Definition
Vomiting is an active rejection of some or all of the gastrointestinal contents through the mouth.
Vomiting must be differentiate by:
- Gastroesophageal reflux (corresponds to the reflux of gastric contents into the esophagus).
- Regurgitation (effortless rejection of liquid that has not yet reached the stomach).
- Pituite (rejection in the morning on an empty stomach in alcoholics).
- Merycism: the infant voluntarily raises the food bolus to the mouth.
Pathophysiology
Vomiting is controlled by a nerve center located in the brain bulb.
Vomiting takes place in several phases:
| Closing of the pylorus (orifice that connects the stomach and the duodenum (small intestine) |
| ↓ |
| Contraction of the antrum (terminal portion of the stomach located before the pylorus) |
| ↓ |
| Contraction of diaphragm and abdominal muscles |
| ↓ |
| Opening of the cardia (orifice communicating the esophagus and the stomach) |
| ↓ |
| Violent evacuation of gastric fluid |
VOMITING-CAUSES
Vomiting can be accompanied by digestive or extra-digestive conditions such as: occlusion, kidney colic.
Gastrointestinal infiammation
- Gastroenteritis
- Hepatitis
- Acute pancreatitis
- Chronic pancreatitis
- Peptic ulcer
- Gastroesophageal reflux
- Appendicitis
- Cholecystitis
- Crohn’s disease
- Peritonitis
Intestinal obstruction
- Atresia of the esophagus
- Intestinal atresia
- Stenosis of the pylorus
- Ileum
- Mechanical obstruction
- Non-mechanical obstruction
- Sub-ileum
- Stenosis
- Scars
- Inflammation
- Malicious
- Foreign bodies
- Volvulus
- Hernia
- Hiatal hernia
- Pseudo-obstruction
- Gastric outflow obstruction
- Esophageal stricture
- Achalasia
- Diabetic gastroparesis
Visceral pain
- Biliary colic
- Ischemic enterocolitis
- Pancreatitis
- Appendicitis
- Peritonitis
Stomach surgery
- Postgastrectomy syndrome (Billroth ll or Roux-Y)
- Vagotomy without pyloroplasty
Gastroparesis
- Diabetes mellitus
- Scleroderma
- Amyloidosis
- Metabolic
- Post-surgery
- Post-viral
- Idiopathic
Various abdominal causes
- Gastric cancer
- Carcinoma of the esophagus
- Esophageal diverticulum
- Esophagitis
- Mesenteric infarction
- Gastrocolic fistula
- Zollinger-Ellison syndrome
- Cholecystolithiasis
- Cholecystitis
- Gallbladder hydrops
- Peritonitis
- Pancreatitis
- Pancreatic cancer
- Urolithiasis
- Renal colic
- Pyelonephritis
- Ovarian cyst torsion
- Rupture of the ovarian tube
- Testicular torsion
- Dysmenorrhea
- Abdominal trauma
Infections
- Acute infections (especially in children)
- Scarlet fever
- Whooping cough
- Food poisoning
- Gastroenteritis
- Viral
- Bacterial
- Eosinophilic
- Parasitic
- Meningitis
- Meningoencephalitis
- Hepatitis
- Q fever
- Spotted fever
- Cholecystitis
- Appendicitis
- Pancreatitis
- Peritonitis
- AIDS
- Intestinal parasitosis
Drugs and toxins
- Alcohol abuse
- Antiarrhythmics
- Antibiotics
- Carbonic anhydrase inhibitors
- Chemotherapy
- Colchicine
- Digitalis(overdose)
- Drug abuse
- Drug side effects
- Ergot alkaloids
- Estrogen
- Food allergy
- Gastroenteritis
- Heavy metals
- Ipecac
- Mushroom poisoning
- Narcotics
- Opiates
- Phytoprotective agents
- Solvents
- Theophylline
- Sulfonamides
- Salicylates
- Reserpine
- Hydralasin
- Antirheumatics
- Procainamide
- Prostigmine
- Pilocarpine
- Estrogen
- Gesture geniuses
- Arsenic
- Ptalium
- Lead
- Nicotine
- Muscarin
Metabolic, endocrine
- Hepatic coma
- Metabolic acidosis
- Addison’s disease
- Kidney failure
- Uremia
- Diabetic precoma
- Thyrotoxicosis
- Hypothyroidism
- Diabetic ketoacidosis
- Hyperemesis gravidarum
- Hypoglycemia with fructose intolerance
- Adrenal insufficiency
- Hepatic porphyria
- Hypercalcemia
- Hyperparathyroidism
- Hyponatremia
- Overhydration
- Dehydration
- SIADH
Post-surgery
- Dumping syndrome
- Vagotomy
- Anastomotic stricture
- Afferent loop syndrome
Nervous system, vestibular disorders
- Travel sickness
- Meniere’s syndrome
- Acoustic neuroma
- Inflammation of the vestibular organ area
- Vestibular neuronitis
- Labyrinthitis
- Vertebrobasilar syndrome
- Ear infection
- Heat stroke
- Increased intracranial pressure
- Cancer
- Head trauma
- Hemorrhage
- Edema
- Meningitis
- Encephalitis
- Hydrocephalus
- Head trauma
- Migraine
- Tabes dorsal
- After cerebral irradiation
Eyes
- Refractive error
- Glaucoma
Cardiovascular
- Heart attack
- Heart failure
- Orthostatic reaction
- Hypertension
- Pulmonary embolism
- Cardiac arrhythmia
- Shock
- Collapse
Psychiatrists
- Anxiety
- Self induced
- Nervous anorexia
- Bulimia
- Psychogenic vomiting
- Occult vomiting
- Strong emotions
- Drug withdrawal
Various
- Morning sickness of the first months of pregnancy
- Motion sickness
- Acute altitude sickness
- After radiotherapy
- Strong pain
- Paroxysmal hemoglobinuria from cold
- Digestive strictures.
