Vomiting in Pediatric Patients (original) (raw)

Abstract

Audience

This classic team-based learning activity is specifically designed for emergency medicine bound medical students and junior residents; however, general pediatrics residents and general medical students may also benefit from this activity. Senior residents and fellows felt that the cases were too basic for them but enjoyed acting as facilitators.

Introduction/Background

Vomiting is a common chief complaint in pediatric patients seen in the Emergency Department. 1–3 Presentations include acute, chronic, and cyclic vomiting, with underlying etiologies such as toxin injection, emotional disturbances, and movement disequilibrium. 1 By understanding these various pathways, it is helpful for physicians to distinguish between gastrointestinal and non-gastrointestinal causes of vomiting. 1 Most cases of vomiting in the pediatric population are self-limiting and require only supportive treatment; however, physicians must be able to recognize red flags associated with vomiting that warrant further evaluation. 1,3 This task may be challenging for medical students and residents in emergency medicine and those with infrequent exposure to pediatric patients. Therefore, this team-based learning activity was developed to help junior learners in differentiating non-emergent and emergent cases of pediatric vomiting. This activity aids learners in formulating a differential based on age, history, and characteristics of vomiting. We also review specific causes of pediatric vomiting that physicians cannot miss including intussusception, pyloric stenosis, malrotation, intestinal atresia, and intracranial pathology.

Educational Objectives

By the end of this TBL session, learners should be able to:

  1. Identify red flag symptoms that should prompt referral for urgent intervention by GI or surgical specialists.
  2. Recognize how chronicity of the vomiting can alter the differential diagnosis
  3. Describe the varying pathways that can cause nausea and vomiting.
  4. Determine the necessity of imaging tests to confirm and possibly treat various causes of vomiting.
  5. Interpret imaging studies associated with specific causes of vomiting.

Educational Methods

Classic Team Based Learning (cTBL)

Research Methods

Learners and instructors provided verbal feedback after the session in a large group format. Learners were specifically asked if they felt the session was education, relevant, high-yield and level appropriate. One instructor provided written feedback to the cases as well.

Results

Overall learners and instructors found the session to be engaging, informative and educational. Learners felt that the session was level appropriate for medical students and junior residents. As a result of feedback from the session, several of the iRAT/gRAT questions were adjusted and the group application cases were re-written and implemented.

Discussion

Overall, the educational content and delivery was effective. This session was presented to a group of emergency medicine students, interns and residents. Learners were divided into smaller groups, and each group had a variety of level of learners, including pediatric emergency medicine fellows, present. The fellows, while not necessary to the delivery of the TBL, were extremely helpful in aiding the residents during the session. The final debriefing and answer review were essential to ensure that learners met all educational objectives and fully understood the materials.

Topics

Pediatric vomiting, intussusception, pyloric stenosis, intestinal atresia, malrotation, gastroesophageal reflux disease, superior mesenteric artery (SMA) syndrome, hyperemesis.

USER GUIDE

List of Resources:
Abstract 1
User Guide 3
Learner Materials 6
iRAT 6
gRAT 11
GAE 17
Instructor Materials 25
RAT Key 26
GAE Key 34

Learner Audience:

Medical students, interns, junior residents

Time Required for Implementation:

Instructor Preparation: 60 minutes

Learner Responsible Content: 15–30 minutes

In Class Time: 90 minutes

Recommended Number of Learners per Instructor:

This activity can include anywhere from 10 learners to 30 learners. Only one instructor is required during this activity. For larger groups with more than 30 learners, it may be helpful to have more instructors to facilitate discussion. For example, we utilized pediatric emergency medicine fellows as additional facilitators; additionally, senior residents could be used as facilitators.

Topics:

Pediatric vomiting, intussusception, pyloric stenosis, intestinal atresia, malrotation, gastroesophageal reflux disease, superior mesenteric artery (SMA) syndrome, hyperemesis.

Objectives:

By the end of this TBL session, learners should be able to:

  1. Identify red flag symptoms that should prompt referral for urgent intervention by GI or surgical specialists.
  2. Recognize how chronicity of the vomiting can alter the differential diagnosis
  3. Describe the varying pathways that can cause nausea and vomiting.
  4. Determine the necessity of imaging tests to confirm and possibly treat various causes of vomiting.
  5. Interpret imaging studies associated with specific causes of vomiting.

