Vomiting

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

1. See Also
   1. Vomiting in Children
   2. Gastroenteritis
   3. Pediatric Gastroenteritis
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):263-86