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CHAPTER I

INTRODUCTION

a. Introduction

Vomiting (emesis) is a symptom which often occurs in children

indicating a large number of conditions inside the body, many of which are

results from disorder in the gastrointestinal tracts. It can be seen really often

as a common symptom in the clinical practice. Vomiting is a generally

unpleasant activity that results in the expulsion of stomach contents through

the mouth. It is a physical act that has clearly associated gastrointestinal

motor activity. Nausea, on the other hand, although frequently accompa

nying vomiting, is not universally associated with it and does not have an

obvious physical mechanism. It is an uncomfortable feeling !nown to be

relieved by vomiting."

Vomiting itself results from the activation of protective physiological

mechanisms that exist in order to eliminate toxins from the body. #herefore,an understanding of pathophysiology and pharmacology are fundamental to

management, as it needed to be recogni$ed as early as possible to prevent any

complication that could happen, such as dehydration and electrolyte

imbalance. %

b. Definition

Vomiting involves a protective reflexive process, which contribute the

forceful expulsion of gastric content that is highly coordinated. Vomiting

itself is a symptom which occurs as a manifestation of many conditions inside

one&s body, both acute and chronic disorder, such as gastrointestinal tract

disease or extraintestinal disease, such as high intracranial pressure, etc. "

Vomiting usually preceded by nausea and retching and then the whole

series events are executed by vomiting.

Nausea is an unpleasant and difficult to describe experience in humans. It

is typically associated with decreased gastric motility and increased tone in

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the small intestine. 'dditionally, there is often reverse peristalsis in the

proximal small intestine.

etching (*dry heaves*) refers to spasmodic respiratory movements

conducted with a closed glottis. #his effort can be seen as preparation to

vomit. +hile this is occurring, the antrum of the stomach contracts and the

fundus and cardia relax. #his condition consists of diaphragm, both costal and

crural, and abdominal muscle contraction. 't the same time, the lower

esophageal sphincter (-) also relaxes and pulled up by the contraction of

upper longitude esophageal muscle. /uring the retching event, the gastric

content pushed in by the esophagus due to intraabdominal pressure and the

presence of elevated negative intrathoracal pressure, after that the whole

gastric content will be pushed bac! into the stomach which results from the

presence of esophagus peristaltic. #hus, in the retching event, the gastric

content is not expulsed out from the stomach to the mouth. #his is what

differs retching and vomiting. "

CHAPTER II

CONTENT

c. Physiology

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Vomiting is a protective response to eliminate toxin within the humans&

body. #he physiology of vomiting cannot be separated from an area in the

brainstem called the central vomiting center (0V0), which always involved in

the presence of vomiting. #he other one is 0hemoreceptor #rigger 1one

(0#1), both of which are located in medullary structure on the brain called

area postrema.(2ig "). #hese two areas have receptors, which then activated

by some proemetic chemicals within the blood circulation or cerebrospinal

fluid resulting in vomiting. #he central vomiting center contains of

muscarinicreceptors, while the chemoreceptor trigger $one contains of 34#

receptors and /opamine5 receptors.6

It also receives impulses fromexogenous substances that circulate in the body which are mostly drugs,

uremia, radiation, chemotherapy, toxins, hormones and peptides. 's well as

opiates, digitalis or aspirin via 0anaboid, ubstance 7, and

4ydroxytryptamine receptors. #hese receptors are activated by some factors

which then initiate vomiting. 3

2igure ". 'rea postrema

#here are several pathways involved which are able to induce vomiting 8

". 9astrointestinal tract : lead to be the main cause and the most common

disorder present at the clinical practice, mainly the stomach. It is going

via vagus and sympathetic route to the vomiting center and will send and

afferent impulses via serotonin receptors.

5. -xtragastrointestinal tract : the vomiting signals can also arise from non

gastrointestinal sources, including 8

a. 4igher center of the brain, which send impulses directly to the

vomiting center of the brain

b. 4eart and genitalia, through vagus and sympathetic route directly to

the vomiting center.

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c. ;lood vessels, which contain endogenous and exogenous substances

send impulses to the 0#1.

d. #he vestibular system as it control coordination and balance system

of the body, send impulses via the vestibular nuclei in the brainstem

and then to the 0#1 and to the vomiting center at the end.