Linked objectives and methods

Pediatric vomiting is a frequent chief complaint encountered in the emergency department. The National Hospital Ambulatory Medical Care Survey (NHAMCS) showed 9.46% of pediatric emergency visits presented with vomiting as the chief complaint.2 There are a wide variety of differential diagnoses ranging from benign to critical which can present as vomiting. The majority of these children with vomiting will ultimately have uneventful courses and benign diagnoses; however, it is important for physicians to be aware of the critical diagnoses.3 Therefore, this team-based learning activity was designed to help learners differentiate between these causes of pediatric vomiting. The iRAT and gRAT questions broadly cover all of the objectives. Case 1 covers acute vomiting in a teenage female with a history of diabetic ketoacidosis (DKA), and it reviews pertinent blood tests required for acute vomiting and reminds learners to obtain a urine pregnancy test. Overall, Case 1 demonstrates objectives 2, 3, and 4 in the work up for the patient and discussion of the case questions. Case 2 covers and reviews the variety of reasons for vomiting in the neonate, objectives 1, 2, 3 and 4, by prompting learners to discuss and consider the differential diagnosis, blood work, and imaging that is necessary for an acutely vomiting neonate. Case 3 covers abdominal pain, vomiting, and GI bleeding in a younger pediatric patient with a final diagnosis of intussusception. Learners are asked to determine the labs and imaging they would like to order, prompting learning of objectives 1, 2, 3, 4 and 5. Lastly, case 4 covers the very important non-gastrointestinal causes of pediatric vomiting and prompts learners to perform full review of systems and physical exam, important for objectives 2 and 3. Throughout the activity, learners are encouraged to discuss the cases with each other and instructors.

This TBL is based on the article: “Vomiting in Children” by T. Matthew Shields, MD, and Jenifer R. Lightdale, MD, MPH. We recommend that instructors read this article prior to administering the TBL so that they are prepared for the session. The article is available here: https://pedsinreview.aappublications.org/content/39/7/342. Alternatively, any article or book chapter on vomiting in pediatric patients would be appropriate. Please see the references for further suggestions.

Learner Responsible Content (LRC)

This TBL is based on the article: “Vomiting in Children” by T. Matthew Shields, MD, and Jenifer R. Lightdale, MD, MPH. We recommend that learners read this article prior to the TBL so that they are prepared for the session. The article is available here: https://pedsinreview.aappublications.org/content/39/7/342.

Results and tips for successful implementation

This Pediatric Vomiting TBL was tested on a group of 17 emergency residents including interns, junior and senior residents who completed the TBL, 5 pediatric emergency medicine fellows, and 4 medical students. The fellows acted as small groups facilitators and helped guide the discussions. Learners provided verbal feedback which was overall very positive. Residents commented that the session was “relevant,” “interactive,” and “high-yield”. Some senior level residents felt that the questions and cases were slightly too easy for them but still found them to be educational and good review. Pediatric emergency medicine fellows acted as faculty facilitators and reported that they enjoyed their role and felt that they were able to add to the discussion among residents and students. The pediatric emergency medicine fellows also provided verbal and written feedback on the cases, and several small changes to the iRAT/gRAT and GAE cases were suggested, and edits to the final TBL were made.

Prior to session, instructor will need to prepare:

Conducting the session:

LEARNER MATERIALS

Vomiting in Pediatric Patients TBL: individual Readiness Assessment Test (iRAT)

