Gastroenterology Book

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VomitingAka: Nausea, Emesis, Retching, Dry Heaves, Projectile Vomiting, Hematemesis, Coffee-ground Emesis, Stercoraceous Vomiting, Bilious Emesis

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  1. See Also
    1. Vomiting in Children
  2. Definitions
    1. Nausea
      1. Urge to vomit, "sick to stomach" or "queasy"
    2. Vomiting (Emesis)
      1. Forcible expulsion of stomach contents
    3. Retching
      1. Spasms of respiratory muscle activity before emesis
    4. Regurgitation
      1. Passive retrograde flow of esophageal contents
    5. Rumination
      1. Chewing and swallowing of regurgitated food
    6. Dry Heaves (non-productive vomiting)
      1. Retching without expulsion of any gastric contents
    7. Projectile Vomiting
      1. Forceful emesis without preceding nausea
      2. Associated with increased Intracranial Pressure
    8. Chronic nausea and vomiting
      1. Nausea and vomiting persisting longer than one month
    9. Hematemesis
      1. Vomiting of fresh blood
    10. Coffee-ground emesis
      1. Vomiting of black blood (altered)
    11. Stercoraceous Vomiting
      1. Vomiting of fecal material (due to obstruction)
    12. Bilious Emesis
      1. Vomiting of bile stained (green) fluid
  3. Pathophysiology
    1. Nausea usually precedes vomiting
    2. Physiologic Control of Vomiting
      1. Lateral reticular formation in medulla
      2. Chemical stimulation via chemoreceptor trigger zone
    3. Vomiting is of Involuntary mechanism
      1. Glottis closes
      2. Diaphragm contracted and fixed
      3. Pylorus closes
      4. Gastric wall and esophageal orifice relaxes
      5. Abdominal muscles contract forcefully
    4. Associated physiologic events
      1. Ptyalism (Excessive Salivation)
      2. Tachycardia (occurs with nauses)
      3. Bradycardia (occurs with retching)
      4. Defecation (may accompany vomiting)
  4. Causes
    1. See Vomiting Causes
    2. See Vomiting Causes in Children
    3. See Vomiting in Pregnancy (Morning Sickness)
    4. See Vomiting in Cancer
    5. See Psychogenic Vomiting
    6. See Medication Induced Vomiting
    7. Most Common Causes
      1. Acute Gastroenteritis
      2. Medication Induced Vomiting
  5. History
    1. See Vomiting Causes for Clinical Clues
    2. Nutrition intake
      1. Timing between food and emesis
      2. Weight loss
    3. Gastrointestinal Symptoms or Signs
      1. Abdominal Pain before vomiting (red flag)
      2. Signs of Gastrointestinal Bleeding
        1. Hematemesis
        2. Melana
      3. Heartburn or indigestion
      4. Dysphagia
      5. Constipation
      6. Diarrhea
      7. Jaundice
    4. Systemic Symptoms and Signs
      1. Fever
      2. Malaise or Fatigue
      3. Weight loss (red flag)
    5. Neurologic Symptoms and Signs
      1. Focal neurologic deficits
      2. Papilledema
      3. Altered Level of Consciousness
  6. Examination
    1. Observe for dehydration
      1. Weight loss since prior exam
      2. Decreased skin turgur
      3. Dry mucus membranes
      4. Tachycardia
      5. Orthostatic Hypotension
    2. Neurologic Examination
      1. Nystagmus
      2. Papilledema
      3. Focal neurologic deficits
      4. Peripheral Neuropathy
      5. Cerebellar exam (coordination and gait testing)
      6. Altered Level of Consciousness
    3. Abdominal examination
      1. Abdominal distention
      2. Inguinal Hernia or abdominal wall hernia
      3. Abdominal tenderness to palpation
        1. Epigastric Pain: Gastric Ulcer
        2. Right upper quadrant pain: Cholecystitis
      4. Bowel sounds
        1. High pitched suggests Bowel Obstruction
        2. Absent or decreased suggests ileus
    4. Skin
      1. Jaundice
  7. Differential Diagnosis
    1. See Vomiting Causes
    2. Ptyalism (Excessive Salivation)
    3. Gastroesophageal Reflux Disease (Acid Reflux)
    4. Forceful Coughing
    5. Undigested Food Regurgitation
      1. Esophageal Obstruction
      2. Esophageal Diverticulum
      3. Overfilled Stomach
  8. Labs
    1. Complete Blood Count
    2. Serum Electrolytes (e.g. Chem8 or SMA-7)
    3. Liver Function Tests
    4. Serum Lipase
    5. Erythrocyte Sedimentation Rate
    6. Urinalysis
    7. Urine Pregnancy Test
    8. Consider Thyroid Stimulating Hormone (TSH)
    9. Consider serum drug levels of current medications
    10. Consider stool studies for concurrent Diarrhea
      1. Stool Leukocytes
      2. Fecal Occult Blood
      3. Clostridium difficile
      4. Stool Culture
      5. Ova and Parasites (and Giardia antigen)
    11. Electrocardiogram
  9. Imaging (as clinically directed)
    1. Abdominal Flat and Upright XRay Indications
      1. Signs or symptoms of mechanical obstruction
      2. Small Bowel Obstruction
      3. Gastric outlet obstruction
    2. Chest XRay
    3. Upper GI with small bowel follow through
      1. Double-contrast barium studies are more accurate
      2. Evaluation of function (e.g. Gastroparesis)
    4. Abdominal CT with oral and IV Contrast
      1. Detection of Intestinal Obstruction or abdominal mass
    5. Right upper quadrant ultrasound
    6. MRI Head
      1. Indicated to evaluation for intracranial mass
  10. Diagnostics
    1. Upper endoscopy
      1. Most sensitive for mucosal lesions
    2. Gastric Emptying Study (Evaluates for Gastroparesis)
      1. Ingestion of radiolabeled meal
    3. Electrogastrography (Abnormal gastric emptying)
      1. Electrodes placed on abdominal skin over antrum
    4. Antroduodenal Manometry
      1. Measures intraluminal pressure over time
  11. Management: Symptomatic
    1. See Antiemetic
    2. See Vomiting Management in Children
    3. See Vomiting in Pregnancy
    4. See Postoperative Nausea and Vomiting
    5. See Vomiting in Cancer
  12. Management: Persistent Unexplained Vomiting
    1. Complete history, physical, diagnostics completed
    2. Consider dysmotility evaluation
      1. Consider possible Gastroparesis causes
      2. Consider empiric prokinetic
    3. Consider functional causes or Psychogenic Vomiting
    4. Consider longterm symptomatic therapy
  13. Complications
    1. Dehydration
    2. Electrolyte disturbance
      1. Hypokalemia
      2. Metabolic Alkalosis
    3. Mallory Weiss Tear
    4. Esophageal Rupture
    5. Aspiration Pneumonia
  14. References
    1. (1988) Dorland's Medical Dictionary, Saunders, p. 1848
    2. Feldman (1998) Sleisenger Gastrointestinal, p. 117-126
    3. Friedman (1991) Medical Diagnosis, Little Brown, p. 174
    4. Heilenbach in Marx (2002) Rosen's Emergency Med, p. 178
    5. Quigley (2001) Gastroenterology 120(1):263

