Vomiting is a protective reflex that results in forceful ejection of stomach contents up to and out of the mouth. It is a common complaint and may be the presenting symptom of several life-threatening conditions. It can be caused by a variety of organic and non-organic disorders; Gastro Intestinal (GI) or outside of GI [1]. The primary care practitioner needs to remember that vomiting does not localize the problem to the GI system in young infants but can be a non-specific manifestation of an underlying systemic illness such as a urinary tract infection, sepsis, or an inborn error of metabolism. Non-organic causes are much more difficult to identify and often are viewed as diagnoses of exclusion. Examples of non-organic causes of vomiting are psychogenic vomiting, cyclic vomiting syndr ome, abdominal migraine and bulimia [2].

Initial evaluation is directed at assessment of airway, breathing and circulation, assessment of hydration status and red flag signs (bilious or bloody vomiting, altered sensorium, toxic/septic/apprehensive look, inconsolable cry or excessive irritability, severe dehydration, concern for symptomatic hypoglycemia, severe wasting). Management priorities include treatment of dehydration, stoppage of oral fluids/feeds and decompression of the stomach with nasogastric tube in patients with bilious vomiting [1].

One year descriptive study included 1301 infants and children admitted to gastro-enterology and hepatology unit of Assiut University Children Hospital during the period from August 2015 to July 2016 presenting with vomiting. Their age varied from 1 month to 17 years, they were 786 male and 515 female.

Inclusion criteria

All cases presented with vomiting either isolated or associated with other symptoms.

Exclusion criteria

Neonates are not included in our study.

Full thorough history and clinical examination were done to all cases: age, sex, weight, diarrhea, constipation, abdominal distention, respiratory symptoms, sore throat, dysuria, polyuria, convulsions, fever, hemodynamic stability, dehydration. Abdominal tenderness, bowel sounds, neurological, cardiac, chest, abdominal examinations.

All cases were subjected to the following investigations: complete blood picture, serum creatinine, serum electrolytes, random blood glucose, arterial blood gases. The following investigations were done according to clinical symptoms and signs associated with vomiting in every case as liver enzymes, pancreatic amylase, urinalysis, cerebro- spinal fluid, blood culture, chest X-ray, abdominal ultrasound, CT scan, GI endoscopy and gastrograffin studies. The metabolic and endocrinal essay was done when indicated (Tables 1-7).

After exclusion of gastroenteritis, Table 1 show that commonest GI cause of vomiting in infancy is GERD (12%) while most common non- GI causes of vomiting in infancy is upper respiratory infections (14.7%). this is comparable with American Academy of Pediatrics (AAP) [3]. In toddler and children, it was found that commonest GI cause of vomiting is intussusception (2.2%) while most common Non-GI causes of vomiting is meningitis (6.7%) however this is disagree with AAP [3] who stated that most common GI cause of vomiting is GERD and most common non-GI cause of vomiting is Urinary Tract Infection (UTI). In Adolescences it was found that commonest GI cause of vomiting is H. Pylori infection (10.4%) and this is agree with Ozen et al. who states that the age for H. pylori infection is Adolescences [4], although the commonest presentation is recurrent abdominal pain [5].

Table 1: GI causes and non-GI causes of vomiting according to the age after exclusion of gastroenteritis.

Regarding the associated symptoms with vomiting (Table 2), there was statistically significant difference between GI and non-GI causes of vomiting. abdominal distention was most associated symptom in cases with vomiting due to GI causes (25.8%). this may be due to most of our cases were intestinal obstruction (Malrotation and Intussusception) after excluding cases of gastroenteritis. this agrees with Bales and Liacouras [6] who stated that intestinal obstruction is commonly associated with abdominal distention. On other hand, the most associated symptom in cases with vomiting due to non-GI causes was fever (63.8%) followed by convulsions (32.2%). This most probably is due to CNS infections or hydrocephalus and intra-cranial Hemorrhage. This is comparable to that reported by Prober and Mathew who stated that convulsions occur in 20-30% of patients with meningitis [7].

