Vomiting is unpleasant and can cause dehydration, because fluid is lost and because the ability to rehydrate by drinking, is limited.
Nausea is the feeling approaching vomiting and is often accompanied by autonomic changes such as increased heart rate and salivation. Nausea and vomiting usually occur one after the other, but they can also independently for use. As when vomiting without previous nausea as a result of increased intracranial pressure. Vomiting is unpleasant and can cause dehydration, because fluid is lost and because the ability to rehydrate by drinking, is limited. Pathophysiology vomiting is the last part of a series of events that are coordinated by the vomiting center in the medulla. The vomiting center can activate by afferent nerve pathways from the digestive organs (eg. As throat, stomach, small intestine) and nondigestiven organs such as heart and testicles the chemoreceptor trigger zone of the area postrema on the floor of the fourth ventricle and other CNS centers such. B. brainstem or organ of equilibrium. In this process, dopamine and serotonin receptors play a role. Etiology The causes of vomiting vary with age, ranging from relatively benign to potentially life-threatening (see table: Some causes of vomiting in infants, children and adolescents). Vomiting is a protective mechanism that helps the body expel toxins possible. but it can also be an indication of a serious illness (such. as intestinal obstruction). Poison Green vomiting indicates a high intestinal obstruction and requires especially in an infant an immediate investigation. Babies infants usually spit small amounts (typically <5-10 ml) during or shortly after feedings when they burp need. Fast feeding, air swallowing and overfeeding may be causes, although spitting may occur even without these factors. Occasional vomiting may also be normal, but repeated vomiting is not normal. among the most common causes of vomiting in neonates and infants: Acute viral gastroenteritis Gastroesophageal reflux disease to other important causes in neonates and infants include pyloric stenosis intestinal obstruction (eg, meconium ileus, volvulus, intestinal atresia, stenosis.) intussusception (usually in infants ages 3 and 36 months) to the less common causes of recurrent vomiting include sepsis and food intolerances. Metabolic disorders (eg. As urea cycle disorders, organic Acidämie) are rare, but can manifest with fever. Older children, the most common cause is acute viral gastroenteritis also other infections as gastrointestinal infections can have episodes of vomiting result. Other causes that have to be considered, severe infection (eg. As meningitis, pyelonephritis), acute abdomen (z. B. appendicitis), increased intracranial pressure are secondary to a lesion (eg., Caused by trauma or a tumor ) and cyclic vomiting. In adolescents are among the causes of vomiting and pregnancy, eating disorders and toxic ingestion (eg. As acetaminophen, iron, ethanol). Some causes of vomiting in infants, children and adolescents cause * Suspicious findings Diagnostic procedure vomiting in infants Viral gastroenteritis Usually with diarrhea sometimes fever and / or contact with a person who has similar symptoms Physical examination sometimes rapid immunoassays for viral antigens (eg . as rotavirus, adenovirus) Gastroesophageal reflux disease Rezidiviere hands unrest during or after breastfeeding may poor weight gain, curvature of the spine, recurrent respiratory symptoms (eg. B. cough, stridor, wheezing) Empirical tests of acid suppression Sometimes examination of the upper GI tract, a milk scan, esophageal pH monitoring and / or impedance study or endoscopy bacterial enteritis or colitis Usually with diarrhea (often bloody) fever, cramping abdominal pain, swelling Clinical examination Sometimes emaciated Often contact with a person who has similar symptoms stool examination for leukocytes and culture pyloric stenosis Recurring, surge-like vomiting immediately after feeding in newborns aged 2-12 weeks, rare chairs can and be dehydrated sometimes noticeable "Olive" in the right upper quadrant ultrasound of the pylorus, if an ultrasound is not possible or too uncertain contrast examination of the upper urinary tract. Congenital atresia or stenosis abdominal rigidity bilious vomiting (with reduced severity of stenosis vomiting may be delayed) within the first 24-48 hours of life Sometimes polyhydramnios during pregnancy, Down syndrome, jaundice plain abdominal Upper urinary series or contrast enema depending on the findings intussusception colic Exemplary abdominal pain, inconsolable crying, lethargy, tightening the legs to the chest Later bloody ( "current jelly") chair Typical age 3-36 months, but may be outside this period are abdominal ultrasonography If the ultrasound scan is positive or not to diagnose air or contrast enema (unless the child has signs of Peritoniti s or perforation) Hirschsprung disease Neonates: Delayed passage of meconium, abdominal distention, bilious vomiting plain abdominal contrast enema Rectal biopsy malrotation with volvulus In newborns: bilious vomiting, abdominal distention and pain Bloody stool plain abdominal contrast enema or upper GI series sepsis fever, lethargy, tachycardia, tachypnea Increasing pulse pressure, hypotension cell counts and cultures (blood, urine, cerebrospinal fluid) Chest X-ray If pulmonary symptoms Food intolerance abdominal pain, diarrhea may eczematous rash or urticaria exclusion diet Sometimes skin test and / or Radioallergosorbenstest (RAST) metabolic disorders Poor eating, failure to thrive, lethargy, hepatosplenomegaly, jaundice Sometimes unusual odor, cataract electrolytes, ammonia, liver