Hematemesis (C0018926)

Definition (MSH)Vomiting of blood that is either fresh bright red, or older "coffee-ground" in character. It generally indicates bleeding of the UPPER GASTROINTESTINAL TRACT.
Definition (NCI)Hematemesis; vomiting blood.
ConceptsPathologic Function (T046)
ICD9578.0, 578.0
MSHD006396
BasqueHEMATEMESIA/ODOL GOITIKOA
DanishBlod i opkast/haematemese
DutchHaematemesis/bloed braken
EnglishEMESIS BLOODY, HAEMATEMESIS, Hematemeses, Hematemesis, Hematemesis/vomiting blood, Vomiting blood, Vomiting of blood
FinnishVERIOKSENNUS/HEMATEMESIS
FrenchHematemese, Hematemese/vomissement de sang
GermanBluterbrechen/Haematemesis
Hebrewhematemezis
Hungarianhaematemesis/veres hanyas
ItalianEmatemesi, Ematemesi/vomito sanguinolento
NorwegianOPPKAST MED BLOD/HEMATEMESE
PortugueseHematemese/vomito de sangue
Spanishhematemesis, Hematemesis/vomito sanguineo, vomito de sangre
SwedishHEMATEMES/BLODKRAKNING
Parent ConceptsGastrointestinal Hemorrhage (C0017181), Hemorrhage (C0019080), Hemorrhagic Disorders (C0019087), Digestive System Disorders, General, Functional and NEC (C0549522), GASTRIC/DUODENAL (C0549614), Gastrointestinal system (C0012240), Symptoms and Complaints Component (C0497525), Vomiting (C0042963), Upper gastrointestinal hemorrhage (C0041909), Duplicate concept (C1274013)
SourcesAOD, CCS, COSTAR, CSP, CST, DXP, ICD9CM, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, LCH, MSH, MTH, MTHICD9, MTHMST, MTHMSTFRE, MTHMSTITA, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Nausea (C0027497)

Definition (MSH)An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses.
Definition (CSP)unpleasant sensation in the stomach usually accompanied by the urge to vomit.
Definition (NCI)The sensation that one is about to vomit.
ConceptsSign or Symptom (T184)
MSHD009325
BasqueGORAGALEAK
DanishKvalme
DutchMisselijkheid
EnglishC/O - nausea, Feeling bilious, FEELING QUEASY, Feeling sick, Finding of nausea, Nausea, Nausea symptoms, Nauseated, Nauseous, Observation of nausea, QUEASY
FinnishPAHOINVOINTI
FrenchNausee
GermanUebelkeit
Hebrewbxila
Hungarianhanyinger
ItalianNausea
NorwegianKVALME
PortugueseNausea
Spanishhallazgo de nausea, Nausea, nauseas, nauseoso, observacion de nauseas
SwedishILLAMAENDE
Parent ConceptsDigestive symptom (C0476288), Signs and Symptoms, Digestive (C0037089), Digestive System Disorders, General, Functional and NEC (C0549522), GASTRIC/DUODENAL (C0549614), Gastrointestinal system (C0012240), Symptoms and Complaints Component (C0497525), [D]Nausea and vomiting NOS (C0027498), Nausea (C0027497), Gastrointestinal tract finding (C1261141), Erroneous concept (C1274015), Ambiguous concept (C1274012), Duplicate concept (C1274013)
SourcesAOD, COSTAR, CSP, CST, DXP, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, LCH, LNC, MSH, MTH, NCI, NDFRT, OMIM, PNDS, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Vomiting (C0042963)

Definition (MSH)The forcible expulsion of the contents of the STOMACH through the MOUTH.
Definition (CSP)forcible expulsion of stomach contents through the mouth.
Definition (NCI)The reflex act of ejecting the contents of the stomach through the mouth.
ConceptsSign or Symptom (T184)
ICD9787.0
MSHD014839
DanishOpkastning
DutchBraken
EnglishBeing sick, Emesis, Finding of vomiting, Observation of vomiting, Throwing up, Vomiting, Vomiting disorder, Vomiting symptom, Vomiting symptoms
FinnishOKSENTELU
FrenchVomissement
GermanErbrechen
Hungarianhanyas
ItalianVomito
NorwegianOPPKAST/BREKNINGER EKS W05
PortugueseVomito
Spanishdescompostura con vomitos, emesis, sintoma de vomito, sintomas de vomito, vomito, vomito - hallazgo, vomito - observacion, vomitos
SwedishUPPKASTNING
Parent ConceptsDigestive symptom (C0476288), Signs and Symptoms, Digestive (C0037089), Digestive System Disorders, General, Functional and NEC (C0549522), GASTRIC/DUODENAL (C0549614), Gastrointestinal system (C0012240), Symptoms and Complaints Component (C0497525), [D]Nausea and vomiting NOS (C0027498), Gastrointestinal Diseases (C0017178), Increased GI Motility (C1372333), Disease (C0012634), Vomiting (C0042963), Functional finding of gastrointestinal tract (C0577078), Erroneous concept (C1274015), Finding reported by subject or history provider (C1689949), Duplicate concept (C1274013), Reason not stated concept (C1276325)
SourcesAOD, COSTAR, CSP, CST, DXP, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, LCH, LNC, MEDLINEPLUS, MSH, MTH, MTHICD9, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


[D]Projectile vomiting (C0221151)

ConceptsSign or Symptom (T184)
EnglishProjectile vomiting, VOMITING PROJECTILE
Spanishvomito en chorro, vomito en proyectil
Parent ConceptsStomach Diseases (C0038354), Vomiting (C0042963), Duplicate concept (C1274013)
SourcesCST, DXP, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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