It then sends out signals to the vagus nerve (to the esophagus, stomach

and duodenum), the phrenic nerve (to the diaphragm) and spinal nerves (to

the intercostals and abdominal rectus). #hese signals begin in a series of

coordinated events that lead to the coordinated and complex act of vomiting.3

Pathogenesis

#rue vomiting can be divided into two broad categories8 nonbilious and

bilious. ;ilious vomiting occurs when bile is purged along with the gastric

contents. 'lthough some small intestinal reflux into the stom ach is common

with all vomiting, in nonbilious vomiting, antegrade intestinal flow is preserved,

and the ma=ority of the bile drains into the more distal portions of the intestine. If

an obstruction is present, nonbilious vomiting implies that the obstruction is

proximal to the ampulla of Vater. 0onditions leading to bilious vomiting involve

either a disorder of motility or physical bloc!age to this antegrade flow of

proximal intestinal contents distal to the ligament of #reit$."

9astroesophageal reflux (9-), although not true vomiting, fre quently is

included in discussions of vomiting. In contrast to the mechanism of true

vomiting dis cussed previously, 9- occurs as a result of failed normal

esophageal function. Normally, the lower eso phageal sphincter (-) relaxes

with swallowing and propagation of esophageal peristalsis, allowing a food

bolus to enter the stomach. Its basal contraction prevents food from reentering

the esophagus from the stomach. #ransient relaxation of the - predisposes to

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9- and is the ma=or mechanism in infants who have 9-. #he - is aided by

sur rounding structures, especially the crural diaphragm, and disruption of these

structures, as with a hiatal her nia, contributes to the 9- in some patients.

Nicotine, alcohol, caffeine, and some medications can increase relaxation of the

-, contributing to 9- in some individuals. 9- also is distinguished from

true vom iting by its symptoms? the emesis of 9- is effortless and generally

not associated with retching or auto nomic symptoms.@

d. Ty#es of "o!iting

Vomiting can be classified according to its nature and cause, as well as by

the character of the vomiting itself.

'ccording to the nature, vomiting can be classified as 8

". 7ro=ectile.

7ro=ectile vomiting refers to a forceful vomiting and may indicate an

elevated intracranial pressure, especially if it occurs early in the morning.

5. Nonpro=ectile.

Nonpro=ectile vomiting are seen more commonly in gastroesophageal

reflux disease and other disorder."

Vomiting also classified according to its duration of symptoms 8

1. 'cute vomiting occurring less than or within " wee!. Asually

associated with obstruction, ischemic, toxic, metabolic, infectious,

neurological, and postoperative reasons.

2. 0hronic vomiting occurring for more than " month, usually due to

partial obstruction, motility disorder, neurological chronic conditions,

pregnancy or functional reasons.

3. 0yclic vomiting refers to vomiting of which onset is repetitice but

interrupted cycles of high frequency vomiting, followed by an

asymptomatic phase usually due to viral

%. ecurrent vomiting

Causes of $o!iting

'lthough the causes of vomiting in children are many, a thorough his tory of

the nature of the vomiting and any associated signs or symp toms as well as a

complete physical examination generally helps narrow the differential diagnosis

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(#able "). #argeted studies help identify the cause of the illness.

A. Non %ilious Infectious&infla!!atory

'cute gastroenteritis is the most common cause of vomiting in

children. It is usually associated with diarrhea and abdominal

pain, and viruses are common etiologic agents, although bacterial

patho gens also must be considered. #he most common viral

agent in infants is rotavirus. ;acterial pathogens include

Salmonella, Shigella, Campylobacter, andEscherichia coli.

;acterial infections are associated more commonly with bloody diarrhea and high

fevers than are viral infections. -nterohemorrhagicE coli B"3

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'. etabolic&endocrinologic

;oth inborn errors of metabolism and endocrinologic disorders can cause vomiting

(#able 5). #he inborn errors of metabolism generally present in early infancy, and

the vomiting is associated with symptoms of lethargy, hypo or hypertonia, sei$ures,

or coma. #he constellation of symptoms is similar to that seen in sepsis, neces

sitating a high index of suspicion in the evaluation of these patients. #he presence or

absence of meta bolic acidosis, hypoglycemia, hyper ammonemia, or !etosis and a

family history that includes possible con sanguinity can help to determine

the diagnosis. Cne endocrinologic condition associated with vomiting is diabetes

mellitus. Vomiting can complicate acute !etoacidosis or occur in patients who have

had longstand ing diabetes and consequent gastro paresis. lowed gastric motility

usually presents after diabetes mellitus has been present for approximately "B years.

-arly satiety and a sense of fullness frequently precede the onset of vomiting in

diabetic gastroparesis."B

Vomiting as a consequence of foodrelated sensitivity always should be considered.

#he variants encountered most commonly in pediatric patients are cow mil! and soy

protein intolerance, type I (Ig-mediated) food allergy, and celiac disease. 0ow mil!protein intolerance affects 5D to


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characteri$ed by acuteonset periodic episodes of nausea and vomiting interspersed

with conspicuous periods of wellness. 'pproximately


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*. Anato!ic

#he anatomic and, thus, the generally surgical causes of nonbilious

vomiting are those that affect the intestinal tract proximal to the

point of bilious drainage (ampulla of Vater), which is proximal to the

ligament of #reit$ (#able %). +hereas congenital anomalies usually

present in the newborn period, acquired lesions can present at any

age. 'ny infant who exhibits persistent nonbilious vomiting, with or

without feeding, in the immediate newborn period must be suspected

of having an intestinal atresia or a luminally obstructing lesion

(pyloric stenosis, luminal band, web) proximal to the point of bile

drainage (ampulla of Vater).%

'n easy and rapid test to evaluate possible esophageal atresia is the

ability to pass a nasogastric tube easily into the stomach. 'fter the

tube has been passed, it is important to obtain a radiograph to assure

that the tube is in the stomach and not coiled in an atretic esophagus. 'ny resistance

to passage of the tube is an indication for evaluation by contrast radio graph for an

obstruction. If an obstruction is present, nasoesophageal tube drainage is important toprevent aspiration of pooled esophageal secretions. 0ontrast studies are the standard

for the diagnosis of these conditions. >

%. %ilious

'lthough not absolute, anatomic conditions causing luminal

obstruction distal to the ligament of #reit$ usually cause bilious

vomiting. ;ilious vomiting is an ominous sign that mandates

immediate evaluation (#able 3).

In the newborn period, intestinal atresias and stenosis and

malrotation with or without volvulus need to be ruled out

immediately. In the older child, malrotation with volvulus also is a

surgical emergency that is diagnosed relatively easily by

gastrointestinal contrast study. 'fter the diagnosis has been established

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radiographically, the gastrointestinal tract should be decompressed with a nasogastric

tube, food and drin! withheld, and the patient supported with intravenous fluids until

definitive surgical intervention can be underta!en.%

e. Clinical !anifestation

Vomiting in children usually indicate a sign of infection. 2ever, nausea,

abdominal pain, or diarrhea become symptoms accompanying the vomiting that

already existed in infected children. #his condition will stop within %@ hours.

+hen vomiting remains, concerns any other serious conditions. 0hildren are in

higher ris! to develop dehydration, particularly when accompanied by diarrhea.

Viral infections become the most common cause compared to other pathogens.

Vomiting accompanied by fever are more common caused by bacteries rather

than virus or parasites. 7eptic ulcer needs to be in mind when vomiting comes

right after having meal, while in food poisoning vomiting occurs about "@ hours

after meals. Vomiting et causa food borne disease such as almonella needs

more time to develop symptoms due to its incubation period. 'nother cause of

vomiting in children is also oral candidiasis."B

7ro=ectile nonbillous type of vomiting in babies is a probable sign of

gastrointestinal obstruction, such as pyloric stenosis. 7yloric stenosis usually

found in the second wee! of birth, but rarely found at birth. 7ersistent vomiting

in neonates which usually happen at night has a possibility of any hiatal hernia.

0auses of this abnormality are often viral infection, drugs induced, and trauma.

'nother symptoms beside vomit are epigastric pain and left upper quadrant

which at some point loo! ali!e gastritis but unresponsive to antagonist receptor

45 treatment. "

7hysician needs to rule out any surgical abnormalities immediately in

children with vomiting. #here are some clues that can be used to eliminate all

the possibilities, such as (") stomach pain which occurs before the vomit andFor

continuous for more than 6 hours, (5) bile liquid among the vomiting fluid, and

(6) abdominal distention. Volvulus in neonates occurs to be some episodes of

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greenish vomiting in few days after birth and followed by any signs of

obstruction in gastrointestinal system also peritonitis. 'lmost >BD of children

with volvulus presents vomiting and @BD of them complains about stomachache.5

Vomiting can also be caused by any disorder from extraintestinal, for

example respiratory tract infection or urinary tract infection. ome medicines

li!e histamines, phenytoin, chemotherapy agents, aspirins, and some antibiotics.

can also induce vomiting.6

Vomiting after mild head in=ury found in "3D children and most of them

have a history of recurrent headache and motion sic!ness. #herefore, vomiting in

mild head in=ury associates with individual intrinsic factor. Vomiting due to

functional disorder mostly found in children 5< years of age with migrain,

motion sic!ness, and gastrointestinal tract disorder such abdominal pain and

defecation disorder. ometimes, anorexia nervosa of bulimia might be stay in

mind for any possibilities of psychiatry disorder.

