VOMITING GENERAL APPROACH By: Dr. Doaa Al-Masri
Definition • It is generally unpleasant activity that results in the expulsion of stomach contents through the mouth. • Nausea is an uncomfortable feeling known to be relieved by vomiting.
Physiology • It occurs after stimulation of either the vomiting center or the chemo-receptor trigger zone(CTZ). • Pathways to stimulation: • 1.Psychological stress. • 2.The labyrinth of the inner ear. • 3.Chemical signals from bloodstream and CSF. • 4.The vagal and visceral nerves by G.I. irritation,distension and delayed gastric emptying.
Physiology • The act of vomiting starts by nonperistaltic contractions in S.I. ,the gallbladder contracts and some of the duodenal contents regurgitate into the stomach. • Then a large retrograde peristaltic wave that pushes S.I.contents and pancreatobiliary secretions into the stomach and suppresses gastric activity. • The inspiratory muscles contract against closed glottis resulting in esophageal dilatation along with the abdominal muscles which contract and force the gastric contents to the distal esophagus.
Physiology • The cycles of retching quicken until the esophagus no longer empties between the cycles and the contents are finally extruded. • The motor events are mediated through the vagal and sympathetic efferents from the vomiting center as are the autonomic events associated with the act of vomiting.
Pathogenesis • It can be divided into: • 1.Bilious • 2.nonbilious • G.E.R.:effortless and not associated with retching or autonomic symptoms.
Causes of vomiting • Nonbilious: • Infectious/inflammatory. • Metabolic/endocrinologic • Neurologic. • Obstructive lesion • Psychological. • Bilious: • Distal obstructive lesion.
Nonbilious vomiting • Infectious/inflammatory: • Acute gastroenteritis.:-Viruses:rotavirus -Bacteria:Sallmonella,Campylobacter,E.coli., Clostridium difficile ,Giardia lamblia. • Diagnosis:stool culture,rotazyme,stool for ova and parasite,detection for C difficile toxin. • Sepsis,C.N.S infection,U.T.I, and pneumonia. • Labyrinthitis and pancreatitis • Inflammatory bowel disease.
Metabolic/Endocrinologic • In-born errors of metabolism: • It presents early in infancy and associated with symptoms of lethargy,hypo-or hypertonia,seizures or coma. • Metabolic acidosis , hypoglycemia,hyperammonemia or ketosis and family history.
Metabolic/Endocrinologic • Diabetes mellitus:due to ketoacidosis or gastroparesis. • Food related sensitivity: -cow milk - soy protein intolerance -type 1 food allergy. -celiac disease.
Neurologic • It occurs in any condition that increases the intracranial pressure,seizures autonomic disorders and conditions that affect the floor of the fourth ventricle. • Cyclic vomiting:it occurs at early school age and characterized by acute-onset periodic episodes of nausea and vomiting interspersed with conspicuous periods of wellness with some identifiable precipitating events. • Those patients have increased incidence of migraine headaches and prevalence of epilepsy and irritable bowel syndrome. • Diagnosis by exclusion.
Psychological • Rumination is a serious condition that occurs in infants when there is a failure in reciprocal interaction between the infant and the caregiver. • The failure to thrive does not improve with the traditional medical intervention but requires sensitive and interactive nurturing. • Bulimia among teenagers.
Anatomic • The anatomic causes of nonbilious vomiting are those that affect the intestinal tract proximal to ampulla of Vater which is proximal to the ligament of Treitz and if it presents in the near neonatal period pyloric stenosis should be ruled out.
Bilious vomiting • It is an omnious sign that mandates immediate evaluation. • In the neonatal period intestinal atresia and stenosis and malrotation with or without volvulus need to be ruled out immediately. • In the older child, malrotation with volvulus is a surgical emergency. • Management
Vomiting of blood • Bright red blood implies active bleeding in the esophagus,stomach,or proximal duodenum. • Coffee-ground color implies a recent history of bleeding. • Minimal bleeding can be treated with histamine-2 blockers or antacids but larger hemorrhages require further intervention.
The end Thank you