red flag symptoms suggesting a disorder other than GOR (GORD)
Last reviewed 08/2021
'Red flag' symptoms suggesting disorders other than GOR
| Symptoms and signs | Possible diagnostic implications | Suggested actions |
| Gastrointestinal | ||
| Frequent, forceful (projectile) vomiting | May suggest hypertrophic pyloric stenosis in infants up to 2 months old | Paediatric surgery referral |
| Bile-stained (green or yellow-green) vomit | May suggest intestinal obstruction | Paediatric surgery referral |
| Haematemesis (blood in vomit) with the exception of swallowed blood, for example, following a nose bleed or ingested blood from a cracked nipple in some breast-fed infants | May suggest an important and potentially serious bleed from the oesophagus, stomach or upper gut | Specialist referral |
| Onset of regurgitation and/or vomiting after 6 months old or persisting after 1 year old | Late onset suggests a cause other than reflux, for example a urinary tract infection. Persistence suggests an alternative diagnosis |
Urine microbiology investigation Specialist referral |
|
Blood in stool
|
May suggest a variety of conditions, including bacterial gastroenteritis, infant cows' milk protein allergy or an acute surgical condition |
Stool microbiology investigation Specialist referral |
| Abdominal distension, tenderness or palpable mass | May suggest intestinal obstruction or another acute surgical condition | Paediatric surgery referral |
| Chronic diarrhoea | May suggest cows' milk protein allergy | Specialist referral |
| Systemic | ||
|
Appearing unwell Fever |
May suggest infection |
Clinical assessment and urine microbiology investigation Specialist referral |
| Dysuria | May suggest urinary tract infection |
Clinical assessment and urine microbiology investigation Specialist referral |
| Bulging fontanelle | May suggest raised intracranial pressure, for example, due to meningitis | Specialist referral |
|
Rapidly increasing head circumference (more than 1 cm per week) Persistent morning headache, and vomiting worse in the morning |
May suggest raised intracranial pressure, for example, due to hydrocephalus or a brain tumour | Specialist referral |
| Altered responsiveness, for example, lethargy or irritability | May suggest an illness such as meningitis | Specialist referral |
| Infants and children with, or at high risk of, atopy | may suggest cows' milk protein allergy | Specialist referral |
Perform an urgent (same day) upper GI contrast study for infants with unexplained bile-stained vomiting. Explain to the parents and carers that this is needed to rule out serious disorders such as intestinal obstruction due to mid-gut volvulus.
Consider an upper GI contrast study for children and young people with a history of bile-stained vomiting, particularly if it is persistent or recurrent.
Offer an upper GI contrast study for children and young people with a history of GORD presenting with dysphagia.
Arrange an urgent specialist hospital assessment to take place on the same day for infants younger than 2 months with progressively worsening or forceful vomiting of feeds, to assess them for possible hypertrophic pyloric stenosis.
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