Gastrointestinal The most common cause for vomiting is often GI.

It can be helpful to think of the GI tract as a long tube, stretching from the mouth to the anus, with four buds sticking out in the middle: the liver, the gall bladder, the pancreas and the appendix. When faced with a patient who may have a GI cause to their vomiting, it is helpful to simply start at the top and work down. Anything that either obstructs or inflames the tube or any of its buds may cause vomiting. Obstruction Anything that obstructs the GI tract or any of its buds, including foreign bodies, idiopathic hypertrophic pyloric stenosis, intussusception, indirect inguinal hernias, appendicitis, volvulus and gastroesophageal reflux, may cause vomiting. Foreign Bodies Foreign bodies (FBs) in the esophagus may be occult. Pathophysiology The most common foreign bodies in children are coins.[1] The two places where coins most commonly lodge are at the cricopharyngeous and the lower esophageal sphincter (LES; see Figures 1). The LES has the smallest diameter of the GI tract, and if a FB can pass into the stomach it can generally pass through the anus. Historical Facts Children are often witnessed swallowing the coins or tell their parents soon after. Some will develop abrupt respiratory distress with partial (or complete) airway obstruction. Most will have vomiting. Pertinent Physical Examination Findings Coins at the cricopharyngeous are rarely a diagnostic dilemma: these children drool and may be stridorous and dyspneac. The coin should be removed at the time of presentation, usually in the operating room by an otorhinolaryngologist. Coins at the level of the LES may be occult. A metal detector has been successfully used in the past to determine the presence of coins.[1] Therapeutics If the child is not drooling or vomiting, coins at the LES can be watched for 24 h to see if the coin passes into the stomach spontaneously; if not, the child should be referred to a gastroenterologist for removal.[2] Removal with a Foley catheter[2] and bougienage[3] has been described. Sharp FBs and button batteries should have immediate GI referral. Infantile Hypertrophic Pyloric Stenosis Infantile hypertrophic pyloric stenosis (PS) is a relatively common cause of vomiting in young infants.[4] Pathophysiology The etiology is hypertrophy of the circular musculature of the pylorus, which then obstructs the lumen. Historical Facts The typical patient first develops symptoms at 3 weeks of age and is typically diagnosed at 5 weeks. Children with PS have nonbilious projectile vomiting. The child with PS is always hungry; children with vomiting from gastroenteritis or a metabolic cause are usually anorexic. There is no history of diarrhea or fever. PS often runs in families, and is frequently observed in first-born males. The use of erythromycin in this age group is associated with the development of infantile hypertrophic PS.[5] Pertinent Physical Examination Findings Classically, these children are dehydrated and malnourished, and have a hypovolemic, hypochloremic metabolic alkalosis (a 'contraction' alkalosis) with hypoglycemia and hypokalemia, but recent studies demonstrate that the majority of infants with PS have normal electrolytes and only mild dehydration.[6] In order to determine whether the child has PS, the primary-care provider (PCP) should flex their hips and knees, and give them a bottle to drink, which they will take avidly. With patience, an 'olive' is often palpable deep just to the right of the spinal column. Ultrasound is the diagnostic imaging of choice if the pylorus is not palpated Therapeutics All patients with PS should be given electrolytes and an Accucheck should be performed, and the child should be rehydrated with D5NS with K+.[7] Treatment is surgical (after the child achieves metabolic balance).[4] Intussusception Intussusception is usually observed in patients aged 3-18 months.[8-10] Pathophysiology These children suffer from telescoping of a portion of their proximal intestine into a portion more distal, with obstruction and eventual mucosal ischemia. Ileocolic intussusception is most common. Intussusception after 2 years of age may be due to a lead point: a polyp or tumor on the intestinal wall. Henoch Schoenlien Purpura may also present with intussusception Historical Facts Vomiting, abdominal pain and bloody, mucoid stools (that look like 'currant jelly') are classic, although it is rare that all three present in the same patient. The symptoms are episodic, in time with the peristaltic waves, and in between the child is left exhausted, sometimes to the point of coma. Pertinent Physical Examination Findings The child is intermittently fussy and typically has guaiac-positive stool (bloody). An allantoid-shaped mass is sometimes palpable in the right upper quadrant (RUQ). Therapeutics Diagnosis is most commonly made by ultrasound, although this is technician dependant. An air-contrast enema is both diagnostic and is curative in approximately 80% of patients if carried out within the first 48 h after onset of symptoms. Perforation with an enema occurs with 2.5% of enemas; therefore, surgical physicians should be consulted prior to sending the child to the radiology suite. Intussusception recurs in 10% of patients within 24 h and so all patients should be hospitalized overnight. Indirect Inguinal Hernia Indirect inguinal hernia is rare in females. Pathophysiology Embryologically, a loop of peritoneum extends through the inner and outer inguinal rings down into the scrotum to form the tunica vaginalis. If this does not properly involute, a loop of bowel may follow this tract into the groin or all the way

into the scrotum. A hernia may slide in and out (reducible) or become trapped (incarcerated). Premature infants have an increased incidence of inguinal hernias.[12] Historical Facts Some patients with reducible hernias present with a history of a mass, but nothing upon examination. The PCP should slide their finger up into the external inguinal ring and have the patient cough or bear down: a loop of bowel may be palpable as it bounces against the examiner's fingertip. Incarcerated hernias most commonly present as a painful mass noted in the groin, extending into the upper part of the scrotum, but may present with simple vomiting, as did the patient described in the case report of this article. Pertinent Physical Examination Findings The child is usually in pain, fussy and a mass is noted in the inguinal crease or scrotum Therapeutics Patients with a history compatible with an inguinal hernia (but nothing present upon examination) should be referred to a surgeon for elective repair. The parents should be asked to take a picture of the mass the next time it is present. Children with incarcerated hernias should have an attempt at reduction, but surgical physicians should make the final decision as to which hernias are reducible and which are truly incarcerated. A hernia that remains incarcerated for a prolonged period of time may become ischemic and 'strangulated', and, if reduced, can lead to perforation and sepsis.[13,14] Appendicitis Pathophysiology Appendicitis starts with an obstruction of the lumen, usually by a fecalith. This causes swelling and subsequent ischemia of the antimesenteric surface, which becomes inflamed and then progresses over 36-48 h to perforation. Appendicitis is the most common surgical emergency in childhood, and vomiting is the most common symptom, followed by fever and abdominal pain. The rate of perforation is much higher in the pediatric population.[15-17] It is especially difficult to diagnose in children over 4 years of age.[18] Historical Facts Classically, the child presents with anorexia, periumbilical pain, low-grade fever and vomiting. Over the course of 24-36 h, the pain radiates to the right lower quadrant. If not diagnosed, perforation and peritonitis occurs. A 'classic' presentation is rare. Pertinent Physical Examination Findings The child with appendicitis will lie quietly in the bed; he/she may resist your examination, but screaming and thrashing does not occur. The child starts out with a low-grade fever, and although he/she points to their belly-button the child will have right lower quadrant tenderness from the beginning. Then, after perforation, the child develops generalized peritonitis, with diffuse peritonitis upon examination, and the vomiting diminishes. Therapeutics The work-up and management of appendicitis alone can fill chapters of literature. For the purposes of this review, let it be said that abdominal pain and vomiting, without diarrhea, must have appendicitis in the differential, and the clinician should be fairly certain that appendicitis is not the cause of the child's symptoms prior to letting him/her go home, or else additional work-up (ultrasound, CT scan of the abdomen and pelvis or surgery consult) should be entertained (see Figures 7-9). Ultrasound is sensitive and specific, but is technician dependent. A CT scan is even more accurate (and less dependent on operator experience) but entails significant radiation exposure to a young child.[19] A protocol using ultrasound and CT scans has increased sensitivity of preoperative diagnosis and has decreased the negative laparotomy rate from 17% to less than 5% over a 3-year period Volvulus Volvulus can occur in any age group but is most common in neonates.[21-23] Pathophysiology Volvulus is the sequelae to a malrotation of the intestine. When malrotation occurs, the mesentery does not adhere to the retroperitoneum along a line from the ligament of Trietz to the cecum, but instead adheres along a slender base surrounding the celiac axis. This makes twisting of the bowel possible, with subsequent ischemia. Historical Facts The infant presents with bilious vomiting, abdominal pain (if old enough to complain) and somnolence. Older children may have intermittent symptoms, as the intestine twists back and forth. Pertinent Physical Examination Findings Upon examination, the child may be critically ill, in hypotensive shock. The child will have a taut, tender abdomen, high pitched (or no) bowel sounds and distended loops of bowel with air/fluid levels can be observed on x-ray Therapeutics This is a medical and surgical emergency. Resuscitation, repeated boluses of NS (20 cc/kg), antibiotics and often pressors are needed, along with an immediate surgical consult. Although many references suggest going straight to CT scan or an upper GI series, the PCP should hesitate before filling the stomach of a neonate who is vomiting. A barium enema will determine whether malrotation is present, and essentially diagnose volvulus. Gastroesophageal Reflux Gastroesophageal reflux (GER) is included in this report because GER is so often mistaken for true vomiting and is the exact opposite of an obstruction. These are the classic 'wet burps', observed in almost 100% of infants. Pathophysiology Almost all infants have GER: retrograde flow of formula or breast milk up through the lower esophageal sphincter and out of the mouth (re-flux). Exactly why this occurs is unclear, but infants do have poorly coordinated swallowing and delayed gastric emptying. This, plus the fact that children are on an all-liquid diet and they spend so little time in the upright position, all probably contributes to reflux, especially after a large feeding when intragastric pressures are high. All of the above mechanisms tend to diminish with time, and it is rare to see a patient with significant reflux after 12 months of age. GER disease (GERD) occurs when the child develops aspiration and recurrent pneumonias, failure to thrive or esophagitis (which will present as true vomiting and fussiness - see below). GERD can also present in young infants as an apparent life-threatening event.

Historical Facts The PCP should ask the parents about feedings. Typically, these patients are infants who have 'vomiting' that is not forceful but drools down their front, is bottle fed and routinely takes in large volumes, gulping it down avidly (also developing aerophagia) and then 'vomits 15-times a day' but has no diarrhea or fever. The PCP should ask the parents about fussiness and true vomiting, and any cough or previous pneumonias. Pertinent Physical Examination Findings Upon examination, the child looks entirely well, happy, well fed and well hydrated. The PCP should check the child's growth over time, listen for evidence of respiratory symptoms and look for symptoms of esophagitis (see below). Therapeutics The PCP should try to persuade the mother to reduce the volume of each feed and increase the number of feeds per day so that total intake per day does not change. A time-honored trick is to add one teaspoon of rice cereal to each ounce of formula, which works for some children but not others. The use of playtex nursers (formula-filled bags that collapse down as the infant suckles) will also decrease aerophagia. Many PCPs will call this a food allergy and switch formulas; however, formula allergies rarely present with reflux, and as long as the child is growing and does not have recurrent pulmonary symptoms the PCP should wait until the child is older and sitting up. Diet and hydrostatic pressures will make everything all better, no matter what formula the child is having.[24] Inflammation Anything that inflames the tube of the GI tract or any of its buds, including esophagitis, gastroenteritis, peptic ulcer disease, hepatitis, pancreatitis, cholecystitis or appendicitis, may cause vomiting. Esophagitis In pediatrics, esophagitis is rarely observed, except in the infant with GERD. Pathophysiology Most of these patients will be infants who have always had 'wet burps' but are now fussy and have true, forceful vomiting. Historical Facts The parent will provide the PCP with a history of frequent 'wet burps' that, similar to all GER, involves drooling down the front of the bib, but lately, the child has become fussy and has developed true, nonbilious vomiting. The fussiness appears to improve slightly during feeds, but then quickly recurs. There may be a positional component: "We can't lay him down or he/she cries," or "every time we lay him down he/she cries and arches his back." Pertinent Physical Examination Findings Most of these children present to PCPs because of their fussiness and the vomiting is discovered in the review of systems, although some children will vomit to the point of a Mallory-Weiss tear, and have blood streaks in their vomitus. The child's stomach is not tender. The PCP should check for guaiac-positive stool, and if this is positive then the PCP should check the child's hematocrit. The child's examination will be otherwise normal. Therapeutics A 5 cc dose of Maalox will quiet the child for the first time in days. The PCP should try the patient on ranitidine (75 mg/5 cc, 10 mg/kg/day, divided in two doses). All patients need follow-up with their PCP after 3-4 days.[25,26] Acute Gastroenteritis Acute gastroenteritis (AGE) is the most common cause of vomiting in the pediatric age group.[27,28] Pathophysiology Most cases of gastroenteritis are associated with some degree of vomiting. Rotavirus, the most common known etiology of gastroenteritis, causes vomiting in almost all cases. Bacterial causes of AGE, on the other hand, are associated with vomiting in less than 50% of cases. Historical Facts Whatever the etiology, the signs and symptoms of gastroenteritis usually follow a fairly set pattern. The child will develop fever, vomiting and (in older children) vague bouts of periumbilical abdominal pain that may be quite severe. This is followed by diarrhea after a few hours. The fever is usually low-grade, but in shigellosis may reach 104F. The fever peaks within 24 h and then fades over 48 h. The vomiting also peaks quickly and is much improved within 24 h after onset, and is essentially gone within 48 h. Significant vomiting lasting longer than 48 h needs to be evaluated for something other than AGE. Stomach pain is typically worst before the diarrhea begins, and then becomes paroxysmal, occurring just before the child has a stool. Diarrhea is worst over the first 2 days, and will last in some diminished form for 4-7 days, depending on severity and etiology. [29,30] The parent should be asked about time course, and the physician should try to fit the child into the pattern seen in Figure The PCP should also ask the parent about the number of episodes of vomiting and diarrhea over the last 24 h. It is not advisable to ask the parent about how much is vomited - parents are notoriously unable to quantitate volume of stool or vomitus. The PCP should also ask about the presence of blood or mucous in the diarrhea, two fairly reliable markers of bacterial disease. The PCP should ask about the 'three great signs of dehydration': tears, drool and urine production. The three great signs are so named because they are common findings that anyone can use to determine whether or not a child is dehydrated. Tears and drool and a wet diaper are almost always signs of a well-hydrated baby. Unfortunately, these signs are not infallible. Infants less than 2 or 3 months of age often do not have tears or drool, no matter what their fluid status. A dehydrated child sucking on a bottle may have a wet mouth and a well-hydrated child with fever and excessive mouth breathing may have a dry mouth. However, overall, the three great signs are the most accurate indicators of fluid status that parents are capable of using. Pertinent Physical Examination Findings Upon examination, the most important consideration is the degree of dehydration; this is often quite difficult. The PCP should look for dry lips: most children drool or suck on a pacifier and their lips are glistening with saliva. Dry lips are worrisome. Significant dehydration is observed when the child has sunken eyes: the retro-orbital fat pad shrinks and the eyes retract. Parents may say the eyes 'look dark' because the overlying orbit casts shadows over the eyes. Poor capillary refill and diminished pulses are observed in children who are more than 10% dry, but it is often very difficult to decide.

Dehydration can be accurately assessed only if a recent weight is available. The findings of increased heart rate, sunken eyes and fontanel, decreased skin turgor, poor capillary refill and the three signs noted above all vary with fever, age, nutritional status and the experience of the observer. Assigning numbers - 'percentage dehydration' - is subjective at best. The following calculations work as well as any:

y y y

Less than 5%: lots of diarrhea and vomiting but the child looks well; More than 10%: quite ill, usually in shock; 7%: everything else.

Many older children will complain of abdominal pain and have some tenderness on examination, all of which resolves with hydration and an antiemetic (see below). No laboratory tests are needed in the vast majority of cases, except an Accucheck (infants and young children have limited glycogen stores and can quickly become hypoglycemic with prolonged vomiting and starvation) or a set of electrolytes in cases of moderate or severe dehydration. Hypoglycemic children are commonly fussy and refuse to drink and, therefore, will often need intravenous fluids and admission to a hospital. Children who refuse repeated attempts of oral fluids, those who appear to be clinically moderately/severely dehydrated, those with a serum Na+ of more than 150 mEq/l or a bicarb of less than 14 mEq/l should be admitted to hospital. Therapeutics Owing to the self-limited nature of vomiting associated with gastroenteritis, no therapy is usually needed. Worldwide, children with gastroenteritis and dehydration are rehydrated with oral solutions, except in the USA where the average child is administered NS after vomiting six times. The use of antiemetics is in a state of flux. For years they were thought to be contraindicated owing to the frequency of dystonic reactions, but with the advent of the newer 5HT3 antagonists (especially ondansetron oral dissolving tablets) this has become much less of an issue.[24] Ondansetron oral dissolving tablets can be used at a dose of 2 mg (<5 years of age), 4 mg (5-10 years of age) or 8 mg (10 years of age to adulthood), and is very helpful in avoiding intravenous hydration, getting children out of the ED and avoiding hospitalization. Metoclopramide (0.1 mg/kg intravenous, maximum 20 mg), dolasetron (0.35 mg/kg intravenous/intramuscular, maximum 12.5 mg) or promethazine (as a suppository only, and only in children >2 years of age, at a dose of 0.5 mg/kg/dose) are also used occasionally.[31] With the onset of oral antiemetics for all age groups, a simple protocol of oral rehydration in the outpatient setting might be to administer the appropriate dose of ondansetron, and then a trial of small volumes of any rehydration solution: although Pedialyte is most popular, it contains only 50 mEq/l of sodium, compared to the 90 mEq/l in the WHO formulation (and in the dehydrated state, sodium is absorbed and water passively follows) making Pedialyte less of a rehydration formula and more of a maintenance solution. Nonetheless, Pedialyte is better than juice or sports drinks and more appropriate solutions (WHO formula or Rehydralyte) are not universally available. Pedialyte (and other brands) is the oral solution of choice (by default) in infants and young children. Sport drinks are appropriate for children over 4 years of age. The child should be given a dose of ondansetron, wait 30 min, and then 1-2 oz of Pedialyte. If the child tolerates an oz every 15-30 min for 1-2 h, the child should be sent home with one more dose of ondansetron to use if the child has more than three episodes of vomiting at home. Small, frequent volumes of Pedialyte should be continued for the next 24 h, and then the child's diet should be built back up to a full diet in 2-3 days. The PCP should try to ensure that the child is on clear liquids for no more than 24 h: a common complication is that the infant stays on clear liquids for days and continues to have diarrhea (because of the lack of solids in their diet) and failure to thrive ensues.[25,26] It is noteworthy that the vomiting associated with the vast majority of patients with gastroenteritis lasts less than 48 h; therefore, if the PCP sends the patient home on antiemetics, the PCP should only administer one or two doses. Again, the natural history of most cases of AGE is that the vomiting should improve within 48 h, and if the child continues to need antiemetics after this then another cause for their vomiting should be entertained. It is also healthy to culture stools that are bloody or mucoid. If the child goes to day-care, and if anyone in the family works as a food handler, the importance of good hand washing should also be stressed. Intravenous Rehydration If the child requires hospitalization and intravenous fluids, calculations to replace fluid losses should be made (if the child's Na+ level is <160 mEq/l, fluid deficit should be replaced in 24 h) using D5NS with 20 mEq KCl/l (giving half the dose over the first 8 h and half of the dose over the next 16 h), as well as to replace on-going losses and give maintenance fluids. All children admitted for dehydration need strict recording of intake and outputs, and losses are replaced every shift, oneto-one with NS. Usual maintenance fluids are given (4 cc/kg/h for the first 10 kg, 2 cc/kg/h for the second 10 kg, and 1 cc/kg/h for every kg beyond 20 kg). If the child is hyperosmolar (usually hypernatremic) replace 1/48th of the deficit hourly over 48 h. Maintenance and on-going losses are unchanged.[32] Hepatitis Pathophysiology The most common cause of hepatitis in children is hepatitis A. The exact incidence of the disease is unknown, because hepatitis A often presents in an anicteric form and is misdiagnosed as a case of simple gastroenteritis (i.e., typical symptoms of fever, vomiting, abdominal pain and occasionally diarrhea).[33] Hepatitis A is found only in humans, and the development of a vaccine in 1978 led to the belief that the disease could be eradicated. Routine hepatitis A vaccination has been instituted over the last few years, and will make this a rare event in the near future. Other pathogens causing hepatitis include hepatitis B, cytomegalovirus, Epstein-Barr virus and many drugs (e.g., valproic acid, acetaminophen, isoniazide and oral

contraceptives). If there is any question of an intentional ingestion, the PCP should check acetaminophen levels and ask about suicidal ideation. Historical Facts Parents should be asked about sick contacts and the color of the child's stool: if the stools are acholic the PCP should be sure to check liver enzymes. The PCP should also ask the parents about medication uses, especially acetaminophen. Pertinent Physical Examination Findings Look for icterus (which, again, may not be present) and RUQ tenderness. A positive Murphy's sign (increased pain with palpation of the RUQ while the patient takes a deep breath) is often present. Therapeutics Unless the diagnosis is obvious, vomiting with abdominal pain should lead the PCP to check liver enzymes and perform a lipase test as part of their work-up. The classic 'liver function tests' are actually 'liver damage tests', and will rise with hepatocyte lysis. The PCP should check for liver function, including a serum ammonia and prothrombin time. A hepatitis panel should be checked for the etiology. -globulin should be given to contacts, but only after the PCP knows exactly which pathogen is involved.[33] The importance of good hand washing should be stressed to the family (which should be done in any case of diarrhea). Peptic Ulcer Disease Peptic ulcer disease (PUD) is occasionally observed in older children (preteens and teenagers). PUD is a catch-all diagnosis, and includes GERD, gastritis, a true ulcer and a perforated ulcer.[34] Pathophysiology For various reasons there is a breakdown of the protective mucous barrier of the stomach, which allows gastric acid to erode into the muscularis layer. The excess acid lowers LES tone and can cause irritation of the gastric wall and of the duodenum. In children, PUD may present with little prodromal. Steroid or NSAID use are common precipitants. Concomitant infection with Helicobacter Pylori is uncommon in children younger than 10 years of age.[35] Historical Facts Peptic ulcer disease in pediatrics usually presents with abdominal pain (which may be quite severe) that awakens the child from sleep. Vomiting is universal. The child may complain of water 'brash': burping gastric acid into the back of the mouth. Many patients will have had similar symptoms in the past, and will have been successfully treated with antacids. Others, however, simply have poorly defined upper abdominal pain, which may have no relation to food. Pertinent Physical Examination Findings Upon examination, the patient typically has isolated epigastric tenderness. All such patients should have a rectal examination (to prove that there is no GI bleed). Therapeutics The patient will typically improve with a GI cocktail (1 cc/kg Maalox [maximum of 30 cc] and 0.3 cc/kg 2% viscous xylocaine [maximum 10 cc]). If their symptoms improve, no additional work-up is needed. PUD is not usually stress related in the pediatric age group, as it is in adult. As long as the child is not a runaway, involved with drugs, failing at school or seeing a therapist, among other issues, the PCP should reassure the family that their child is not 'stressed out' and start him/her on an H2 blocker - ranitidine (Zantac 4 mg/kg/day given twice daily, maximum of 300 mg/day). The patient should continue follow-up with their PCP for a more detailed work-up if their condition does not improve in 2-3 days, sooner if worse. Children with persistent or recurrent symptoms need referral to a gastroenterologist Gall Bladder Disease Gall bladder disease is rare in pediatrics.[36] Pathophysiology Gall bladder disease most commonly occurs in children with an underlying precipitant, such as sickle cell disease, previous intravenous hyperalimentation or pregnancy. There are no risk factors in approximately 30% of cases. Although it can be observed in all age groups, in children without some sort of predisposition it is most common in obese adolescent girls. Cholecystitis is defined as 'inflammation of the gall bladder', as evidenced by elevated white blood cell count and inflammatory markers (C-reactive protein and erythrocyte sedimentation rate) and a thickened gall bladder wall, with pericholic fluid on ultrasound. This is an indication for hospitalization on antibiotics and a surgical consult and emergent or urgent cholecystectomy. Biliary colic occurs when the patient has gall stones and one passes through the common bile duct and into the duodenum. This causes severe pain with abrupt onset, which resolves spontaneously within 3-4 h. Gall stones will be observed on the ultrasound but inflammatory markers are negative. If the pain resolves, this is an indication for elective cholecystectomy.[37] Historical Facts In pediatric patients, cholecystitis is much more common. The child typically presents with periumbilical or RUQ abdominal pain and vomiting, and sometimes complains of pain in the right shoulder. Occasionally, a child will have symptoms consistent with passage of a gall stone: abrupt, excruciating RUQ pain and vomiting. Pertinent Physical Examination Findings On examination, the child will have RUQ tenderness and a low-grade fever is common. There may be a positive Murphy's sign: the child has increased pain with inspiration when the fingers are wrapped around the right costal margin. Therapeutics Laboratory tests and physical examination have poor sensitivity and specificity for gall bladder disease, and if the clinical presentation is worrisome, examination should proceed quickly to an ultrasound. If the ultrasound is normal, the patient should be placed on an H2 blocker and the PCP should arrange for outpatient follow-up - a radionucleotide scan (HIDA scan) may be indicated. Pancreatitis Pancreatitis is very rare in pediatrics. Pathophysiology In the pediatric age group, pancreatitis is most commonly idiopathic, but can be caused by trauma, drugs (e.g., diuretics, trimethoprim-sulfa or H2 blockers), gall stones or infections (e.g., mumps or varicella). Historical Facts These children will present with epigastric pain and vomiting, and often a history as noted above.

