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BMJ 2005;330(7484):186–188 Lara-Torre E The physical examination in pediatric and adolescent patients Clin Obstet Gynecol 2008;51(2):205–213 McGreal S, Wood P Recurrent vaginal discharge in children J Pediatr Adolesc Gynecol 2013;26:205–208 Neinstein LS, Gordon CM, Rosen DS, et al Vaginitis and vaginosis In: Hwang Ly, Shafer MB, eds Adolescent Health Care: A Practical Guide 5th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2008:723–732 Someshwar J, Lufti R, Nield LS The missing “Bratz” doll: a case of vaginal foreign body Pediatr Emerg Care 2007;23(12):897–898 Stricker T, Navratil F, Sennhauser F Vulvovaginitis in prepubertal girls Arch Dis Child 2003;88(4):324–326 Sweet RL, Gibbs RS Atlas of Infectious Diseases of the Female Genital Tract Philadelphia, PA: Lippincott Williams & Wilkins 2005 Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC) Sexually transmitted diseases treatment guidelines, 2010 MMWR Recomm Rep 2010;59(RR-12):40–67 CHAPTER 81 ■ VOMITING MARIDETH C RUS, CARA DOUGHTY INTRODUCTION Vomiting is the forceful oral expulsion of gastric contents associated with contracture of the abdominal and chest wall musculature Vomiting may be caused by a number of problems in diverse organ systems Vomiting is extremely common in the pediatric emergency department (ED), and usually represents a transient response to a self-limited infectious, chemical, or psychological insult However, vomiting may also be the primary presentation of significant gastrointestinal, infectious, neurologic, or metabolic disorders requiring immediate evaluation and treatment to prevent morbidity and mortality Thus, an orderly approach to diagnosis is crucial Vomiting is a complex act with multiple phases: pre-ejection, retching, and ejection phases Gastric relaxation and retroperistalsis occur in the first phase, followed by rhythmic contractions of chest and abdominal wall muscles against a closed glottis in the retching phase In the ejection phase, contraction of the abdominal muscles combines with relaxation of the esophageal sphincter to result in ejection “Projectile” vomiting should be concerning as a sign of gastric outlet obstruction such as pyloric stenosis Therapeutic advances have arisen from an evolving understanding of neurotransmitter activity in the central nervous system (CNS), GI tract, and other sites Serotonin (5-hydroxytryptamine) receptors are prevalent in the CNS and gut and participate in the induction of emesis Use of serotonin receptor antagonists (such as ondansetron) has proven to be successful in decreasing or preventing emesis associated with many chemotherapeutic and radiotherapeutic cancer treatments, in emetogenic poisonings, and in children with viral gastroenteritis Increasing evidence shows that ondansetron use in pediatric patients with viral gastroenteritis is safe, effective in reducing emesis, and unlikely to mask underlying pathology in appropriately selected patients A related complaint, often heard in the ED, is that of young infants who “spit up.” This refers to the nonforceful reflux of milk into the mouth, which often accompanies eructation Such nonforceful regurgitation of gastric or esophageal contents is most often physiologic and of little consequence, although it occasionally represents a significant disturbance in esophageal function with clinical consequences for the infant It is convenient to organize the many diverse causes of regurgitation and vomiting into age-related categories ( Table 81.1 ) Although there is considerable overlap, the most common and serious entities can be easily organized into such groupings EVALUATION AND DECISION General Approach Given the myriad causes of vomiting, an orderly approach to the differential diagnosis of this symptom is critical Three clinical features should guide initial evaluation and management: the child’s age , evidence of obstruction , and signs or symptoms of extra-abdominal disease Other important considerations include appearance of the vomitus, overall degree of illness (including the presence and severity of dehydration or electrolyte imbalance), and associated GI symptoms History The history should focus on the key elements noted above The patient’s age is often significant because certain critical entities (especially those that cause intestinal obstruction) are seen predominantly in neonates and older infants, and are less common in children beyond the first year of life Evidence of obstruction, including abdominal pain, obstipation, nausea, distention, and increasing abdominal girth, is sought in addition to vomiting Associated GI symptoms may include diarrhea and anorexia The suspicion of significant extra-abdominal organ system disease is raised by neurologic symptoms such as severe headache, stiff neck, blurred vision or diplopia, clumsiness, personality or school performance change, or persistent lethargy or irritability; by genitourinary symptoms such as flank pain, dysuria, urgency and frequency, hematuria, or amenorrhea; by infectious complaints such as fever, sore throat, or rash; or by respiratory complaints such as cough, increased work of breathing, or chest pain ( Tables 81.2 , 81.3 , and 81.4 ) Other associated GI symptoms may include diarrhea, anorexia, flatulence, and frequent eructation with reflux The appearance of the vomitus (by history and inspection when a specimen is available) is often helpful in establishing the site of pathology Undigested food or milk should suggest reflux from the esophagus or stomach caused by lesions such as esophageal atresia (in the neonate), gastroesophageal reflux (GER), or pyloric stenosis Bilious vomitus suggests obstruction distal to the ampulla of Vater, although it may occasionally be seen with forceful prolonged vomiting of any cause when the pylorus is relaxed Fecal material in the vomitus is seen with obstruction of the lower gastrointestinal tract “Coffee-grounds” emesis suggests blood that has been exposed to gastric acid Hematemesis usually reflects a bleeding site in the upper GI tract; its evaluation is detailed in Chapter 33 Gastrointestinal Bleeding Physical Examination The physical examination should begin by evaluating the overall degree of toxicity Are there signs of sepsis or poor perfusion? Is there the inconsolable irritability of meningitis? Are there signs of severe dehydration or concern for symptomatic hypoglycemia? Does the child exhibit the bent-over posture, apprehensive look, and pained avoidance of unnecessary movement typical of peritoneal irritation in appendicitis? Next, attention is directed to the abdominal examination Are there signs of obstruction such as ill-defined tenderness, distention, high-pitched bowel sounds (or absent sounds in ileus), or visible peristalsis? A complete physical examination must include a search for signs of neurologic, infectious, toxic/metabolic, and genitourinary causes, as well as an evaluation of hydration status (see Chapter 22 Dehydration ) ... caused by a number of problems in diverse organ systems Vomiting is extremely common in the pediatric emergency department (ED), and usually represents a transient response to a self-limited infectious,... poisonings, and in children with viral gastroenteritis Increasing evidence shows that ondansetron use in pediatric patients with viral gastroenteritis is safe, effective in reducing emesis, and unlikely