Chapter 65 Vomiting in an Infant (Case 46)
Differential Diagnosis
| Esophageal atresia | Midgut volvulus | Pyloric stenosis |
| Bowel atresias | Gastroesophageal reflux disease |
PATIENT CARE
Clinical Thinking
• There are many causes of vomiting in infants and children. In the newborn, these conditions may be congenital, and surgical correction will be performed prior to discharge. In contrast, vomiting in older infants and children is usually due to acquired conditions and so the patient has likely been feeding at home for a period of time.
History
• The most important determination is whether the emesis is bilious or nonbilious. Bilious vomiting is a surgical emergency and requires urgent evaluation.
• The age of the patient is important in determining the proper differential dx, regardless of the character of the emesis.
• The feeding hx provides clues to the differential dx. Determine if the patient has ever been able to feed without emesis.
Physical Examination
• General physical examination can provide clues to congenital abnormalities. For example, patients with esophageal atresia may have a heart murmur, limb abnormalities in the upper extremities, or anal anomalies as a part of VACTERL syndrome.
Tests for Consideration
| $100 | |
| $305 |
| Clinical Entities | Medical Knowledge |
|---|---|
| Esophageal Atresia | |
| PΦ | Esophageal atresia is a spectrum of anomalies that may have an associated fistula to the tracheobronchial tree. The basic pathology common to the majority of cases is an upper esophageal segment or pouch that is not in direct continuity with the distal esophagus. |
| TP | Difficulty swallowing saliva or inability to swallow the first feeding is the usual presenting sign. Prenatal dx is suspected with maternal polyhydramnios and absence of a fetal stomach bubble. In suspected cases, the presentation is inability to pass an orogastric tube. |
| Dx | The dx of esophageal atresia is confirmed by placing an orogastric tube until resistance is met, injecting 5 to 10 cc of air into the tube, and taking a CXR to confirm an air-filled pouch that usually ends in the upper thorax. The presence of air in the GI tract on an abdominal x-ray will confirm the presence of a fistula to the tracheobronchial tree. |
| Tx | The esophageal atresia is surgically corrected by mobilizing the two ends of the esophagus and creating an anastomosis. In about 85% of cases a fistula to the tracheobronchial tree is present and is ligated prior to sewing the esophagus together. The patient without a tracheoesophageal fistula will usually undergo initial placement of a gastrostomy tube for feeding. Further evaluation will determine the timing and choice of operations to repair the esophageal atresia. See Sabiston 71, Becker 56. |
| PΦ | Duodenal atresia is a failure of recannalization of the duodenum resulting in a duodenal obstruction. Jejunoileal atresia is an intestinal obstruction that results from a prenatal vascular accident that affects varying amounts of intestine. |
| TP | The patient with duodenal atresia presents with vomiting after the first few feedings that may be bilious or nonbilious, depending on whether the atresia is proximal or distal to the ampulla of Vater. Patients with intestinal atresia present with bilious vomiting, failure to pass meconium, and progressive abdominal distention over the first day or two of life. |
| Dx | The dx of duodenal atresia is suspected with early and vigorous vomiting and is supported by the presence of a “double-bubble” sign on abdominal x-ray. The dx of jejunoileal atresia is usually suspected by the hx and physical examination and is further supported by the presence of dilated bowel loops with air-fluid levels on abdominal x-ray. Limited upper GI contrast studies may be needed in either type of atresia if malrotation with a midgut volvulus is suspected. A contrast enema may be needed to confirm the dx of distal ileal atresia. A complete physical examination is done to determine associated anomalies (i.e., Down syndrome with duodenal atresia). |
| Tx | Tx is surgery and involves creating an anastomosis between the ends of the intestine to achieve continuity of the gastrointestinal tract. See Sabiston 71, Becker 57. |
| PΦ | Midgut volvulus is a condition associated with malrotation of the gastrointestinal tract and involves twisting of the bowel mesentery. This leads to duodenojejunal obstruction and/or vascular compromise of the affected bowel. |
| TP | The typical presentation is bilious vomiting. Most will present within the first month of life. Children older than 1 year may present with abdominal pain. Early on, the abdominal examination is often normal. |
| Dx | Bilious vomiting should prompt an immediate evaluation for possible malrotation. Abdominal x-ray may demonstrate a gasless abdomen or a double-bubble with distal bowel gas, or it may be unremarkable. Dx is confirmed by upper GI series, which demonstrates failure of the duodenojejunal junction to cross to the left of the vertebral column. Once the dx is made, the patient should be taken to surgery immediately. |
| Tx | The surgical tx is Ladd’s procedure. A transverse upper abdominal incision is made and the volvulus (if present) is reduced by twisting counterclockwise until it is untwisted. Ladd’s bands are divided, the appendix removed and the small bowel is placed in the right side of the abdomen, and the colon is placed in the left side of the abdomen. See Sabiston 71. |
Gastroesophageal Reflux Disease
| PΦ | Gastroesophageal reflux results when gastric contents reflux retrograde into the esophagus. Most infants have some degree of reflux due to the physiologic nature of the lower esophageal sphincter. |
| TP | The typical patient presents with obvious discomfort with feeds, excess spitting or vomiting, arching, or feeding aversion with inadequate weight gain and failure to thrive. Older infants may have chronic cough or recurrent middle ear fluid. There may be recurrent microaspiration leading to chronic lung disease. Older children may have heartburn, hoarseness, recurrent sore throat, and episodic wheezing. |
| Dx | A careful hx is taken to confirm nonbilious emesis. Nuclear medicine gastric emptying scan may demonstrate reflux, and will quantify gastric emptying. A pH probe is the gold standard test. Upper GI series is used to document normal anatomy. Severe cases may undergo upper endoscopy and biopsy to r/o eosinophilic esophagitis, usually caused by milk protein allergy. |
| Tx | Medical therapy consists of H2 blockers or proton pump inhibitors. Formula can be thickened for infants, and some physicians will add prokinetic agents. Indications for surgical therapy include failure of medical therapy and serious complications of their reflux such as recurrent pneumonia, apneic spells, esophageal strictures, or failure to thrive. A variety of different types of fundoplications can be performed, using either open surgery or laparoscopy. See Sabiston 71, Becker 27. |
| PΦ | Pyloric stenosis is an acquired hypertrophy of primarily the circular muscle of the pylorus, resulting in gastric outlet obstruction. |
| TP | The classic presentation is a 3- to 6-week-old male infant with progressive nonbilious projectile vomiting. Frequently, several formula changes have been attempted without success. As the vomiting becomes more frequent and forceful, many infants lose weight. During vomiting, a reverse peristaltic wave can be seen crossing the abdomen. |
| Dx | The dx is suspected clinically, and confirmed by either palpating a mass in the epigastrium that is typically the size and texture of an olive, or by ultrasonography demonstrating increased muscle thickness and/or an elongated pyloric channel. The classic “string sign” is seen on upper GI series, demonstrating pyloric obstruction. Progressive vomiting leads to hypovolemia and hypochloremic hypokalemic metabolic alkalosis. |
| Tx | Initial tx is medical stabilization prior to operation. A 20-cc per kilogram bolus of normal saline is given and repeated until the child voids. Once the patient voids, intravenous fluid therapy is continued with dextrose-containing saline solutions that have potassium chloride added. These fluids are given at higher than maintenance rates until the patient’s serum electrolytes are normal and adequate urinary output is established. Surgical tx is a pyloromyotomy and involves splitting the hypertrophic pyloric muscle to relieve the gastric outlet obstruction. See Sabiston 71, Becker 57. |
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