Pertinent Physical Examination Findings Upon examination, these are miserable, dehydrated patients, with significant pain and protracted vomiting, who have a very tender epigastrium and decreased bowel sounds. Diabetes may coexist. Therapeutics Again, patients with abdominal pain and vomiting without an obvious etiology should have liver function tests and a serum lipase. Lipase is usually three-times that of normal. These children are usually dehydrated and need volume resuscitation, control of their pain and nausea and a CT scan of the abdomen. All such patients need hospitalization. A RUQ ultrasound and endoscopy are part of the work-up. Management involves bowel rest and case-specific therapy.[38,39] Appendicitis Appendicitis begins as an obstructive lesion that causes an inflammatory state. Details can be found in previous sections of this review. CNS Disease There are four relatively common CNS causes for vomiting in pediatrics: concussion/postconcussion syndrome, increased intracranial pressure (ICP), migraine headache and viral meningitis. Concussion/Postconcussion Syndrome Pathophysiology Concussion is defined as "a trauma-induced alteration in mental status that may or may not involve loss of consciousness. Confusion and amnesia are hallmarks of concussion".[40] A concussion occurs when an acceleration/deceleration mechanism causes a shearing stress applied to the brain between the brain stem and the cerebral cortices. With a mild injury, axons become dysfunctional but are not damaged. Some change in mentation occurs, which is termed as concussion. When the shearing force is severe, axons are lysed and do not heal, and the patient is then said to be suffering from a diffuse axonal injury.[41] Patients with a concussion have symptoms that last, by definition, less than 6 h; longer than this the patient is assumed to have had a diffuse axonal injury. Diffuse axonal injury may be mild, moderate or severe, with a variable degree of morbidity and mortality. Historical Facts Memory loss and the inability to form new memories are the hallmarks of a concussion. The child will not remember being struck or the few moments leading to the injury (retrograde amnesia) or the period of time immediately after the blow (anterograde amnesia). Occasionally, the child will have problems forming memories and will repeatedly ask: "What happened to me?" and appear to be quite agitated, only to calm down when reassured, until the process starts again 5 min later. A younger child will simply cry uncontrollably for an excessive length of time, inconsistent with the injury. Vomiting is very common In all cases of head trauma, PCPs should ask the parent: "Did the child cry immediately after he/she was sick, or was the child unresponsive for a period?" and, "Did the child act normally after the injury or did the child cry excessively; were you unable to console him/her?" The PCP should ask the child: "Do you remember falling? Hitting the ground? Who was the first person to talk with you? What did he/she say? Did you get up by yourself or did somebody help you?" Pertinent Physical Examination Findings A Glasgow Coma Scale (GCS) score should be assigned (Table 1) and a complete neurological examination preformed. PCPs should check for blood behind the auricle, or blood and/or CSF behind the tympanic membrane or dripping from the external auditory canal. PCPs should also check for anisochoria and look for a hematoma of the scalp. Therapeutics Generally, children with a history consistent with a concussion should have a CT scan of the head. If this is normal, the majority of patients can be managed as outpatients. There are a number of recommendations as to when the pediatric athlete can return to sports after a concussion.[42] Postconcussion Syndrome Pathophysiology Although a concussion, by definition, lasts less than 6 h, approximately 15% of children will suffer from a postconcussion syndrome, which consists of persistent headache, 'cloudy' mentation, nausea with occasional vomiting and personality changes that can run from 'being moody' to school failure, to (in adults) losing one's job or divorce.[43] Historical Facts The PCP should ask the parents about recent head trauma, as well as the psychosocial issues listed previously. Pertinent Physical Examination Findings There should be little in the way of physical examination findings. Therapeutics The parents should be warned about postconcussion syndrome when the diagnosis of concussion is made, and should be told to seek help from their PCP if symptoms are persistent. Increased Intracranial Pressure There are four basic types of increased ICP: hydrocephalous (Figure 13), cerebral edema, intracranial bleeding and tumors. All are associated with vomiting, especially at night (when hydrostatic pressures come into play). Pathophysiology Since the skull functions as a rigid container, increases in the volume of any of the brain's three compartments blood, CSF or parenchyma - will result in increased ICP. In addition to this, any mass effect - tumor or blood - within the skull will increase ICP. Hydrocephalus may be due to obstruction of the flow of CSF from the ventricles or an inability to absorb it in the arachnoid granulations. The ventricles swell and ICP increases. The majority of these children were premature and had intraventricular bleeding and now have ventricular-peritoneal shunts in place.[44] Cerebral edema develops after some asphyxic or anoxic event (Figure 14). Approximately four of the five most common pediatric brain tumors are cerebellar and, therefore, typically present with hHead trauma with vomiting should always raise the possibility of intracranial hemorrhage. Increased blood volume within the skull can be broken down into four types: epidural, subdural, subarachnoid and intraparenchymal (Figures 15-18).[45,46] They may be indistinguishable in their presentation: a severe blow to the head followed by an abrupt

change in mentation. The vast majority of children that present will be obviously sick. The clinical presentation of the four injuries listed above are interchangeble except for some children with epidural bleeds. Approximately 20% of children with an epidural hematoma will present with a lucent period: a blow occurs that causes a concussion and an injury to the middle meningeal artery. The child wakes up from their concussion, only to later slip into unconsciousness from their enlarging epidural hematoma and subsequent increase in ICP.eadache and vomiting, especially at night or early in thHistorical Facts Although there are some questions that are similar to all of the diagnoses above (vomiting, headache and change in mentation), many historical points are specific to the pathophysiology involved. The longer a ventricular-peritoneal shunt has been in place, the less likely it is to become dysfunctional or become infected. Cerebral edema is common in patients with near-drowning or strangulation, and is rarely observed in diabetic ketoacidosis (DKA). Tumors classically present in the early morning, after the child has been lying flat during the night, and their tumor swells and obstructs the fourth ventricle, causing headache and vomiting. The child may have developed 'clumsiness', or true ataxia. The different types of intracranial hemorrhage are usually only determined after the CT scan is carried out. Pertinent Physical Examination Findings Similar to concussion, this is specific to the mechanism of the problem. The PCP should check the head circumference (if the patient is younger than 2 years of age), and try to catch a glimpse of the fundus and disc, which is not easy in any pediatric patient. The PCP should then watch the child walk and look for ataxia. Therapeutics Primary-care providers are advised to have a low threshold for getting a CT scan of the head. Although much better resolution of the cerebellum is achieved with MRI, evidence of acute bleeding, increased ICP and/or hydrocephalous is usually evident on a noncontrast CT scan. Management follows accordingly. Some children with shunts have a normal CT scan and a normal shunt series. In other words, when worried about shunt malfunction, the PCP should always call a neurosurgeon prior to discharge.[47] Migraine Headaches Migraine headaches (MHAs) are so often associated with vomiting, and the lay population sometimes refer to them as 'sick' headaches. PCPs should be advised to be careful when obtaining a history of migraine headaches in a patient: many people consider any severe headache a 'migraine'. Pathophysiology The exact etiology of MHA is in evolution. At one time it was thought that vasoconstriction occurs, which leads to distal ischemia (with the subsequent 'aura'), which then led to an area of vasodilatation and a concomitant 'throbbing' headache. Now it is thought to have more to do with serotonin release from the brainstem and spread to other parts of the brain.[48] Nonmigraine headaches are not uncommon in children as young as 3 years of age, and are usually associated with viral illness or fever.[49] There appears to be an increase in the incidence of headaches that occur at approximately 10 years of age, which is thought to be due to complete aeration of the sinuses, and the child's first 'sinus' headache. Strep throat commonly causes headache. Historical Facts Pediatric MHAs must have three of the following seven criteria: abdominal pain, nausea or vomiting, throbbing headache, unilateral location, associated aura (usually preceding the headache), relief following sleep or a positive family history.[50] Migraine headaches are divided into 'classic' (those associated with an aura, which is usually visual but may be sensory or motor) and 'common' (those without an aura). There are also many pediatric 'migraine variants', including cyclic vomiting: recurrent, prolonged bouts of vomiting lasting 72 h or less, without any diagnostic markers or historical facts, pertinent physical examination findings or laboratory tests. The first few episodes are commonly misdiagnosed, but then the pattern becomes clear and management with intravenous fluids and antiemetics (and sometimes hospitalization) falls into place. Cyclic vomiting, 'abdominal migraine' and episodes of ataxia can all be atypical migraine, and present with little headache, but, as the child ages, typical MHA commonly develops.[51] Patients with migraine typically get better with sleep; headache that awakens the child from sleep is unusual. Pertinent Physical Examination Findings These findings may be entirely normal, unless there is an aura present. The patient may be extremely sensitive to light and/or sound. The PCP should be sure that they are not missing a case of viral meningitis: there is no nuchal rigidity in MHA, and fever is rare. The PCP should look for evidence of strep throat. Therapeutics A CT scan of the head is indicated at some time in anyone with MHAs; PCPs should have a low threshold for carrying out CT scans at the time of presentation. There are more than a dozen drugs used for MHA, but the vast majority of children do well with simple analgesic NSAIDs for mild attacks, or, if the headache is severe, intravenous prochlorperazine (0.10.15 mg/kg intravenous over 15 min, maximum of 10 mg). It is noteworthy that the use of intravenous antiemetics is sometimes associated with a dystonic reaction, and many clinicians also routinely administer diphenhydramine (1-2 mg/kg slow intravenous).[52] All children should have a referral to a pediatric neurologist in follow-up. e morning. Viral Meningitis Pathophysiology Viral meningitis is typically a summertime disease, caused by arboviruses (mosquito borne) or enteroviruses (fecal-oral transmission). It may occur in epidemics: 456 cases were documented in 3 months one summer in Cincinnati, OH, USA in 1978.[53] There is something about viral meningitis itself that makes the child vomit, because it occurs even if the ICP is normal, and children with bacterial meningitis usually do not have much in the way of emesis. Historical Facts The child typically presents with fever, headache, photophobia and vomiting.

