Day: May 2, 2016

What Causes Vomiting?

Patient Presentation
A 4-year-old female came to clinic with a history of increasing rhinorrhea, coughing for 10 days, emesis and poor sleep. Her mother said that the rhinorrhea was clear but was in copious amounts and the cough was described as “phlegmy.” The patient had used her albuterol inhaler without much relief. The emesis was non-bilous, non-bloody and “looked like the cold coming out her nose.” Her mother noted that she frequently would gag. The mother stated that she would lie down, then after a while would start coughing forcefully and then she would have emesis. This was occurring at night and was bothering both the child’s and mother’s sleep. She did not have emesis at other times. The mother thought that the rhinorrhea and cough had started after exposure to other ill children at daycare. The family had pet fishes but no other animals in the home. The past medical history revealed a child with mild intermittent asthma and atopic dermatitis that was well-controlled with intermittent albuterol and lubricants. The family history was positive for asthma, seasonal allergic rhinitis and atopic dermatitis. There was no history of gastrointestinal diseases. The review of systems was negative for fever, chills, constipation, and nausea, but was positive for dry skin.

The pertinent physical exam showed a tired appearing female who was appropriately responsive. Vital signs were normal with growth parameters in the 10-25% for age. HEENT showed dark circles under her eyes with atopic pleats. Her conjunctiva showed mild erythema with some cobblestoning. Her nose was boggy with copious clear rhinorrhea. Pharynx and ears were normal. Her lungs had no wheezing and her skin examination showed general xerosis without acute inflammation. The diagnosis of a probable upper respiratory infection starting the rhinorrhea and cough, but with components of allergic rhinitis was made.. The mother was counseled that the emesis was because of an appropriate gag reflex because of the post-nasal drip. The patient was started on cetirizine to help with the allergic rhinitis, and counseled. The physician also counseled about decreasing exposure to environmental allergens particularly as it appeared that the child and family all had environmental allergies.

Discussion
Regurgitation is a passive expulsion of ingested material out of the mouth. It is a normal part of digestion for ruminants such as cows and camels. Nausea is an unpleasant abdominal perception that the person may describe as feeling ill to the stomach, or feeling like he/she is going to vomit. Anorexia is frequently observed. Nausea is usually associated with decreased stomach activity and motility in the small intestine. Parasympathetic activity may be increased causing pale skin, sweating, hypersalivation and possible vasovagal syndrome (hypotension and bradycardia). Retching or dry heaves is when there are spasmodic respiratory movements against a closed glottis. This often occurs just before emesis.

Emesis, vomiting or vomition is when stomach (sometimes small intestine also) contents are propelled up the esophagus and out the mouth.
It is composed of three basic parts:

  • A deep breath is taken, the glottis closed to prevent aspiration into the lungs, while the larynx is raised which helps to open the upper esophageal sphincter. There is a decrease in respiration.
    The soft palate also closes to try to protect the posterior nares. The pylorus also contracts.

  • The diaphragm contracts downward sharply which creates negative thoracic pressures. This also assists the opening of the lower esophageal sphincter and the esophagus itself.
  • As the diaphragm contracts, the abdominal wall muscles vigorously contract which increases the intragastric pressure. As the pylorus is closed, the path of least resistance is through the relatively open esophagus.

A differential diagnosis of bilious emesis in a neonate can be found here.
A differential diagnosis emesis in a neonate can be found here.
A differential diagnosis of hematemesis can be found here.

Learning Point
The differential diagnosis of emesis include:

  • Normal variation, i.e. “spitting up”
  • Feeding problems
    • Overfeeding or force feeding
    • Incorrect feeding – delay in giving solid foods and food aversion
    • Refeeding syndrome
  • Excessive crying
  • Gastroesophageal reflux, severe
  • Gastrointestinal obstruction
    • Achalasia
    • Annular pancreas
    • Diaphragmatic hernia
    • Gastric/intestinal atresia/stenosis/duplications
    • Incarcerated hernia
    • Intestinal or viscous organ perforation with peritonitis
    • Intussception
    • Imperforate anus
    • Hirschsprung disease
    • Malrotation/volvulus
    • Meconium plug and ileus
    • Organomegaly
    • Pseudoobstruction syndrome
    • Pyloric stenosis
    • Superior mesenteric artery syndrome
    • Tumor
    • Tracheoesophageal fistula
    • Vascular rings
  • Gastroenterology, other
    • Constipation/encopresis
    • Celiac disease
    • Foreign body – esophageal, lactobezoar
    • Nutrient intolerance – lactose intolerance
    • Sensitive gag reflex
    • Swallowed blood – epistaxis and maternal
  • Allergy/Respiratory
    • Allergies
    • Cystic fibrosis
    • Asthma
  • Drug overdose
    • Aspirin
    • Iron
    • Lead
    • Theophylline
    • Digoxin
  • Genitourinary
    • Inguinal hernia
    • Testicular or ovarian torsion
    • Pelvic inflammatory disease
    • Pregnancy
  • Infections
    • Appendicitis
    • Cholecystitis
    • Encephalitis, meningitis, brain abscess
    • Gastroenteritis
    • Hepatitis
    • Necrotizing enterocolitis
    • Otitis media
    • Pancreatitis
    • Peptic ulcer disease
    • Pertussis
    • Perihepatitis
    • Peritonitis
    • Sepsis
    • Urinary tract infection
  • Metabolic
    • Diabetic ketoacidosis
    • Hyperammoninemia
    • Inborn errors of metabolism
      • Aminoacidemia
      • Congenital adrenal hyperplasia
      • Galactosemia
      • Hypercalcemia
      • Organic acidemia
      • Urea cycle defects
    • Reye’s syndrome
  • Neurologic
    • Cerebral edema
    • Cyclic vomiting
    • Familial dysautonomia
    • Head trauma
    • Hydrocephalus
    • Intracranial bleeding
    • Kernicterus
    • Mass lesion
    • Migraine
    • Seizures
    • Vestibular disorders – motion sickness
  • Psychological/Psychiatric
    • Attention seeking
    • Strong emotions – anxiety, fear
    • Intentional – bulimia
    • Munchausen by proxy
    • Neglect – rumination
    • Psychogenic
  • Renal
    • Obstruction
    • Uremia
  • Surgery and Trauma
    • Post-anesthesia
    • Non-accidental trauma

Questions for Further Discussion
1. How is bilious emesis defined?
2. What are “red flags” for potential serious causes of emesis?
3. What are the most common causes of emesis at different ages?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Nausea and Vomiting.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Sheldon SH, Levy HB. Pediatric Differential Diagnosis. Second Edition. Raven Press: New York. 1985:167-174.

R. Bowen. Physiology of Vomiting. Available from the Internet at http://www.vivo.colostate.edu/hbooks/pathphys/digestion/stomach/vomiting.html (rev. 4/10/96, cited 3/1/16).

Di Lorenzo C, Gastroesophageal Reflux in Pediatrics a Primary Care Approach. Berkowitz C. edit. W.B. Saunders Company, Philadelphia PA. 1996:334-339.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1351-1354.

Colosini DM. Nausea and Vomiting in Infants and Children. Merck Manual. Available from the Internet at http://www.merckmanuals.com/professional/pediatrics/symptoms-in-infants-and-children/nausea-and-vomiting-in-infants-and-children (rev. 8/2013, cited 3/1/16).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital