VOMITING IN CHILDREN SULAIMAN YUSUF Pediatric Gastroenterology Univ of Syiah Kuala, Banda Aceh 19/03/2020 1 Vomiting Gastroesophageal reflux Regurgitation 19/03/2020 2 Vomiting Forceful expulsion of gastrointestinal contents through the mouth 19/03/2020 3 Gastroesophageal reflux the involuntary passage of gastric contents into the esophagus Regurgitation reflux dribles effortlessly into or out of the mouth 19/03/2020 4 19/03/2020 5 S.motorik somatik S. Simpatis Saraf otonom S. Parasimpatis N. Vagus Saraf enterik pl. mienterikus asetil kolin pl. submukosa pleksus mienterikus S.motorik somatik 19/03/2020 motilitas sal.cerna 6 19/03/2020 7 Impuls endogen exogen afferen N. Vagus Chemo-receptor Trigger Zone Gastrointestinal tract, … Vomiting center vomiting Impuls 19/03/2020 8 Vomiting centre Blood Brain Barrier Chemo-receptor Trigger Zone esophagus 19/03/2020 9 LES Fundus Corpus Tonus decrease Antrum Peristaltic decrease Pylorus Duodenum Tonus increase 19/03/2020 10 Vomiting Most common in children (> infant) Confusing the parents Life-threatening causes of vomiting Three distinct phases (1) nausea, (2) retching, (3) emesis Not preceded in raised intracranial pressure or mechanical obstruction 19/03/2020 11 Approach Age: neonates, infant, child Gastrointestinal tract obstruction non obstruction Extra-gastrointestinal 19/03/2020 tract 12 Etiology Neonates Atresia esophagus, pylorus stenosis, spitting up GER, NEC, chalasia, Infection (UTI, OMA, sepsis) Infants pylorus stenosis, intususeption, hernia RGE, gastroenteritis, infection, drugs, aerophagia Children Intusuception, stricture, gastritis, apendisitis Infection, drugs 19/03/2020 13 Scanning 19/03/2020 gambar HPS 14 Therapy ~ etiology treat acid and base inbalanced Drugs Domperidone Metoclopramide Cisapride 19/03/2020 15 Gastroesophageal reflux Just spitting up, or something more serious ? 19/03/2020 16 Regurgitation 20% general infant population 40% of children consulting a pediatrician 70% of all 4 months old infants regurgitate at leats 1 x/day 25% is considered by the parents as ‘a problem’ RGE 8% abnormal pH esophagus monitoring 1/300 – 1/1000 ‘severe’ GER (Chouchou, 92; Nelson et al, 1997) 19/03/2020 17 19/03/2020 18 19/03/2020 19 162 infants (1-12 month olds), outpatients clinic for immunization, RSCM Freq of regurgitation 0-3 mo 4-6 mo 7-9 mo 10-12 mo 1-4 time/day 84% 65% 30% 7% > 4 time/day 30% 14% 6% 0 Problem 24% 18% 16% 4% 19/03/2020 20 GER The involuntary passage of gastric contents into the esophagus saliva, ingested food, drinks, gastric/pancreatic/ biliary secretions normal phenomenon, +/- accompanying symptoms physiologic or pathologic reflux (Carre 1983; Vandenplas, 1992; Orenstein, 1994; Vandenplas, 1993) 19/03/2020 21 GER Physiologic occurs mainly after meal does not normally cause symptoms short duration of reflux episodes Pathologic reflux reflux frequent reflux episodes of longer duration reflux episodes occuring during the day/night may produce symptoms & inflamation/mucosal injury 19/03/2020 22 Mechanisms of GER Deficient or delayed esophageal acid clearance attenuated swallows, dysfunctional peristalsis Length of LES, Maturation of LES TLES relaxation delayed gastric delayed gastric emptying emptying, distention distension Incompeten t LES Inadequate gravitation 19/03/2020 23 RGE Acid,Regional blood flow, tissue prostaglandin E2 permeability to acid susceptibility to inflamation inflamation dysfunction vagal nerve acid/bile edema Impairment of LES fibrosis