;ased on its quality, vomiting can be classified as bilious, bloody, non

bilious and nonbloody. Vomiting that comes from stomach is usually yellow

or clear and contains remnants of previously ingested food."B

+hen the vomiting is dar! green, it may referred as bilious because it

indicates the presence of bile. ;ilious vomiting frequently is pathologic

because it may be a sign of an underlying abdominal problem such asintestinal obstruction beyond the duodenal ampulla of Vater, where the

common bile duct empties.>

#he presence of blood in the emesis, also !nown as hematemesis,

indicates acute bleeding from the upper portion of the 9I tract, as can occur wit

gastritis, Eallory+eiss tears, or peptic ulcer disease. 0offee groundli!e

material often is representative of an old 9I hemorrhage because blood dar!ens

to a blac! or dar!brown color when exposed to the acidity of the gastric

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secretions. #he more massive or proximal the bleeding, the more li!ely it is to be

bright red. "

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f. Differential diagnosis

#here are a large number of conditions, which indicated by vomiting as

the main andFor other symptom. -tiology of vomiting may vary according to

each systems of the body.

0ommon causes of vomiting in infancy 8

". 9- and 9-/9astroesophageal reflux (9-) is the effortless and nonpro=ectile passage of stomach

contents into the esophagus and can be a normal physiologic process. It is common

in healthy term infants, children, and adults. egurgitation is often used

interchangeably with 9-. 7ea!s at 6 to % months (


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not warrant additional investigation. 9- can be confirmed by monitoring

esophageal p4 for 5% hours (p4meter) . eflux index G 3D shows pathologic 9-

(9-/). 7arental education about the natural course of infantile 9- is the !ey to

successful management. Eostly resolve by "5 months of age. "B If symptoms persist

past "@ months of age the child warrants an evaluation. 9-/ symptoms 8 frequent

heartburn (G5 times a wee!), chest pain, regurgitation of partially digested food into

the bac! of the throat, trouble swallowing, breathing difficulties similar to asthma,

coughing, sore throat, a sour taste in the bac! of the mouth. 9-/ ris! factors 8

genetics, in=ury and trauma to the esophagus, hiatal hernia, diabetes, connective

tissue disorders that wea!en the -, 1ollinger -llison syndrome.6

5. 7yloric tenosis

Cccurs in 5 to 6 infants per "BBB live births. Eore common in males, with a male

female ratio of %8" to 8". #ypical presentation8 a 6 to wee!old infant with

progressive or intermittent vomiting after feeding (often pro=ectile). 7hysical

examination 8 an oliveli!e mass in the right midepigastrium, mostly after emesis.

Visible gastric peristalsis is seen with feeding. /iagnosis is usually made by

abdominal A9. >

6. Intestinal 'tresia

Cccurrence of 5.@ per "B,BBB live births. /uodenal atresia (%>D), =e=unal atresia

(6D) and ileal atresia ("%D). Infants present with bilious vomiting, abdominal

distension, and failure to pass meconium. 4istory of maternal polyhydramnios.

'bdominal radiographs show the pathognomonic Hdouble bubble. "

0ommon causes of vomiting beyond infancy 8

". 'cute 9astroenteritis

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'lthough may occur in infants, acute gastroenteritis is the most common reason for

vomiting beyond infancy. Viruses (otavirus) are the most common cause, followed

by bacteria and parasites. #ypical presentation is acute onset of vomiting followed by

diarrhea. Vomiting is a selfprotective process that may reduce the load of the

infectious organisms and associated toxins or irritants that cause the vomiting.

ehydration (oral, enteral, or intravenous) is !ey to successful management of acute

gastroenteritis.@

Initial care in the emergency department should focus on correction of dehydration.

#he type and amount of fluid given should reflect the degree of dehydration in the

child.

Minimal or no dehydration

No immediate treatment is required. If the child is breastfed, the mother should be

encouraged to breastfeed more frequently than usual and for longer at each feed. If

the child is not exclusively breastfed, then oral maintenance fluids (including clean

water, soup, rice water, yogurt drin!, or other culturally appropriate fluid) should be

given at a rate of approximately 3BB mFday for children younger than 5 years, "BBB

mFday for children aged 5"B years, and 5BBB mFday for children older than "B

years.

In addition, ongoing fluid losses should be replaced with "B mF!g body weight of

additional C for each loose stool and 5 mF!g body weight of additional C for

each episode of emesis (both for breastfed and nonbreastfed children). "B

Mild-to-moderate dehydration

0hildren should be given 3B"BB mF!g of C over a 5 to %hour period to replace

their estimated fluid deficit, with additional C given to replace ongoing losses ("B

mF!g body weight for each stool and 5 mF!g body weight for each episode of

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emesis). 'fter the initial rehydration phase, patients may be transitioned to

maintenance fluids as described above.6

C should be given slowly by the parent using a teaspoon, syringe, or medicine

dropper at the rate of 3 m every "5 minutes. If tolerated by the patient, the rate of

C delivery can be increased slowly over time.