  1. Which of the following are associated with acute, episodic vomiting?
    1. Inborn errors of metabolism
    2. Food protein-induced enterocolitis syndrome (FPIES)
    3. Cannabinoid hyperemesis syndrome (CHS)
    4. All of the above
    5. None of the above
  2. 1-year-old male, born full term, with no known medical problems, and up to date on immunizations, presents to the ED with his parents. They state for the past two weeks he’s been irritable and crying more than normal. They explain that he has been having “spells” where he cries and “scrunches up” or holds his stomach. They state that his stools have been getting darker, and today he had one episode of bloody stool an hour prior to arrival to the ED. On exam his abdomen is soft; however, you palpate a mass within the right lower quadrant. What is his presumed diagnosis?
    1. Pyloric stenosis
    2. Intussusception
    3. Meckel’s diverticulum
    4. Wilm’s tumor
  3. 6-week-old male, born full term via uncomplicated vaginal delivery is brought to the ED by his mother for evaluation of forceful vomiting after feeds for the past 4 days. He is up to date on immunizations. This is the mother’s first child, and she states that he seems to “always be hungry.” He is breastfed, and feeds for 30 minutes every 2 hours. Mom reports no wet diapers for the past 24 hours. You decided to get labs and they reveal a hypochloremic, hypokalemic metabolic alkalosis. What is the diagnosis?
    1. Malrotation with volvulus
    2. Breast milk jaundice
    3. Intestinal atresia
    4. Pyloric stenosis
  4. A 24-month-old male is brought in to the ED with by his dad for vomiting for the last 24 hours. The dad reports that the whole family has been ill since attending a lunch picnic yesterday. On physical exam the patient is mildly tachycardic, has dry mucous membranes, and a soft minimally tender abdomen. The first step in management is:
    1. Abdominal radiograph
    2. Antiemetics and fluids
    3. Antibiotics for likely bacterial colitis
    4. NG tube for bowel decompression
  5. 7-month-old female, born full term and up to date on immunizations presents for evaluation of bilious emesis; parents deny bloody stools. On exam, the child is sick appearing and abdomen is distended. You order a stat KUB (kidneys, ureters, bladder) which shows air-filled levels, and dilated stomach and bowel in the upper quadrants with a paucity of air distally.
    What is your diagnosis and treatment?
    1. Malrotation with volvulus; decompression with nasogastric intubation (NGT) and surgery consult
    2. Pyloric stenosis; pyloromyotomy
    3. Intestinal atresia; surgery consult
    4. Intussusception; air enema
  6. Which of the following are “Red Flag” signs & symptoms that require urgent evaluation?
    1. Hematemesis/Hematochezia
    2. Bilious emesis
    3. Abdominal distension/absent bowel sounds
    4. Vomiting that wakes child from sleep
    5. All the above
  7. 4-month-old female, born term and up to date on immunizations, presents to the ED for evaluation of being more irritable and fussier after feeds. She’s breastfed solely. Mother states that she has had issues with “spitting up” after feeds but has always been “happy,” and even though she appears hungry mom feels like the patient is losing weight. What is the most likely diagnosis?
    1. GERD (gastroesophageal reflux disease)
    2. Breastfeeding jaundice
    3. Milk protein allergy
    4. Eosinophilic esophagitis
  8. 3-year-old boy presents with colicky abdominal pain and non-bilious vomiting. He appears non-toxic. Parents state during these episodes he cries uncontrollably and at times they wake him up from sleep for the past week. They deny bloody stools. What is the diagnostic study to best evaluate and treat this patient?
    1. Ultrasound
    2. Air contrast enema
    3. Surgery
    4. EGD (esophagogastroduodenoscopy)
  9. You are on your NICU rotation and called to come evaluate a newborn male with history of trisomy 21. The baby has been having bilious vomiting after his first feed with a distended abdomen. You order a stat KUB which shows a large gastric bubble and then a distal smaller bubble of air. What is your presumed diagnosis?
    1. Intestinal atresia
    2. Pyloric Stenosis
    3. NEC (necrotizing enterocolitis)
    4. GERD
  10. An 8-year-old boy presents with acute vomiting that began after lunch yesterday with one to two episodes, but then became intractable late last night. The patient has dry mucous membranes, his abdomen is soft, non-tender and non-distended. His vital signs are HR 120, BP 90/84, RR 18. What diagnostic studies would you order?
  11. Chem 7 & KUB
  12. Chem 7, LFTs (liver function tests), amylase/lipase, EGD, MRI/CT head
  13. Chem 7, ammonia, pyruvate, abdominal US, urine studies
  14. Urine studies only
  15. The pathways of emetic reflex are best described by:
  16. Motion
  17. Emotional Responses
  18. Toxins introduced by drugs/food/environment
  19. Eating too much
  20. All the above
  21. 14-year-old female with history of migraines presents to the ER for evaluation of vomiting spells for the past week that occur upon waking up from sleep. She’s had an MRI and CT head that have been negative for masses. The patient’s mother states that with her migraines she only gets headaches, and never experiences nausea or vomiting. Which elements of the history are important to obtain in order to help you with your diagnosis?
  22. Social
  23. Alleviating factors
  24. Sexual & Surgical
  25. Birth
  26. All the above
  27. A 16-year-old male presents to his primary care physician’s office with complaints of episodic post-prandial vomiting. He reports that it started after he lost 20 pounds when he joined the high school football team. He reports that when he eats he gets crampy abdominal pain, but it improves if he leans forward. What do you expect to see on upper GI series?
  28. A sharp cutoff sign where the contrast is unable to pass through the duodenum
  29. Distended small bowel with air fluid levels
  30. Diffuse constipation
  31. Dilation of the esophagus with no contrast past the lower esophageal sphincter

Vomiting in Pediatric Patients TBL: group Readiness Assessment Test (gRAT)

Use scratch off stickers https://www.amazon.com/Kenco-Scratch-Off-Stickers-Silver/dp/B0839QF79D/ref=sr_1_8?dchild=1&keywords=scratch+off+stickers&qid=1586830370&sr=8-8 to hide the answers/stars so that learners get immediate feedback on their answer choice. See the example below.

graphic file with name jetem-5-4-t1f3.jpg

Vomiting in Pediatric Patients TBL: group Readiness Assessment Test (gRAT)

