Vomiting

INTRODUCTION

VOMITING IN INFANCY

Important warning signs in neonates:

• excessive drooling of frothy secretions from mouth

• bile-stained vomitus—always abnormal

• delayed passage of meconium (>24 h)

• inguinal hernias

First question: Is the vomiting bile stained?

• Green vomiting = urgent surgical referral ?intestinal malrotation

• Non-bile-stained vomitus ?pyloric stenosis, gastro-oesophageal reflux, feeding problems, etc. Both pyloric stenosis and GOR cause projectile vomiting.

Oesophageal atresia

• Vomiting occurs with the first feeding

• Excessive drooling of frothy secretions

• Pass 10 g French catheter through mouth to aid diagnosis

Congenital hypertrophic pyloric stenosis

• Usually sudden onset 3rd–6th wk

• Projectile vomitus

• M:F ratio = 5:1

• Gastric peristalsis during test feeding

• Metabolic alkalosis with Na↓ Cl↓

CYCLICAL VOMITING

• Most common in children (mean age 5 yrs) but any age

• Severe, unexplained nausea and/or vomiting at varying intervals in healthy person

• Lasts hours to days

• Regarded as a migraine variant; treat with antimigraine therapy

CHRONIC IDIOPATHIC NAUSEA AND VOMITING

Applies to those who experience chronic nausea and vomiting without an identifiable cause. Dietary modification with CBT is recommended. Consider anti-emetic medication.

SYMPTOMATIC RELIEF OF VOMITING

The first-line management is to ensure that any fluid and electrolyte imbalance is corrected and that any underlying cause is identified and treated. Various anti-emetics can give symptomatic relief.

Note: Avoid the use of the dopamine antagonist drugs (e.g. metoclopramide and prochlorperazine) in children because of risk of extrapyramidal side effects.

Drug-induced nausea and vomiting

• Metoclopramide 10 mg (o) or IM 8 hourly prn

For chemotherapy and radiotherapy:

• metoclopramide 10 mg (o) or IM 1 to 2 hours prior to therapy then 8 hourly (if mild) or

• ondansetron 4 mg (o or SL) bd + dexamethasone 4 mg (ο)/d

For severe cases:

• ondansetron 8 mg (o) or IV prior to therapy then two doses 6 hourly plus

• dexamethasone 8 mg IV 30 minutes prior to therapy, then 2 ...