Vomiting Baby

Hx: 1) 2) 3) 4) 5) 6) PE: 1) 2) 3) 4) Ask: age of patient, duration of sx, what is being vomited, fever Age limits DDx Bilious distal to pylorus; non-bilious proximal to pylorus Fever infection Hunger evaluates how sick patient is Tearing, skin turgor, UOP (diapers), lethargy evaluates volume status palpable pyloric obstruction? does NGT go down? Signs of shock/dehydration Palpable mass?

DDx: 1) Overfeeding and not allowing child to burp most common causes of vomiting 2) Esophageal atresia without tracheoesophageal fistula a. Sx: vomiting with first feed, lots of saliva b. Cant get NGT down c. Rad: CXR to see coiled NGT and (-) gas in abdomen d. Tx: i. Suction blind pouch ii. IVFs iii. Stretch esophagus before anastomosis with stomach 3) Esophageal atresia with TEF a. 90% of esoph. atresia cases have fistulas b. Type A: no fistula c. Type B: fistula to trachea from proximal esophagus d. Type C: fistula from distal esophagus (most common type) e. Type D: fistula from both proximal and distal esophagus f. Type E: H-type fistula from continuous esophagus g. Sx: excessive oral secretions, vomiting h. Signs: respiratory compromise, aspiration pneumonia, gastric distension i. Rad: i. CXR to see coiled NG ii. Abdominal xray (+) gas in abdomen iii. U/S of kidneys (renal problems associated with TEF) iv. Cardiac echo (cardiac problems associated with TEF) j. Tx: i. Initial: prevent pneumonia 1. suction the pouch 2. Abx 3. upright position 4. stretching of esophagus ii. Surgery: 1. thoracotomy: division of fistula + esophageal anastomosis 2. if Type E, then right neck incision to sever fistula 4) Hiatal hernia a. pressure in stomach GERD

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b. Sx: emesis, aspiration pneumonia, FTT c. Rad: bronchoscopy, UGI d. Tx: i. Medical: H2 blockers, small meals, head elevation ii. Surgical: Nissen fundoplication Pyloric stenosis a. Mechanism: hypertrophy of SM of pylorus obstruction b. Risk factors: male, first child c. Sx: 2wks 2mon, regurgitation non-bilious emesis, hunger after vomiting, +/coffee-brown emesis (gastritis due to stasis some blood in emesis), icterus d. Signs: visible gastric waves, palpable olive (near liver edge) e. DDx: pyloric stenosis, overfeeding, reflux, CNS lesions, bowel obstruction, intususseption, volvulus f. 4mm thick & 16mm long g. Rad: UGI string sign (elongated pylorus) + shoulder sign (bulge of pylorus into antrum); U/S shows 4mm x 16mm pylorus; Abdominal Xray h. Tx: i. stabilize electrolytes: lose Cl-, H+, Na+, K+ hypokalemic hypochloremic metabolic alkalosis with paradoxical aciduria ii. recusitate with NS fluid bolus (20cc/kg) + D10 or NS with 10 or 20KCl @ 1.5 maintenance rate; NS b/c want lots of Cl-; 20 KCl b/c want lots of K+; use D10 b/c babys glycogen stores tiny, so need to protect against muscle breakdown iii. monitor UOP (wet diaper) iv. operate on baby after electrolytes stable; anesthesia causes respiratory alkalosis which is deadly if patient has underlying metabolic alkalosis; CO2 of CNS respiratory drive respiratory distress death v. pyloric myotomy open vs lap; destroy muscularis and serosa layer, mucosa intact 1. beware of vein of Mayo which crosses pylorus vi. post-op TPN for several weeks to allow pylorus to loosen Duodenal atresia a. Mechanism: ischemic insult or failure to canalize b. Sx: bilious vomiting if distal to ampulla of Vater, otherwise non-bilious vomiting c. Rad: double bubble on xray (distended stomach and distended duodenum) d. Associated with Downs Syndrome, polyhydramnios, cardiac defects e. Tx: duodenoduodenostomy or duodenojejunostomy Jejunoileal atresia a. Mechanism: vascular insult or hernia through abdominal wall defect b. Sx: bilious vomiting, abdominal distension, failure to pass meconium c. Rad: i. abdominal xray showing air-fluid bubbles ii. Barium enema showing microcolon from disuse d. Tx: i. NGT for decompression, IVFs ii. Surgical: disimpaction, resection with reanastamosis e. Associated with CF and polyhydramnios Meconium ileus a. Mechanism: intestinal obstruction from solid meconium b. Most patients have CF c. Sx: bilious vomiting, abdominal distention, failure to pass meconium d. Rad

i. abdominal xray showing Neuhausers sign (soap bubble appreance of meconium mixing with air) ii. barium enema showing microcolon from disuse e. Tx: i. Gastrografin enema: contrast is hypertonic drawing fluid into lumen, releasing meconium 9) Volvulus a. Sx: bilious vomiting b. Rad: i. UGI with SB followthrough shows ligament of Treitz shifted to R ii. Barium enema shows abnormal position of cecum 10)Hirschsprungs dz/toxic megacolon a. Most common cause of neonatal colon obstruction b. Sx: no stools, bilious emesis c. Rad: abdominal xray shows dilated colon d. Bx: (-) gland cells e. Tx: limited lap with multiple bx 11)Intussusception a. Sx: irritable, crampy abdominal pain,oral intake, current jelly stool (blood + sloughed mucosa) b. Signs: (-) BS in RLQ b/c cecum pushed out of RLQ c. Mechanism: Ileum telescoping into cecum; can get so bad that patient presents with rectal prolapse d. Age: 10 month old, range = 6 mon 3 yrs (usually b/c of hyperplasia of lymphoid tissue in distal ileum or Meckels diverticulum acting as a lead point); in adults with suspected intussusception, think of cancer or Meckels diverticulum as a lead point; if recurrent intussusception, think about lead points (i.e. Meckels diverticulum) and do surgery e. Tx: i. Fluids + Abx ii. Reduction via barium/air enema (contraindicated in pts with perforation or peritoneal signs) iii. Reduction via surgery (squeeze colon distally so that SB comes out) iv. Concurrent appendectomy if surgery is indicated 12)Others: foreign bodies, chemicals 13)Note: the lower in GI tract obstruction if located, longer after birth it takes to vomit