Regurgitation

Regurgitation and
and
Vomiting
Vomiting
 REGURGITATION
Definition:
Non forceful expulsion of food &
secretions from esophagus or
stomach through the mouth
 VOMITING
Definition:
 Forceful expulsion of stomach contents
through the mouth
 May be accompanied by nausea & retching
 May be evidence of gastro-duodenal reflux
(bile stained )
Differences :
Regurgitation is:
« NOT accompanied by nausea
& retching
« NO forceful contraction of abd.
muscles
 Physiological Regurgitation
“Posseting”
Happy Spitter
 In early weeks of life
– 50% of infants 0-3 months
– 67% of infants at 4th month
 Short time after feeds
 Small amounts of milk
 Baby is calm and happy
 Weight gain is NORMAL
 No treatment needed
 Reassure parents
 Causes of Regurgitation:
 Physiological regurg. (posseting)
 Faulty feeding techniques
 Gastroesophageal reflux (GER)
 Hiatal hernia
 Achalasia of cardia
 Congenital: E. atresia + TE fistula
 Foreign body, Esophagitis, Stricture
Esophagus: Anatomy
Normal Intraluminal pressures
Hiatal Hernia
 Gastroesophageal reflux
“G.E.R or Chalazia”
Causes:
 Hypotonia of Lower E. Sphincter (LES)
 Transient LES relaxations at inappro- priate
moments
 Failure of LES to adapt to intragastric
pressure during crying or straining
 Abolished effect of gravity
 PHYSIOLOGICAL G.E.R.
 GER is a NORMAL phenomenon
 Occurring virtually in everyone
 Characteristically :
– Brief
– + 5 times in post-prandial hour
– Then frequency decrease rapidly to Zero
IN PATHOLOGICAL G.E.R.D.

 There is increased frequency of GER

– During fasting
– During sleep
 Volumes are large (soak clothes)
 Weight gain is affected
GER: Clinical presentations
 Regurgitation / Vomiting.....................97 %
 Failure to thrive, malnutr., anemia.....20 %
 Respiratory complications..................12 %
 Esophagitis & its complications......... 5 %
 Silent Esophagitis

 Dysphagia, Heartburn, excessive cry

 Hematemesis Anemia
Respiratory complications
Aspiration of refluxate Vagal stimulation

 Nocturnal cough  Stridor, croup

 Asthma  Apnea
 Recurrent aspiration  Bradycardia
pneumonia  S.I.D.S.
Acid-Related Asthma
Acid-Related Asthma (cont…)
 Diagnosis of G.E.R
 Clinical : suspect, weight curve
 Barium swallow fluoroscopy
 Esophageal pH monitoring
 Isotope scan (Gamma camera)
 Endoscopy + Biopsy
Management of G.E.R
 Phase I:
 Milk thickening , Positioning
 Avoid certain foods at bed time
 Phase II : all phase I + Domperidone
 Phase III : all phase I & II +

Cimetidine, Ranitidine, etc.

 Phase IV: Surgery
 Anti-Trendlenberg
position at 30 o

GER

Old method

Positional Treatment
 Causes of Vomiting
 Stimulation of supramedullary centers

 Stimulation of Chemoreceptive T. Z.

 Stimulation of peripheral receptors

 Obstruction of Gastrointestinal tract

 Supramedullary Centers Stim.
 Increased Intracranial pressure
 Psychogenic vomiting (school phobia..)
 Vestibular disease (motion sickness...)
 Vascular causes (migraine, B.P. )
 Seizures
 Stimulation of C.T.Z
 Drug overdose: opiate, digoxin, aspirin..
 Metabolic : acidosis, ketosis, uremia..
 Hypervitaminosis A & D
 Endocrinal : diabetes, adrenal insuf.,..
 Irradiation
 GIT obstr.& Periph. Stim.
 Pharyngeal: P.N.D, self induced, etc.
 Esophageal: G.E.R, achalasia, etc.
 Gastric: gastritis, ulcer, dysmotility, bezoar
 Intestinal: infection, appendicitis, obstruction
 Hepatobiliary: hepatitis, cholecystitis, etc.
 Pancreatic: pancreatitis, etc.
 Dietetic: Cow’s milk & food allergies
Improper feeding techniques
 Cardiovascular: intestinal ischemia
 Renal: Pyeloneph., calculi, hydroneph.
 Respir.: Common cold, sinusitis
Tonsilopharyngitis,Otitis media
Pneumonia, Severe cough
 Miscellaneous: infectious fevers,
malaria, sepsis, peritonitis, cyclic vomiting,
 Main causes in Newborn
 Birth trauma (I.C.Hge), septicemia
 Meconium aspiration
 Congenital G.I.T malformations
 Inborn errors of metabolism
Main causes in Infancy
 Gastroenteritis, dehydration, acidosis
 G.E.R & other functional disorders
 Infectious fevers, septicemia, etc.
 Overfeeding & other dietetic causes
 Hypervitaminosis A or D
 Anatomic obstruction: pyloric stenosis
 Main causes in Children
 Gastroenteritis, dehydration, acidosis
 Tonsillopharyngitis, otitis media, etc.
 Systemic infections
 Psychogenic ( relief by hospitalization)
 Drugs, chemicals & toxins
 Pertussis syndrome
Main causes in Adolescents
 Gastroenteritis
 Systemic infections
 Toxic ingestion, drugs, medication
 Psychogenic, bulimia
 Appendicitis
 Migraine
Cong. Hyp. Pyloric Stenosis
HOW TO PALPATE ?
 Diagnostic Evaluation
 Vomiting: Age of onset, frequency, duration,
timing, precipitating factors (cough, food..)
 Associated S & S: fever, coryza, headache,
diarrhea, cough, pain, constipation, jaundice,
seizures, dysuria, polydipsia, weight loss
 History of drug intake, chemical, irradiation
 Examination of G I T
 Exam.of other systems: CVS, Resp., CNS..
 Investigations
Depending on suspicion:
 Stools (parasites, melena, pus cells, etc.)
 Urine (pus cells, bacteria, casts, etc.)
 Liver function tests: hepatitis
 C.B.C + differential count
 Blood electrolytes, pH, Urea, Ketones
 Skull X-ray & fundus : ? I.C.T.
 Imaging studies: ulcers, obstructions, etc.
 Treatment: General lines
 Diet:stop oral intake or only fluid sips
 Correct water, electrolyte & acid-base
 Drugs:
¥ Prokinetic: metoclopramide, domperidone
¥ Anticholinergic: atropine, scopolamine
¥ Antihistamines: dimenhydrinate
¥ Chlorpromazine (potent, use cautiously)