Projectile Vomiting

Projectile vomiting can be defined as the forceful expulsion of vomit, being preceded by the gagging sensation. Nausea is not often encountered before the projectile vomiting. In fact, in the majority of the cases, the onset is pretty sudden, without any warning signs (no discomfort or pain at the level of the abdomen). The severe vomiting can lead to dehydration, especially if no measures are taken to re-hydrate the body.

As you will have the opportunity to see below, projectile vomiting is often seen in newborns. In this situation, the underlying diagnosis is represented by the pyloric stenosis. While it is true that all babies may vomit from time to time, it is also true that projectile vomiting is not the regular vomit experience, typical for newborns and small babies. According to the most recent statistics, 1 in 500 babies suffer from pyloric stenosis, this condition being often diagnosed in the first three months of life (only rarely diagnosed after that age). The administration of antibiotics, such as erythromycin, in the first two weeks of life, increases the risk for pyloric stenosis and projectile vomiting. So, great care must be taken when administering such kind of treatments.

Symptoms of Projectile Vomiting

In babies who are suffering from pyloric stenosis, the following symptoms are present, apart from the projectile vomiting:

• Dehydration signs
  • Dry mouth
  • Lethargy
  • No wet diaper (for more than several hours)
• Feeling constantly hungry
• Weight loss
• Reduced number of stools/loose bowel movements
• The tummy appears to be swollen
• Contractions at the level of the abdomen
• Anxiety and agitation right before vomiting.

Causes of Projectile Vomiting

These are the most common causes that lead to the appearance of projectile vomiting:

• Gastric outlet obstruction
  • The passage between the stomach and the small intestine is blocked (partially or completely)
• Triggers with influence over the brain (chemoreceptor trigger zone/vomit center – medulla)
• Bowel obstruction
• Any disease or process that may result in the delayed emptying of the gastric contents
• Increased pressure at the level of the cranium (sudden onset)
  • Hydrocephalus
  • Intracranial bleeding (hemorrhage)
  • Tumor
  • Infections (meningitis, encephalitis)
  • Head injuries
• Intoxication or poisoning with different substances
• Forced feeding/overeating
  • Associated distension (esophagus, stomach, duodenum etc.)
  • Gut motility is impaired
• Other causes
  • Peptic ulcer disease
  • Gallstone obstruction (Bouveret syndrome)
  • Gastric/duodenal polyps
  • Accidental ingestion of toxins/poisoning
  • Medication (emetics)
  • Purging substances
• Rare/unusual causes
  • Psychogenic causes
    • Extreme fear or shock (children)
    • Abuse or violence
    • Exposure to violent images
  • Shaken baby syndrome
    • Sudden increase in intracranial pressure
    • Can also lead to spinal cord injury
  • Kidney problems
    • Changes in pH
    • May also lead to acidosis or uremia
    • Can stimulate the chemoreceptor trigger zone, leading to projectile vomiting.

These are the major causes of projectile vomiting in children:

• Stomach/bowel obstruction
• Gastric outlet obstruction – pyloric stenosis (newborn, babies and infants)
  • Congenital condition
  • Diagnosed in the first three months after birth
  • Forceful vomit (no bile content)
  • Bile content present – obstruction distal to the pylorus (duodenal atresia)
• Intussusception – medical condition in which a part of the intestine invaginates into another section of the intestine
• Hirschsprung’s disease – medical condition in which the ganglia at the level of the distal colon are absent
• Intestinal malrotation – medical condition characterized by an abnormal rotation of the midgut (congenital anomaly)
• Ingested foreign objects – more common in toddlers or older children; can lead to obstruction at the level of the upper gut
• Ingestion of toxic or poisonous substances.

Diagnosis

These are the methods used for the diagnosis of pyloric stenosis in babies:

• Physical examination
• Ultrasound of the belly
• Blood tests – electrolyte levels
• Barium X-ray – visualization of the intestines.

Treatment

The treatment is concentrated on two directions. On one hand, it is important that the patient is stabilized, with the vital signs maintained within the normal levels. Intravenous fluids are administered, in order to prevent dehydration and compensate for the recent loss of fluids. On the other hand, the treatment will concentrate on the underlying cause. For babies diagnosed with pyloric stenosis, the recommended treatment is surgical. The procedure is known as a pyloromyotomy, allowing for the stenosis to be removed and things to go back to normal (normal or laparoscopic approach). The laparoscopic technique is today preferred to the open, normal approach, due to the fact that it is less invasive and it requires fewer days in the hospital. Plus, given the fact that only small incisions are made, the recovery is better and faster.

The surgical intervention is completely safe, being considered a standard procedure. Generally, the babies have to spend one or two days in the hospital and they can return to the breast milk or formula, as soon as the administration of intravenous fluids has been stopped. It may happen that one or two episodes of projectile vomiting occur after the surgical intervention but that is completely normal. However, if the projectile vomiting continues after the surgery, it is for the best to re-visit the doctor. There are some babies (1-2%) who may require a second surgical intervention, in order to escape from such problems. This is because the procedure has been incompletely performed, requiring the second intervention for the correction of the defect.

It is important to understand that only a few cases of pyloric stenosis can be treated solely with medication (the majority require surgical intervention). Atropine is one of the most commonly used substances for the treatment of pyloric stenosis, being administered either orally or intravenously. However, it should be mentioned that the treatment with atropine has a success rate of 85-89%, in comparison to the surgical intervention, where the success rate is of 100%. The treatment with atropine is often recommended in children for whom the surgery is not advised, either because of the associated complications or the anesthesia-related risks.

Complications

In the situation that a baby suffers from projectile vomiting, immediate intervention is more than necessary. Among the complications that can occur, there are: severe dehydration, weight loss and vascular shock.