From the Guidelines
The diagnostic workup for persistent recurrent vomiting in infants should start with a thorough clinical evaluation, including history and physical examination, to identify potential causes such as gastrointestinal obstruction, infections, or metabolic disorders 1. The initial assessment should categorize vomiting as nonbilious or bilious, with the latter suggesting a point of obstruction distal to the ampulla of Vater.
- A thorough history can help differentiate between vomiting and regurgitation, with the latter often being related to gastroesophageal reflux (GER) 1.
- Physical examination can lead to the diagnosis in most instances, such as feeling the classic “olive” of hypertrophied muscle in hypertrophic pyloric stenosis (HPS) or identifying signs of increased intracranial pressure 1. Key considerations in the diagnostic workup include:
- Viral gastroenteritis, which often appears in epidemics with sudden onset of vomiting, mild fever, diarrhea, and a relatively short duration 1
- Systemic infections and metabolic disorders, which may be diagnosed by clinical and laboratory criteria 1
- Intussusception, which may be diagnosed clinically by crampy, intermittent abdominal pain sometimes progressing to bloody stools and lethargy 1 A systematic approach to the diagnostic workup, prioritizing clinical evaluation and targeted laboratory and imaging tests, is essential to identify the underlying cause of persistent recurrent vomiting in infants 1.
From the Research
Diagnostic Approach
The diagnostic workup for persistent recurrent vomiting involves a comprehensive clinical history and physical examination to guide further evaluation [ 2, 3 ]. The following steps are recommended:
- Define the patient's symptoms and determine whether they are acute or chronic 2
- Consider medication or toxin adverse effects 2
- Use the patient's presentation, severity of symptoms, and physical examination findings to formulate a differential diagnosis and guide evaluation 2
- Direct treatment based on knowledge of neurotransmitters and receptors involved in the emetic pathways 2
Evaluation and Testing
For chronic nausea and vomiting, testing for an underlying cause should be performed, and medication adverse effects, neurologic causes, gastrointestinal diseases, metabolic or endocrine conditions, and psychogenic disorders should be considered 2, 4. Specific investigations, carefully guided by clinical assessment and tailored for each patient, would be more beneficial in diagnosing chronic nausea and vomiting than empirically performing a blanket of investigations 3.
Differential Diagnosis
The differential diagnosis for chronic nausea and vomiting is broad and can include:
- Gastrointestinal causes (e.g., gastroparesis, cyclic vomiting syndrome) 4, 5
- Non-gastrointestinal causes (e.g., medications, vestibular, and neurologic disorders) 4, 5
- Metabolic and endocrine conditions 4
- Psychogenic disorders 4
Treatment
Treatment for nausea and vomiting should be based on a thoughtful discussion of benefits, side effects, and costs 5. Nonpharmacologic management options include fluid and electrolyte replacement, small, frequent meals, and avoidance of trigger foods 4. Antiemetic drugs can effectively reduce symptoms of acute nausea and vomiting, but chronic symptoms are often more challenging to treat 4, 6.