- Medication intake.
- Endocrine or metabolic disruption.
- Neurological causes.
- Psychological and/or psychiatric causes.
Complications
- Dehydration: monitoring of the skin fold, dryness of the mucous membranes, reduction in diuresis, constipation, tachycardia.
- Malnutrition: anorexia.
- Fluid and electrolyte disturbance: hyponatremia, hypokalemia.
- Esophagitis due to acidity of gastric fluid.
- Mallory-Weiss syndrome (damage to the esophageal mucosa).
- Spontaneous rupture of the esophagus.
- Eventration in the operated.
Treatments
- Anti-emetics.
- Compensate for hydroelectrolyte disorders.
- Treatment of the causes of vomiting.
VOMITING-what you need to evaluate
–When did the vomiting start?
-What was he doing at the moment?
-Does it occur at any particular moment of the day?
-What have you eaten in the last 24 hours? Does anyone in your family or friends have similar symptoms?
-Have you had a head injury in the last few days?
-What color is vomit (yellow, green, bright red, dark red, coffee color)?
- Vomiting of gastric juice: colorless.
- Bilious vomiting: yellow.
- Fecaloid vomiting: brown, foul-smelling.
- Bloody vomiting: bright red or black blood.
-What is the content of the vomit (food, fecaloid)?
-Does vomit have any particular smell?
-How much did he vomit at one time?
-How many times do you vomit in a day?
-Are you able to retain food or liquids after ingesting them?
-What did you try to do to stop the vomiting?
-It worked? Does anything improve you (lying still, eating crackers, drinking soda)?
-What makes it worse (for example, eating)?
-What other symptoms do you have (retching, nausea, pain, fever, abdominal distension, diarrhoea, weakness, neck stiffness, headache)?
Look for accompanying signs
Pallor, sweating, feeling sick, dizziness.
Abdominal pain.
Transit disorder.
Fever, change in pulse and blood pressure.
Sample form for vomiting data collection
| Content | Digested foods Undigested foods Aqueous Bilious Bright red blood Blood clots Caffeinated Fecaloid |
| Frequency | ….times/hour ….times/day |
| Odor | like sourness very bad smell |
| Quantity | little plentiful |
| Impulsivity | impulsive not impulsive |
| Preceded by | Nausea Abdominal pain Headache |
| Correlation with meals | just eaten ….hours after the meal it has no correlation with meals morning |
HOSPITALIZATION CRITERIA
The presence, even subtle, of symptoms such as:
- neurological symptoms
- the abdomen protected
- suspected bowel obstruction
- the doubt of coronary syndrome
- diabetic decompensation
require hospitalization for tests.
Clinical data to investigate
Investigate the characteristics of the vomiting (food, bilious or fecaloid), the mode of onset (postprandial, morning), any associated symptoms (headache, diarrhea, abdominal pain), age and clinical history (previous abdominal surgery , metabolic diseases, drugs).
SUGGESTIVE ELEMENTS OF DISEASE
It is necessary to distinguish vomiting from regurgitation, especially in the infant. Vomiting and epigastric pain may be the first signs of an acute appendicitis (useful clinical control within 6-12 hours).
The suspicion of intestinal obstruction is confirmed by the general conditions (dehydration), by the characteristics of the vomiting (bilious), by the abdominal examination (distension, softness, metal stamps) and by the finding of an empty rectal ampoule.
In the elderly, the finding of subocclusion due to faecal impaction (rectal exploration) is frequent.
Biliary colic often relapses in patients known to have gallbladder stones (pain in the right hypochondrium, radiating posteriorly).
DIAGNOSTIC ASSUMPTIONS OF PARTICULAR SEVERITY
In the infant, consider hypertrophic pyloric stenosis (voracity and weight loss).
Sudden jet presentation, associated with severe headache and/or vertigo syndrome, may be a sign of meningeal irritation and/or increased intracranial pressure.
Diabetic decompensation with severe metabolic acidosis can cause vomiting in the absence of abdominal pain.
Nausea and vomiting may be the only symptoms of an acute myocardial infarction.
In infants and in the elderly, vomiting may be associated with aspiration pneumonia (ab ingestis).
DIAGNOSTIC ASSUMPTIONS IN RELATION TO THE PATIENT’S AGE
In children, acetonemic vomiting is frequent in feverish states (malnutrition).
Intestinal flu is a frequent cause of vomiting in young people, as is the abuse of alcohol and/or drugs.
In young women always consider pregnancy, eating disorders (remember that anorexia and bulimia are often associated).
Biliary colic is frequent in multiparous women.
In diabetics, consider a possible metabolic decompensation, while subocclusions due to slow intestinal transit are frequent in the elderly (dehydration, drugs, hypokalaemia)