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VOMITING IN CHILDREN
Rahmini Shabariah SpAFak. Kedokteran Univ Muhammadyah Jakarta
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Vomiting
Regurgitation
Gastroesophageal reflux
Forceful expulsion of gastrointestinal contents through the mouth
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Vomiting
◦the involuntary passage of gastric contents into the esophagus
◦reflux dribles effortlessly into or out of the
mouth
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Gastroesophageal reflux
Regurgitation
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S.motorik somatik28/04/23 6
S.motorik somatik
Saraf otonomS. Simpatis
S. Parasimpatis
Saraf enterikN. Vagus
asetil kolinpleksus mienterikus
motilitas sal.cerna
pl. mienterikuspl. submukosa
The StomachThe Stomach
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Impuls
Chemo-receptor Trigger Zone
Gastrointestinal tract, …
Vomiting center
endogen exogen
Impuls
vomiting
afferen N. Vagus
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Vomiting centre
Chemo-receptor Trigger Zone
Blood Brain Barrier
esophagus
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LES FundusCorpus
Tonus decrease
Antrum Peristaltic decrease
PylorusDuodenum
Tonus increase
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
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Vomiting
ApproachApproach
Age: neonates, infant, childGastrointestinal tract
◦obstruction◦non obstruction
Extra-gastrointestinal tract
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EtiologyEtiology
• 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
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Scanning gambar HPS
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~ etiologytreat acid and base imbalancedDrugs
◦Domperidone◦Metoclopramide◦Cisapride
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Therapy
Gastroesophageal reflux
Just spitting up, or something more serious ?
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RegurgitationRegurgitation20% general infant population
◦40% of children consulting a pediatrician◦70% of all 4 months old infants
regurgitate at least 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)
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162 infants (1-12 month olds), 162 infants (1-12 month olds), outpatients clinic for immunization, RSCMoutpatients clinic for immunization, RSCM
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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%
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)
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GER
GERGERPhysiologic reflux
◦occurs mainly after meal◦does not normally cause symptoms◦short duration of reflux episodes
Pathologic reflux◦frequent reflux episodes of longer duration◦reflux episodes occuring during the day/night◦may produce symptoms & inflamation/mucosal
injury
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Mechanisms of GERMechanisms of GER
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attenuated swallows, dysfunctional peristalsis
Length of LES, Maturation of LESTLES relaxation
Inadequate gravitation
delayed gastric emptying, distension
Deficient or delayed esophageal
acid clearance
Incompetent
LES
delayed gastric emptyingdistention
RGERGE
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Acid,Regional blood flow,tissue prostaglandin E2permeability to acidsusceptibility to inflamation
Impairment of LES
dysmotility
esophagitis
inflamationdysfunctionvagal nerve
acid/bile
edema
fibrosis
pylorospasm
Trigger factors favoring GERTrigger factors favoring GER
Increased abdominal pressure (overweight, constipation)
Increased respiratory effort related to exercise
(food) allergy, crying, cigarette smoking Hereditary predisposed
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Clinical manifestation GERClinical 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
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Symptoms of GER (- disease)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
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Symptoms of GER (- disease)Symptoms of GER (- disease)Unusual presentations
◦~ chronic respiratory disease◦apnea, apparent life threatening, SIDS
~ to congenital and/or CNS abnormalities◦cerebral palsy, psychomotory retardation
A careful history, observation of feeding, & physical examination are mandatory
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- Number of reflux episode- Number of reflux episode- Number of reflux episodes longer than 5 - Number of reflux episodes longer than 5 minmin- Longest reflux episodes- Longest reflux episodes- Fraction time pH below 4.00- Fraction time pH below 4.00
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Treatment recommendationsTreatment recommendations1. a. Parental reassurance b. Milk-thickening agents (?)2. Prokinetics3. Positional adjuvant therapy4. a. H2 receptor antagonist b. Proton pump inhibitors5. Surgery
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Regurgitation and feedingRegurgitation and feedingFrequent 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)
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Formula and milk-thickeningFormula and milk-thickeningThickening formula should be considered
as the first stepCan not be given to breastfed infantsGastric emptying : Casein >
Wheyhydrolysate
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Gastrokinetic action indirect release of acetylcholine
in the myentericus plexusReduces regurgitation
◦The LES pressure and motility◦Esophageal peristalsis, gastric emptying
Increased salivary secretion◦protect esophagus via salivary component
(bicarbonat buffer)
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Prokinetics
Position, crying, and refluxPosition, 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)
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GER - ASTHMAGER - ASTHMA
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Vagal stimulation leading to bronchospasm
Laryngeal irritation by refluxate
Pulmonary aspiration of refluxate
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)
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Uncomplicated GER
No No investigations
Phase 1 Phase 1 (1-2 (1-2 weeks)weeks)
Phase 2 Phase 2 (1-3 (1-3 weeks)weeks)
?? reconsider diagnosis of GER ?? reconsider diagnosis of GER ????
pH pH monitoring
NormalNormal AbnormalAbnormal
? GOR ?? GOR ? UGIS ?UGIS ?Endoscopy ?Endoscopy ?
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Complicated GER : esophagitis ?
EndoscopyEso > Grade 3?Eso > Grade 3?
NO
YES
phase 1 + 2phase 1 + 2A-R Formula A-R Formula Cisapride 1-3 Cisapride 1-3
momo
phase 1 + 2 + 3 + 4phase 1 + 2 + 3 + 4(+ Positional treatment, (+ Positional treatment,
H2 / Omeprazole)H2 / Omeprazole)
control endoscopy
stop phase 3stop phase 3continue phase continue phase
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Eso > Grade 3 ?Eso > Grade 3 ?
UGIS ??UGIS ??? ?
Surgery ?Surgery ?
NO
YES
THANK YOU
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