Hematemesis, vomiting - Pediatric Surgery

Hematemesis, vomiting - Pediatric Surgery Hematemesis, Vomiting . Gastroesophageal Reflux . click the images for more details   Incidence.  The gastroesophageal reflux is one of the most common causes of vomiting and hematemesis in the first year of life. It is not a massive hematemesis; the infants bring up traces of blood or of coffee-ground appearance.  Clinical significance. 1. This leading symptom indicates that the suspected reflux has a clinical significance (esophagitis). 2. In general, reflux is one of the most common causes of vomiting during infancy. 3. Reflux may lead to chronic symptoms and, in some, to a lifelong disability. 4. It is a possible cause of sudden infant death.   Etiology.Illustrations The cause of reflux is either a delayed maturation or, less frequently, a congenital malformation of the cardia, leading to an insufficient closure of the esophagogastric junction, and to a reflux of gastric contents and especially acid gastric juice in the esophagus and possibly into the larynx and the bronchi. show details Pathology, anatomical types.Illustrations The described gastroesophageal reflux can be visualized with an upper gastrointestinal study with contrast or isotopes, and indirectly demonstrated by pH monitoring. In some of the children, the angle between the esophagus and the stomach is obtuse (angle of His), and in 10 %, parts of the stomach of different size are permanently visible above the diaphragm (hiatal hernia). show details Pathophysiology  The pathophysiology depends on the type of complicated reflux.   Clinical presentation (history, findings, clinical skills).Illustrations From the first day of life, regurgitation or vomiting occurs repeatedly following or during feeding with an acid smack, sometimes with force. Upright positions like sitting and standing and change of food to thickened feeds following development, and eating from the table lead to an amelioration of regurgitation and vomiting and may simulate recovery from reflux. In complicated reflux there are different signs and symptoms either as single or as combined leading symptoms: 1. Failure to thrive. 2. Hematemesis, blood in the stool or chronic anemia. 3. Recurrent respiratory infections, stridor and hoarseness. 4. SIDS, sudden infant death following aspiration of acid gastric fluid into the lungs. 5. Dysphagia (peptic esophageal stenosis). 6. Torticollis (Sandifer syndrome). 7. Unexplained crying; epigastric, retrosternal and abdominal pain; halitosis. show details Natural history.Illustration Without treatment, vomiting subsides in 60 % due to a maturation of the lower esophageal sphincter. Some of the patients remain only slightly symptomatic up to the 5th decade when the symptoms appear again. In case of persistent esophagitis, in which hematemesis, blood in the stool and/or chronic anemia may be absent or overlooked, development of a circular stenosis with dysphagia, or of a secondary brachyesophagus due to a retraction in the longitudinal direction is possible; the latter complication is combined with the risk of a carcinoma in adulthood. show details Differential diagnosis.Illustrations The differential diagnosis includes all causes of vomiting, regurgitation and dysphagia. In case of complicated reflux the differential diagnosis depends on the leading symptom as blood in the stool, symptoms and signs of the respiratory system in infants and older children, torticollis, and chronic recurrent abdominal pain. In hematemesis, one has to consider blood from the mother, erosive gastritis, gastroduodenal ulcer, gastric tubes in newborns and infants, blood swallowed following epistaxis, surgery or instrumentation, and trauma in older children. show details Work-up examinations.Illustrations 24-hour monitoring of the pH: A pH of less than 4 in more than 5 % (10 % in infants) of the registration time is abnormal (sensivity 100, and specifity 94 %). Upper gastrointestinal study with contrast: Exclusion of a hiatal hernia, of esophageal motility disorders, of a gastric outlet syndrome, and of an esophageal stenosis. Endoscopy and biopsy: Macroscopic and histologic evaluation of an esophagitis. The latter two examinations are necessary in complicated reflux. show details Therapy.Illustrations Simple reflux: Medical treatment over a limited time with frequent, small and thickened feedings, semi-seated position, and, in case of severe reflux, with Histamin H2 receptor antagonists. Indications for surgery: Hiatal hernia, severe types of complicated reflux, resistance to medical treatment or absent adherence, and in neurological diseases. In addition, in some patients following repair of an esophageal atresia, gastroschisis and omphalocele and diaphragmatic hernia. Open or laparoscopic Nissen's or anterior Thal-Ashcraft's fundoplication. show details Prognosis.  Longterm results of medical treatment up to adulthood are not available. Following fundoplication, vomiting, failure to thrive and recurrent respiratory infections are cured in 90 %. Relapses are observed in 10 %, higher in neurological diseases.