From the Guidelines
Projectile vomiting in infants is most commonly caused by gastroesophageal reflux (GER), while in other cases, it can be due to underlying obstruction, infectious etiologies, neurologic diseases, mechanical, or metabolic causes. The clinical differentiation between vomiting and regurgitation may be challenging, but bilious emesis or repeated forceful vomiting should be evaluated for underlying obstruction 1.
Common Causes of Projectile Vomiting
- Gastroesophageal reflux (GER)
- Underlying obstruction, such as malrotation with or without volvulus, atresia of the antropyloric region, annular pancreas, atresia/stenosis of the small bowel or colon
- Infectious etiologies, such as viral gastroenteritis
- Neurologic diseases, such as raised intracranial pressure
- Mechanical causes, such as hypertrophic pyloric stenosis (HPS), pylorospasm, formula intolerance
- Metabolic causes, such as metabolic disorders (phenylketonuria, hyperammonemia, maple syrup urine disease, galactosemia, diabetes, adrenocortical hyperplasia, and methylmalonic acidemia)
Diagnostic Approach
A diagnostic workup should start with a thorough clinical evaluation, including history and physical examination, which can lead to the diagnosis in most instances 1. Viral gastroenteritis often appears in epidemics, with sudden onset of vomiting, mild fever, diarrhea, and a relatively short duration. Systemic infections and metabolic disorders may be diagnosed by clinical and laboratory criteria.
Management
If projectile vomiting occurs, it is essential to seek medical attention promptly, especially if it occurs with severe headache, stiff neck, or after head injury, as these could indicate serious conditions like increased intracranial pressure 1. For infants, contact a pediatrician immediately as projectile vomiting can indicate pyloric stenosis or other serious conditions. Avoid solid foods until vomiting subsides for 4-6 hours.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Causes of Projectile Vomiting
- Various disorders can cause vomiting, including acute or chronic conditions 2
- Underlying causes of nausea and vomiting can be associated with high morbidity and poor quality of life, particularly in those with chronic symptoms 3
- Possible causes of vomiting include:
- Gastrointestinal diseases, such as gastroenteritis 4, 5, 6
- Medication or toxin adverse effects 3, 6
- Neurologic causes, such as cyclic vomiting 5
- Metabolic or endocrine conditions 3, 6
- Psychogenic disorders 3, 6
- Small bowel obstruction 5
- Gastroparesis 5
- Vestibular disturbances 6
- Early pregnancy 6
- Foodborne illness 6
- Acute migraine headaches 6
Diagnostic Approach
- A correct diagnosis is possible by conducting careful histories and physical examinations 2
- Further testing, including laboratory studies, radiological images, endoscopic evaluation, and gastrointestinal motility tests, can also be considered in cases of severe vomiting 2
- A 5-step approach to the clinical evaluation and treatment of nausea and vomiting can be used, including defining the patient's symptoms, determining whether symptoms are acute or chronic, considering medication or toxin adverse effects, using the patient's presentation to formulate a differential diagnosis, and directing treatment based on knowledge of neurotransmitters and receptors involved in the emetic pathways 3