Table 2: Symptoms of GI cause and non-GI causes of vomiting other than gastroenteritis.

Regarding the clinical signs (Table 3), there was statistically significant difference between GI and non-GI causes of vomiting. Dehydration (25.2%) was the most common sign in cases with vomiting due to GI causes after excluding cases of gastroenteritis. This may be related to poor oral intake and/or persistent vomiting. This agrees with Granado-Villar et al. [8]. On other hand, it was observed that most common sign in cases with vomiting due to non-GI causes was disturbed consciousness (37.3%) followed by signs of meningeal irritation and ↑ ICP (31.6%). This was due to CNS infections. This agrees with Prober and Mathew who stated that Alterations of mental status are common among patients with meningitis and may be the consequence of increased ICP [7].

Table 3: Signs of GI cause and non-GI causes of vomiting other than gastroenteritis.

Regarding laboratory investigations (Table 4), it was observed that all laboratory investigations are significantly different between GI and non-GI causes of vomiting. Anemia (≤ 11 g/dl, microcytic hypochromic) was present in 86.8% of the cases with vomiting due to GI causes. This may be related to poor oral intake and may be due to associated parasitic infestation. Leukocytosis (>10.5 × 10^3 cells/ mm3) was present in 35.1% of the cases with vomiting due to Non-GI causes. This is most probably due to CNS infections and respiratory infections. Positive antibodies against H. pylori infection in serum was present in 19.9% of cases diagnosed as H. pylori infection. This agrees with Blanchard and Czinn [5] who stated that serologic assays using validated immunoglobulin G antibody detection may be helpful for screening children for the presence of H. pylori [5].

Table 4: Lab investigations of GI cause and non-GI causes of vomiting other than gastroenteritis.

Regarding abdominal U/S (Table 5), picture suggestive of CHPS was present in 15 cases out of 27 with GI causes of vomiting. This agrees with Niedzielski et al. who stated that the specificity and sensitivity of ultrasound in diagnosing CHPS in the hands of experienced pediatric radiologists are very high with 98 and 100%, respectively [9]. Regarding plain erect, air-fluid level picture of intestinal obstruction was present in 10 cases out of 18 with GI causes of vomiting. This agrees with Bales and Liacouras who stated that a plain radiograph is the initial diagnostic study and can provide valuable information about potential associated complications, Upright or cross table lateral views typically demonstrate a series of air–fluid levels in the distended loops [6].

Regarding cases of vomiting due to acute gastroenteritis (Table 6), it was observed that dehydration (74.3%) was most common symptom followed by fever (55.7%). This agrees with Bhutta who stated that without early and appropriate rehydration, many children with acute diarrhea would develop dehydration with associated complications [10].

Regarding etiology of gastroenteritis (Table 7), it was observed that infectious causes of gastroenteritis were present in 96.4% of the cases. This may be due to bacterial, viral, parasitic or fungal infections. Graves Reported that viral gastroenteritis represent 50%-70%, bacterial gastroenteritis represent 15%-20%, parasitic gastroenteritis represent 10%-15% of total cases of gastroenteritis [11]. This is confirmed from our results where leukocytosis was present in 8.8%, this indicate that the use of antibiotics in diarrhea is of limited scope. Therefore the use of antibiotics in acute gastroenteritis should be limited to cases of specific enteric bacterial infection, systemic infection, infections in immunocompromised patients.

From this study we concluded that the commonest cause of vomiting in infancy was GERD while in children was Intussusception and in adolescence was H. pylori infection , the most common surgical cause of vomiting was CHPS, abdominal U/S and gastrograffin were useful tools for diagnosis of CHPS, vomiting with convulsions was most probably due to CNS infection, outcome of both medical and surgical cause was very satisfactory, percentage of infectious gastroenteritis was 96.4%, however bacterial infection was limited to 8.8% of the cases.