vomiting in children
Introduction
Introduction to vomiting in children Vomiting is one of the common symptoms in children. If you do not get timely and correct treatment, it will affect the intake of nutrients in the children. In severe cases, it will cause dehydration and electrolyte imbalance. Vomiting is a kind of reflex action that the contents of the stomach are reversed into the esophagus and spit out through the mouth. It can be divided into three stages, nausea, retching and vomiting, but some vomiting can be a precursor to nausea or retching. basic knowledge The proportion of illness: 10% Susceptible people: infants and young children Mode of infection: non-infectious Complications: aspiration pneumonia
Cause
Causes of vomiting in children
nausea
Refers to the phenomenon of non-mandatory digestive tract secretions or stomach contents from the stomach or esophageal outflow, usually without nausea or mandatory abdominal muscle contraction. The nausea can be physiological or caused by pathological causes. .
Physiological (20%):
Infants with a few weeks of priming can see that there is milk in the mouth (with or without milk) about 0.5 to 1 hour after the upgrade. It is usually called overflowing milk. The appetite, sleep, spirit and weight gain of the baby are normal, often Significant incentives can be found, and there is no need to deal with it naturally within 7-8 months.
Pathological (20%):
1. Feeding problem refers to vomiting caused by improper feeding techniques, such as incorrect posture during breastfeeding (such as nipple, poor connection between areola and baby's mouth, close contact with the nose, incorrect posture, etc.), milking Fast, the milk speed is almost normal, the baby sucks and swallows too fast, the amount of milk is too much, the teat is invaginated, the sucking difficulty is low, the milk temperature is low, the diameter of the teat hole is too small, or the heat card in the milk is insufficient and the feeding is less, the baby There are often non-nutritive sucking and there is a lot of odor in the stomach. After the milk, there is no gas in the standing position. After the milk, the gas in the stomach is not discharged, or the baby is given various cares after the milk (changing the diaper, taking a bath, feeding Medicine, etc., can not be chewed to solid food in infants, forced infants, especially premature infants to eat, crying before and after eating can cause.
2, congenital esophageal obstruction, relying on X-ray examination diagnosis.
(1) Intraluminal and tube wall, complete and incomplete obstruction caused by abnormal structure of the esophagus itself.
1 congenital esophageal atresia: esophageal atresia is a congenital malformation of unknown cause, clinically not very rare, 1 case of about 4,000 live births, esophageal atresia may or may not be combined with esophageal tracheal fistula, but often complicated by the spine, Anal, heart, kidney and limb malformations, generally divided into five types, namely type I (blind end of the esophagus, blind end, no esophageal tracheal fistula), type II (the proximal end of the esophagus has a fistula connected to the trachea, the distal end is blind End, lower and stomach pass), type III (the end of the esophagus is blind, the distal end has a fistula and trachea), type IV (esophageal atresia, but the upper and lower segments are connected by a fistula and trachea) and V-type (esophageal patency, But somewhere there is a fistula and tracheal traffic from the bottom to the top) or N-type, of which type III is the most common, accounting for more than 90%, followed by type I, only 5% to 7%.
Children with congenital esophageal atresia have obvious difficulty in swallowing. In the early postpartum period, the mouth is foaming, the milk is sweating, and it is sprayed from the mouth or nostrils. Because the milk is not exposed to stomach acid, the spit does not contain milk clots. Bile, newborns often suffer from dyspnea and purpura due to aspiration, and obviously improve after sucking "". Such recurrent episodes, early secondary pneumonia and life-threatening, the diagnosis mainly depends on the insertion of No. 10 rubber or silicone tube in the food. Standing X-ray film.
2 congenital esophageal stenosis: rare, the cause is unknown, there are various theories, according to histology can be divided into three types: that is, a certain section of the esophageal wall hypertrophy, membrane or diaphragm and intratracheal bronchial cartilage residual, the clinical manifestations of the diaphragm type Similar to esophageal atresia, esophagoscopy can be diagnosed at the same time. Children with esophageal stricture often have vomiting when eating food supplements for several months after birth, difficulty in swallowing, aspiration, repeated respiratory infections, weight loss and malnutrition, X-ray esophagus Contrast and endoscopy can be diagnosed, but more common in the 1/3 or lower esophageal cartilage remains in surgery or pathological diagnosis, this disease may be associated with congenital esophageal atresia.
3 congenital esophageal repetitive malformation: in the congenital digestive tract repeat deformity, its incidence is second only to the ileum, clinical is not uncommon, can be expressed as cysts, tubular or diverticulum-like, more common in the lower right esophageal mediastinum, and There were vertebral body malformations or intramedullary masses in the spinal cord. There were statistics in 8 of the 65 patients (12.3%) with intra-abdominal repeat deformity, sometimes without any symptoms, only found in the occasional X-ray examination of the chest. Some of the respiratory symptoms such as cough, wheezing, pneumonia, hemoptysis and chest pain are the main complaints. About 15% of the sick children have dysphagia, nausea, vomiting, upper abdominal pain and blood in the stool, relying on the X-ray positive lateral chest and abdomen plain film. Esophageal angiography, B-ultrasound or color Doppler ultrasound, CT, radionuclide and magnetic resonance imaging can be diagnosed before operation. When spinal tube tumors are suspected, spinal canal angiography is required. Attention should be made to distinguish lymphoma, neurogenic tumor and hemangioma. .
4 achalasia (sputum sputum, idiopathic esophageal dilatation): the cause is unknown, there are statistics 167 cases of pediatric cases, 5.3% of newborns, cholinergic nerve dysfunction from the esophageal wall, resulting in lower esophageal muscle contraction The lower esophageal sphincter pressure rises, the food stays in the food, gradually expands, the inflammatory changes of the mucosa and ulcer formation, the degree of difficulty in swallowing varies, progressively worsened, sometimes affected by mental factors, the content is milk without milk clot Juice or undigested food is refluxed or spit out from the esophagus to the mouth, sometimes containing brown mucus. After a long time, there is weight loss, anemia and malnutrition. Children can complain of heartburn or chest pain caused by digestive esophagitis. X-ray photo plus meal Contrast can be diagnosed, esophagoscopy and manometry are applied gradually.
5 gastroesophageal reflex (GER) refers to the phenomenon that the stomach and part of the duodenum contents flow back into the esophagus. In addition to the physiological part of the child, it disappears about 8 to 10 months after birth, and other pathological conditions. It can cause serious complications. This disease is one of the hotspots in pediatric surgery research at home and abroad in recent years. The reasons are complex and diverse, mainly due to the abnormally lower continuous esophageal sphincter (LESP) in the lower esophagus. Other factors such as larger His angle, diaphragmatic elasticity, abdominal pressure, esophageal mucosal folds, gastric volume and other factors reduce the anti-reflux barrier function of the esophagus, decrease the esophageal clearing ability, and cause abnormal function of the stomach and duodenum. Gastroesophageal reflux occurs. Flow, which leads to inflammatory changes in the esophageal mucosa, ulcers, hemorrhage and stenosis.
Some people think that 50% of GER is in the neonatal and infancy, 60% to 80% of them have vaginal vomiting within one week after birth, 40% have pyloric stenosis, sputum can contain bile and brown bloody fluid, and older children can have sternum Post-burning, swallowing pain, difficulty swallowing and wheezing, asthma, asphyxia and chronic respiratory infections, according to statistics, 25% to 80% of asthmatic children, 46% to 63% of chronic respiratory diseases with GER Some diseases related to neuropsychiatric factors, such as cerebral palsy, mental retardation, ruminating and head and neck, Sandifer syndrome in different upper body postures, GER, blood in the stool, anemia, chronic malnutrition, after some esophageal atresia, Even children with growth retardation can occur.
X-ray esophagus and gastric sputum angiography are commonly used in the diagnosis of GER. It can be diagnosed and divided into light and heavy. It is diagnostic when measuring LESP<1.96kpa (20cm H2O). In recent years, Wang Weilin used esophagogastric double pH. The microelectrode was used to monitor the fasting and lying position of the children (excluding meals and 2 hours after the meal) and 24 hours. Results: Acidic gastroesophageal reflux refers to the esophageal pH<4 time exceeding 4% of the total monitoring time. In the fasting stomach, gastric pH>4 is an alkaline reflux standard, gastric pH>7, is alkaline gastroesophageal reflux, such as gastric pH>4, esophageal pH<7, it is alkaline gastroesophageal reflux, the conclusion is that : Gastroesophageal reflux on the basis of duodenogastric reflux is one of the main types of gastroesophageal reflux in children. The double pH monitoring of gastroesophageal segment in fasting and lying position is more meaningful in pathological reflux. . In addition, endoscopy, isotope scanning and ultrasound examinations also contribute to comprehensive judgment and differential diagnosis.
6 esophageal hiatus hernia: this disease is a more common congenital malformation, esophageal hiatus is abnormally wide due to dysplasia of the diaphragm, when the supine or abdominal pressure rises, the fundus, cardia and part of the esophagus slide into the mediastinum, resulting in stomach content Reflux into the esophagus, causing mucosal inflammation, even ulcers and hemorrhage, and finally forming scar stenosis, sick children vomiting food, may contain brown or red blood, supine and nighttime aggravation, eventually esophageal stricture, difficulty swallowing, anemia and malnutrition, Respiratory symptoms such as cough, asthma and inflammation can be caused by mistakes. In severe cases, apnea or sudden death can be diagnosed mainly by X-ray sputum angiography of esophagus and stomach. Lipiodol and diatrizoate are used to prevent sputum in young infants. Aspiration, small babies to change position and increase food viscosity can significantly reduce vomiting.
7 congenital short esophagus: very rare, the cardia and part of the fundus in the mediastinum, due to pressure caused by dysphagia, gastric reflux, causing esophageal inflammation and ulcers and "vomiting" blood, X-ray barium angiography can confirm the diagnosis, attention and esophagus The difference between the hiatus.
(2) extraluminal, the esophageal pressure caused by congenital diseases outside the esophagus, unobstructed by the cheating, and swallowing after eating, especially when eating solid foods, it is difficult to swallow, at this time there may be vomiting, aspiration or Asphyxia, which can be seen in cases of congenital vascular annulus around the esophagus, is rare in clinical practice.
Acquired esophageal disease (10%):
1, esophageal inflammation and stenosis: due to a variety of congenital and acquired diseases, such as gastroesophageal reflux, achalasia, pneumonia, scarlet fever, diphtheria, Helicobacter pylori infection, asthma and other sick children repeated vomiting, stomach acid stimulation food Mucosal inflammation, ulcers and stenosis, emergencies of nausea or vomiting, as well as common children who are mistakenly taken care of household alkaline water, alkaline liquids in batteries or industrial strong acid and alkali, causing corrosive liquids such as acute food mucosa or (and) muscles Layer damage, causing inflammation, perforation or stenosis.
2, esophageal foreign bodies such as coins, pins, fish bones, melon seeds, peanuts, beans, jujube nucleus, plastic toys, etc., light can cause saliva, poor pharyngeal and vomiting: severe cases can cause burning sensation and pain after the sternum, Even perforation, abscess formation, can form esophageal fistula after rupture, in young children can also be difficult to breathe due to foreign body pressing the trachea forward.
3, the cause of post-esophage abscess has a posterior pharyngeal wall abscess, a variety of causes of esophageal perforation, secondary abscess, mediastinal lymph abscess, tracheotomy tube compression ulcer and spinal tuberculous abscess, etc., due to oppression Obstruction, dysphagia or pain and nausea and vomiting, as well as reports of local tracheobronchial lymph node inflammation adhesion, local esophageal dilation, pseudo-dip chamber formation, food retention, mucosal inflammatory changes, causing nausea.
4, trauma: esophageal trauma in addition to foreign body causes, mostly iatrogenic, such as endoscopy and injection treatment of esophageal varices, accidental injury, insertion of gastrointestinal decompression tube or artificial ventilation, etc., at this time vomit is often bloody According to the medical history, X-ray angiography and photographs are not difficult to diagnose. When there is foamy liquid in the chest drainage tube after esophageal atresia endoscopic anastomosis, the anastomotic leakage is often indicated, and the oral cavity of the sick child may also have foamy mucus reflux.
5, ruminant: domestic literature is rarely reported, more common in 3-4 months, the baby will swallow the food after swallowing and then swallow, they look up, tongue and jaw, rhythmically chew and swallow until there is reflux, this Some foods are spilled out of the mouth, while others are swallowed. The baby's mood is good and alert. Parents often complain of vomiting or weight loss, sometimes when the mother is frightened by the baby's illness, depressed or unable to intervene. Infants with low mental retardation or mental dysfunction can show persistent rumors, at which point nurses or others can recover from the care and care of the baby.
6. Others: When the intra-abdominal pressure rises due to swelling of the tumor, ascites, organ enlargement, and difficulty in breathing due to difficulty in breathing, the sputum is swollen, the lower esophagus or stomach is distorted, and reflux may occur after neonatal anesthesia is withdrawn. Or nausea.
(two) vomiting
It means that the contents of the stomach or part of the small intestine are forcibly discharged through the mouth, often accompanied by nausea and strong abdominal muscle contraction.
The many causes of vomiting can be divided into three major categories: obstructive, reactive and central. The former is often a surgical cause, and the latter two are caused by medical diseases.