dysmotility pylorospasm esophagitis 19/03/2020 24 Trigger factors favoring GER Increased abdominal pressure (overweight, constipation) Increased respiratory effort related to exercise (food) allergy, crying, cigarette smoking Hereditary predisposed 19/03/2020 25 Clinical manifestation GER Emesis & regurgitation are the most common ‘primary’ GER disease ‘secondary’ GER disease infection, metabolic disorders, & food allergy stimulation vomiting center in the dorsolateral reticular formation by efferent & afferent impuls 19/03/2020 26 Symptoms of GER (- disease) Usual manifestations Specific manifestation regurgitation, nausea, vomiting Possibly related to complications ~ anaemia (iron defiency anaemia) haematemesis & melena dysphagia, weight loss, irritable infants ect ~ adult 19/03/2020 27 Symptoms of GER (- disease) Unusual presentations ~ to congenital and/or CNS abnormalities ~ chronic respiratory disease apnea, apparent life threatening, SIDS cerebral palsy, psychomotory retardation A careful history, observation of feeding, & physical examination are mandatory 19/03/2020 28 19/03/2020 29 - Number of reflux episode - Number of reflux episodes longer than 5 min - Longest reflux episodes - Fraction time pH below 4.00 19/03/2020 30 Treatment recommendations 1. a. Parental reassurance b. Milk-thickening agents (?) 2. Prokinetics 3. Positional adjuvant therapy 4. a. H2 receptor antagonist b. Proton pump inhibitors 5. Surgery 19/03/2020 31 Regurgitation and feeding Frequent small feeding Decrease the number of transient LES relaxations Reduced volume cause of distress to infants Restriction volume in clearly overfed babies Thickening infants formula Decrease the frequency & volume of regurgitation time crying, improves sleep, caloric retention , coughing (after feeding) (Vandenplas, 1994, Borelli, 1997) 19/03/2020 32 Formula and milk-thickening Thickening formula should be considered as the first step Can not be given to breastfed infants Gastric emptying : Casein > Wheyhydrolysate 19/03/2020 33 Prokinetics Gastrokinetic action indirect release of acetylcholine in the myentericus plexus Reduces regurgitation The LES pressure and motility Esophageal peristalsis, gastric emptying Increased salivary secretion protect esophagus via salivary component (bicarbonat buffer) 19/03/2020 34 Position, crying, and reflux Sleeping and crying decrease GER Crying increases abdominal pressure, but also increases LES-P 300 prone anti-trendelenburg position SIDS ? Beyond the age of SIDS ( > 12 months) (Orenstein, 1990; Orenstein, 1997; Tobin, 1997) 19/03/2020 35 19/03/2020 36 Laryngeal irritation by refluxate Vagal stimulation leading to bronchospasm Pulmonary aspiration of refluxate GER - ASTHMA 19/03/2020 37 Recent studies report that 45-75% of children with uncontrolled asthma suffer GOR Prokinetic GER ~ cough episodes at night in 50% children remission of resp. symptoms or less anti-asthma medication (McVeagh, 1987; Orenstein, 1988; Tucci F, 93; Pransky SM, 1992) 19/03/2020 38 Uncomplicated GER No investigations Phase 1 (1-2weeks) Phase 2 (1-3 weeks) ?? reconsider diagnosis of GER ?? pH monitoring Normal Abnormal ? GOR ? UGIS ? Endoscopy ? 19/03/2020 39 Complicated GER : esophagitis ? Endoscopy Eso > Grade 3? NO YES phase 1 + 2 phase 1 + 2 + 3 + 4 A-R Formula Cisapride 1-3 mo (+ Positional treatment, H2 / Omeprazole) control endoscopy Eso > Grade 3 ? NO stop phase 3 continue phase 2 19/03/2020 YES UGIS ?? ? Surgery ? 40 THANK YOU 19/03/2020 41