  1. Which of the following are associated with acute, episodic vomiting?
    • a. Inborn errors of metabolism
    • b. Food protein-induced enterocolitis syndrome (FPIES)
    • c. Cannabinoid hyperemesis syndrome (CHS)
    • ★. All of the above
    • e. None of the above
  2. 1-year-old male, born full term, with no known medical problems, and up to date on immunizations, presents to the ED with his parents. They state for the past two weeks he’s been irritable and crying more than normal. They explain that he has been having “spells” where he cries and “scrunches up” or holds his stomach. They state that his stools have been getting darker, and today he had one episode of bloody stool an hour prior to arrival to the ED. On exam his abdomen is soft; however, you palpate a mass within the right lower quadrant. What is his presumed diagnosis?
    • a. Pyloric stenosis
    • ★. Intussusception
    • c. Meckel’s diverticulum
    • d. Wilm’s tumor
  3. 6-week-old male, born full term via uncomplicated vaginal delivery is brought to the ED by his mother for evaluation of forceful vomiting after feeds for the past 4 days. He is up to date on immunizations. This is the mother’s first child, and she states that he seems to “always be hungry.” He is breastfed, and feeds for 30 minutes every 2 hours. Mom reports no wet diapers for the past 24 hours. You decided to get labs and they reveal a hypochloremic, hypokalemic metabolic alkalosis. What is the diagnosis?
    • a. Malrotation with volvulus
    • b. Breast milk jaundice
    • c. Intestinal atresia
    • ★. Pyloric stenosis
  4. A 24-month-old male is brought in to the ED with by his dad for vomiting for the last 24 hours. The dad reports that the whole family has been ill since attending a lunch picnic yesterday. On physical exam the patient is mildly tachycardic, has dry mucous membranes, and a soft minimally tender abdomen. The first step in management is:
    • a. Abdominal radiograph
    • ★. Antiemetics and fluids
    • c. Antibiotics for likely bacterial colitis
    • d. NG tube for bowel decompression
  5. 7-month-old female, born full term and up to date on immunizations presents for evaluation of bilious emesis; parents deny bloody stools. On exam, the child is sick appearing and abdomen is distended. You order a stat KUB (kidneys, ureters, bladder) which shows air-filled levels, and dilated stomach and bowel in the upper quadrants with a paucity of air distally.
    What is your diagnosis and treatment?
    • ★. Malrotation with volvulus; decompression with nasogastric intubation (NGT) and surgery consult
    • b. Pyloric stenosis; pyloromyotomy
    • c. Intestinal atresia; surgery consult
    • d. Intussusception; air enema
  6. Which of the following are “Red Flag” signs & symptoms that require urgent evaluation?
    • a. Hematemesis/Hematochezia
    • b. Bilious emesis
    • c. Abdominal distension/absent bowel sounds
    • d. Vomiting that wakes child from sleep
    • ★. All the above
  7. 4-month-old female, born term and up to date on immunizations, presents to the ED for evaluation of being more irritable and fussier after feeds. She’s breastfed solely. Mother states that she has had issues with “spitting up” after feeds but has always been “happy,” and even though she appears hungry mom feels like the patient is losing weight. What is the most likely diagnosis?
    • ★. GERD (gastroesophageal reflux disease)
    • b. Breastfeeding jaundice
    • c. Milk protein allergy
    • d. Eosinophilic esophagitis
  8. 3-year-old boy presents with colicky abdominal pain and non-bilious vomiting. He appears non-toxic. Parents state during these episodes he cries uncontrollably and at times they wake him up from sleep for the past week. They deny bloody stools. What is the diagnostic study to best evaluate and treat this patient?
    • a. Ultrasound
    • ★. Air contrast enema
    • c. Surgery
    • d. EGD (esophagogastroduodenoscopy)
  9. You are on your NICU rotation and called to come evaluate a newborn male with history of trisomy 21. The baby has been having bilious vomiting after his first feed with a distended abdomen. You order a stat KUB which shows a large gastric bubble and then a distal smaller bubble of air. What is your presumed diagnosis?
    • ★. Intestinal atresia
    • b. Pyloric Stenosis
    • c. NEC (necrotizing enterocolitis)
    • d. GERD
  10. An 8-year-old boy presents with acute vomiting that began after lunch yesterday with one to two episodes, but then became intractable late last night. The patient has dry mucous membranes, his abdomen is soft, non-tender and non-distended. His vital signs are HR 120, BP 90/84, RR 18. What diagnostic studies would you order?
  1. The pathways of emetic reflex are best described by:
  1. 14-year-old female with history of migraines presents to the ER for evaluation of vomiting spells for the past week that occur upon waking up from sleep. She’s had an MRI and CT head that have been negative for masses. The patient’s mother states that with her migraines she only gets headaches, and never experiences nausea or vomiting. Which elements of the history are important to obtain in order to help you with your diagnosis?
  1. A 16-year-old male presents to his primary care physician’s office with complaints of episodic post-prandial vomiting. He reports that it started after he lost 20 pounds when he joined the high school football team. He reports that when he eats he gets crampy abdominal pain, but it improves if he leans forward. What do you expect to see on upper GI series?

Vomiting in Pediatric Patients TBL: Group Application Exercise (GAE)

Case 1

15-year-old female with history of Type 1 Diabetes presents with nausea and vomiting for the past week, accompanied by her mother. Patient states last menstrual period was 2 months ago, though she has irregular periods and denies being sexually active. She denies any bloody stools, abdominal pain, and has never been in DKA per mother.

