Vomiting Case files– Need for urgent diagnosis as symptomatic treatment does not work
M3 India Newsdesk May 27, 2019
Summary
Dr. YK Amdekar, through the following cases, explains how to interpret and evaluate forceful vomiting, vomiting due to obstruction or due to metabolic disturbance.
Before you begin, take the quiz below to test your knowledge.
Vomiting may not be considered only as primary gastrointestinal disorder as it is caused by diseases of almost every system in the body, though finally it is mediated through GI system. Thus attention should be given to every organ in the body that may be responsible for vomiting.
Case 1
A two-month-old infant presented with a history of vomiting for last two weeks. Infant was well till the onset of this symptom and was on exclusive breast feeds and growing well. Vomit was forceful and contained large amounts of curdled milk. Prior to vomiting, the infant was restless but felt relieved after a vomit and took feeds well. However vomiting recurred after few hours again.
In the two weeks prior, he had passed stools infrequently and had not gained weight since then. Physical examination showed mild dehydration and distension of upper abdomen more in left hypochondrium and epigastrium. There were no other abnormalities.
In view of forceful vomiting containing curdled milk without bile and distension of upper abdomen, it suggests pyloric obstruction. As the infant was otherwise asymptomatic, it could be due to mechanical cause that must have been present since birth. Hence it is congenital pyloric stenosis.
Question arises why it did not present at birth. It is not complete obstruction – atresia but partial obstruction and hence referred to as stenosis. Over the first few weeks, due to partial obstruction, curdled milk is retained in stomach for longer time that causes inflammation of pylorus due to acidic nature of curdled milk. Thus over time, congenital partial obstruction becomes complete and hence there is delayed presentation.
Rarely if pyloric obstruction is near complete at birth, neonate may present with pyloric stenosis within few days. Diagnosis can be easily confirmed by USG and needs surgical correction of the defect. Absence of general symptoms such as fever in an otherwise well infant indicates mechanical cause.
Forceful vomit suggests obstruction. Vomitus not containing bile localises obstruction proximal to second part of duodenum. Presenting so early in life favours a congenital lesion. Hence diagnosis is easy to arrive at and is totally curable with surgery. It is important to diagnose early enough to avoid dehydration and malnutrition.
Case 2
A two-month-old infant presented with a history of acute onset of vomiting followed by drowsiness. He was apparently well prior to onset of this illness. He was on exclusive breastfeeding and was gaining weight well. Physical examination showed drowsy infant barely responding to painful stimuli. There were no other abnormal findings.
What starts acutely may be due to mechanical, neurological, vasogenic, metabolic or immune-mediated disorder. There has been no history of trauma. Vascular aetiology affects localised part of the brain related to the vascular supply and hence not likely in this child.
Immune-mediated disorders are rare at this age and are often accompanied with general symptoms such as fever or skin rash. Primary neurological condition that may result in acute onset of drowsiness is viral encephalitis but would have presented with fever and other prodrome of viral infection such as cold, cough etc.
Thus, it is mostly a metabolic disorder. It is not possible to guess which metabolic disorder it could be. This infant was hospitalised and put on IV fluids and some laboratory tests were ordered. Within 24 hours, the infant improved dramatically and seemed to be normal. This is typical of metabolic disorder as oral feeds were stopped, offending agent coming through feed was withdrawn and so this fast improvement. Further laboratory tests confirmed it to be galactosemia.
An infant is born with this type of metabolic error. It is treated with lactose and galactose-free diet. Early diagnosis and treatment prevents permanent neurological handicap. Acute onset of vomiting and drowsiness clearly denotes central cause of vomiting. Sudden onset and equally sudden recovery on withdrawal of oral feeds indicates metabolic disorder. Further laboratory tests help in pinpointing a cause.
Case 3
An eight-month-old infant presented with vomiting since a month and cough off and on. He was apparently well until onset of the problem. He would start feeding but would vomit while feeding and vomitus contained milk as such. Occasionally, he would suddenly chock while feeding with severe cough. It kept on happening over one month. At times, milk would go down the stomach without vomiting.
Physical examination did not show any abnormality. As vomitus contained milk as such and not curdled milk, it is clear that milk does not reach the stomach at all and so the problem lies in the oesophagus. When liquids cannot go down the oesophagus, it is unlikely to be due to mechanical obstruction and hence it must be because of functional obstruction.
It suggests malfunction of oesophageal muscle that does not allow liquids to travel down. Retained milk is mostly vomited out but occasionally would be inhaled into airways and result in severe chocking and cough. Further investigations demonstrated achalasia – failure of oesophagus to relax and so remains mostly contracted.
The condition can be managed by repeated dilatation. When solid food can’t go down the stomach, it is likely to be mechanical obstruction but when solid food can go down due to gravity but liquids can’t do down, it is often a symptom of muscle dysfunction, often of neurological abnormality.
