PEDIATRICS
■ Urine may be sent to rule out a UTI.
■ Diarrhea may lead to severe dehydration, as well as a non–anion gap
metabolic acidosis due to loss of bicarbonate in the stool.
TREATMENT
■ Oral rehydration therapy is often effective, but can be labor intensive and
time consuming.
■ IV fluids of either normal saline or lactated ringers in boluses of 20 cc/kg
may be required to treat severe dehydration or if the child is unable to tol-
erate oral intake.
A full-term infant vomits after her initial feeding, and subsequently develops
bilious emesis after each feeding. Physical examination reveals a lethargic
infant with absent bowel sounds. Plain abdominal radiographs reveal a
paucity of air in the distal bowel. What is the most likely diagnosis and management?
Malrotation with volvulus. Management should include IV fluid resuscitation,
NG tube placement, and emergent surgical consultation.Vomiting
Vomiting is a nonspecific sign that may be caused by a wide variety of condi-
tions. All of the conditions described in Table 5.3 may have associated vomit-
ing. The etiology of vomiting can usually be clarified by determining whether
the emesis is bilious, the time course of the symptoms, the associated symp-
toms, and the age of the child. In general, vomiting is caused by:
■ Infection (GI or elsewhere)
■ GI inflammation
■ GI obstruction
■ CNS process
■ Metabolic process
Isolated vomiting is potentially ominous, and careful consideration must be
given to possible increased intracranial pressure (ICP).
SYMPTOMS/EXAM
Vary widely based upon the etiology and extent of vomiting
DIFFERENTIAL
See Table 5.4.
In general, a bowel obstruction distal to the ligament of Treitz will present
with bilious emesis. An obstruction proximal to the ampulla of Vater will pre-
sent with nonbilious emesis.
DIAGNOSIS
Diagnosis is based on a careful history and physical examination. Ancillary stud-
ies, such as barium enema, abdominal or chest radiographs, abdominal or head
CT scans, lumbar puncture, urine analysis, or blood work, may be necessary.