VOMITING IN CHILDREN

ASTRI FALUNA 1102009044

Faculty of Medicine Yarsi
Pediatric Department
Rumah Sakit Bhayangkara tk.I R.S. Sukanto-Jakarta
Periode: 1 Desember 2014 30 January 2015

Definition
Vomiting stomach is evisceration
with active force due to the
contraction of the abdomen , pylorus ,
elevation cardia with the lower
esophageal sphincter relaxation and
dilation of the esophagus

 Gastroesophageal reflux is defined

the return of gastric contents into
the esophagus without visible
abdominal muscle contraction
Regurgitation is the backflow of
stomach contents into the oral
cavity . regurgitation does not
require power and are not
accompanied by nausea

 Rumination is conscious
food expenditure to
chew then swallow back

Etiology
Vomiting
in
Neonatus

Non organik

stomatch irritation to amniotic fluid,

drug, incorrect feeding techniques,
metabolic abnormalities :
galactosemia , hypercalcemia

Vomiting in
Neonatus

Organik

Traktus
Gastrointestinalis

Obstruksi

Non Obstruksi

esophageal atresia, stenosis

pilorus,Hirschsprung
disease,hiatal hernia,intestinal
malrotation, meconium ileus,
laktobezoar

Chalasia,
gastroenteritis,
irritation of
stomach acid

Vomiting
in
Neonatus

Ekstragastrointestinal

sepsis, renal insufficiency,

urinary tract infections,
inborn metabolic error,
adrenal hyperplasia

central nervous system

Meningitis, increased
intracranial pressure,
subdural effusion,
hidrosefalus.

Organik

Vomiting in Infants

Etiology
Non organik

eating technique
, erofagi , motion
sickness , drug

Obstruksi

Organik

Traktus
Gastrointestinalis
Non Obstruksi

pyloric stenosis ,
antral web ,
intussusception ,
volvulus
GER , lactose
intolerance ,
gastroenteritis , peptic
ulcer disease , celiac
disease , appendicitis ,
peritonitis

Ekstra gastrointestinal

Vomiting
in Infants

pertusis, tonsilofaringitis,
OMA, Uremia, Asidosis,
hepatitis, Inborn errors of
metabolism

Organik

Central nervous system

Meningitis, Ensefalitis,
increased intracranial
pressure

Non
organik

anxiety, fear, suggestion,

post nasal drip, motion
sickness

Vomiting
in child
Obstruksi

Organik

intussusception ,
intestinal
obstruction ,
aklasia ,
appendicitis

Traktus
Gastrointestinalis

Non Obstruksi

gastroenteritis ,
appendicitis ,
gastritis , peptic
ulcer , poisoning
eating

Ekstra gastrointestinal

Vomiting
in child

respiratory tract infections

, urinary tract infections ,
otitis media , testicular
torsion , inborn errors of
metabolism,pyelonephritis

Organik

Central nervous
systemSP

hidrosefalus, increased
intracranial pressure,
infection of the central
nervous system.

Pathophysiology
vomiting process consists of :
1. Nausea : This phase is characterized by a
sense of want to throw up in the stomach
and esophagus with various autonomic
symptoms such as increased salivation ,
sweating , pale , tachycardia

2. Retching:
Respiratory
muscle
spasm before vomiting occurs

3. Emesis :a reflex that causes the

urge expulsion of gastric contents
or intestines or both to mouth

Classification
Vomiting can be classified according to its nature and
cause as well as by the character of the vomitus. The
nature of the vomiting may be projectile or non projectile.
Projectile vomiting refers to forceful vomiting and may
indicate increased intracranial pressure, especially if it
occurs early in the morning. Projectile vomiting also is a
classic feature of pyloric stenosis. Non projectile vomiting is
seen more commonly in gastroesophageal reflux.

Classification
Emesis often is classified based on its quality. The
vomitus may be bilious, bloody, or non bloody and non
bilious. Emesis originating from the stomach usually is
characterized as being clear or yellow and often contains
remmants of previously ingested food. Emesis that is dark
green is referred to as bilious because it indicates the
presence of bile. Bilious vomiting frequently is pathologic
because it may be a sign of an underlying abdominal
problem such as intestinal obstruction beyond the
duodenal ampulla of Vater, where the common bile duct
emptics.

Classification
The presence of blood in the emesis, also know as
hematemesis, indicates acute bleeding from the upper
portion of the GI tract, as can occur with gastritis,
Mallory-Weiss tears, or peptic ulcer disease. Coffee
ground like material often is representative of and old GI
hemorrhage because blood darkens to a black or dark
brown color when exposed to the acidity of the gastric
secretions. The more massive or proximal the bleeding,
the more likely is it to be bright red

Clinical Manifestations
One important also to be understood in a child
who is experiencing vomiting is to determine
abnormalities requiring immediate surgery. These
disorders are generally classified into groups of acute
abdominal disease.
Sign suspicion against these disorders, :
1. Abdominal pain arising preceded by vomiting
and / or lasts for more than 3 hours.
2. Vomiting mixed with gall.
3. Abdominal distension.

approach to the diagnosis of vomiting in

children:
Establish / remove infections as a cause of
vomiting (otitis media, diarrhea, intracranial
infections, urinary tract infections or breath,
sepsis, or hepatitis.)
Establish / remove organic gastrointestinal
disorders (atresia of the esophagus,
gastroesophageal reflux, stenosis of the
pylorus, Hirschsprung's disease, peptic
disease.)