2or patients who do not tolerate C by mouth, nasogastric (N9) feeding is a safe

and effective alternative. Eultiple clinical trials have found N9 rehydration to be as

efficacious as IV rehydration, but more cost effective and with fewer adverse events.

7atients should be reassessed frequently by the clinician to ensure adequacy of oral

inta!e and resolution of the various signs and symptoms of dehydration."

Severe dehydration

evere dehydration constitutes a medical emergency requiring immediate

resuscitation with IV fluids. IV access should be obtained and patients should be

administered a bolus of 5B6B mF!g lactated inger () or normal saline (N)

solution over B minutes. If pulse, perfusion, andFor mental status do not improve, asecond bolus should be administered. 'fter this, the patient should be given an

infusion of


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cholera, however, appear to have higher rates of hyponatremia with reduced

osmolarity C compared with standardosmolarity C, without any of the added

benefits seen in patients with noncholera gastroenteritis.3

Eultiple preparations of reducedosmolarity C are available in the Anited tates,

including 7edialyte, Infalyte, and Naturalyte. 'vailable formulations in -urope

include /ioralyte and /iocalm Kunior. In developing countries, clinicians can use

+4C C sachets or a homemade solution of 6 g (" tsp) salt and "@ g ( tsp) sugar

added to " liter of clean water.

New research suggests that polymerbased C, made from complex carbohydrates

such as rice, wheat, or mai$e, may reduce stool output and length of diarrhea

compared with glucosebased C. +ith these solutions, carbohydrates are slowly

digested in the small intestine, releasing glucose to facilitate sodium upta!e without

adding a significant osmotic load to bowel contents. 'lthough not widely available in

the Anited tates currently, polymerbased C may become the preferred solution

for oral rehydration of children with diarrhea in the future."

eeding and nutrition

In general, children with gastroenteritis should be returned to a normal diet as rapidly

as possible. -arly feeding reduces illness duration and improves nutritional outcome.

;reastfed infants should continue to breast feeding throughout the rehydration and

maintenance phases of acute gastroenteritis. 2ormulafed infants should restart

feeding at full strength as soon as the rehydration phase is complete (ideally in 5%

hours). +eaned children should restart their normal fluids and solids as soon as the

rehydration phase is complete. 2atty foods and foods high in simple sugars should be

avoided.

2or the ma=ority of infants, clinical trials have found no benefit of lactosefree

formulas over lactosecontaining formulas. imilarly, highly specific diets, such as

the ;'# (bananas, rice, applesauce, and toast) diet, have not been shown to

improve outcomes and may provide suboptimal nutrition for the patient..

6. 2reedman, tephen ;. et al. Cral Cndansetron for 9astroenteritis in a 7ediatric

-mergency /epartment. 5BB. The !e" England #ournal of Medicine.N -ngl K Eed

63%?"

%. 0ole, arah 1., anham, Kason . 2ailure to #hrive 8 'n Apdate.$m am

%hysician.5B"" 'pr "?@6(@6%.

3. ;owen, . 7hysiology of Vomiting. ">>.

http8FFarbl.cvmbs.colostate.eduFhboo!sFpathphysFdigestionFstomachFvomiting.html

. 2 / ;rown, K ;rown, # 2 ;eattie. +hy do children vomit after minor head in=uryO

#$ccid Emerg Med 5BBB?'/85@:5


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@. #he North Italian -ndoscopic 0lub for the tudy ant #reatment of -sophageal

Varices. 7rediction of the first variceal hemorrhage in patients with cirrhosis of the

liver and esophageal varices. N -ngl K Eed. ">@@? 6">8 >@6>.

>. 'l'mri, Nawaf. -mergency Eedicine 'pproach #o Nausea L Vomiting. 5B"".http8FFwww.slideshare.netFNawaf'l'mriFnauseavomiting"B5B>@%Q

"B. Kurnalis, Rusri /ianne., et al. Ealrotasi dan Volvulus pada 'na!.

http8FF=urnal.f!.unand.ac.id
http://www.slideshare.net/NawafAlAmri/nausea-vomiting-10620984http://jurnal.fk.unand.ac.id/http://www.slideshare.net/NawafAlAmri/nausea-vomiting-10620984http://jurnal.fk.unand.ac.id/

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