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. Chronic Nausea and Vomiting
    1. Nausea and Vomiting persisting longer than one month
  9. Hematemesis
    1. See Upper Gastrointestinal Bleeding
    2. Vomiting of fresh blood (suggests acute or severe Upper Gastrointestinal Bleeding)
  10. Coffee-ground Emesis
    1. See Upper Gastrointestinal Bleeding
    2. Vomiting of black blood (altered by gastric acid)
  11. Stercoraceous Vomiting or Fecal Vomiting
    1. Vomiting of fecal material (due to obstruction)
  12. 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)

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. Examination

  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
  4. Genitourinary exam
    1. Inguinal Hernia
    2. Testicular Torsion (testicular tenderness, swelling, absent Cremasteric Reflex)
    3. Ovarian Torsion
  5. 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
  6. Skin
    1. Jaundice

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 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 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

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

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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Related Studies

Ontology: Hematemesis (C0018926)

Definition (MSHCZE) Zvracení krve nebo zvracení s příměsí krve. Příznak krvácení do horní části zažívací trubice, např. z peptického vředu, žaludečních erozí, jícnových varixů při portální hypertenzi, trhlinek při Malloryho-Weissově syndromu. Vyžaduje urychlené vyšetření (gastroskopie) a léčbu podle příčiny, s eventuálním doplněním objemu tekutin či krve, podáním vazokonstrikčních látek (např. terlipresinu), úpravou hemostatických parametrů apod. Masivní ztráta krve může vést k šoku. Správný tvar je "hematemeze". (cit. Velký lékařský slovník online, 2012 http://lekarske.slovniky.cz/ )
Definition (NCI) Vomiting blood.
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.
Concepts Sign or Symptom (T184)
MSH D006396
ICD9 578.0
ICD10 K92.0
SnomedCT 139339008, 155838009, 249498003, 162064009, 8765009, 281102003
English Hematemeses, Hematemesis, HAEMATEMESIS, HEMATEMESIS, VOMITING BLOOD, vomiting blood (hematemesis), vomiting blood, vomiting blood (symptom), Emesis bloody, Hematemesis [Disease/Finding], Vomiting;blood, vomiting of blood, hematemesis was observed, hematemesis (symptom), hematemesis was observed (physical finding), hematemesis, Blood in vomit symptom, Haematemesis (disorder), Haematemesis, Vomiting of blood, Blood in vomit - symptom, Vomiting blood, Hematemesis (disorder), Blood in vomit - symptom (finding), Haematemesis/vomiting blood, blood; vomiting, vomiting; blood, haematemesis, vomiting out blood
French HEMATEMESE, Vomissement sanglant, Vomissements de sang, VOMISSEMENT DE SANG, Hématémèse
Portuguese HEMATEMESE, Emese sanguínea, Vómitos de sangue, Hematémese, VOMITO HEMATICO, Hematemese
Spanish HEMATEMESIS, Emesis sanguinolenta, Vómitos de sangre, VOMITO DE SANGRE, hematemesis (trastorno), hematemesis, sangre en el vómito - síntoma (hallazgo), sangre en el vómito - síntoma, vómito de sangre, Hematemesis
German HAEMATEMESIS, Erbrechen mit Blut, Erbrechen von Blut, BLUTERBRECHEN, Haematemesis, Blutbrechen, Hämatemesis
Dutch haematemesis, bloederige emesis, bloed; braken, braken; bloed, bloedbraken, Haematemesis
Italian Vomito ematico, Ematemesi
Japanese 吐血, トケツ
Swedish Blodkräkningar
Czech hematemeze, Hematemeze, Zvracení krve, hemateméza, hematemeza
Finnish Hematemeesi
Korean 토혈
Polish Wymioty krwawe
Hungarian Hematemesis, Haematemesis, Véres hányás, Vérhányás
Norwegian Hematemese, Blodig oppkast, Oppkast, blodig

Ontology: Nausea (C0027497)