Case 4
An eight-month-old infant presented with history of vomiting over the last 2 months. He was well prior to onset of this illness. He was growing well. He vomited each time he feeds and in general was reluctant to feed. He had lost 2 kg weight. Apparently there were no other symptoms. Several tests and trials with medicines had failed.
Physical examination revealed malnourished, sick-looking infant, weighing 5.2 kg but with no other abnormal findings. On direct questioning, it was found out that he was very irritable, constipated but passing lots of urine despite of vomiting and severe anorexia. So he had polyuria. Thus it was due to renal tubular disorder.
Further tests confirmed the diagnosis of hypercalcemia. It was a result of vitamin D toxicity. This case demonstrates importance of detailed personal history that pointed to polyuria. Generally one tends to ask for oliguria as a marker of renal disease but renal tubular disorder presents as polyuria besides other metabolic defects.
There are no abnormal physical findings in such a metabolic disorder and it is only a detailed history that gives a clue to probable diagnosis. It is an abnormal metabolite that stimulates central trigger zone to cause vomiting.
Case 5
A four-year-old child presented with vomiting for last two months. He was well prior to onset of this illness. He would vomit on and off and vomitus would contain ingested food. There was no history of headache or any other symptoms. Physical examination did not reveal any abnormality. It suggests central cause of vomiting. In absence of any other clue, one may have to investigate for metabolic disorder.
Initial screening tests were negative. Few days later this child developed neurological abnormality in the form of spasticity and deterioration of milestones. MRI of brain confirmed the diagnosis of adrenoleucodystrophy. This case emphasises a point that few diseases evolve over time to make a final diagnosis.
However, it was easy to consider that vomiting in this child was due to central cause. Diseases with multiple symptoms may start with only one symptom and then come out with other symptoms. In such a case, one may have to keep in mind an evolving disease and even search for it with a single symptom at presentation.
Case 6
An eight-year-old child presented with history of vomiting, abdominal pain and mild fever for last 24 hours. It started with vomiting followed by abdominal pain. Pain was periumbilical, dull, and poorly localised. He had not passed stools for a day. Vomitus contained ingested material. He developed mild fever on day 2.
At this juncture, it was clear that there was intra-abdominal inflammatory pathology evolving without obvious localisation. It is unlikely to be intestinal obstruction as there was no bile stained vomit. By the next day, pain had increased in severity and was localised to right iliac fossa.
It clearly meant localisation now to appendix and hence diagnosis of acute appendicitis was made. It can be confirmed with USG. He was operated and recovered fully. Vomiting in such a case is related to autonomic response to pain. Visceral abdominal pain– related to viscera– is often periumbilical and dull with poor localisation till it localises to the site of inflammation with involvement of peritoneum and leads to increased severity of pain.
Case 7
A ten-year-old healthy child presented with episodes of vomiting and headache on getting up in the morning that would ease over time only to recur next morning again. Severity and duration of these episodes went on increasing over next two weeks. There was no fever.
These symptoms suggest increased intracranial pressure that was gradually worsening. Hence, it is likely to be space-occupying intracranial lesion. Physical examination revealed papilledema on fundus examination and increased tone and brisk deep tendon reflexes in both lower limbs. It suggests slowly increasing hydrocephalus that was proved to be due to aqueduct obstruction.
This child was operated for the same and had ventriculo-peritoneal shunt placed. Vomiting accompanied with headache is classical of raised intracranial pressure. Slow onset of raised ICP manifests first on waking up in the morning as during lying down position, there is circulatory stasis in intracranial compartment that adds to the borderline increased pressure and hence manifests on waking up. With routine movements, intracranial stasis gets reduced and so symptoms of vomiting and headache subside temporarily till pressure further increases and then symptoms get worst through the day.
Case 8
A five-month-old infant presented with vomiting since last 2 months. Prior to onset of vomiting, he was happy and growing well on exclusive breastfeeds. For the first three months, the mother was at her mother’s place with her infant. Since she came back to her home, vomiting started and continued.
Physical examination did not reveal any abnormality though the infant had not gained any weight over the last two months and was irritable. Several tests done were negative and so also empirical therapeutic trials had failed. History of change in place coincided with onset of symptoms and hence it was decided to go into further details.
On further discussion with the family, the psychologist found out the cause of disturbed mother-infant relation as the cause of vomiting. Elder aunt of the infant had taken charge of the baby and mother was allowed to handle the baby only during breast feeding. This infant was craving for mother’s bonding.
Father of the infant was taken into confidence and he managed to send his elder sister out of town on some pretext and from the very day, infant stopped vomiting. So it was a functional disorder and not any organic disease.
This case illustrates possibility of functional disorders even in a young infant. Mother-infant relationship is vital for infant’s secured feeling and it promotes not only sound health but also ideal psychological development. Health is not just physical well-being but also mental, psychological and emotional well-being. Factors disturbing any of these components would affect health.
Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
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