The second in our new series of abridged chapters from the recently expanded and updated Symptom Sorter (sixth edition), which gives a grassroots analysis of common primary care presentations
This is not a problem that GPs regard with relish. And not only because of the potential impact on clothes – in the acute scenario, the differential is wide and encompasses some serious illnesses. Ongoing vomiting is less of an urgent worry, with fewer possibilities.
Differential diagnosis
Common
• URTI (vomiting secondary to coughing).
• Gastro-oesophageal reflux or GORD.
• Gastroenteritis.
• Any acute febrile illness (such as otitis media, tonsillitis, UTI, meningitis, pneumonia).
• Cow’s milk protein intolerance (CMPI).
Occasional
• Feeding mismanagement (overfeeding).
• Pyloric stenosis.
• Intussusception.
• Other causes of bowel obstruction.
Rare
• Metabolic.
• Raised intracranial pressure.
• Other causes of the acute surgical abdomen.
• Diabetes.
Possible investigations
It is highly unlikely that the GP would arrange any investigations in this scenario. If the level of concern or diagnostic uncertainty is such that the child needs investigating, then it would need referral (usually urgently). Even if a UTI is suspected as the cause, investigations in primary care become academic – if the child is unwell enough to be vomiting with a UTI, then it needs hospital assessment.
Top tips
• Take time to clarify the clinical picture. Many parents will describe florid vomiting when they actually mean retching after bouts of coughing. They also have a tendency to call many episodes of vomiting ‘projectile’, so take time to get them to describe what they mean.
• In the acute situation, a precise diagnosis may be difficult and the consultation is more about whether observation or admission are required. Work through the most relevant issues systematically. Is the child dehydrated?
Is this sepsis? Is it an acute abdomen? And, if all the above are negative, is the child ill enough to require admission anyway?
• Bear in mind that gastro-oesophageal reflux and GORD are not the same thing. The former can be considered normal and self-limiting; the latter shares some features with simple reflux but also causes distress or other symptoms.
• In ongoing vomiting in an otherwise well child, the likely diagnoses are feeding mismanagement, GORD or CMPI.
Red flags
• In the acutely ill child, use the NICE traffic-light system and sepsis screens early in your assessment – if the child is seriously ill then it needs admission regardless of precise diagnosis.
• Genuine projectile vomiting in infants up to two or three months of age should be taken seriously – pyloric stenosis must be excluded.
• Bile-stained vomiting, particularly with abdominal swelling, suggests intestinal obstruction.
• Beware the vomiting infant with screaming episodes associated with pallor – this could be intussusception.
• Recurrent vomiting with failure to thrive requires a specialist opinion.
• A bulging fontanelle, decreased responsiveness or rapidly increasing head circumference associated with vomiting suggests raised intracranial pressure – this needs urgent assessment.
Dr Keith Hopcroft is Pulse’s clinical adviser and a GP in Basildon, Essex
