health-process-evidence- based clinical practice guidelines for vomiting jgguerra, md surgery-ommc...

Health-Process-Evidence-based Clinical Practice

Guidelines for Vomiting

JGGuerra, MD

Surgery-OMMC

072706

Vomiting

A. Overview of the Problem– Concept– Common Types– Common Causes

B. General Management Guidelines– Clinical Diagnosis– Paraclinical Diagnosis– Treatment

Clinical Questions1. What is the operational concept of

vomiting?

Definition

• Expulsion of gastrointestinal contents through the mouth due to a mechanical cause

2. How is vomiting classified in terms of etiology?

• Systemic

• Infectious

• Neurologic

• GIT (Mechanical)

Clinical Questions

3. How is vomiting classified in terms of GIT origin?

• Upper GIT

• Lower GIT

Clinical Questions

4. How is vomitus classified in terms of its character?

• Nonbilous• Bilous • Fecaloid

Clinical Questions

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

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

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

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

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

Vomiting

General Management Guidelines

•Clinical Diagnosis

•Paraclinical Diagnosis

•Treatment

VOMITING

Systemic Mechanical

NeurologicInfectious

UGIT LGIT

Stomach Small BowelEsophagus Duodenum Colon

Sphincter Fnxn

Mechanical Obstruction

Mechanical ObstructionA. Stricture (PUD)B. Mass (benign, malignant)

Postoperative Adhesions

Mass

Clinical Diagnosis

Clinical Questions13. If a paraclinical diagnostic procedure is needed

in a patient with esophageal cause of vomiting, what is the most cost-effective procedure to do?

Benefit Risk Cost Availability

UGIS Sn rate: 80-85%

SP rate: 82%

radiation 2k /

Endoscopy Sn rate: 95%

SP rate: 98%

perforation 5k /

CT scan Sn rate: 82%

SP rate: 80%

radiation 3k /

Clinical Questions14. If a paraclinical diagnostic procedure is needed

in a patient with gastric outlet obstruction, what is the most cost-effective procedure to do?

Benefit Risk Cost Availability

UGIS Sn rate: 80-85%

SP rate: 82%

radiation 2k /

Endoscopy Sn rate: 95%

SP rate: 98%

perforation 5k /

CT scan Sn rate: 82%

SP rate: 80%

radiation 3k /

Clinical Questions15. 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?

Benefit Risk Cost Availability

PFA Sn rate: 80%

SP rate: 62%

radiation 2k /

CT scan Sn rate: 82%

SP rate: 80%

radiation 3k /

Clinical Questions16. If a paraclinical diagnostic procedure is needed

in a patient with colonic cause of vomiting, what is the most cost-effective procedure to do?

Benefit Risk Cost Availability

PFA Sn rate: 80%

SP rate: 62%

radiation 2k /

Colonoscopy Sn rate: 95%

SP rate: 93%

perforation 5k /

CT scan Sn rate: 82%

SP rate: 80%

radiation 3k /

Clinical Questions17. What is the most cost-effective initial

treatment for vomiting due to obstruction?

• NGT

Clinical Questions18. What is the most cost-effective

treatment for esophageal cause of obstruction?

• Depends on the nature and extent of the disease

Clinical Questions19. What is the most cost-effective

treatment for Gastric outlet obstruction?

• Benign – vagotomy + pyloroplasty• Malignant – resection with reconstruction

Clinical Questions20. What is the most cost-effective

treatment for small intestinal obstruction?

• Surgery

Clinical Questions21. What is the most cost-effective

treatment for colonic obstruction? • Surgery

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.