function tests, blood urea nitrogen, creatinine, glucose serum , total and direct bilirubin, blood count, Plasmolystest / thromboplastin Neonatal metabolic screening more specific tests depending on the findings Vomiting in children and adolescents Viral gastroenteritis Usually with diarrhea if necessary Fever, contact with a person who has similar symptoms, travel history Clinical examination Sometimes rapid immunoassays for viral antigens (eg. As rotavirus, adenovirus) Bacterial enteritis or colitis Usually with diarrhea (often bloody), fever, cramping abdominal pain, bloating , fecal urgency Often contact with a person who has similar symptoms or travel history Clinical examination if necessary Stool samples for leukocytes, Culture No gastrointestinal infection fever often localized findings depending on the cause, eg. As headaches, earaches, sore throat, cervical lymphadenopathy, dysuria, flank pain, nasal discharge Clinical examination tests as required by the suspected cause appendicitis initial general malaise and periumbilical pain followed by pain that can be localized in the lower right quadrant, vomiting after the onset of pain , loss of appetite, fever, tenderness at McBurney's point, no bowel sounds sonography (is a CT scan because of lower radiation exposure preferred) Dangerous infectious fever, poisoning symptoms, back pain, dysuria (pyelonephritis) Nackenstei stiffness, photophobia (meningitis) lethargy, hypotension, tachycardia (sepsis) cell counts and cultures (blood, urine, cerebrospinal fluid) as indicated by results indicated Cyclic vomiting ? 3 episodes of intense acute nausea and incessant vomiting and sometimes abdominal pain or headache that lasts hours to days In between symptom-free intervals that take weeks to months exclusion of metabolic, GI (eg. . B. Malrotation) or CNS (e.g., brain tumor) diseases Intracranial Hypertension (caused by trauma or tumor) chronic progressive headache; nocturnal awakenings; Vomiting in the morning; Headaches that are aggravated by coughing or Valsalva maneuver; Vision changes brain computed tomography (without contrast) eating disorders Uncontrolled Heißhungerattaken, enamel erosion, weight loss or weight gain Sometimes skin lesions on the hands, resulting from induced vomiting (Russell's sign) Clinical examination pregnancy amenorrhea, morning sickness, bloating, breast tenderness history of sexual activity urine pregnancy test ingestion of toxic doses of substances (eg. B. paracetamol, iron, ethanol) Often a previous ingestion Various findings depending on the recorded substance Qualitative and quantitative sometimes drug levels in serum (depending on the substance) adverse reaction to medication (eg. B. to chemotherapeutic agents) exposure to a particular drug Clinical examination * causes are listed in order of frequency. Many young people do not admit sexual activity. Clarification Clarification includes assessing the severity (z. B. dehydration, surgical or other life-threatening condition) and the diagnosis of the cause. History The history of the current disease should determine when the vomiting began, how often and what type it was such. B. gush, bilious or in small quantities or as regurgitation. Each pattern can be seen in the vomiting (eg. As after feeding, only certain foods, especially in the morning or in recurring cyclical episodes) can be important for diagnosis. Important Accompanying symptoms include diarrhea (with or without blood), fever, loss of appetite and abdominal pain, bloating, or both. The rhythm of bowel movements and their consistency as well as the urine output should be considered. A review of organ systems examined for symptoms of underlying disorders: weakness, problems with breast feeding, failure to thrive (metabolic disorders), delay in passage of meconium, abdominal distention, lethargy (bowel obstruction), headache, neck stiffness and sea clutter (intracranial disorders), food cravings, impaired perception of their own body (eating disorders), lack of menstrual bleeding, swelling of the breasts (pregnancy), rash (eczema or hives with food allergies, petechiae in sepsis or meningitis), ear or throat pain (focal non-GI Unfektion), fever with headache, neck or back pain or abdominal pain (meningitis, pyelonephritis or appendicitis). THe history of prehistory should made trips (possible infectious gastroenteritis), recent head injury or unprotected sex (pregnancy) beachten.Körperliche investigation The vital parameters are indicators of infection (eg., Fever) or volume depletion (eg. As tachycardia, hypotension) checks During the general examination are signs of pain (eg. as lethargy, irritability, inconsolable crying) and signs of weight loss (cachexia) or found weight gain. Because the examination of the abdomen can cause pain, physical examination should begin with his head. The study of head and neck pays particular attention to signs of infection (eg. As red, plump eardrum is bulging fontanelle, enlarged tonsils) and dehydration (dry mucous membranes, lack of tears). The neck should be flexed passively to detect resistance or discomfort, which may indicate to meningeal irritation. The cardiac examination pays attention to tachycardia (dehydration, fever, malaise). The examination of the abdomen pays attention to expansion (distension), bowel sounds (high-pitched sounds, normal sounds, lack of noise z. B), softness of the abdominal wall, signs of tension, rigidity or knocking pain (peritoneal mark), and whether an organ enlargement or a mass to be palpated can. The skin and extremities to petechiae or purpura (severe infection) or other rashes studied (possible virus infection or signs of