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Differential diagnosis of vomiting and gastroesophageal reflux in infants and children

Differential diagnosis of vomiting and gastroesophageal reflux in infants and children
Gastrointestinal disorders Infectious causes
Obstruction
  • Intussusception*
  • Hypertrophic pyloric stenosis*
  • Foreign body
  • Hirschsprung disease
  • Intestinal malrotation or volvulus
  • Duodenal or intestinal hematoma
  • Esophageal, pyloric or intestinal stenosis, atresia, or web
  • Esophageal, gastric, or intestinal duplication
  • Gastric bezoar, volvulus, or tumor
  • Superior mesenteric artery syndrome
  • Intestinal pseudo-obstruction
  • Adhesions, including congenital adhesions
  • Incarcerated hernia
  • Tumors
  • Meconium ileus or equivalent
  • Imperforate anus

Other gastrointestinal disorders

  • Gastroesophageal reflux*
  • Gastritis, esophagitis*
  • Eosinophilic esophagitis/gastroenteritis
  • Food intolerance or allergy*
  • Gastroparesis (eg, postviral)
  • Appendicitis
  • Cholecystitis, cholelithiasis
  • Pancreatitis
  • Ulcerative colitis or Crohn disease
  • Peptic ulcer
  • Achalasia or chalasia
  • Tracheoesophageal fistula
  • Choledochal cyst
  • Gastroenteritis*
  • Group A streptococcal infections* (including pharyngitis)
  • Otitis media*
  • Sepsis
  • Meningitis, encephalitis, or brain abscess
  • Pneumonia
  • Pyelonephritis or other urinary tract infection
  • Hepatitis
  • Hepatic abscess
Endocrine and metabolic causes
  • Diabetic ketoacidosis
  • Uremia (eg, from obstructive uropathy or kidney insufficiency)
  • Renal tubular acidosis
  • Hypercalcemia
  • Congenital adrenal hyperplasia
  • Diabetes insipidus
  • Inborn errors of metabolism, including:
    • Disorders of carbohydrate intolerance (eg, galactosemia, hereditary fructose intolerance)
    • Amino acid and organic acid disorders (eg, maple syrup urine disease)
    • Urea cycle defects
    • Fatty acid oxidation defects
    • Mitochondrial disorders
Genitourinary causes Neurologic causes
  • Hydronephrosis
  • Urinary tract obstruction
  • Kidney stones
  • Hydrometrocolpos
  • Testicular or ovarian torsion
  • Kidney insufficiency
  • Migraine
  • Trauma (postconcussive)
  • Increased intracranial pressure (eg, hydrocephalus, intracranial mass)
  • Epilepsy
  • Subdural hematoma
  • Intracranial hemorrhage
Toxic ingestions Miscellaneous causes
  • Lead intoxication
  • Iron intoxication
  • Alcohol intoxication (ethanol or other toxic alcohol)
  • Vitamin A or D intoxication
  • Organophosphate exposure
  • Medications (ipecac, digoxin, theophylline)
  • Cannabinoid hyperemesis syndrome (chronic cannabis use)
  • Coughing (posttussive)*
  • Pregnancy
  • Falsely reported or induced illness (Munchausen syndrome by proxy)
  • Poor feeding technique
    • Improper formula preparation
    • Excessive air swallowing
    • Inappropriate handling after feeding
  • Psychogenic vomiting or bulimia
  • Rumination syndrome
  • Postnasal drip
  • Cyclic vomiting syndrome
  • Cricopharyngeal incoordination
  • Vestibular injury or inflammation
  • Heart failure

* Common causes.

¶ Important causes to remember because these disorders may not be obvious and prompt diagnosis affects outcome.
References:
  1. Vomiting. In: Signs and Symptoms in Pediatrics, 3rd ed, Tunnessen WW Jr, Roberts KB (Eds), Lippincott Williams & Wilkins, Philadelphia 1999. p.491 and Pediatrics GE reflux clinical practice guidelines. J Pediatr Gastroenterol and Nutr 2001; 32:S1.
  2. Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498.
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