On exam, vital signs are the following: T 98.6, RR 18, HR 100, BP 110/85. The patient appears pale and dry. Abdomen is soft though slightly distended, with normal bowel sounds. Pulmonary and cardiac exam are within normal limits.

Is this patient sick, not sick, or potentially sick?

What labs/interventions/meds would you like to order?

You obtain the following diagnostic results listed below. At this point what is your differential diagnosis?

What other lab work would you like to order or did you order that has not resulted yet?

What imaging (if any) would you like to perform?

What treatment would you like to provide the patient?

Case 2

A 24-hour-old male born via C-Section at 33 weeks secondary to mother having pre-eclampsia presents to the ED. Quad screen was positive for trisomy 21. The labor and delivery nurse calls down and states that the baby was just discharged, and prior to discharge, they noted that he had an episode of bilious emesis and progressively worsening abdominal distention. The doctor called the family and asked them to return immediately. You note a birth weight 2400g, and the baby is formula fed. No bloody stools.

On exam, VS demonstrate T 98.6, HR 145/min, BP 91/60, and RR 50. The infant is lethargic-appearing with poor skin turgor. His abdomen is distended with normal bowel sounds. Pulmonary and cardiac exam are within normal limits.

Is this patient sick, not sick, or potentially sick?

What labs/interventions/meds would you like to order?

You obtain the following diagnostic results below:

At this point what is your differential diagnosis for this patient and what do you think is the most likely diagnosis?

You obtain the following radiograph:

graphic file with name jetem-5-4-t1f4.jpg

Case courtesy of Dr Sebastian Tschauner, Radiopaedia.org, rID: 49592. https://radiopaedia.org/cases/49592

How would you describe the patient’s abdominal radiograph?

What is your diagnosis for this patient?

What is the treatment for this patient?

What is the prognosis for this patient?

Case 3

3-year-old male born at 36 weeks presents to the ED for evaluation of abdominal pain and being irritable for the last 3 days. Patient is fully immunized. Mother states that he has episodes of abdominal pain where he cries and grabs his stomach. After a few minutes pass, he’s “fine.” She states that he started vomiting today, and has had dark red mucous colored stools as well. She looked up his symptoms on WebMD and is worried about some “vascular disease.”

On exam, vitals are T 99.6, HR 124, BP 95/63, Sp O2 97%, wt 20kg. The child is happy and playing. His mucous membranes are moist, abdomen is soft, GU exam shows an uncircumcised penis, testicles symmetric and descended, with no gross blood per rectum. Right as you are about to leave the room, the child squats down grabs his stomach and starts crying. Mother explains this is his “episode.”

Is this patient sick, not sick, or potentially sick?

What labs/imaging/interventions/meds would you like to order?

You obtain the following diagnostic results below:

Imaging shows:

graphic file with name jetem-5-4-t1f5.jpg

Case courtesy of Dr Sally Ayesa, Radiopaedia.org, rID: 63984. https://radiopaedia.org/cases/63984

What are common causes of lower GI bleeding found in kids in this age group?

What is the most likely diagnosis?

Bonus points: What are some pathological conditions associated with this condition?

What imaging would you use to confirm and ultimately treat the patient’s condition?

Case 4

A 16-year-old female presents for an intractable headache. She notes that the onset is first thing in the morning and that it wakes her from sleep and worsens throughout the day. Her mother states the symptoms have been progressively worsening and that the patient appears “off-balance” when she walks. Associated symptoms are nausea/vomiting; she denies blurred vision, hearing changes, weight loss, photophobia. She states her head hurts “all over.” She currently is on her menstrual period. She denies history of migraines. No pertinent family history. Social history is positive for occasional marijuana use.

On exam, vital signs are T 98.7, HR 98, RR 18, SpO2 97% RA. She is 60kg, and 5’7”. The patient is holding both sides of her head and crying; you perform a full neuro exam and notice she has drift on the right. The remainder of your exam is unremarkable.

Is this patient sick, not sick, or potential to be sick?

What labs/imaging/interventions/meds would you like to order?

You obtain the following results below:

What history elements are important to ask a pediatric patient with a headache?

What is the clinical significance of the associated symptom of vomiting that the patient is experiencing?

What is your differential diagnosis for this patient?

You obtain a computed tomography of the head:

graphic file with name jetem-5-4-t1f6.jpg

Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 10374. https://radiopaedia.org/cases/10374

What is your next step in management of this patient?

INSTRUCTOR MATERIALS

Answer keys to all exercises with explanations, are on the following pages.

Learners: Please do not proceed.

