Archive for June, 2015

Vomiting Verse

This the text of the lecture I used to give to (bemused?) 5th year medical students. Part of it appeared in the Student BMJ with a commentary in rhyme from the reviewer.

INTRODUCTION

The subject for discussion

Is the little child who vomits,

Who throws up all her food with the

Trajectory of comets.

But first we must distinguish,

As you’re sure to come across it,

The differences between this and

The gently brought up posset.

The child who only possets

Never puts you in a spin

For she deposits but a drop

Or two upon her chin.

The vomiter however is

A child you can’t ignore

As her most recent meal ends up

Upon the kitchen floor.

A posseter you reassure;

A vomiter – find out more.

Why do children vomit?

Well, like you and me,

When the stimulus is there

It’s a reflex, don’t you see?

Signals from the gut

Or deep within the brain

Go to the medulla

To initiate a chain

Of events that are directed

By a centre that is known

By the sweet nonscanning title of

Chemo-emetic trigger zone.

What follows? Need I tell it?

The stomach will expel it.

It’s vital to remember that,

Like fits or halitosis,

  Vomiting’s a symptom and

  Is not a diagnosis.

I’ll say it once again

Though it might induce hypnosis:

Vomiting’s a symptom and

Is not a diagnosis.

So don’t be tempted just to give

The mother’s head a pat

And dose the kid with Stemetil

Or nostrums such as that.

A CLINICAL APPROACH

A good history and examining

Will help you find the pieces

That fit together giving you

The cause of the emesis.

Thus a clinical approach will in all

Cases give the answer

Which may vary from a sore throat to

A cerebellar cancer.

Yes, causes may be minor

Like an earache or a cold

But miss a mass within the brain

And there’ll be strife untold.

The most helpful thing to aid you

As you search to find the reason

Is the age at which the child

NEONATE

Has now presented. In the season

Of the first week of the neonate

What they swallow during labour

Gastric irritation

May cause some irritation and

Get tossed out like a caber.

Liquor, blood, meconium

Upset the stomach lining

And make the baby puke

And vomit after dining.

Feeding  problems

Also difficulties feeding may

  Upset the infant gut.

These symptoms usually settle and

The baby then thrives, but

Don’t forget that in this period when

The baby very light is

Infections

She’s prone to get infections:

Septicaemia, meningitis.

Here the septic babe

May cry too much or go

Too quiet and apathetic,

Her temp is high or low.

Should these things occur,

Then you must be quick

To do your cultures and begin

An antibiotic.

Congenital gut anomalies 

Also at this time the gut is

New and is untried

And there may be an atresia or

Stenosis deep inside.

Many’s the congenital

Obstruction that may show

Soon after birth with vomiting.

So don’t be slow

To think of duodenal or other atres-

ia, meconium ileus or Hirschsprung’s disease.

If you’re in a bind

And just can’t find

Which part of the babe the trouble is in

There’s a chance it may

Be the DNA:

An inborn error of metabolism.

So at the end of the list

And not to be missed

Some rare faults exist

For the biochemist

Such as hyperammonaemia

Where blood ammonia’s high

And, if treatment isn’t given,

The baby may well die.

EARLY INFANCY 

Vomiting’s a common symptom in the

First few months of life

And it causes much alarm to many a

Mother or a wife.

Feeding problems 

Commonly it’s met where feeding

Isn’t going well.

The baby’s swallowing air and is

Creating merry hell.

She eructates or burps

And the milk returns at speed.

The whole thing is repeated then

With each and every feed.

Or perhaps the hole that’s in the teat

Is made too big and wide;

Gulped air and milk distend her gut –

She can’t keep them inside.

Thus careful note you need to make

Of mum’s technique of feeding

So you can find the faults and change

Disaster to succeeding.

GOR

Quite common too is GOR,

That’s gastro-oesophageal

Reflux where the babe returns

A portion of each meal.

She brings her milk up with no strain,

Of bile there’s not a trace,

But on the carpet there’s a stain;

Despair is in mum’s face.

But your job is to reassure.

“She’ll grow out of it”, you say

But check first that she’s growing well

And that her chest’s OK.

For reflux may result in a

Failure to gain weight

And, in others, food’s return

May make them aspirate.

A variation on this theme

Of GOR is seen when haem-

atemesis gives mum a fright. This

Brings to light oesophagitis:

Acid burn of the gullet

Needs antacid to dull it.

Infections

Also you will often see

An infant with otitis me-

dia, the common cold or such

Presenting ‘cos she vomits much.

Infections present commonly

With vomiting in infancy.

This aphorism’s worth repeating

Over and over if kids you’re treating:

Infections present commonly

 With vomiting in infancy.

Always thus you must consider

Maybe bugs will give a kid a

Gastro or a meningitis,

Chest infection, hepatitis.

Don’t forget the UTI

Lurking unsuspected by

Those not versed in little tricks,

Eg. the using of dipstix.

These causes – feeding, GOR, infection

Are the commonest in this section

Less common but now needing introduction

Intestinal Obstruction

Are some syndromes of intestinal obstruction.

Firstly and most common is a

Major diagnosis:

That’s infantile hypertrophic

 pyloric stenosis.

The cause of this phenomenon,

The pundits now assure us

Is that nitric oxide synthetase is

Low in the pylorus.

This is four times commoner

In boys than little girls.

It can run in a family. The

Firstborn often hurls

His milk across the room in

A projectile fashion.

It’s sudden and complete – he

Then wants his next ration.

The vomiting is not always projectile,

Don’t be caught,

But it occurs soon after feeds;

His mother’s overwrought.

The baby doesn’t thrive, he

May go slightly yellow

And it is quite obvious he’s a

Hungry little fellow.

The clue, apart from hist’ry, you will

Find if you can feel

A round mass, olive-shaped, as the

Baby takes a meal.

Here is how

To do it now:

The baby feeds on mother’s breast, re-

laxed (there is no hustle).

You gently get you fingers to the

Right of rectus muscle.

You’ll feel it then. Your eye may catch, as

It so smoothly pulses

Across the epigastrium, the

Gastric peristalsis.

The other helpful clue to

Make the diagnosis

Is a hypochloraemic hypokalaemic

Metabolic alkalosis:

For –

Although he’s dehydrated, it’s

Acid that he’s lost

And trying to correct, potassium into

Cells has crossed.

The diagnosis is confirmed with

Ultrasound or barium

And with a pyloromyotomy you’ll

Get your honorarium.

The name of the operation I’ll repeat now

Nice and slowly:

You cut the muscle lengthways –

Pyloromyotomy.

OLDER INFANTS

In older infants it’s the in-

fections that are major

Infections

 Causes of the vomiting in

Children at this stage. A

Child of this age also tends to

Pick things up and swallow

Poisoning

All sorts of things that do no good.

Emesis may well follow.

A tablet, insect, leaves and sticks

Enter the oral cavity

So think of poison when she throws up,

Defying gravity.

Rumination

The ruminator brings it up in

to his mouth, rechews it,

Swallows it again or, at

Times, will choose to spew it.

This can be normal but may show a

Child who’s life is boring;

Who’s parents do not stimulate or

Actively ignore him.

Stress

Likewise the infant who has had an

Early life of tension

At times of stress may make a mess;

Vomits to get attention.

If you have been sleeping

Please wake up and listen

As I introduce

Some important conditions.

Concentrate now! Do not doze

As words of wisdom I propose:

Surgical causes

In the first two years there occurs

  A vomit which the surgeon

Would maintain is his terrain.

One is an emergen-

cy, the midgut volvulus.

Here there will exist

A malrotation of the gut which

Gets into a twist.

The circulation to the bowel is

Compromised and should

This state continue long that

Bowel will be no good.

The child with this will vomit bile, goes

In and out of shock, but

Distension’s rare, the stomach’s soft, not

Much to point to rotgut.

To diagnose the midgut volvulus

Make it certain that

A child who brings up bile must have a

Barium meal and that stat.

To be complete,

I must repeat:

To diagnose the midgut volvulus

Make it certain that

A child who brings up bile must have a

Barium meal and that stat.

The other thing that’s surgical and

Vomits at inception

Is telescoping of the bowel that’s

Called intussusception.

This occurs at many sites, is

Often ileocolic.

The baby has a bloody stool and

Pain that’s diabolic.