1, obstructive vomiting
Digestive tract obstruction can be caused by congenital gastrointestinal malformations or certain acquired diseases.
1) Congenital gastrointestinal malformations: including intraluminal atresia, stenosis or wall dysplasia or extravascular compression. In neonates, this is the main cause of surgical vomiting. The digestive tract has food atresia from top to bottom. Gastric torsion, pyloric fistula, pyloric hypertrophic stenosis, pyloric valve, duodenal atresia or stenosis, annular pancreas, poor intestinal rotation, ileal atresia or stenosis, intestinal ganglion syndrome (megacolon), megacolon Disease, rectal anal malformation (including anal atresia or stenosis and sometimes combined rectal urinary fistula, rectal vaginal fistula, rectal vestibular fistula, acupoint anus, etc.) and digestive tract repeat deformity, in addition, small left colon syndrome, giant bladder Small colonic intestinal peristalsis syndrome is rare, as well as gastric wall muscle dysplasia with gastric perforation, meconium obstruction syndrome, meconium peritonitis is not very rare clinically, meconium intestinal obstruction is rare in all ethnic groups in China.
Intestinal wall compression can be caused by congenital duodenum, anterior dysplasia, fibrous membrane or cord, meconium peritonitis adhesion, duodenal anterior portal vein, mesenteric hiatus hernia, incarcerated inguinal hernia or transverse diaphragm Caused by the disease, esophageal hiatus hernia is also caused by malformation caused by incomplete gastrointestinal obstruction and vomiting.
2) Caused by acquired digestive tract diseases: such as adhesion of intestines or abdominal inflammation, acute intussusception (in cecal, kinky or retrograde type), common foreign body (hair group, stomach stones, etc.) And rare sigmoid torsion premature infants can be seen with milk clot intestinal obstruction, children can cause abdominal pain and vomiting due to constipation, accompanied by urinary retention, aphid intestinal obstruction and intestinal torso are only due to the widespread application of chemical fertilizers in large and medium cities Rare.
Due to the different causes of intestinal obstruction, the course of disease is different (acute or chronic), the nature is different (complete, incomplete or sudden) and the location of the lesion is different (high, medium or low), so the time of vomiting There are significant differences in clinical manifestations such as nature, content, color and quantity, and the etiology is closely related to age.
2, reflective vomiting
Mostly caused by biological, physical or chemical stimuli in the gastrointestinal tract, sometimes caused by a mixture of various factors.
1), internal medicine
(1) swallowing syndrome: the newborn swallows amniotic fluid, maternal blood, meconium, etc. during the labor process, spit after birth, and self-healing in 1 to 2 days.
(2) When the infant's respiratory tract infection occurs, the mucus of the nasopharynx causes a mouth-mouth reflex, or occasionally the edema of the edema or the finger is injected into the mouth.
(3) Children's respiratory and digestive tract viruses, bacteria, and even mycoplasma and fungal infections are extremely common causes. Acute upper respiratory tract infections in various age groups, pneumonia and certain other infectious diseases such as whooping cough can cause abdominal wall due to severe cough. And diarrhea, dyspepsia, acute gastroenteritis, infectious diarrhea, viral hepatitis and other gastrointestinal disorders and vomiting symptoms in neonatal and preterm infantile necrotizing enterocolitis are more common, even as this is The main complaint is to see a doctor. When the newborn is tetanus, it can refuse vomiting.
(4) Allergic diseases: such as the addition of gluten food, allergic purpura caused by intestinal cramps.
(5) peptic ulcer: common Helicobacter pylori infection, late pyloric obstruction caused by ulcer scar can cause obvious vomiting.
(6) Food, drugs and chemical poisoning: ipecac, digitalis, theophylline, salicylate, removal of anesthetic, iodine preparation, mustard, lentils and carrion poisoning, etc., also cause vomiting when feeding infants .
(7) Metabolic and endocrine disorders: such as adrenal insufficiency, acidosis, phenylketonuria, fructoseemia, hereditary tyrosinemia, galactosemia, etc.
2), surgical
(1) inflammation of the digestive tract organs, perforation and peritonitis: such as gastric or duodenal ulcer or trauma, tumor caused by perforation, acute appendicitis, cholecystitis, pancreatitis.
(2) ischemic enteritis: can be caused by vascular disease or insufficient blood flow, such as superior mesenteric artery syndrome, intestinal reversal caused by various reasons (intestinal dysplasia of newborn or small infant combined with midgut torsion, aphid intestine Abdominal obstruction, mesenteric hiatus, volvulus, etc.) and hypovolemic shock, stomach and intestinal muscles cause abdominal pain, nausea and vomiting.