Definition (CCC) Distaste for food/fluids and an urge to vomit
Definition (NCI_CTCAE) A disorder characterized by a queasy sensation and/or the urge to vomit.
Definition (NCI_NCI-GLOSS) A feeling of sickness or discomfort in the stomach that may come with an urge to vomit. Nausea is a side effect of some types of cancer therapy.
Definition (NCI) Upper abdominal discomfort associated with an urge to vomit.(NICHD)
Definition (NAN) A subjective unpleasant, wavelike sensation in the back of the throat, epigastrium, or abdomen that may lead to the urge or need to vomit
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.
Concepts Sign or Symptom (T184)
MSH D009325
ICD10 R11.0
SnomedCT 207111007, 422587007, 73879007, 300576004, 158421000, 272043005, 162060000, 139330007, 139334003, 162055004
LNC LP36327-2, MTHU013524, LA15098-9
English Nausea, FEELING QUEASY, Feeling bilious, Feeling queasy, Feeling sick, [D]Nausea, C/O - nausea, Nausea symptoms, [D]Nausea (context-dependent category), Nauseated, Nausea (finding), Observation of nausea, Nauseous, nausea (symptom), nausea, Queasy, Nausea NOS, Nausea [Disease/Finding], rndx nausea, rndx nausea (diagnosis), feeling sick, nausea symptom, feel sick, nausea symptoms, sick feeling, symptom nausea, nauseous, symptoms nausea, nauseated, queasy, nauseas, nauseating, [D]Nausea (situation), Finding of nausea (finding), Nausea (disorder), Finding of nausea, Nausea NOS (finding), NAUSEA
Dutch misselijk, onpasselijk gevoel, onpasselijk, nausea, Misselijkheid
French Sensation de mal au coeur, Mal au coeur, Nauséeux, NAUSEES, Nausées, GUEULE DE BOIS, Nausée
German an Uebelkeit leidend, sich uebel fuehlen, uebel, an Uebelkeit leiden, UEBELKEIT, UNBEHAGLICHKEITSGEFUEHL, Uebelkeit, Nausea, Übelkeit
Italian Sentirsi nauseato, Nauseante, Nauseato, Nausea
Portuguese Sensação de má disposição, Mal disposto, Nauseado, Nauseoso, Náusea, NAUSEAS, SENTIR-SE NAUSEADO, Náuseas, Enjoo, Ânsia de Vômito
Spanish Nauseoso, Sentirse mareado, náuseas, nauseoso, [D]náuseas (categoría dependiente del contexto), observación de náuseas, náuseas (hallazgo), Náusea, NAUSEAS, SENSACION DE DEBILIDAD, Ansia nauseosa, náusea, SAI, náusea, SAI (hallazgo), hallazgo de náusea, hallazgo de náusea (hallazgo), Nausea NOS, [D]náuseas, [D]náuseas (situación), Náuseas, Ganas de Vomitar
Japanese 悪心, 嘔気, 吐き気, オウキ, オシン, ハキケ
Swedish Illamående
Czech nauzea, Nevolnost, Pocit nevolnosti
Finnish Pahoinvointi
Polish Mdłości, Nudności
Hungarian Nausea, Émelygésérzés, Hányinger, Émelygés, Nauzea
Croatian MUČNINA
Norwegian Kvalme

Ontology: Vomiting (C0042963)

