Vomiting

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

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II. 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. Acute Nausea and Vomiting
    1. Nausea and Vomiting for <7 days
  9. Chronic Nausea and Vomiting
    1. Nausea and Vomiting persisting longer than one month
  10. Hematemesis
    1. See Upper Gastrointestinal Bleeding
    2. Vomiting of fresh blood (suggests acute or severe Upper Gastrointestinal Bleeding)
  11. Coffee-ground Emesis
    1. See Upper Gastrointestinal Bleeding
    2. Vomiting of black blood (altered by gastric acid)
  12. Stercoraceous Vomiting or Fecal Vomiting
    1. Vomiting of fecal material (due to obstruction)
  13. Bilious Emesis
    1. Vomiting of bile stained (green) fluid

III. Pathophysiology

  1. Nausea usually precedes Vomiting
  2. Physiologic Control of Vomiting
    1. Lateral reticular formation in Medulla
    2. Chemical stimulation via ChemoreceptorTrigger 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)
  5. Images
    1. vomitingPathway.png

IV. 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
      1. Vomiting should be followed by Diarrhea
    2. Medication Induced Vomiting

V. History

  1. See Vomiting History for Clinical Clues
  2. Systemic Symptoms and Signs
    1. Fever
    2. Malaise or Fatigue
    3. Weight loss (red flag)
  3. Emesis Characteristics
    1. Timing between food and Emesis
    2. Emesis appearance
      1. Undigested food or milk or yellow color (Stomach contents)
      2. Hematemesis (Upper GI Bleeding)
      3. Bilious Emesis (Small Bowel Obstruction)
  4. 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
      1. Diarrhea that follows Vomiting is consistent with Gastroenteritis
      2. Vomiting that follows Diarrhea is consistent with enteritis (or Urinary Tract Infection in girls, women)
    7. Jaundice
  5. Genitourinary Symptoms
    1. Urine Output
      1. At least three times daily in infants and twice daily in children and adults
    2. Dysuria
    3. Urgency or frequency
    4. Hematuria
  6. Neurologic Symptoms and Signs
    1. Altered Level of Consciousness (GCS, mental status)
    2. Focal neurologic deficits
    3. Papilledema

VI. Exam

  1. Observe for Dehydration
    1. Weight loss since prior exam
    2. Decreased skin turgur
    3. Dry mucus membranes (or not making tears in children)
    4. Sinus Tachycardia
    5. Orthostatic Hypotension
    6. Decreased Capillary Refill
  2. Other systemic signs of serious illness
    1. Tachypnea (Sepsis, Metabolic Acidosis)
  3. Abdominal examination
    1. Abdominal Distention
    2. Abdominal wall Hernia
    3. Peritoneal signs (abdominal guarding, Rebound Tenderness)
    4. Abdominal Trauma (e.g. Bruising)
    5. Abdominal tenderness to palpation
      1. Epigastric Pain: Gastric Ulcer
      2. Right upper quadrant pain: Cholecystitis
      3. Right lower quadrant pain: Appendicitis (esp. with Psoas Sign, Rosving's sign)
      4. Flank Pain: Pyelonephritis or Uretolithiasis
    6. Bowel sounds
      1. Hyperactive suggests Gastroenteritis
      2. High pitched suggests Small Bowel Obstruction
      3. Absent or decreased suggests ileus
    7. Other significant findings
      1. Hepatomegaly
      2. Splenomegaly
      3. Abdominal mass
      4. Ascites
  4. Genitourinary exam
    1. Inguinal Hernia
    2. Testicular Torsion (testicular tenderness, swelling, absent Cremasteric Reflex)
    3. Ovarian Torsion
  5. Neurologic Examination
    1. Nystagmus (Acute Vestibular Syndrome)
    2. Papilledema
    3. Focal neurologic deficits
    4. Peripheral Neuropathy
    5. Cerebellar exam (coordination and gait testing)
    6. Altered Level of Consciousness
  6. Skin
    1. Jaundice
    2. Hyperpigmentation (Addison disease)

VII. Differential Diagnosis

  1. See Vomiting Causes
  2. Ptyalism (Excessive Salivation)
  3. Gastroesophageal Reflux Disease (Acid Reflux)
  4. Forceful Coughing
    1. Post-nasal drainage
    2. Asthma, Bronchitis or Bronchiolitis
    3. Pneumonia
  5. Undigested Food Regurgitation
    1. Esophageal Obstruction
    2. Esophageal Diverticulum
    3. Overfilled Stomach
    4. Delayed Gastric Emptying or Gastroparesis

VIII. 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 endocrine conditions
    1. Thyroid Stimulating Hormone (TSH)
    2. Serum Ketones (Diabetic Ketoacidosis)
  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 GiardiaAntigen)
  11. Consider cardiac evaluation
    1. Electrocardiogram
    2. Serum Troponin

IX. 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. Abdominal CT with oral and IV Contrast
    1. Detection of Intestinal Obstruction or abdominal mass
  3. Right upper quadrant Ultrasound
    1. Suspected Cholecystitis
    2. Pancreatitis
  4. Chest XRay
    1. Detection of abdominal free air
  5. Head Imaging (CT Head or MRI Head)
    1. Indicated to evaluation for Intracranial Mass
    2. Consider in Projectile Vomiting, Vomiting without Nausea, morning Vomiting or neurologic changes

X. 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
  5. Upper GI with Small Bowel follow through
    1. Evaluation of function (e.g. Gastroparesis)
    2. Double-contrast barium studies are more accurate

XI. Management

  1. See Vomited Medications
  2. Symptomatic control of Vomiting
    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
  3. Management of Dehydration and Electrolyte loss
    1. See Dehydration Management in Children
    2. See Oral Rehydration Solution

XII. 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

XIII. Complications

  1. Dehydration
  2. Electrolyte disturbance
    1. Hypokalemia
    2. Metabolic Alkalosis
  3. Mallory Weiss Tear
  4. Esophageal Rupture
  5. Aspiration Pneumonia

XIV. References

  1. (2017) Crit Dec Emerg Med 31(4): 19-25
  2. (1988) Dorland's Medical Dictionary, Saunders, p. 1848
  3. Feldman (1998) Sleisenger Gastrointestinal, p. 117-126
  4. Friedman (1991) Medical Diagnosis, Little Brown, p. 174
  5. Heilenbach in Marx (2002) Rosen's Emergency Med, p. 178
  6. Anderson (2013) Am Fam Physician 88(6): 371-9 [PubMed]
  7. Quigley (2001) Gastroenterology 120(1):263-86 [PubMed]
  8. Scorza (2007) Am Fam Physician 76:76-84 [PubMed]

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