(3) gastrointestinal organ bleeding: such as acute, chronic ulcer bleeding, esophageal varices, hemangioma or vascular malformation caused by a large number of bleeding.
3) genitourinary diseases: such as acute pyelonephritis, glomerulonephritis, renal insufficiency, uremia, hydronephrosis, urinary calculi; girl's ovarian cyst torsion, dysmenorrhea in older girls.
4) otolaryngology and ophthalmology diseases: otitis media with labyrinthitis, motion sickness, Meniere's disease, etc., with glaucoma with headache and vomiting.
5) Others: such as gastroparesis syndrome, is an idiopathic gastric neuromuscular disease, the cause is unknown, can be found in diabetes, connective tissue disease, uremia, postprandial discomfort after meals, intermittent nausea, delayed vomiting, stomach raft Empty delay, chronic pseudo-intestinal paralysis (chronic pseudo-intestinal obstruction) has a variety of theories, also known as muscle or / and neurological disorders, diarrhea and constipation in addition to bloating and vomiting, reported in hypothyroidism, In patients with scleroderma, amyloidosis, Down's syndrome, and cytomegalovirus infection, reflex vomiting is also seen in radiation and chemotherapy during neonatal disease.
3, central vomiting
1) Central nervous system disorders: the vast majority of central vomiting, it can be increased by intracranial pressure (cerebral edema, brain tumors, aneurysms, sun, etc.), inflammation (encephalitis, meningitis, brain abscess, Subdural effusion), craniocerebral injury (intracranial hemorrhage, subdural hematoma, cerebral palsy, cerebral hypoxia, meningocele, etc.) and toxic encephalopathy (pneumonia, toxic enteritis, Septicemia) and other diseases.
2) Others: lead poisoning, hypoglycemia, mountain sickness, mental vomiting caused by school or family conflicts, periodic vomiting, anorexia nervosa, hunger and autonomic dysfunction (intestinal fistula, paroxysmal tachycardia), etc. Can cause vomiting.
(1) Pathogenesis
Vomiting is a type of neuroreflex, a process that is extremely complex, with external or endogenous organisms received by peripheral organs and tissues, physical and chemical stimuli, transmitted through the somatic and splanchnic nerves or blood circulation to the central nervous system, in the medulla oblongata. The vomiting pivot (accepting impulses from the gastrointestinal tract and other visceral nerves) and the posterior polar region at the bottom of the fourth ventricle, the chemoreceptor trigger zone (CTZ) (accepting chemical and drug stimuli from the blood circulation), reflection Signals pass through the vagus nerve and spinal nerves to the corresponding organs to cause vomiting. Recent studies have shown that dopamine receptors play an important role in the mediated vomiting of CTZ. CTZ also contains serotonin, norepinephrine, substance P, brain. Some of these endogenous neurotransmitters and neuropeptides can cause vomiting through blood circulation or direct action on CTZ, such as morphine and gamma aminobutyric acid.
Swallowing activity refers to the movement of food from the pharynx to the stomach. It is a series of nerves (both and autonomic, autonomous and non-autonomic, central and peripheral), muscle (striated and smooth muscle, voluntary muscle and involuntary). Muscle), a complex physiological process in which multi-phase (chemical, physical) activities are coordinated, in which any organic or functional disorder can cause dysphagia or other abnormalities (including vomiting).
Usually from the lips, pharynx, gastrointestinal, biliary tract, peritoneum, heart, genitourinary system and organ stimulation, or discomfort visual, olfactory, auditory, gustatory, and even painful stimuli can pass the sensory nerve conduction as an vomiting impulse beyond vomiting Threshold boundaries of the central, in addition, sometimes mental factors, increased intracranial pressure and other stimuli can also cause vomiting, emetics directly affect the vomiting center, abnormal metabolites in the body, such as diabetic ketoacidemia, liver disease, uremia, etc. It can stimulate vomiting center or CTZ and cause vomiting.
