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Health-Process-Evidence-based Clinical Practice Guidelines for Vomiting

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 Questions.

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Health-Process-Evidence-based Clinical Practice Guidelines for Vomiting

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  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 • What is the operational concept of vomiting? Definition • Expulsion of gastrointestinal contents through the mouth due to a mechanical cause

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

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

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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. Vomiting General Management Guidelines Clinical Diagnosis Paraclinical Diagnosis Treatment

  13. Clinical Diagnosis VOMITING Mechanical Systemic Neurologic Infectious UGIT LGIT Esophagus Stomach Duodenum Colon Small Bowel Mass • Mechanical Obstruction • Stricture (PUD) • Mass (benign, malignant) Postoperative Adhesions Sphincter Fnxn Mechanical Obstruction

  14. 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?

  15. 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?

  16. 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?

  17. 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?

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

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

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

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

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

  23. 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.

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