These times of pain are episodes of

Gut contraction when

Ischaemia is occurring at the

Site of obstruction.

Apart from the history and the

Pain, the sign you try to find

Is a sausage-shaped abdominal lump

Either ill- or well-defined.

The management, I’ll briefly say, is

To attempt reduction,

Under X-ray control,

with careful introduction

Of air under pressure

In the colon with a pump:

And with a bit of luck

You’ll get rid of the lump.

Should this fail

It will entail

A surgeon’s knife

To end the strife.

Please make it a rule – if

Money you would earn – you

Must never, never miss an in-

carcerated hernia.

You’ll be alright

If in each mite

You carefully check

Each hernial site.

CHILDHOOD

The older child she vomits less. The

Causes are not many.

Once more infections dominate and

Basically are any.

Infections

Some are less than obvious, re-

quire a little looking

To find the underlying germ, to

Ascertain what’s cooking.

Examples here are hepatitis

That is anicteric

And once again the UTI. And

Then there’s mesenteric

Adenitis that presents with

Pain that on the right is,

Similar to that found in

Acute appendicitis.

Binges

Don’t forget that little kids are

Greedy little devils

And often bring up after being at

Birthday party revels.

Poisoning

  Now, to those children with a fixation that is oral,

Here are some statements; each one with a moral:

The child that reaches for green peaches

Learns the lesson that this teaches.

Likewise she who chews dad’s pills

May go green about the gills.

Nausea and vomits follow

Kids who sundry poisons swallow.

Raised ICP

A group we must not fail to mention

  Have intracranial hypertension.

Infections, tumours – all may cause a

Puke with no preceding nausea.

So always probe for symptoms that

Point to trouble ‘neath the hat.

Headache, squint, a change in form, a

Fit, ataxia or head trauma.

Cyclical vomiting

Now, cyclical vomiting. I’ll

Try to give you a notion of it:

A child who’s well will, like hell,

Suddenly, profusely vomit.

She may get so dry

She may need I

V for rehydration

Yet in a day or so

She’ll want to go

Back to school and her education.

She’s well again, as right as rain

Yet she will be back

Puking like a drain, sunken-eyed again

In the midst of another attack.

The reason why this happens

I wish I could explain

But we know the child may go

On to suffer from migraine.

The recurrent nature of these bouts,

The rude health in between

Should rule out most of your doubts

And keep tests to the routine.

Psychological problems

  Some problems with the psyche

  And certain states of mind

  May make a child quite likely

To vomit be inclined.

A sight, a smell, excitement, joy,

The fear of a needle’s prick

May make a little girl or boy

Quite literally sick.

If an older child comes with vomiting

And the reason seems something of a poser

Just take note

Of the finger in the throat:

It’s a case of anorexia nervosa.

I’ll go on now we’ve been through

Causes and ages

And take a trip through all the

Clinical stages.

HISTORY

  History first. We want to know

More about the vomiting so

Quantity

We ask a few questions. Quantity first.

Is it enough to cause a thirst?

Does it dehydrate the child?

Is this major or only mild?

What proportion of each feed

Is returned and at what speed?

Character

  We’ve partly discussed this –

Projectile or posset?

Is it forceful or with ease

That she manages to toss it?

Contents

  And what’s in the stomach contents as they’re

Ejected or released?

Is it bile or blood or old food or what re-

mains of her last feast?

If blood, think first it’s swallowed

Eg. when a nipple cracks. This

Is like the older child who

Has an epistaxis.

But, as in older folk,

Vomiting blood may be no joke.

It may be from burst varices

Or bleeding peptic ulcer disease.

The presence of a green tint, bile,

Should make you think obstruction;

It may be paralytic il-

eus – needs drip and suction.

But it could be mechanical

Below ampulla of Vater

Where surgery is called for and

Medicine’s a non-starter.

Associated symptoms

Nausea we’ve discussed. It’s

Presence is suggestive

Of trouble that relates to part

Of the tract digestive.

In its absence, don’t be dull —

Think of trouble in the skull.

Associated symptoms

You need to find to sew up

The underlying cause that

Makes a little child throw up.

Diarrhoea would suggest the

Cause is enteritis.