The vomiting reaction consists of abdominal muscles, diaphragm and intercostal muscle contraction, abdominal pressure rise, breath holding, palpitations, sweating, upper small intestine and gastric peristalsis, lower esophageal sphincter relaxation and increased salivary secretion. The nausea often precedes vomiting. Occurrence, older children may have a premonition and narynx or abdominal discomfort, and some may be controlled by the cortex to some extent. Infants and young children often show irritability, make faces, yawn, pale, sweating, drooling and not sucking Fist, premature infants, full-term newborns and some small babies often have no signs of vomiting due to immature development of the nervous system. Sputum can be ejected from the mouth and mouth, and the swallowing reflex and glottis opening and closing reflexes are not coordinated. The vomit is easily abused. The newborn also has a small gastric capacity and a large amount of fluid, so it is easy to ingest too much. The gastric mucosa is sensitive to temperature, volume, hypoxia and chemical stimulation; often supine; esophagus Muscle layer elastic fiber development is poor; lower esophageal sphincter development is less mature, His angle is more blunt, etc., the gastric contents are easily reversed from the esophagus when the stomach is reversed.
(two) pathophysiology
Due to the complex and diverse causes of vomiting, the occurrence and duration of vomiting are different, the degree varies, and the age varies. Therefore, the impact on the body is very different. The lighter has no effect, only transient discomfort, long-term chronic vomiting. Digestive esophagitis, hypovolemia, hypokalemia, low sodium, alkalosis and other metabolic disorders, further anemia, malnutrition, stagnant growth and development, can cause water and electrolyte balance disorders, shock or aspiration, suffocation, Induced arrhythmia or even death, due to surgical reasons can also lead to digestive tract perforation, diffuse peritonitis, shock, sepsis and other serious consequences, those with motor nerve dysfunction are also prone to aspiration after vomiting, need to be more vigilant .
Prevention
Pediatric vomiting prevention
1. Let the child lie on his side to prevent vomiting.
2, the drug should not be too hot when administered, medication should be slow, can be used in a small number of times, if necessary, can take a bite, stop, and then serve.
3, actively identify the cause of vomiting, for the treatment of the cause.
Complication
Pediatric vomiting complications Complications, aspiration pneumonia
Severe vomiting in children can cause apnea and cyanosis in infants. If you inadvertently inhale the lungs, it can cause aspiration pneumonia. Repeated vomiting can lead to complicated water, electrolysis disorder, and even death.
Symptom
Pediatric vomiting symptoms Common symptoms vomiting appetite loss, acute abdomen, abdominal muscle tension, abdominal pain, bloating, belching, intestinal paralysis, burning heart
Analysis of several symptoms
It is always necessary to combine age and disease spectrum considerations to try to distinguish vomiting as functional or organic and medical or surgical as early as possible in order to determine the principles of diagnosis and treatment.
1, vomiting
Pay attention to its occurrence, performance and changes.
(1) Time and frequency: The time when vomiting starts to appear and the number of vomiting per day can be significantly different due to diseases. For example, the start of spitting brown mucus within 3 hours after birth and the repeated vomiting of brown color for 3 years old children obviously originated from For different reasons, the former may be caused by misdiagnosing maternal blood, while the latter may have more chances of esophageal hiatus.
(2) Mode: It can be overflowed, such as milk flowing out from the mouth of the newborn, or flowing out from the mouth, or spit out from the mouth, or simultaneously from the mouth and nostrils. In the neonatal period, the former may be Physiological, the latter is more common in congenital hypertrophic pyloric stenosis.
(3) Content and nature: It has important reference value for the diagnosis of digestive tract obstruction.
1 clear or foamy mucus, undigested milk or food: indicates that saliva is blocked, obstruction is above the cardia, found in neonatal congenital esophageal atresia, esophageal stricture and achalasia caused by food inflammation in all age groups, etc. .
2 mucus, milk clot, stomach contents: indicates obstruction of the pylorus, seen in neonatal pyloric hypertrophic stenosis, pyloric valve and pyloric scar stenosis after elderly gastric ulcer, occasionally children after swallowing chemical corrosive liquid When there is a small amount of blood or coffee, it can be seen in esophageal hiatal hernia and gastroesophageal reflux in children of all ages. Excessive consumption can spit sour taste and not digest food.
3 yellow or green clear mucus, sometimes mixed with a small amount of milk or food: often indicates that the obstruction is located in the twelve designated intestines, which is seen in severe functional vomiting in all age groups, and is more common in duodenal atresia or stenosis in neonates. The annular pancreas and the intestine are poorly rotated.
(4) Yellow-green liquid mixed with a small amount of chyme: indicating that the intestinal tract near the proximal jejunum is not smooth, seen in high jejunal atresia or adhesive intestinal obstruction, intestinal paralysis.
(5) Light brownish green fecal sample, taste sniffing: indicates that the obstruction site is in the lower segment of the jejunum or its distal end. In the neonatal period, it is considered to be empty ileum or colon atresia, no intestinal ganglia or rectal anal malformation, in other The age group indicates low-grade digestive tract obstruction due to various reasons.