Pertinent Physical Examination Findings The child usually has fever and light hurts their eyes. The child may be slightly dehydrated due to protracted vomiting. Meningismus is common, but may be missing. A viral exanthem may be present. Change in sensorium is uncommon. Therapeutics All children with symptoms consistent with meningitis need a lumbar puncture (even those presenting during an epidemic of viral disease) to rule out the possibility of a bacterial infection. Although white cell counts of more than 1000 cells/high-power field and CSF glucose values less than 30 mg/dl can be observed in viral meningitis, any equivocal results (cells: >250; glucose: <50; protein: >70) should be assumed to be bacterial, and treated with antibiotics until cultures are negative for 72 h.[54] More typical cases may be managed as an outpatient, with pain control and antiemetics. Pulmonary Problems Pathophysiology Pulmonary problems are classically observed in pertussis (which is rare) and in asthma (which is common). Some children with asthma have no wheezing, just a cough (cough-variant asthma).[55] Children will cough up a fleck of sputum that initiates a gag response, and the child will have an episode of post-tussive emesis. In addition, children do not expectorate: they swallow whatever they cough up. This leads to nausea, decreased appetite and occasional vomiting. The vomitus in both situations is thick, mucoid and stringy. Adults with waning immunity are the reservoir of pertussis: as much as 15% of adults with a cough for longer than 2 weeks have grown out pertussis.[56] Historical Facts The PCP should ask if the child has asthma. Some may have a cough without wheezing and never been diagnosed as having asthma. The PCP should ask about any coughing, whether the night is worse than the day and any associated wheezing. Many children with mild asthma will have a prolonged, nagging cough for a week or two after viral illnesses, while their classmates cough for just 2-3 days. The PCP should also ask if the infant has ever had color change or syncope with these spells (more typical of pertussis), and ask if there has been any adult contact with a recent persistent cough. Pertinent Physical Examination Findings The PCP should check for wheezing and ronchi on examination, and a prolonged inspiratory:expiratory ratio. The child may have a significant cough during the examination. Sometimes the examination is entirely normal, and the diagnosis is made by history alone. Therapeutics The PCP should try a peak flow before and after an albuterol nebulizer (physicians should note to use an appropriate dose of albuterol: 2.5 mg if the child is younger than 5 years of age, and 5 mg if the child is older than 5 years). If this appears to help, the PCP should send the patient home on an albuterol metered dose inhaler and a spacer. If symptoms are severe, or continues for more than a week, add prednisone (2 mg/kg/day for 5 days) or dexamethasone 0.6 mg/kg (maximum of 18 mg) immediately;[57] administer another dose in 24 h if necessary. It is noteworthy that asthmatics are commonly underdosed on their albuterol. The PCP should always use a spacer. The patient should puff twice, breathe for a few minutes, wait for a few minutes, then repeat. This is one treatment; repeat this four- to sixtimes per day for 5 days. PCPs should never prescribe albuterol on an every 4-6 h basis. It is essentially impossible to overdose on albuterol, and the one thing that should be avoided is having a child who is short of breath but the mother thinks she cannot give another treatment because "it has not been 4 h yet".[101] Renal Disease Pathophysiology There are three renal problems that may present with vomiting: acute or chronic renal failure, urinary tract infections in neonates and pyelonephritis in older children and adults, and kidney stones. Renal Failure Pathophysiology Vomiting is due to the metabolic derangements typical with renal failure. Uremia and acidosis will both cause vomiting. Acute renal failure is usually difficult to miss, with elevated blood pressure and tea-colored urine, and is typically caused by poststreptococcal acute glomerulonephritis, hemolytic uremic syndrome or Henoch-Schoenlien Purpura. Chronic renal failure may be much more occult, presenting with growth failure or hypertension, or a number of nonspecific complaints, including back pain, fatigue and weight loss (or gain from edema).[58] Historical Facts The PCP should ask the parents about vomiting, weight gain, headache, urine output (volume and color), recent strep infections and a family history of renal disease, as well as about medications. Pertinent Physical Examination Findings The PCP should check blood pressure, fundi, edema and growth curves. An electrocardiogram (ECG) should be ordered and the PCP should look for evidence of hypertension and hyperkalemia. A set of electrolytes and a urinalysis (UA) should be obtained, looking for proteinuria plus hematuria, and red cell/white cell casts. A throat culture should be carried out, and an acute antistreptolysin 'O' titer should be drawn. Complete blood count should be checked for evidence of microangiopathic hemolytic anemia, and a complete examination (including guaiac stool) should be carried out to check for Henoch-Schoenlien Purpura. Therapeutics Acutely, the PCP should make sure the patient has a normal potassium and ECG. Most of the time the hypertension need not be treated, but if there is a true hypertensive emergency (with end-organ damage, such as change in mentation or ECG changes), hypertension should be treated with nitroprusside or labetolol, and a nephrologist should be involved early on. Pyelonephritis Pathogenesis This is an infection of the parenchyma of the kidney itself, usually caused by coliforms (Escherichia coli is most common). Infants with fever and an infected urine may have cystitis or pyelonephritis - it is impossible to determine at the time of presentation: PCPs should assume that all patients have pyelonephritis.[59] For unclear reasons, neonates with urinary tract infections often develop a direct hyperbilirubinemia.[60]