Fever, stiff neck, crying point to

Likely meningitis.

A little trick- if a child is sick

As each new day is dawning

She may be in the grip of a postnasal drip

With a gut full of snot every morning

EXAMINATION

  Examination. There are two

Questions to select:

One: what caused the vomiting? and

Two: what’s its effect?

Hydration and nutrition

Two first: Check the child for the de-

gree of dehydration.

Is she still well nourished or

Showing emaciation?

A weak child may be short of

Ions: potassium, sodium, chloride

And may need their replacement intra-

venously supplied.

General

  Examination takes the form that

You’ve been taught so well:

All systems of the body may

Have a tale to tell.

Jaundice – that’s the liver;

Fever – that’s a bug;

Neonate, distension that could

Be meconium plug.

Abdomen

  The abdomen’s the focus of your

Int’rest like as not.

Can you palpate an organ?

Is there a tender spot?

Gaseous distension an

Obstruction would suggest

And peristalsis you can see will

Help you in your quest.

Don’t forget the rectal – it can

Help you when one sees

A low intussusception or per-

haps Hirschsprung’s disease.

Other systems

  Don’t ignore the ENT,

  Otitis you may miss

But I can’t talk of everything in a

Paper such as this.

SPECIAL TESTS

Investigations are dictated very

Much by what you find

But here are some remarks which you

Ought to keep in mind.

Always test the urine; Acid

Base if weak or dry

Along with the electrolytes which

May be low or high.

X-rays may be plain or contrast,

Use mainly in obstruction –

Barium can go in the top or by

Rectal introduction.

Ultrasound has got a place for

Seeking out of masses

That may cause copious vomiting in

Little lads and lasses.

These days its use for intussus-

ception or pyloric

Stenosis, GOR is nothing

Short of meteoric.

Other tests you order will re-

late to your conclusion

As to where you think the trouble is – of

These there’s a profusion.

But all in all our main help is

Always to be found

  When hist’ry and examination

  Are complete and sound.

Now remember at the start

Of this great work of art

A sentence that I’d like you

To learn off by heart.

Open your eyes

And lift that drooping ptosis:

Vomiting’s a symptom and is

  NOT a diagnosis.

TREATMENT

So – Management is One: General (re-

plenish body stores

of fluid and electrolytes);

Two: Specific (treat the cause).

Just one more thing: resist the urge,

Though mother may be keen,

To stop the kiddy’s vomit with a

Phenothiazine,

For Stemetil or Valoid

Are toxic to a baby

Or child and could produce a

Dyskinesia maybe.

So treat the cause and you will win

And baby’ll keep her dinner in.

So ends this thesis

On childhood emesis.

Early morning Hungarian rhapsody

Yes, for once in this chronicle of change and loss, I can wax rhapsodical. It is 4.30 am. I am driving home after a spell in the hospital with a critically ill baby. FMR plays an uninterrupted playlist at that time of day. An orchestral version of Liszt’s most famous Hungarian Rhapsody begins with its firm C sharp minor chord. Pah-dah! I eagerly anticipate the sharp-bestrewn fast section that I have had great fun getting my fingers round on the piano. And here it is – the orchestra playing showers of sharps, violinists’ fingers racing up and down F sharp major scales. We are nearing the end and I am taking the 270 degree left turn from the N2 on to the M5 when it dawns on my crepuscular consciousness that the players would have been playing C minor and F major, the simpler keys of the orchestral version! One up for Westwood…..worth being up at that time. Pah-dah!

B flat goes down to A

Strictly this is ‘back down to A’. The Scherzo of Mahler’s 1st symphony is written in A major. I turned on the car radio in the middle of the vigorous first section. I was not surprised to be hearing it up a semitone in B flat. Not what I would have chosen as my brain ‘sees’ the violins playing the wrong notes, so I can’t hear music purely for itself. When this section ends after whooping horns take over the rapid rising 5 note string theme, a single horn holds the key note of A, slows the music down and the A becomes part of the F major chord key for the slow Landler-type middle section. So the horn should have held a B flat to my altered key sense. But immediately it was an A and the music and I, in concert once more, moved into the written key of F, and stayed there. That is, till we parted company again when the Scherzo music returned….

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