 Find the possibility of problems in food (lactose

intolerance, food allergies, overeating,
engineering feeding / drinking is wrong)
Look for a possible influence of drugs,
psychological disorders and metabolic
disorders.

Diagnosis
Approach to the identification of very important
issues, including:
1. Age and sex
2. Decide in advance what is encountered: vomiting
or other
3. How the nutritional state of children
4. Is there a predisposing factor
5. Is there a disease that strikes children interkuten
6. What form (content) vomit, whether as milk /
food origin (the sign of the esophagus), or have a
milk clot (stomach contents), containing bile
(duodenal contents) or is there blood

7. Do you currently associated with

vomiting when eating or drinking.
8. What changes in body position affects
vomiting
9. Information Diet: quality, quantity, and
frequency of meals (especially for small
children)
10. What techniques of drinking
11. How psychosocial conditions at home

Laboratory Tests
Urine :
Urine complete, reduction, culture

Blood tests :
complete blood count, BUN, serum creatinine, blood
gas analysis, amino acid analysis, blood glucose,
ammonia

Radiological and Other Support

- Radiological with or without
contrast
- Ultrasound
- Esophageal pH monitoring (pHmetri)
- Hydrogen breath test
- IVP
- CT scans
- Endoscopy, biopsi

Treatment
1. Local effects.
Mallory-Weiss tear usually only cause minor
bleeding so that no action was necessary.
Instead rips esophagus require radical action.
2. Metabolic Effects In patients with
recurrent and prolonged vomiting can occur
fluid and electrolyte balance disorders that
require fluid and electrolyte replacement

3. Aspiration
Apirasi massive gastric contents require
anibiotika and sometimes corticosteroids

4. The effect of nutrition

Explaining to parents about how making
techniques drinks / food and eating.

Drug Antiemetic
Symptomatic management to
reduce or eliminate symptoms of
vomiting often needs to be done
first

Antiemetic Drug Classes

Anticholinergics (vestibular system disorders):
Hyosine, buskopan, holopon, atropine
Antihistamines (vestibular system disorders):
Dimenhydrinate (Dramamin, Antimo), Meclozine
(Tavegyl), promethazine (Fenergan, Avropeg)

Phenothiazines :
Proklorperazine (Stenetil). Pervanazine (Avomit)
Tietilperazine maleate (Torecan)

Dopamine antagonist (work on the center CTZ

and peripheral gastrointestinal :
Metoclopramide (Vomitrol), Domperidone
(Motilium)

Increasing acetylcholine :
Metoclopramide (Vomitrol)

Direct on muscarinic receptors:

Bethanecol

Drugs that affect intestinal motility.

Mechanisms of action

Motility stimulants

Direct effect on muscarinic Betanechol

Prokinetic drugs
-

receptors

Antagonis reseptor dopamine -

Metoklopramid,

Domperidon

Increasing acetylcholine

Metoklopramid,
Cisaprid

A DRUG OFTEN USED TO TREAT

VOMITING AND GASTRIC
MOTILITY DISORDERS

1. Metoclopramide
Quite effective, way of working is the blockade of
dopamine receptors in the CTZ, so it can control
nausea and vomiting both centrally.

2. Domperidone

The workings of the blockade of dopamine

receptors in the CTZ and intestines either. Can be
administered orally or suppository. Oral doses of
1mg/kg.bb/day
(more
effective
than
metoclopramide 0.5 mg/kg.bb/day) Dosage in
children 0.2-0.4 mg/kg.bb/day orally, 4-8 hour
intervals.

3. Cisapride
New
prokinetic
drug,
increased
spending
physiologically selective acetylcholine at the level of
post-ganglionic nerves in myenteric plexus. Do not
have the nature of the blockade of dopamine
receptors, but the increase peristaltic gastroduodenal.
in children are also effective in preventing reflux and
repair klerens of reflux in the esophagus. Dose 0,20,4mg/kg.bb/day.

4. Betanekhol
A selective kholinester with the workings of
the muscarinic receptor. In children RGE used
for therapy, a dose of 0.6 mg/kg.bb/day,
divided into 3 doses, orally 0.15 to 0.2
mg/kg.bb/day sub-cutaneous.

COMPLICATIONS
Loss of fluids and electrolytes ,
aspiration of gastric contents , malnutrition
and failure to thrive , Mallory - Weiss
syndrome
(
tear
in
epithelial
gastroesophageal junction due to repeated
vomiting ) , Boerhave syndrome ( rupture of
the esophagus ) , and peptic esophagitis.

PROGNOSIS
The prognosis of patients with symptoms of
vomiting depends on the degree of
dehydration and treatment of dehydration,
the etiology of the disease which causes
vomiting, as well as complications of vomiting
itself.

Prevention
Prevention is meant here is the
prevention of complications due to vomiting ,
such as fluid and electrolyte balance disorders
( dehydration , acidosis / metabolic alkalosis ,
hypokalemia , hyponatremia ) , aspiration ,
nutritional disorders , peptic esophagitis ,
Mallory - Weiss syndrome .

Conclusion
Vomiting is one of the most common clinical
manifestations shown by a child with disorders of
the digestive tract and out of the digestive tract .
The causes of vomiting in children vary widely ,
therefore the introduction of specific clinical
manifestations of each disease as the cause of
vomiting that often needs to be understood by a
physician . Proper approach and speedy diagnosis
would lead to optimal management .

THANK YOU