Vomiting in Children with emphasis on Cyclical Vomiting Syndrome.
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Transcript of Vomiting in Children with emphasis on Cyclical Vomiting Syndrome.
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Vomiting in Children with emphasis onCyclical Vomiting
Syndrome
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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
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• 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
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– 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
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• 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
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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
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• 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• CNS – Awake, but withdrawn.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
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Management• Admitted to ward• Rehydrated with IV fluids• Allowed to take orally as desired• Panado, Cyclizine for vomiting
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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
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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
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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
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• 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
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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
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• 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
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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
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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
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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
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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
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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
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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
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• 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
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• If no diagnosis still, consider– Upper GI contrast study, ultrasound
abdomen – Gastroscopy PLUS biopsy – high
diagnostic yield, ease of performance, safe
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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
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– 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
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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!
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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
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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
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• Cyclic– Idiopathic– If other cause –
extraintestinal• Neurologic• Renal• Metabolic• Endocrine
• Chronic– GIT disorders
• Peptic oesophagitis
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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”
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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
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• 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
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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
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• 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
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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
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– 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
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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
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• 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
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–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
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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
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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
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• 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
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– Family support• Crucial – unpredictable, disruptive,
unexplained illness, often misdiagnosed, few definitive answers