Historical Facts The PCP should ask about back pain, which develops slowly. Vomiting and fever are common. There may or may not be symptoms of cystitis, so the PCP should ask about dysuria and frequency. Pertinent Physical Examination Findings These patients look miserable, febrile and clutch their back. They have marked costovertebral angle tenderness to fist percussion. The PCP should look for jaundice in infants. Therapeutics Pyelonephritis in children can be treated orally (either with cefixime or amoxicillin clavulanate),[61] but the vomiting child will need to be hospitalized. Blood cultures are rarely positive. The PCP should give a dose of ceftriaxone (50 mg/kg, maximum of 1 g) prior to transferring to the floor. It is noteworthy that clean-catch UA is considered accurate in continent children. In other words, a child who is not toilet trained should have a catheterized (or suprapubic) UA. Kidney Stones Kidney stones are uncommon in children, and any child with a kidney stones needs to be worked-up for metabolic disorder, especially cystinuria. Historical Facts Kidneys stones are another in a list of relatively unsubtle causes of vomiting. Excruciating, colicky flank pain develops abruptly, supposedly worse than anything normal people can imagine, associated with blood in the urine (in 85% of the time) and vomiting. The pain usually starts at the costovertebral junction, but may radiate anterior toward the lower quadrants of the abdomen and into the testes/labia. A positive family history is common. Pertinent Physical Examination Findings Upon examination, these patients are writhing about on the bed or walking around looking for a comfortable position. Palpation does not reproduce the pain of their chief complaint. Therapeutics Pain control with a narcotic is paramount, and an NSAID will relax the ureter and facilitate passage of the stone. Antiemetics and intravenous fluid are sometimes needed, but there is no need to 'flush' the stone out. Unless this is typical of previous stones, all patients need a noncontrast CT scan of the abdomen in order to confirm the diagnosis and help the urologist. A stone high up near the uretero-pelvic junction may need lithotripsy or a stent; those at the uretero-vesicular junction rarely do. The same applies to size: a stone 4 mm in size or smaller almost always passes, and those larger than 6 mm rarely pass. The PCP should make sure there is no concomitant infection; such patients should be hospitalized. If the pain can be controlled, the patient can be sent home with narcotics and an NSAID. The patient should strain their urine and try to catch the stone; urologists will need it in order to determine etiology and long-term management. All these children should also see a pediatric nephrologist.[62] Endocrine/Metabolic Disorders There are three endocrine problems that commonly cause vomiting: DKA[63,64] and congenital adrenal hyperplasia and inborn errors of metabolism. The last two are rarely observed, as they are now part of the newborn metabolic screen. Diabetic Ketoacidosis Pathophysiology Diabetic ketoacidosis is typically observed in new-onset diabetes, in adolescents who are noncompliant with their insulin or children who are sick whose parents do not give them their insulin "because they are not eating much". The details of DKA is beyond the scope of this article, but, simplistically, it revolves around lack of insulin and the build-up of glucose and ketone bodies, which function as osmotic diuretics, leading to a child who presents with vomiting, both shock and dehydration, acidosis and a hyperosmolar state. This hyperosmolarity is thought to be the cause of the cerebral edema observed in some children with DKA.[65,66] Historical Facts The PCP should ask about usual insulin needs, diet and recent blood sugars, and try to seek out an etiology for their DKA: infection is not as common as it is in adults (most common is noncompliance). Pertinent Physical Examination Findings The PCP should assess the degree of dehydration, look for signs of infection and check mental status. A GCS score should be assigned at the time of presentation. Therapeutics The mantra for the fluid management of DKA: 'correct their hypovolemia and shock now, correct their dehydration later'. These children are in a hyperosmolar state, both intracellularly and extracellularly. Correction of the extracellular dehydration and hyperosmolarity is easy. While correcting the dehydrated, extracellular state, fluid will cross the blood-brain barrier quickly and the brain may absorb free fluid and cerebral edema sets in, which can be fatal. Therefore, in the acute-care setting, sufficient NS should be provided to correct the child's hypovolemia and shock, 10 cc/kg at a time, and then the child should be given fluids to correct their dehydration over 48 h in the intensive care unit, replacing 1/48th of the deficit each hour. Assessing the degree of hypovolemia is difficult: anti-insulin hormones, such as adrenaline, are high so it is difficult to rely on heart rate, and they often have a metabolic encephalopathy so their mentation may not improve after their intravascular volume improves. The PCP should ensure that the child has peripheral pulses, adequate capillary refill and an appropriate blood pressure (for age) and then get the child into the intensive care unit. At the time of arrival, an Accucheck blood glucose, blood chemistries, complete blood count and a venous blood gas (as accurate a measurement of serum pH as anarterial gas) should be obtained. The child should be resuscitated (i.e., get out of shock) with NS. A total of 20 mEq KCL/l intravenous fluids should be added if the blood K+ level is less than 5.0 mEq/l. Most clinicians also test serum ketones, but these can be misleading. If the blood sugar is higher than 250 mg/dl and pH is less than 7.30, a drip of insulin at 0.1 u/k/h should be started. The PCP should be sure to check the child's glucose again before starting insulin, because the dilutional effect of the intravenous bolus(es) is sometimes enough to bring the blood sugar down to approximately 250 mg/dl. If blood glucose is lower than 300 mg/dl, glucose should be added to the intravenous fluids (typically D5NS). While on a drip, Accucheck should be obtained every 30 min. If the blood glucose is lower

than 250 mg/dl, the drip should be cut in half until the child gets to the intensive care unit. Generally speaking, a child should never be given bicarb. Drugs There are many drugs with some degree of GI side effects, but vomiting is relatively rare. Pathophysiology Only a few commonly used drugs cause vomiting when given in appropriate doses - codeine, erythromycin, some birth control pills, theophylline and, for some unknown reason, some of the proton pump inhibitors. These symptoms are always worse when taken on an empty stomach. Many other drugs will make the patient vomit when overdosed - digoxin, aspirin, iron and acetaminophen to name a few.[67] Historical Facts The PCP should always ask if any drugs were taken and what drugs are in the house (even if the family is 'certain' that the child could not have become involved with drugs). Pertinent Physical Examination Findings There are toxidromes that point to specific ingestions, such as narcotics (miosis, somnolence and respiratory depression), sympathomimetic (mydriasis, tachycardia and diaphoresis) and anticholenergic, but many present with vomiting and somnolence and little else. Therapeutics The PCP should decide if the injestion is potentially significant. Poison Control should be called in 100% of patients. In general, any significant ingestion should be treated the same way: all patients should have a urine drug screen, acetaminophen level, aspirin level, ECG and electrolytes tests (and a pregnancy test if applicable). Lavage is indicated if the ingestion occurred less than 60 min prior to arrival, is potentially dangerous and the child is awake and alert. Activated charcoal (with sorbitol) should be given (1 gm/kg, maximum of 50 g) to these patients if the child is compliant. In general, if the PCP needs to place an nasogastric tube, then the charcoal should be omitted entirely. Somnolent patients are different; they will need to be intubated and their airway controlled prior to lavage or administration of charcoal.[68] Psychological There are two well-defined clinical psychological entities that are associated with vomiting: anorexia nervosa and bulimia.[69,70] Pathophysiology Both anorexia nervosa and bulimia have a very similar psychological basis, which revolves around problems with dependence and individuation. Often the parents are excessively attached and dependent upon their offspring (women more common than men in a ratio of 10:1) than is appropriate. This functions to increase the child's dependence on his/her parents, and retard their efforts at individuation. The parents often lack confidence in their parenting skills, which is compounded by their child's hyperemesis. Anorexics are very thin; bulimics may be almost chubby. Historical Facts Most of these patients are adolescent females. The PCP should ask about body image (most patients, however thin they might be, think they are fat and want to be thinner). PCPs should ask about diet: many are on very restricted diets. Excessive exercise is common: 300 sit-ups at a time. The patient should also be questioned about 'purging' and use of laxative. Pertinent Physical Examination Findings Most of these patients are very thin and many have delayed menarche. The PCP should check for evidence of bruxism, a side effect of regurgitation of stomach acid. Carotinemia is common. Therapeutics Electrolytes and liver function tests should be checked. All such patients should be managed in conjunction with a psychotherapist: anorexia nervosa has a 1-10% mortality.[71] Streptococcal Pharyngitis For unclear reasons, strep throat may cause significant vomiting.[72] Historical Facts The PCP should ask the following questions:

y y y y y y y

What is the child's age? Streptococcal pharyngitis (caused by group A b-hemolytic streptococci [GABHS]) rarely occurs in children younger than 2 years of age, and is not observed in children younger than 1 year of age; Does the child have a fever? Almost all children with a strep throat will have had a fever higher than 101F at some time during the illness, although the child might be afebrile at the time of examination; Does the child have a rash? Scarlet fever occurs only in GABHS infections; Is the child suffering from headache, abdominal pain and vomiting? All are very common; Is the child sick during the months of November through to May? Strep infections occur during the school year, and the incidence will vary on a weekly basis: six this week, two next week, none for 3 weeks, then three the next week and five the following week; What symptoms does the child present? No viral symptoms, typically cough, conjunctivitis, a viral rash or diarrhea are common; Does the child have classic presentation? Streptococcal infection causes sore throat, fever, anterior cervical adenitis and a bright red pharyngeal mucosa, but exudates are rare in children younger than 8 years of age.

Pertinent Physical Examination Findings Again, exudates are uncommon in children younger than 8 years of age, and so small exudates lying on the crypts of the tonsils in younger children are almost always a marker for viral disease. Oral ulcers or gingivitis also indicate viral disease. In patients with strep throat, the oral mucosa is bright red, and petechiae on the palate are common. The patient has a muffled voice. It is noteworthy that the use of clinical criteria to diagnose strep throat has been debated for decades, but the fact is that there has never been any study that demonstrated that clinical criteria alone is much better

10

than flipping a coin. The most commonly used clinical criteria in adults are the 'Centor Criteria',[73] republished by the Centers for Disease Control (CDC) in 2001: fever, exudative tonsillitis, anterior cervical adenitis and lack of cough means the patient has GABHS pharyngitis.[74] However, this scale is not applicable to patients younger than 12 years of age. The CDC recommends treating with four points, getting a rapid strep test or throat culture for those with two to three points, and diagnosing the patients with one or zero points as having viral disease and doing no testing. Although clinical diagnosis is difficult, diagnosing GABHS pharyngitis with laboratory tests also has its problems. Technique is very important: a good swab commonly causes gagging of the child. PCPs should recognize that rapid diagnostic tests are highly specific but sensitivity is (on average) approximately 75%; all negative tests should have a throat culture carried out as a back-up. Culture is sensitive and specific, but takes 24-48 h, and neither proves an infection: infection can only be proven by antibody titers, which are of little use in the acute-care setting. Both tests will be positive in streptococcal carriers and, because as many as 20% of children are carriers during the winter, there is a high risk of infection. Finally, there are few rheumatogenic strains prevalent now, and so missing a case of GABHS infection in not the potential catastrophe it used to be. However, the Red Book[75] says that the diagnosis of strep throat in children should be confirmed by either throat culture or rapid diagnostic test prior to treatment. However, on the other hand, diagnostic tests should not be carried out without screening for viral disease, for fear of treating a streptococcal carrier. There is a high risk of confusion, but the diagnosis of GABHS can be summarized as follows: a diagnostic test should be carried out if the patient appears to have strep throat on clinical grounds, but if the preponderance of the history and physical examination points to viral disease, this should be diagnosed but not acted upon. Therapeutics If the PCP decides to treat the infection, phenoxymethyl penicillin 250 mg twice daily (in children) or 500 mg twice daily (in teens and adults) should be used. Amoxicillin in the same dose can be given once per day. The parent should always be offered benzathine penicillin: the dose is 600,000 units intramuscularly (for children <30 kg) and 1.2 million units intramuscularly (for patients >30 kg). Single dosing is very convenient. Pregnancy Pathophysiology Women who are pregnant often vomit, for unclear reasons, but morning sickness is very common. Its incidence usually decreases markedly by the end of the first trimester, but hyperemesis graviderum is occasionally diagnosed at any time.[76] Historical Facts First, the PCP should decide if this is due to the pregnancy. Vomiting may be the presenting symptom of a pregnancy; therefore, the PCP should be quick to check a urine pregnancy test in any female of child-bearing age who presents with vomiting, and vomiting in the pregnant woman is not always due to hormonal imbalance: PCPs should consider the differential diagnosis and look for the diabetic or the woman with AGE or pyelonephritis. Stomach pain is not usually observed with morning sickness or hyperemesis graviderum, and such patients need a work-up. Pertinent Physical Examination Findings These patients can be miserable and dehydrated. Again, PCPs should not assume hyperemesis: they should look for other etiologies. Therapeutics Any of the usual antiemetics are commonly used, but metoclopramide (10 mg intravenous) and ondansetron (4-8 mg intravenous) are the only 'category B' drugs. UAs should be repeated and follow the patient's ketonuria; if the patient is tolerating oral fluids and their urinary ketones are improving they can be discharged on an oral antiemetic with 24-h follow-up. Stress Many children will vomit following stress of any sort. This may be quite severe (children with sepsis or shock of any cause may vomit because of an ileus) but, much more commonly, it is relatively minor: children with otitis media may vomit once or twice, as might a child who is crying for any reason. This is sometimes quite confusing: children who bump their heads, without a concussion or intracranial injury, will often vomit a couple times. But how can you be sure the vomiting is due to stress? Vomiting associated with minor stress is never prolonged or protracted - rarely is there more than two separate episodes - and has no other associated symptoms: diarrhea and abdominal pain, among others. However, unless the diagnosis is obvious, the clinician is forced to go through the differential of vomiting as listed above and see if anything fits. It always makes the PCP worry, sometimes to the point of a CT scan. The PCP should never stop worrying, but should recognize that this is common and usually benign.

11