Vomiting in Pediatric Patients TBL: Readiness Assessment Test Key (RAT Key)

  1. Which of the following are associated with acute, episodic vomiting?
    • a. Inborn errors of metabolism
    • b. Food protein-induced enterocolitis syndrome (FPIES)
    • c. Cannabinoid hyperemesis syndrome (CHS)
    • ★. All of the above
    • e. None of the above
      Discussion:
      Acute episodic vomiting is vomiting that presents rapidly over 24–48 hours, and occurs intermittently with periods of no vomiting. All of the above including intestinal malrotation with intermittent volvulus are associated with acute episodic vomiting (pg. 344). Chronic vomiting is typically over several days to weeks, is low volume and infrequent and rarely associated with dehydration. Chronic vomiting is associated with diseases such as peptic ulcer disease, gallbladder disease, and gastritis.
  2. 1-year-old male, born full term, with no known medical problems, and up to date on immunizations, presents to the ED with his parents. They state for the past two weeks he’s been irritable and crying more than normal. They explain that he has been having “spells” where he cries and “scrunches up” or holds his stomach. They state that his stools have been getting darker, and today he had one episode of bloody stool an hour prior to arrival to the ED. On exam his abdomen is soft; however, you palpate a mass within the right lower quadrant. What is his presumed diagnosis?
    • a. Pyloric stenosis
    • ★. Intussusception
    • c. Meckel’s diverticulum
    • d. Wilm’s tumor
      Discussion:
      Intussusception is thought to be caused by a lead point in kids <5 (ie: Peyer’s patches from recent viral illness. In kids >5, common causes include Henoch-Schonlein purpura, lymphoma, Meckel’s diverticulum, cystic fibrosis. This child presents with intermittent, colicky generalized abdominal pain, +/− bloody stools, classically described as resembling “currant jelly.” During episodes parents describe the child as inconsolable. A physical exam may reveal a RUQ “sausage like mass.” The diagnosis is made by abdominal US, which shows a “target sign,” and treatment is an air-contrast enema, or possible surgical intervention/reduction if the enema is unsuccessful.
  3. 6-week-old male, born full term via uncomplicated vaginal delivery is brought to the ED by his mother for evaluation of forceful vomiting after feeds for the past 4 days. He is up to date on immunizations. This is the mother’s first child, and she states that he seems to “always be hungry.” He is breastfed, and feeds for 30 minutes every 2 hours. Mom reports no wet diapers for the past 24 hours. You decided to get labs and they reveal a hypochloremic, hypokalemic metabolic alkalosis. What is the diagnosis?
    • a. Malrotation with volvulus
    • b. Breast milk jaundice
    • c. Intestinal atresia
    • ★. Pyloric stenosis
      Discussion:
      One of the most common GI causes of vomiting in infants. It is due to thickening of the pyloric muscle leading to narrowing of the pylorus. It is more common in males, age 2–7 weeks, and associated with preterm birth, drug use (such as erythromycin), small-for-gestational-age (SGA), C-Sections, and maternal smoking. Patients present with forceful, projectile vomiting. A palpable mass, “olive” in the RUQ is considered pathognomonic.
      US is the diagnostic tool of choice. Labs are usually ordered when child presents as failure to thrive and clinically dehydrated and reveal a hypochloremic, hypokalemic metabolic alkalosis. Definitive treatment is fluid resuscitation to correct electrolyte imbalance and a pyloromyotomy.
  4. A 24-month-old male is brought in to the ED with by his dad for vomiting for the last 24 hours. The dad reports that the whole family has been ill since attending a lunch picnic yesterday. On physical exam the patient is mildly tachycardic, has dry mucous membranes, and a soft minimally tender abdomen. The first step in management is:
    • a. Abdominal radiograph
    • ★. Antiemetics and fluids
    • c. Antibiotics for likely bacterial colitis
    • d. NG tube for bowel decompression
      Discussion:
      This patient is stable, has a soft abdomen and is showing signs of dehydration. The most likely diagnosis is food poisoning. The patient can likely be given antiemetics and then give PO fluids for oral rehydration. Abdominal radiograph and/or NG (naso-gastric) tube would be appropriate if concern for obstruction or need for decompression. Antibiotics are not needed since the patient is afebrile and not sick appearing.
  5. 7-month-old female, born full term and up to date on immunizations presents for evaluation of bilious emesis; parents deny bloody stools. On exam, the child is sick appearing and abdomen is distended. You order a stat KUB (kidneys, ureters, bladder) which shows air-filled levels, and dilated stomach and bowel in the upper quadrants with a paucity of air distally.
    What is your diagnosis and treatment?
    • ★. Malrotation with volvulus; decompression with nasogastric intubation (NGT) and surgery consult
    • f. Pyloric stenosis; pyloromyotomy