atopy) and jaundice (possible metabolic disorder) and signs of dehydration such. B poor skin turgor, delayed capillary refill. Growth parameters and signs of progress in development are also beachten.Warnhinweise The following findings are of particular importance: Galli gene vomiting lethargy or listlessness inconsolable and bulging fontanelle in infants stiff neck, sensitivity to light and fever in older children peritoneal signs or abdominal distention (surgical abdomen) Persistent vomiting in bad growth or delayed development interpretation of the findings Initial findings will help determine how severe the disease is and how necessary an immediate intervention. All newborns or babies with recurrent or bilious (yellow or green) or gush vomiting most likely has a gastrointenstinale obstruction and is likely to require surgical intervention. An infant or child with colic-like abdominal pain, signs of intermittent pain or apathy accompanied by a missing or bloody bowel movements must be tested for intussusception. A child or adolescent with a fever, stiff neck and sensitivity to light should be tested for meningitis. A child or adolescent with fever and abdominal pain with vomiting, loss of appetite and decreased bowel sounds should be evaluated for appendicitis. Any recent history of head injury or chronic progressive headache with vomiting in the morning, and visual disturbances indicate intracranial hypertension. Other findings are dependent on the age judged primarily (see table: Some causes of vomiting in infants, children and adolescents). Restlessness, choking and respiratory symptoms and signs such as wheezing in infants may be manifestations of gastroesophageal reflux. A development is lagging behind and neurological abnormalities have a disorder of the central nervous system or a metabolic disease suggest. Delayed passage of meconium, followed by vomiting or both indications of Hirschsprung's disease or intestinal stenosis at the same time can be. In children and adolescents fever may indicate an infection. The combination of vomiting and diarrhea points to acute gastroenteritis. Lesions on fingers and erosion of tooth enamel or a young person who makes about his weight loss not worry or has a distorted body image, suggest an eating disorder. Morning sickness and vomiting, amenorrhea and weight gain may indicate a pregnancy. Episodes of vomiting in the past, the episodic, short-lived and without further concomitant symptoms have cyclic vomiting hin.Tests tests should be performed depending on the presumed underlying disease (see table: Some causes of vomiting in infants, children and adolescents). Imaging techniques are typically displayed in a suspected pathology of the abdomen or the CNS. Various special blood tests or --kulturen can be performed to diagnose inherited metabolic disorders or serious infections. If dehydration is suspected, serum electrolytes should be measured. Treatment Treatment of nausea and vomiting depends on the underlying disease. Rehydration is important. Drugs that are commonly used in adults to minimize nausea and vomiting are rarely used in children. Reasons for this are: the effectiveness of the treatment has not been proven side effects are possible and the drugs can mask the causative disease. However, if nausea or vomiting is severe or constantly, antiemetics can be used in children> 2 years careful. Suitable drugs include promethazine: in children> 2 years, p.o. 0.25 to 1 mg / kg (maximum 25 mg) i.m., i.v. or rectally every 4 to 6 hours prochlorperazine: in children> 2 years weighing 9-13 kg 2.5 mg p.o. every 12 to 24 hours; for those who weigh 13 to 18 kg 2.5 mg p.o. every 8 to 12 hours; for those who weigh 18 to 39 kg 2.5 mg p.o. every 8 hours; for those> 39 kg, 5 to 10 mg p.o. every 6 to 8 hours metoclopramide: 0.1 mg / kg p.o. or iv every 6 hours (maximum 10 mg / dose) Ondansetron: 0.15 mg / kg (up to 8 mg) i.v. every 8 hours or when the oral form is used for children between 2 and 4 years old, 2 mg every 8 hours; for those between 4 to 11 years, 4 mg every 8 hours; for those ? 12 years, 8 mg every 8 hours promethazine is an H1 receptor blocker (antihistamine), which inhibits the vomiting center in response to peripheral stimulants. The most common side effects are respiratory depression and sedation; the drug is contraindicated <2 years in children. Therapeutic doses of promethazine can extrapyramidal side effects, including torticollis cause. Prochlorperazine is a weak dopamine receptor blocker that suppresses the chemoreceptor trigger zone. Akathisia and dystonia are the most common side effects that occur with up to 44% of patients. Metoclopramide is a dopamine receptor antagonist that acts both centrally and peripherally, by increasing the gastric motility and decrease of afferents to the chemoreceptor trigger zone. Akathisia and dystonia occur in up to 25% of children. Ondansetron is a selective serotonin (5-HT3) receptor blocker, which inhibits the initiation of the vomiting reflex in the periphery. A single dose of ondansetron is responsive in children, the acute oral rehydration (ORT), safe and effective. By facilitating ORT this drug can the need intravenous fluids or receiving infusions in children, prevent hospitalization. Typically, only a single dose is used because repeated doses can cause persistent diarrhea. Conclusion In general, the most common cause of vomiting acute viral gastroenteritis. Associated diarrhea suggests an infectious cause the gastrointestinal tract. Bilious vomiting, bloody stools or lack of bowel movements indicates an obstructive cause. Persistent vomiting (especially in an infant) requires immediate clarification.