extra-abdominal causes Appendicitis can present with vomiting in children, along with other symptoms including abdominal pain, anorexia, and fever Often, pain will begin in the periumbilical region and then shift to the right lower quadrant, and pain may be increased with coughing or hopping (Chapters 53 Pain: Abdomen and 116 Abdominal Emergencies ) Other nonobstructive causes of vomiting in older children related to the digestive system include pancreatitis, cholelithiasis and cholecystitis, gastritis, and peptic ulcer disease Children with pancreatitis may present with vomiting and severe pain and tenderness in the epigastric region Children with cholelithiasis may present with vomiting and pain in the right upper quadrant, with symptoms worsening particularly after eating fatty foods, while those with cholecystitis may present with similar symptoms with the addition of fever Peptic ulcer disease may also present with vomiting, as well as abdominal pain worst in the epigastric region and hematemesis in severe cases Acute gastroenteritis (AGE) is the most common cause of vomiting in this age group AGE is an infection characterized by diarrhea, often accompanied by vomiting and is a common reason for children to present to the ED Fever may or may not be present The degree of dehydration will help to determine how to manage the child Several scales exist to assess the severity of dehydration (mild, moderate, or severe) in children with AGE based on physical examination, including criteria from the World Health Organization (WHO), the Gorelick scale, and the Clinical Dehydration Scale (CDS) These scales may have limited utility in some settings, and percentage loss of weight, although not often readily available in the ED, is the gold standard for assessing degree of dehydration Laboratory studies may also be helpful in children with signs of severe dehydration, with serum bicarbonate level having been shown to correlate with dehydration in several studies, but are rarely indicated in children with mild or moderate dehydration (see Chapter 22 Dehydration ) Intravenous fluids are generally recommended for the treatment of severe dehydration, and admission to the hospital may be indicated in these children, particularly if ongoing losses exceed intake However, oral rehydration should be attempted prior to intravenous rehydration in children with mild or moderate dehydration Ondansetron may be helpful in children prior to attempting oral rehydration in vomiting patients It is important that parents realize that rehydration in the ED is only the first phase of treatment of dehydration, with the second and third phases being replacement of ongoing losses and continuation of normal feeding Education on how to replace ongoing fluid losses after discharge from the ED should be provided Symptoms will generally improve over a few days to a week