    • g. Intestinal atresia; surgery consult
    • h. Intussusception; air enema
      Discussion
      Malrotation with volvulus should always be considered in patients with acute or episodic vomiting that is bilious. During episodes of malrotation with volvulus, children may cry inconsolably, have severe abdominal pain, and be toxic-appearing. This can also occur without volvulus and lead to chronic painless vomiting.
      The diagnosis of malrotation with volvulus is usually made with abdominal x-ray (KUB) in the ER or CT abdomen/pelvis. A KUB will show an air-filled, dilated bowel proximal to the level of the obstruction and a lack of air distal to the obstruction. Treatment is decompression with NGT followed by emergent surgery consult.
      Figure 2 in “Vomiting in Children,” by T. Matthew Shields, MD, and Jenifer R. Lightdale, MD, MPH, shows an excellent example of a dilated stomach in a patient with malrotation and volvulus: https://pedsinreview.aappublications.org/content/39/7/342.
  6. Which of the following are “Red Flag” signs & symptoms that require urgent evaluation?
    • a. Hematemesis/Hematochezia
    • b. Bilious emesis
    • c. Abdominal distension/absent bowel sounds
    • d. Vomiting that wakes child from sleep
    • ★. All the above
      Discussion
      Red flag symptoms that should prompt referral for urgent evaluation by GI specialists include hematemesis (especially with the first episode of vomiting), hematochezia, recurrent bilious emesis, clinical dehydration, evidence of shock, focal neurologic changes, abdominal distention, and absent or tympanic bowel sounds. In addition, it is critical to carefully evaluate vomiting that wakes a child from sleep. These help determine the emergent causes of pediatric GI diagnosis and treatment.
  7. 4-month-old female, born term and up to date on immunizations, presents to the ED for evaluation of being more irritable and fussier after feeds. She’s breastfed solely. Mother states that she has had issues with “spitting up” after feeds but has always been “happy,” and even though she appears hungry mom feels like the patient is losing weight. What is the most likely diagnosis?
    • ★. GERD (gastroesophageal reflux disease)
    • b. Breastfeeding jaundice
    • c. Milk protein allergy
    • d. Eosinophilic esophagitis
      Discussion
      GER is the most common physiologic causes of vomiting within infancy; it presents usually by 4 months and resolves by 1 year. Infants usually experience painless spitting up after feeds if infants are otherwise growing and developing appropriately. Infants with GER are “happy spitters,” and don’t require any acid suppressant treatment, but instead parents should be provided with reassurance. GER becomes pathologic (GERD) once there are any associated features along with GER such as weight loss, failure to thrive, poor feeding, and irritability. Treatment for GERD is conservative (smaller meals, frequent burping, sitting upright during feeds, thicken formula), Ranitidine or Reglan may be used, and if very severe, may need surgical procedure (Nissan).
  8. 3-year-old boy presents with colicky abdominal pain and non-bilious vomiting. He appears non-toxic. Parents state during these episodes he cries uncontrollably and at times they wake him up from sleep for the past week. They deny bloody stools. What is the diagnostic study to best evaluate and treat this patient?
    • a. Ultrasound
    • ★. Air contrast enema
    • c. Surgery
    • d. EGD (esophagogastroduodenoscopy)
      Discussion
      Intussusceptions can present as a triad of abdominal pain, vomiting, and bloody stools (only presents 50% of the time). US is used to diagnose, showing a “target sign.” It presents more frequently in male patients between 3 months and 3 years of age. If air enema fails (used to diagnose and treat), the next step is surgery.
  9. You are on your NICU rotation and called to come evaluate a newborn male with history of trisomy 21. The baby has been having bilious vomiting after his first feed with a distended abdomen. You order a stat KUB which shows a large gastric bubble and then a distal smaller bubble of air. What is your presumed diagnosis?
    • ★. Intestinal atresia
    • b. Pyloric Stenosis
    • c. NEC (necrotizing enterocolitis)
    • d. GERD
      Discussion:
      Duodenal atresia is a type of intestinal atresia that is most common in newborns, particularly with Down Syndrome, with congenital abnormalities. It presents with bilious vomiting within the first feedings of life and abdominal distention. KUB shows a classic double bubble sign—dilation of the stomach and proximal duodenum with absent distal gas. Treatment is NGT, nothing by mouth (NPO), correct any fluid/electrolyte imbalances, ampicillin and gentamicin (present post op infection), surgery.
  10. An 8-year-old boy presents with acute vomiting that began after lunch yesterday with one to two episodes, but then became intractable late last night. The patient has dry mucous membranes, his abdomen is soft, non-tender and non-distended. His vital signs are HR 120, BP 90/84, RR 18. What diagnostic studies would you order?

