1

What are the common reasons for vomiting in pediatric patients?

Children vomit with almost any kind of illness, so the list of causes is extensive. By far, however, the most common cause of vomiting in children of any age is gastroenteritis.

2

What are the usual culprits for gastroenteritis?

The answer depends on your practice setting. While bacterial and parasitic causes are more commonly encountered in resource-poor settings, in developed countries, viruses are much more prevalent.

3

If vomiting is so common, how can I know if a dangerous condition might be present ( Table 20.1 )?

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  Appearance of the vomit: bright green or yellow (bilious)

  
  
  
  

  Table 20.1

  
  

  Worrisome Causes of Vomiting by Age Group

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Infancy	Early Childhood	Adolescence
  Volvulus from malrotation	Intussusception	Appendicitis
  Pyloric stenosis	Toxic ingestion	Toxic ingestion
  Increased intracranial pressure	Increased intracranial pressure	Increased intracranial pressure
  Inborn errors of metabolism	Diabetic ketoacidosis	Diabetic ketoacidosis
  Other causes of obstruction	Appendicitis	Torsion of ovary/testis

   
  
  
  
  
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  Pain: especially severe or constant

  
  
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  Exam: marked tenderness or distension

  
  
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  Symptoms or signs of elevated intracranial pressure

4

Why is bilious emesis worrisome? Is it always?

Vomiting of bile can signify an intestinal obstruction distal to the sphincter of Oddi. More frequently, however, bilious emesis simply follows vomiting of nonbilious contents and does not indicate an emergency.

5

A 13-day female patient presents with two episodes of vomiting in the past few hours. The parents show you a blanket with a small bright yellow stain from her emesis. What should you do?

Bilious emesis in young infants should be considered an emergency until proven otherwise. This is a classic presentation (even if well appearing!) for neonatal obstruction, the most common cause being intestinal malrotation (entraining volvulus). This child should be urgently referred for an upper gastrointestinal (GI) study.

6

How do I know if the baby I’m seeing simply has reflux?

Physiologic reflux (“spitting up”) is the most common cause of vomiting in infants. Clues to this diagnosis are well appearance, normal growth, and nonacute presentation. Reflux typically peaks in the second month of life and usually does not require pharmacologic intervention.

7

A 7-week infant has had worsening vomiting for 5 days. There is no bile. The caregiver thinks that the emesis is becoming more forceful. What diagnosis should you consider?

Hypertrophic pyloric stenosis usually presents in the second month of life, and it is more common in males. Given the anatomic location of the obstruction, vomitus is nonbilious. Babies are often well appearing, and unless they present later in the course of their illness, the “classic” electrolyte pattern of a hypochloremic, hypokalemic metabolic alkalosis will be absent. They have progressive “projectile” vomiting and lack satiety. It is diagnosed by ultrasound.

8

List some common causes for a presenting complaint of “blood in the stool” for infants and young children

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  Lack of true blood (red dyes, cefdinir)

  
  
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  Anal fissures

  
  
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  Infectious diarrhea

  
  
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  Swallowed maternal blood

  
  
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  Milk protein intolerance (infants)

  
  
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  Ileocolic intussusception (late finding)

9

My patient has fever and diarrhea but now is complaining of blood in the stool. Guaiac testing is positive. The child looks well. Given the presence of blood, is there anything different that should be done?

While routine stool cultures are not recommended for children with acute diarrhea, up to 20% of cultures will grow a bacterial pathogen when gross blood is present. Therefore, it is advisable to obtain a stool culture in this setting. Nevertheless, antibiotic treatment is not recommended for healthy children in most cases of bacterial enteritis.

10

A 4-month-old female patient presents with 2 days of diarrhea, vomiting, and fever. She is well appearing, and you think the most likely diagnosis is viral gastroenteritis. What one test should you consider for this patient?

Urinary tract infections (UTIs) are common in young children, more so in girls. Data are conflicting as to whether gastrointestinal symptoms are more common in children with UTI. Although young infants can lack the expected findings on urinalysis, consider obtaining urine for this child. While a catheter specimen is preferred, a bagged urine that is “clean” may reassure against UTI; if the bag urinalysis suggests infection, obtain a catheterized specimen for culture.

11

What diagnosis should always be considered in older infants and young children with isolated vomiting?

Ileocolic intussusception is the most common gastrointestinal emergency in young children. The usual age range is 6–36 months of age, but all the “classic” findings (vomiting, pain, lethargy, abdominal mass, “currant jelly” stools) are not usually present. Kids can appear well, especially if the obstruction is intermittent. The preferred diagnostic modality is ultrasound, and hydrostatic enema is usually successful for reducing the intussusception.