If no diagnosis still, consider

    • Upper GI contrast study, ultrasound abdomen
    • Gastroscopy PLUS biopsy – high diagnostic yield, ease of performance, safe
slide23

Cyclic Vomiting Syndrome (CVS)

  • Paroxysmal, especially severe, recurrent vomiting disorder
  • Mysterious disorder, unknown aetiology, and pathophysiology
  • Substantial increase in interest and understanding of disease in past decade
  • Previously considered rare, may be 2nd only to GORD as cause of recurrent vomiting in children
slide24

Under-recognised

    • No specific laboratory, radiographic or endoscopic markers for CVS
    • Typically misdiagnosed for years – viral GE, food poisoning, GORD, psychogenic vomiting => leads to inappropriate therapy
      • Surgery
      • Psychiatric hospitalisation
      • Very distressing to patients and families
  • Prevalence
    • Being diagnosed with increasing frequency, but actual prevalence remains unknown
    • 0.04-2% among school-aged children
      • Overdiagnosed sometimes, and often underdiagnosed
slide25

Age and Sex distribution

  • Females>males
    • Similar to distribution in migraine sufferers
  • All races, nut more in Caucasians
  • Usually affects children of 4-7 yrs but some as young as 6 mths
    • Bimodal peaks: 4.8 and 35 yrs!
slide26

Course

  • Often delays in diagnosis
    • Average 2.7 years = ±20 episodes in children
  • Median age of resolution 10 years
    • In those whose vomiting resolves, about 1/3 develop migraine headaches around same time
  • Children ill <10% of time, but causes substantial medical and academic morbidity
    • Recurrent school absences
    • Recurrent admissions for IV fluids
    • Recurrent outpatient visits, hospital stays, missed work for parents
slide27

FeaturesHallmark – cyclic vomiting pattern => severe, recurring, discrete, stereotypical

  • Cyclic
    • high intensity, low frequency
    • More often require IV rehydration
    • Higher incidence of family members with migraine
    • Migraine symptoms – headaches, photophobia, phonophobia
    • Investigate causes outside GIT
  • Chronic
    • low intensity, high frequency, daily pattern
    • Investigate causes inside GIT
slide28

Cyclic

    • Idiopathic
    • If other cause – extraintestinal
      • Neurologic
      • Renal
      • Metabolic
      • Endocrine
  • Chronic
    • GIT disorders
      • Peptic oesophagitis
slide30

Clinical Features

  • Short prodromal phase
    • 1.5 hours
    • Nonspecific premonitory signs such as pallor, lethargy, anorexia, nausea
  • Episode itself
    • Defined by median of 15 emeses, duration of 24 hours
  • Recovery phase
    • From last emesis to point of tolerating liquids and food, resume play – remarkably short 6 hours, often marked by sleep. “Turning off a switch”
slide31

Other Symptoms

  • Other than vomiting
  • 3 categories
    • Systemic
      • Lethargy &/or pallor, withdrawal, flushing, fever, drooling
      • Extreme pallor could even mimic shock
      • Profound lethargy , inability to walk, talk, or interact can simulate semi-coma, confuse with meningitis, toxin ingestion
slide32

GI symptoms

    • Anorexia, nausea, retching, abdominal pain (common), diarrhoea
    • fever and diarrhoea could confuse with viral GE – except for stereotypical recurrences. Also CVS patients look sicker, are often more dehydrated
    • Abdominal pain can mimic acute abdomen
  • Neurologic symptoms
    • Headache, photophobia, phonophobia, vertigo
    • <50% have classic migraine symptoms, but high occurrence of these symptoms supports link to migraines
    • Adolescents may assume foetal position to cope with hypersensitivity to light, sound, touch, upright positioning
slide33

Features (cont)

  • Periodicity
    • Over 24 period – most common onset between 2am-4am and 6am-8am
      • ?relationship to Corticotropin Releasing Factor
    • Over 1-3 month period – commonly every 4 weeks, but only half can predict next episode within 1 week on either side. Rest are sporadic
    • Seasonal – many worse in winter
slide34

Triggers

    • Numerous events can trigger episode
    • Parents can often identify trigger
    • Most common
      • Psychologic – usually positive excitement rather than negative
      • Infectious – URTI’s, sinusitis, streptococcal pharyngitis
    • Also physical exhaustion, lack of sleep, dietary (chocolate, cheese, MSG), menstruation, motion sickness, asthma, allergies
slide35

Differential Diagnosis

  • Recurrent vomiting may be caused by neurologic, metabolic, endocrine, renal, gastrointestinal pathology
  • Cyclic vomiting - 12% have surgically-correctable lesion or metabolic disorder => therefore not Idiopathic CVS
    • NB: exclude malrotation, intermittent volvulus => if unrecognised could result in bowel resection
    • Genitourinary – acute hydronephrosis due to uretero-pelvic junction obstruction mimics CVS. Also nephrolithiasis
    • CNS – subtentorial neoplasms
slide36

Non-surgical GIT problems – GORD, food allergy to milk, wheat proteins

  • Chronic sinusitis
  • Metabolic – mitochondrial enzymopathies – infants, toddlers. Acute intermittent porphyria – adolescents – fasting and alcohol
  • Endocrine – Addison’s disease
  • Psychological – Munchausen-by-proxy, anxiety
slide37

Diagnosis

  • Approach guided by need to exclude treatable underlying disorders
  • Imaging
    • First-line => Small bowel radiography, abdominal ultrasound/CT – exclude structural defects
    • Usually when child well – so can retain oral contrast
    • Second-line => sinus CT, CT or MRI head. Also gastroscopy if peptic disorders suspected
slide38

Laboratory Investigations

    • U&E, Glucose, lactate, ammonia, amino acids, urine organic acids
      • Assess complications (dehydration) and assist with diagnosis (metabolic disorders)
      • Screening for metabolic, endocrine disorders best done during episode as may be intermittently symptomatic
  • How much testing should be done?
    • High cost of complete testing vs potential morbidity of missed diagnosis
      • Single most useful test is small bowel series
slide39

Move on to 2nd line tests OR repeat 1st line tests for

    • Frequent, severe, prolonged episodes requiring repeated hospitalisations
    • Atypical features – severe headache
    • Refractory to medical management
slide40

Relationship to migraine

  • CVS thought to be migraine variant
  • Often family history of migraine
  • High rate of improvement on anti-migraine therapy
  • Can progress to migraine headaches once CVS episodes have ceased
slide41

Treatment

  • Only empiric therapy at present
  • 5 aspects
    • Avoidance of precipitating factors
      • Food and stressful events possible
      • Mostly unavoidable
    • Prophylactic agents
      • Anti-migraine – propranolol, amitryptiline
      • Anti-epileptic – phenobarbital, valproate
      • Prokinetic agents – erythromycin
    • Abortive agents
slide42

Parenteral

    • Anti-migraine agents – Sumatriptan (5HT1B/1D agonist)
    • Anti-emetic agents – Ondansetron (5HT3 antagonist), even more effective with benzodiazepine (Lorazepam)
  • Supportive care
    • IV fluids – 10% dextrose-containing electrolyte solution – rehydration, terminate ketosis
    • Quiet, dark, non-stimulating environment
    • Sedatives –help to sleep, sleep may initiate recovery phase
    • Phenothiazine anti-emetics INEFFECTIVE in CVS
    • Opiates for pain may help but can worsen nausea
slide43

Family support

    • Crucial – unpredictable, disruptive, unexplained illness, often misdiagnosed, few definitive answers