*See Shields TM, and Lightdale JR. Vomiting in Children. Pediatrics in Review. 2018;39(7):342–358. Table 3: Laboratory and Radiographic Evaluation for Patients with Vomiting by Temporal Pattern. 11. The pathways of emetic reflex are best described by:

  1. 14-year-old female with history of migraines presents to the ER for evaluation of vomiting spells for the past week that occur upon waking up from sleep. She’s had an MRI and CT head that have been negative for masses. The patient’s mother states that with her migraines she only gets headaches, and never experiences nausea or vomiting. Which elements of the history are important to obtain in order to help you with your diagnosis?

Vomiting in Pediatric Patients TBL: Group Application Exercise (GAE) Key

Case 1

15-year-old female with history of Type 1 Diabetes, presents with nausea and vomiting for the past week, accompanied by her mother. Patient states last menstrual period was 2 months ago, though she has irregular periods and denies being sexually active. She denies any bloody stools, abdominal pain, and has never been in DKA per mother.

On exam, vital signs are the following: T 98.6, RR 18, HR 100, BP 110/85. The patient appears pale and dry. Abdomen is soft though slightly distended, with normal bowel sounds. Pulmonary and cardiac exam are within normal limits.

Is this patient sick, not sick, or potentially sick?

What labs/imaging/interventions/meds would you like to order?

You obtain the following diagnostic results listed below. At this point what is your differential diagnosis?

What other lab work would you like to order or did you order that has not resulted yet?

What imaging (if any) would you like to perform?

What treatment would you like to provide the patient?

Case 2

A 24-hour-old male born via C-Section at 33 weeks secondary to mother having pre-eclampsia presents to the ED. Quad screen was positive for trisomy 21. The labor and delivery nurse calls down and states that the baby was just discharged, and prior to discharge, they noted that he had an episode of bilious emesis and progressively worsening abdominal distention. The doctor called the family and asked them to return immediately. You note a birth weight 2400g, and the baby is formula fed. No bloody stools.

On exam, VS demonstrate T 98.6, HR 145/min, BP 91/60, and RR 50. The infant is lethargic-appearing with poor skin turgor. His abdomen is distended with normal bowel sounds. Pulmonary and cardiac exam are within normal limits.

Is this patient sick, not sick or potentially sick?

What labs/imaging/interventions/meds would you like to order?

You obtain the following diagnostic results below:

At this point what is your differential diagnosis for this patient and what do you think is the most likely diagnosis?

You obtain the following radiograph:

graphic file with name jetem-5-4-t1f7.jpg

Case courtesy of Dr Sebastian Tschauner, Radiopaedia.org, rID: 49592. https://radiopaedia.org/cases/49592

How would you describe the patient’s abdominal radiograph?

What is your diagnosis for this patient?

What is the treatment for this patient?

What is the prognosis for patient?

Case 3

3-year-old male born at 36 weeks presents to the ED for evaluation of abdominal pain and being irritable for the last 3 days. Patient is fully immunized. Mother states that he has episodes of abdominal pain where he cries and grabs his stomach. After a few minutes pass, he’s “fine.” She states that he started vomiting today and has had dark red mucous colored stools as well. She looked up his symptoms on WebMD and is worried about some “vascular disease.”

On exam, vitals are T 99.6, HR 124, BP 95/63, Sp O2 97%, wt 20kg. The child is happy and playing. His mucous membranes are moist, abdomen is soft, GU exam shows an uncircumcised penis, testicles symmetric and descended, with no gross blood per rectum. Just as you are about to leave the room, the child squats down grabs his stomach and starts crying. Mother explains this is his “episode.”

Is this patient sick, not sick, or potentially sick?

What labs/imaging/interventions/meds would you like to order?

You obtain the following diagnostic results below:

Imaging shows:

graphic file with name jetem-5-4-t1f8.jpg

Case courtesy of Dr Sally Ayesa, Radiopaedia.org, rID: 63984. https://radiopaedia.org/cases/63984

What are common causes of lower GI bleeding found in kids in this age group?

There are many common causes of lower GI bleeding in pediatrics aged 2–5:

What is the most likely diagnosis?

Bonus points: What are some pathological conditions associated with this condition?

What imaging would you use to confirm and ultimately treat the patient’s condition?

graphic file with name jetem-5-4-t1f9.jpg

Case courtesy of Dr Sally Ayesa, Radiopaedia.org, rID: 63984. https://radiopaedia.org/cases/63984

Case 4

A 16-year-old female presents for an intractable headache. She notes that the onset is first thing in the morning and that it wakes her from sleep and worsens throughout the day. Her mother states the symptoms have been progressively worsening and that the patient appears “off-balance” when she walks. Associated symptoms are nausea/vomiting; she denies blurred vision, hearing changes, weight loss, photophobia. She states her head hurts “all over.” She currently is on her menstrual period; she denies history of migraines. No pertinent family history. Social history is positive for occasional marijuana use.

On exam, vital signs are T 98.7, HR 98, RR 18, SpO2 97% RA. She is 60kg, and 5’7”. The patient is holding both sides of her head and crying; you perform a full neuro exam and notice she has drift on the right. The remainder of your exam is unremarkable.

Is this patient sick, not sick, or potential to be sick?

What labs/imaging/interventions/meds would you like to order?

You obtain the following results below:

What history elements are important to ask a pediatric patient with a headache?

What is the clinical significance of the associated symptom of vomiting that the patient is experiencing?

What is your differential diagnosis for this patient?

You obtain a computed tomography of the head:

graphic file with name jetem-5-4-t1f10.jpg

Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 10374. https://radiopaedia.org/cases/10374

What is your next step in management of this patient?

References/suggestions for further reading