Definition (ICF-CY) Functions of moving food or liquid in the reverse direction to ingestion, from stomach to oesophagus to mouth and out, such as in gastro-esophegeal reflux, recurrent vomiting, pyloric stenosis.
Definition (CCC) Expulsion of stomach contents through the mouth
Definition (NCI_CTCAE) A disorder characterized by the reflexive act of ejecting the contents of the stomach through the mouth.
Definition (NCI_NCI-GLOSS) To eject some or all of the contents of the stomach through the mouth.
Definition (NCI) Forceful ejection of the contents of the stomach through the mouth.(NICHD)
Definition (MSH) The forcible expulsion of the contents of the STOMACH through the MOUTH.
Definition (CSP) forcible expulsion of stomach contents through the mouth.
Concepts Sign or Symptom (T184)
MSH D014839
ICD10 R11.1 , R11.10
SnomedCT 207113005, 207112000, 422400008, 249497008, 15387003, 162063003, 236082001, 139342002, 139335002, 158423002, 162061001, 139337005, 158422007, 162067002, 300359004
LNC LP75931-3, MTHU013530, LA15099-7
English Emesis, Vomiting, EMESIS, Being sick, Throwing up, Vomiting NOS, [D]Emesis, [D]Vomiting, [D]Emesis (context-dependent category), [D]Vomiting (context-dependent category), Vomiting disorder, Vomiting symptoms, Vomiting (disorder), vomiting (symptom), vomiting, vomiting (physical finding), vomiting was observed, Vomited, Vomiting, unspecified, Vomiting [Disease/Finding], vomited, vomits, symptoms vomiting, throw up, vomiting symptoms, Vomiting NOS (finding), Vomiting disorder (disorder), [D]Vomiting (situation), Vomiting NOS (disorder), Vomiting (finding), [D]Emesis (situation), VOMITING, emesis, vomit, Observation of vomiting, Finding of vomiting (finding), Finding of vomiting, gastric contents; regurgitation, regurgitation; gastric contents, Vomiting, NOS, throwing up, Vomiting symptoms (disorder), Vomiting symptom (finding), Vomiting symptom
French VOMISSEMENT, Vomi, Vomissement SAI, Vomissement
German ERBRECHEN, erbrach, Erbrechen NNB, EMESIS, Emesis, Erbrechen, Vomitus
Spanish síntoma de vómito (hallazgo), síntoma de vómito, Vómitos NEOM, emesis, síntomas de vómito, síntomas de vómito (trastorno), vómitos, [D]emesis (categoría dependiente del contexto), vómitos (trastorno), [D]vómitos (categoría dependiente del contexto), EMESIS, VOMITOS, hallazgo relacionado con el vómito, vómito - hallazgo, hallazgo relacionado con el vómito (hallazgo), vómito - hallazgo (hallazgo), vómito - observación, [D]vómitos, Vomiting NOS, [D]vómitos (situación), vómitos, SAI (trastorno), [D]emesis, vómito, vómitos, SAI, vómito (trastorno), [D]emesis (situación), vómitos, SAI (hallazgo), descompostura con vómitos, vómito, SAI, Emesis, Vómitos
Dutch braken NAO, emesis, gebraakt, maaginhoud; regurgitatie, regurgitatie; maaginhoud, braken, Braken, Emesis
Italian Vomitato, Vomito NAS, Emesi, Vomito
Portuguese Vómitos NE, Emese, Vomitado, EMESIS, VOMITOS, Vómito, Vômito, Êmese
Japanese 嘔吐NOS, オウトNOS, オウト, 嘔吐
Swedish Kräkning
Czech zvracení, Zvracení, Zvracení NOS
Finnish Oksentaminen
Polish Wymiotowanie, Wymioty
Hungarian Vomitus, Hányt, Hányás k.m.n., Emesis
Norwegian Oppkast, Vomitus, Emesis

Ontology: Projectile vomiting (C0221151)

Definition (NCI) Foreceful expulsion of the contents of the stomach through the mouth.
Concepts Sign or Symptom (T184)
ICD10 R11.12
SnomedCT 308151006, 207115003, 139338000, 8579004
Italian Vomito a getto, Emesi a getto
English [D]Projectile vomiting (context-dependent category), [D]Projectile vomiting, vomiting spraying across room (symptom), vomiting spraying across room, projectile vomiting, Projectile vomiting, Vomiting projectile, projectile vomit, [D]Projectile vomiting (situation), Projectile vomiting (finding), Projectile emesis, Projectile Vomiting, Projectile vomiting (disorder)
Japanese 噴出性嘔吐, フンシュツセイオウト
Spanish [D]vómitos en proyectil (categoría dependiente del contexto), [D]vómitos en proyectil, [D]vómitos en proyectil (situación), Vómitos en escopeta, vómito en chorro (trastorno), vómito en chorro, vómito en proyectil, Vómito explosivo
Czech Projektilové zvracení
Hungarian Sugárhányás
German Explosionsartige Emesis, Erbrechen explosionsartig
Portuguese Emese em projétil, Vómito projéctil
Dutch projectiel braken
French Vomissement en jet

Ontology: Vomiting bile (C0232599)

