1. Health-Process-Evidence- based Clinical Practice Guidelines for Vomiting JGGuerra, MD Surgery-OMMC 072706

2. Vomiting A. Overview of the Problem –Concept –Common Types –Common Causes B. General Management Guidelines –Clinical Diagnosis –Paraclinical Diagnosis –Treatment

3. Clinical Questions 1.What is the operational concept of vomiting? Definition Expulsion of gastrointestinal contents through the mouth due to a mechanical cause

4. 2. How is vomiting classified in terms of etiology? Systemic Infectious Neurologic GIT (Mechanical) Clinical Questions

5. 3. How is vomiting classified in terms of GIT origin? Upper GIT Lower GIT Clinical Questions

6. 4. How is vomitus classified in terms of its character? Nonbilous Bilous Fecaloid Clinical Questions

7. 5. How does the character of vomitus localize the site of obstruction? Nonbilous – proximal to ligament of treitz Bilous – distal to Ligament of Treitz Fecaloid – distal bowel Clinical Questions

8. 6. How is vomiting classified in terms of its onset? Early (postprandial) Late Clinical Questions

9. 7. How does the onset of vomiting localize the site of obstruction? Early (postprandial) – upper GIT Late – lower GIT Clinical Questions

10. 8. What are the levels of GIT obstruction that exhibit vomiting? Esophagus Stomach Small intestine Colon Clinical Questions

11. 9. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient is vomiting due to esophageal obstruction? Onset – immediately postprandial Characteristic – undigested food particles (chyme) Abdominal distention - none Clinical Questions

12. 10. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient is vomiting due to gastric outlet obstruction? Onset – early postprandial Characteristic – partially digested food Abdominal distention – minimal epigastric distention Clinical Questions

13. 11. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient is vomiting due to small intestinal obstruction? Onset – >2 days postprandial* Characteristic – bilous* Abdominal distention – minimal * Snape: Best Practice of Medicine. 2003 Clinical Questions

14. 12. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient is vomiting due to colonic obstruction? Onset – late Characteristic – fecaloid* Abdominal distention - marked * Tan Lay Zye: Merck. 2002 Clinical Questions

15. Vomiting General Management Guidelines Clinical Diagnosis Paraclinical Diagnosis Treatment

16. VOMITING Systemic Mechanical Neurologic Infectious UGIT LGIT Stomach Small Bowel EsophagusDuodenumColon Sphincter Fnxn Mechanical Obstruction A.Stricture (PUD) B.Mass (benign, malignant) Postoperative Adhesions Mass Clinical Diagnosis

17. Clinical Questions 13. If a paraclinical diagnostic procedure is needed in a patient with esophageal cause of vomiting, what is the most cost-effective procedure to do? BenefitRiskCostAvailability UGISSn rate: 80-85% SP rate: 82% radiation2k/ EndoscopySn rate: 95% SP rate: 98% perforation5k/ CT scanSn rate: 82% SP rate: 80% radiation3k/

18. Clinical Questions 14. If a paraclinical diagnostic procedure is needed in a patient with gastric outlet obstruction, what is the most cost-effective procedure to do? BenefitRiskCostAvailability UGISSn rate: 80-85% SP rate: 82% radiation2k/ EndoscopySn rate: 95% SP rate: 98% perforation5k/ CT scanSn rate: 82% SP rate: 80% radiation3k/

19. Clinical Questions 15. If a paraclinical diagnostic procedure is needed in a patient with small intestinal cause of vomiting, what is the most cost-effective procedure to do? BenefitRiskCostAvailability PFASn rate: 80% SP rate: 62% radiation2k/ CT scanSn rate: 82% SP rate: 80% radiation3k/

20. Clinical Questions 16. If a paraclinical diagnostic procedure is needed in a patient with colonic cause of vomiting, what is the most cost-effective procedure to do? BenefitRiskCostAvailability PFASn rate: 80% SP rate: 62% radiation2k/ ColonoscopySn rate: 95% SP rate: 93% perforation5k/ CT scanSn rate: 82% SP rate: 80% radiation3k/

21. Clinical Questions 17. What is the most cost-effective initial treatment for vomiting due to obstruction? NGT

22. Clinical Questions 18. What is the most cost-effective treatment for esophageal cause of obstruction? Depends on the nature and extent of the disease

23. Clinical Questions 19. What is the most cost-effective treatment for Gastric outlet obstruction? Benign – vagotomy + pyloroplasty Malignant – resection with reconstruction

24. Clinical Questions 20. What is the most cost-effective treatment for small intestinal obstruction? Surgery

25. Clinical Questions 21. What is the most cost-effective treatment for colonic obstruction? Surgery

26. 1. Jaffin BW, Kaye MD: The prognosis of gastric outlet obstruction. Ann Surg 1985 Feb; 201(2): 176-9. 2. Levine MS, eds. Textbook of Gastrointestinal Radiology. 2nd ed. Philadelphia, Pa: WB Saunders; 2000: 514-45. 3. Rosen, RT. Rosen's Emergency Medicine: Concepts and Clinical Practice,Nausea and Vomiting 5th ed. St. Louis: Mosby; 2002:178-85. 4. Snape, WJ. Best Practice in Medicine. 536.2.Aug, 2003.