(6) Blood: According to the amount of bleeding, speed and location, the blood content and color in the vomit are different. After a small amount of blood and stomach acid, it is brown, which can be seen after the newborn swallows the amniotic fluid containing the mother blood or the nipple. Neonatal natural hemorrhagic disease, early gastric perforation, advanced pyloric hypertrophic stenosis, esophageal hiatus hernia in all age groups, repeated severe vomiting due to various causes and critical illness with diffuse intravascular coagulation, less blood, brown or Dark red, thrombocytopenic purpura, hemophilia, aplastic anemia, especially at some stage of leukemia, gastrointestinal tract may cause hemorrhage, vomiting, portal hypertension combined with esophageal varices, burn or asphyxia, gastric mucosal ulcer bleeding Oral salicylic acid or theophylline and other drugs cause acute hemorrhagic gastritis, can cause vomiting blood, vomiting a large amount of bleeding can also spit out blood, suffocation in children is not easy to identify with vomiting blood, depends on other symptoms and signs.
It is worth noting that the content and traits of vomiting may vary with the course of the disease. For example, early neonatal low intestinal obstruction can vomit colorless mucus, and after 1 to 2 days, it turns into biliary, systemic infection, and the condition is improved after severe sepsis treatment. The content of relieved vomiting or gastrointestinal decompression can be changed from yellow-green contaminated fecal to clear mucus. Therefore, combined with other accompanying symptoms and signs, dynamic observation can more accurately determine the clinical significance of vomiting.
2, bloating
Often accompanied by vomiting symptoms, need to distinguish between abdominal distension is abdominal mass, abdominal cavity or intestinal cavity caused by a large amount of fluid or gas accumulation, abdominal distension is limited or full abdominal performance, abdominal distension with intestinal type, stomach type or peristalsis Wave, the degree of bloating is light, moderate or severe.
3, abdominal pain is also often accompanied by vomiting symptoms, need to carefully understand the relationship between the beginning of abdominal pain, the nature of abdominal pain (paroxysmal, persistent or persistent bursts of aggravation) and abdominal pain, etc., accompanied by abdominal pain, vomiting Should be alert to the possibility of surgical acute abdomen, especially pay attention to newborns, especially premature infants in the digestive tract malformation of complete intestinal obstruction often lack of expression of abdominal pain, even in perforated peritonitis is only apathetic, but no abdominal muscles tension.
4, abnormal stool
Can be expressed as traits, amount, time and frequency and discharge site and other abnormalities, short-term vomiting, while the number and amount of stools are reduced, dry, sick children without other obvious discomfort, the possibility of digestive dysfunction, such as accompanied by Rugged, fever, indicating gastroenteritis, vomiting with abdominal pain and stop bowel movements, should first consider queuing surgical acute abdomen, especially in newborns have special significance, usually more than 90% of full-term newborns should be after birth 24 Within the hour, about 98% should start meconium excretion within 48 hours after birth, and exhausted within 2 to 3 days, the total amount is about 60-90%. Congenital hypertrophic pyloric stenosis, constipation caused by a lot of vomiting, even secret The main complaint is, the colon, the colon is closed, the distal colon is small, no meconium, sometimes only a small amount of gray-green mucus is discharged. When the neonatal intestine has no ganglion disease, there is no automatic meconium history after birth, but in the anus. According to the diagnosis, after opening the gel or washing the intestines, a large amount of gas is accompanied by meconium discharge, accompanied by obvious yellow-green bilious vomiting, while intestines without ganglion often show constipation and bloating in other age groups. No vomit When the congenital anal stenosis, the meconium volume is significantly reduced. When the rectal anus is locked, there is no meconium discharge (when there is no sputum) or the meconium discharge outlet is abnormal (in the perineum, vestibule, vagina, scrotum, urethra or bladder). When the intestine is twisted, the intestine is narrowed, the intussusception, the intestinal overlap deformity, the Meckel's diverticulum and other causes of gastrointestinal bleeding can show different degrees of bloody stools (tar, dark red, bright red, etc.) Or only occult blood test positive, when the stool is green, there are mucus and milk flaps, watery, purulent, mucus blood is often a medical cause.
5, other symptoms
Vomiting is a very common symptom in pediatric clinical work, but it is often not the only symptom. In addition to the above-mentioned bloating, abdominal pain and fecal abnormalities, there may be other digestive symptoms, such as loss of appetite, loss of appetite, and fight. Hemorrhoids, belching, acid reflux, heartburn, etc. Some or/and certain respiratory, cardiovascular, urinary, endocrine or neurological symptoms may be associated with vomiting, and fever is more common. These symptoms should be taken seriously and Think carefully so that you can choose the focus in your physical examination, lab, and imaging.
