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CHAPTER 81 ■ VOMITING
MARIDETH C. RUS, CARA DOUGHTY

INTRODUCTION
Vomiting is the forceful oral expulsion of gastric contents associated with

contracture of the abdominal and chest wall musculature. Vomiting may be
caused by a number of problems in diverse organ systems. Vomiting is extremely
common in the pediatric emergency department (ED), and usually represents a
transient response to a self-limited infectious, chemical, or psychological insult.
However, vomiting may also be the primary presentation of significant
gastrointestinal, infectious, neurologic, or metabolic disorders requiring
immediate evaluation and treatment to prevent morbidity and mortality. Thus, an
orderly approach to diagnosis is crucial.
Vomiting is a complex act with multiple phases: pre-ejection, retching, and
ejection phases. Gastric relaxation and retroperistalsis occur in the first phase,
followed by rhythmic contractions of chest and abdominal wall muscles against a
closed glottis in the retching phase. In the ejection phase, contraction of the
abdominal muscles combines with relaxation of the esophageal sphincter to result
in ejection. “Projectile” vomiting should be concerning as a sign of gastric outlet
obstruction such as pyloric stenosis.
Therapeutic advances have arisen from an evolving understanding of
neurotransmitter activity in the central nervous system (CNS), GI tract, and other
sites. Serotonin (5-hydroxytryptamine) receptors are prevalent in the CNS and gut
and participate in the induction of emesis. Use of serotonin receptor antagonists
(such as ondansetron) has proven to be successful in decreasing or preventing
emesis associated with many chemotherapeutic and radiotherapeutic cancer
treatments, in emetogenic poisonings, and in children with viral gastroenteritis.
Increasing evidence shows that ondansetron use in pediatric patients with viral
gastroenteritis is safe, effective in reducing emesis, and unlikely to mask
underlying pathology in appropriately selected patients.
A related complaint, often heard in the ED, is that of young infants who “spit
up.” This refers to the nonforceful reflux of milk into the mouth, which often
accompanies eructation. Such nonforceful regurgitation of gastric or esophageal
contents is most often physiologic and of little consequence, although it
occasionally represents a significant disturbance in esophageal function with

clinical consequences for the infant.


It is convenient to organize the many diverse causes of regurgitation and
vomiting into age-related categories ( Table 81.1 ). Although there is
considerable overlap, the most common and serious entities can be easily
organized into such groupings.

EVALUATION AND DECISION
General Approach
Given the myriad causes of vomiting, an orderly approach to the differential
diagnosis of this symptom is critical. Three clinical features should guide initial
evaluation and management: the child’s age , evidence of obstruction , and signs
or symptoms of extra-abdominal disease. Other important considerations include
appearance of the vomitus, overall degree of illness (including the presence and
severity of dehydration or electrolyte imbalance), and associated GI symptoms.

History
The history should focus on the key elements noted above. The patient’s age is
often significant because certain critical entities (especially those that cause
intestinal obstruction) are seen predominantly in neonates and older infants, and
are less common in children beyond the first year of life. Evidence of obstruction,
including abdominal pain, obstipation, nausea, distention, and increasing
abdominal girth, is sought in addition to vomiting. Associated GI symptoms may
include diarrhea and anorexia. The suspicion of significant extra-abdominal organ
system disease is raised by neurologic symptoms such as severe headache, stiff
neck, blurred vision or diplopia, clumsiness, personality or school performance
change, or persistent lethargy or irritability; by genitourinary symptoms such as
flank pain, dysuria, urgency and frequency, hematuria, or amenorrhea; by
infectious complaints such as fever, sore throat, or rash; or by respiratory

complaints such as cough, increased work of breathing, or chest pain ( Tables
81.2 , 81.3 , and 81.4 ). Other associated GI symptoms may include diarrhea,
anorexia, flatulence, and frequent eructation with reflux.
The appearance of the vomitus (by history and inspection when a specimen is
available) is often helpful in establishing the site of pathology. Undigested food
or milk should suggest reflux from the esophagus or stomach caused by lesions
such as esophageal atresia (in the neonate), gastroesophageal reflux (GER), or
pyloric stenosis. Bilious vomitus suggests obstruction distal to the ampulla of
Vater, although it may occasionally be seen with forceful prolonged vomiting of
any cause when the pylorus is relaxed. Fecal material in the vomitus is seen with


obstruction of the lower gastrointestinal tract. “Coffee-grounds” emesis suggests
blood that has been exposed to gastric acid. Hematemesis usually reflects a
bleeding site in the upper GI tract; its evaluation is detailed in Chapter 33
Gastrointestinal Bleeding .

Physical Examination
The physical examination should begin by evaluating the overall degree of
toxicity. Are there signs of sepsis or poor perfusion? Is there the inconsolable
irritability of meningitis? Are there signs of severe dehydration or concern for
symptomatic hypoglycemia? Does the child exhibit the bent-over posture,
apprehensive look, and pained avoidance of unnecessary movement typical of
peritoneal irritation in appendicitis? Next, attention is directed to the abdominal
examination. Are there signs of obstruction such as ill-defined tenderness,
distention, high-pitched bowel sounds (or absent sounds in ileus), or visible
peristalsis? A complete physical examination must include a search for signs of
neurologic, infectious, toxic/metabolic, and genitourinary causes, as well as an
evaluation of hydration status (see Chapter 22 Dehydration ).