Concepts Finding (T033)
ICD9 787.04
ICD10 R11.14
SnomedCT 139341009, 71419002, 162065005
Dutch gal spugen, braken; gallig, gallig; braken
French Vomissements bilieux
German Erbrechen von Galle
Italian Vomito biliare
Portuguese Vómitos biliosos
Spanish Vómitos biliosos, vómito - teñido con bilis (trastorno), vómito - teñido con bilis, vómito biliar, vómito bilioso (trastorno), vómito bilioso
Japanese 胆汁嘔吐, タンジュウオウト
English vomiting yellow-green liquid (symptom), vomiting yellow-green liquid, vomiting bile (physical finding), vomiting bile, vomiting of bile was observed, bilious vomiting, Bilious emesis, bile vomiting, bile vomit, vomit bile, vomiting bilious, Vomiting - bile stained (finding), Bilious vomiting, Vomiting - bile stained, Vomiting - bile stained (disorder), Bilious vomiting (disorder), bilious; vomiting, vomiting; bilious, Vomiting bile
Czech Biliární zvracení
Hungarian Epés hányás

Ontology: Retching (C0232602)

Definition (NCI_NCI-GLOSS) The action of the stomach and esophagus to try to vomit (eject some or all of the contents of the stomach). Retching that does not cause vomiting is called dry heaves.
Concepts Sign or Symptom (T184)
SnomedCT 162066006, 207116002, 366960002, 84480002
English RETCHING, [D]Retching, dry heaves (symptom), dry heaves, dry heave, heaving, Retch, Vomiturition, retch, Dry heaves, Heaving, Retching (finding), retching, Retching
Italian Conati di vomito, Vomiturizione
Dutch kokhalzen, vomituritie, braakneiging
French Vomissements à sec, EFFORTS DE VOMISSEMENT, Vomiturition, Efforts de vomissement
German trockenes Wuergen, BRECHREIZ, Vomiturition, Brechreiz
Portuguese Asma equina, ESFORCO DE VOMITO, Vomiturição, Esforços para vomitar
Japanese レッチング, レッチング, カラオウト, 空嘔吐
Czech Pocit na zvracení, Zvedání žaludku
Spanish Basca, Esfuerzo por vomitar, arcadas (hallazgo), arcadas, Arcadas, ARCADAS, vomiturición, vómito seco
Hungarian Öklendezés, Öklendezés/hányiger hányás nélkül, Vomituritio

Ontology: Faecal vomiting (C0241706)

Concepts Finding (T033)
Dutch fecaal braken, braken; faeces, faeces; braken
French Vomissements fécaux
German Stuhlerbrechen, Faekalerbrechen
Italian Vomito fecale, Vomito di feci
Portuguese Vómitos fecais
Spanish Vómito fecaloideo
Japanese 吐糞症, トフンショウ
Czech Fekální zvracení
English fecal vomiting, fecal; vomiting, vomiting; fecal, Faecal vomiting, Fecal vomiting
Hungarian Széklet hányás, Bélsárhányás

Ontology: Coffee ground vomiting (C1510416)

Concepts Sign or Symptom (T184)
SnomedCT 139340005, 40835002
Dutch koffiedikemesis, koffiedik braken
French Vomissement marc de café, Vomissements marc de café
German Kaffeesatzerbrechen
Italian Vomito a fondo di caffè
Portuguese Vómitos em borra de café, Emese em borra de café
Spanish Vómito como posos de café, Vómitos en poso de café, emesis en borra de café, vómito en borra de café (trastorno), vómito en borra de café, vómito negro
Japanese コーヒー残渣様吐物, コーヒーザンサヨウトブツ
English vomiting 'coffee grounds' material, vomiting 'coffee grounds' (physical finding), vomiting 'coffee grounds' material (hematemesis), vomiting 'coffee grounds', vomiting 'coffee grounds' material (symptom), vomiting of 'coffee grounds' material was observed, hematemesis ('coffee grounds'), Vomiting blood - coffee ground (finding), Coffee ground emesis, Vomiting blood - coffee ground, Coffee ground vomiting (disorder), Coffee ground vomiting
Czech Zvracení vzhedu kávové sedliny
Hungarian Kávéalj-szerű hányás

Ontology: Stercoraceous vomiting (C1611181)

Concepts Sign or Symptom (T184)
Dutch stercoraal braken, braken; stercoraal, stercoraal; braken
French Vomissements stercoraires
German sterkorales Erbrechen
Italian Vomito stercoraceo
Portuguese Vómitos estercorários
Spanish Vómito estercoráceo
Japanese 吐糞症, トフンショウ
Czech Sterkorální zvracení
Hungarian Feculens hányás
English stercoral; vomiting, vomiting; stercoral, Stercoraceous vomiting