Examine
Pediatric vomiting examination
1, such as simple vomiting routine examination is generally normal, such as vomiting caused by infection may have bloody signs, showing increased peripheral blood leukocytes and neutrophils, such as concomitant water, electrolyte disorders, often have the corresponding laboratory results, should be checked Serum sodium, potassium, chlorine, calcium, blood pH, urea nitrogen, blood sugar, urine ketone body, etc.
2, regular X-ray, B-ultrasound and other checks, actively looking for the cause.
3, abdominal X-ray or plain film, gastrointestinal barium meal perspective or radiography, endoscopy, etc., help to understand digestive tract obstruction, abdominal inflammation or congenital gastrointestinal malformations, suspected intracranial hemorrhage, intracranial space When the lesion is used, it can be used for brain ultrasound, cerebral angiography, computed tomography brain scan and magnetic resonance imaging.
Diagnosis
Diagnostic diagnosis of vomiting in children
diagnosis
Because vomiting is only a symptom, its etiology is complex and diverse, with different symptoms and similar expressions, so it is necessary to carefully collect medical history, carefully check the physical examination, and select the laboratory and imaging examinations in a targeted manner. An objective comprehensive analysis can lead to a preliminary diagnosis.
Differential diagnosis
The first identification is galactorrhea or vomiting, caused by improper feeding or disease factors. Secondly, it is caused by gastrointestinal diseases or systemic diseases. It is caused by medical diseases or internal surgical diseases. It is further examined, diagnosed early and treated in time.
Identification of refractory vomiting:
1, acute gastroenteritis: more common types of children with acute simple gastritis, may be due to improper diet or medication, manifested as upper abdominal discomfort, pain, nausea, vomiting, loss of appetite, generally not serious, clinically common due to Acute gastroenteritis caused by eating food contaminated with bacteria, the symptoms are different, within a few hours or 24 hours after eating, nausea, vomiting, abdominal pain is more severe, often accompanied by watery diarrhea, severe with fever, water loss, acid Poisoning or even shock, the general course of disease is shorter, after 1 to 2 days of treatment, the condition is improved.
2, viral hepatitis: vomiting often occurs early in the onset, vomiting gradually reduced after the appearance of jaundice.
3, biliary tract mites: this disease is paroxysmal right upper abdomen severe cramps, accompanied by frequent vomiting, often spit mites or bile.
4, acute appendicitis: the main symptoms are abdominal pain, may be associated with nausea, vomiting or diarrhea, vomiting occurs more than a few hours after the onset of abdominal pain, generally not heavy.
5, congenital esophageal atresia (congenital esophageal atresia): a total of 5 types, of which type III (the upper end of the esophagus with the lower end of the esophagus tracheal fistula) is the most common, accounting for 85% to 95% of the total, pregnant women often have amniotic fluid Too many episodes, the earliest symptom is the increase of saliva. Salivation is seen from the mouth and nostrils soon after birth. The first time after giving birth, the milk will vomit, cough, bruising, difficulty breathing or even suffocation. After nasal secretions, the symptoms can be alleviated, and it is easy to be combined with aspiration pneumonia and atelectasis. When the oral cavity is inserted into the 8th urinary catheter to 8-12cm, it is blocked and returned. X-ray angiography can confirm the diagnosis.
6, hypertrophic pyloric stenosis (hypertrophic pyloric stenosis): mostly due to abnormal development or degeneration of pyloric ring muscle tissue, resulting in pyloric ring muscle hypertrophy, resulting in pyloric stenosis, the incidence of about 1:300 ~ 1:2000, more common in men The first child, vomiting is the main manifestation of the disease, more than 2 to 3 weeks after birth began to appear, persistent, progressive aggravation, vomiting is jetting, the amount is too much, vomit contains milk clots and gastric juice, but not Containing bile, abdominal examination see upper abdominal distension, visible reverse peristaltic wave, obvious after eating or rolling abdominal, often weight loss, less stool, vomiting can be combined with dehydration, low chlorine, low potassium, alkalosis or acidosis Some may be accompanied by jaundice, more than 90% of cases, under the cost of the right upper abdomen, the deep part of the rectus abdominis can touch the olive-sized hard mass, which is an important sign of the disease. The peristalsis is strong, the gastric emptying is delayed, and the pyloric tube is linearly narrow.
