regurg & vomiting

8/6/2019 Regurg & Vomiting

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Regurgitation andRegurgitation and

VomitingVomiting

Regurgitation andRegurgitation and

VomitingVomiting



REGURGITATIONREGURGITATIONDefinition:

Non forceful expulsion of food & secretions from esophagus

or stomach through the

mouth



VOMITINGVOMITINGDefinition:

Forceful expulsion of stomach

contents through the mouth May be accompanied by nausea &

retching

May be evidence of gastro-duodenal reflux (bile stained )



Differences :Differences :Regurgitation is:

« NOT accompanied by nausea & retching

« NO forceful contraction of abd. muscles



Physiological RegurgitationPhysiological Regurgitation

P osseting P osseting

Happy Spitter 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: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: AnatomyEsophagus: Anatomy



Normal Intraluminal pressuresNormal Intraluminal pressures



Hiatal HerniaHiatal Hernia



Gastroesophageal refluxGastroesophageal reflux

³³G.E.R or ChalaziaG.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



PHY

SIOLOGIC AL

PHY

SIOLOGIC AL G.E.R.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 P ATHOLOGIC AL

G.E.R.

D.IN

P ATHOLOGIC AL

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

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



R espiratory complicationsR espiratory complications Aspiration of refluxate

N octurnal cough

Asthma

Recurrent aspiration pneumonia

Vagal stimulation

Stridor, croup

Apnea

Bradycardia S.I.D.S.



Acid Acid--Related AsthmaRelated Asthma



Acid Acid--Related Asthma (cont )Related Asthma (cont )



Diagnosis of G.E.R 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 Management of

G.E.R

Phase I :

M ilk 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



Positional Treatment

Old method

GER

Anti-Trendlenberg

position at 30 o



Causes of VomitingCauses of Vomiting Stimulation of supramedullary centers

Stimulation of Chemoreceptive T. Z.

Stimulation of peripheral receptors

Obstruction of Gastrointestinal tract



Supramedullary Centers Stim.Supramedullary Centers Stim. Increased Intracranial pressure

Psychogenic vomiting (school phobia..)

Vestibular disease (motion sickness...)

Vascular causes (migraine, B.P. )

Seizures



Stimulation of C.T.ZStimulation of C.T.Z Drug overdose: opiate, digoxin, aspirin..

M etabolic : acidosis, ketosis, uremia.. Hypervitaminosis A & D

Endocrinal : diabetes, adrenal insuf.,..

Irradiation



GIT obstr.&

P

eriph. Stim.G

IT obstr.&P

eriph. 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 M iscellaneous: infectious fevers,

malaria, sepsis, peritonitis, cyclic vomiting,



Main causes in NewbornMain causes in Newborn Birth trauma (I.C.Hge), septicemia

M econium aspiration

Congenital G.I.T malformations

Inborn errors of metabolism



Main causes in InfancyMain 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 ChildrenMain causes in Children Gastroenteritis, dehydration, acidosis

Tonsillopharyngitis, otitis media, etc.

Systemic infections

Psychogenic ( relief by hospitalization)

Drugs, chemicals & toxins

Pertussis syndrome



Main causes in AdolescentsMain causes in Adolescents Gastroenteritis

Systemic infections

Toxic ingestion, drugs, medication

Psychogenic, bulimia

Appendicitis

M igraine



Cong. Hyp. Pyloric StenosisCong. Hyp. Pyloric Stenosis

HOW TO PALPATE ?HOW TO PALPATE ?



DiagnosticE

valuationDiagnosticE

valuation 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., C N S..



InvestigationsInvestigations

Depending on suspicion: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:G

eneral linesTreatment:G

eneral 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)

regurg & vomiting

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