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vomiting

Vomiting is the forceful expulsion of gastric contents through the mouth. Etiology: 1) infectious diseases - bacterial, viral, parasitic - gastroenteritis, hepatitis, otitis, meningitis 2) enterotoxins 3) acute abdomen - appendicitis - intestinal obstruction - cholecystitis - visceral inflammation - pancreatitis - intestinal perforation - peritonitis - mesenteric ischemia 4) pharmaceutical agents - antineoplastic agents: cisplatin, doxorubicin ... - digitalis, digoxin - levodopa - potassium chloride - estrogens - opiates - theophylline - ferrous sulfate - antibiotics: tetracyclines, erythromycin - NSAIDs - azathiaprine 5) alcohol 6) increased intracranial pressure 7) pregnancy, generally confined to 1st trimester 8) gastric retention - gastroparesis, pyloric obstruction 9) peptic ulcer disease 10) upper GI bleeding: - blood in the stomach may stimulate vomiting 11) aerophagia 12) metabolic & endocrine disorders - diabetic ketoacidosis, adrenal insufficiency, thyrotoxicosis, uremia, hypercalcemia, hyponatremia 13) labyrinthine diseases - acute labyrinthitis, Meniere's disease 14) cardiac disease - congestive heart failure (CHF), myocardial infarction (MI) 15) pain 16) autonomic dysfunction (common with advanced cancer) 17) psychogenic - anorexia nervosa, bulemia, emotional upset - cyclic vomiting syndrome Pathology: 1) triggered by receptors in the stomach & CNS 2) vomiting receptors in the CNS are found in the lateral reticular formation & the chemoreceptor trigger zone (CTZ) of the area postrema in the floor of the 4th ventricle 3) the vestibulocochlear nerve associated with movement 4) cerebral cortex associated with anxiety Clinical manifestations: - hematemesis from upper GI hemorrhage - bright red suggests esophageal bleeding - dark red vomit with clots suggests severe gastric bleeding - coffee-ground emesis suggests less severe gastric bleeding - yellow vomit suggests bile Laboratory: 1) pregnancy test 2) basic metabolic panel - metabolic alkalosis 3) urine chemistries - urine potassium increased - urine chloride decreased 4) liver function tests, amylase, lipase Special laboratory: - gastric lavage until clear - gastric occult blood - esophagogastroduodenoscopy (EGD) Radiology: 1) plain abdominal radiograph: intestinal obstruction 2) upper GI series - motility & mucosa of the proximal GI tract 3) gastric emptying scan - gastroparesis 4) computed tomography or magnetic resonance imaging of brain Complications: 1) dehydration 2) hypokalemia 3) metabolic alkalosis 4) aspiration pneumonitis 5) malnutrition 6) dental caries 7) ruptured esophagus (Boerhaave's syndrome) 8) Mallory-Weiss tear Management: 1) hydration is probably the most effective antiemetic [5] a) oral sugar-containing fluids for home management - pedialyte vs gatorade - sugar diminishes nausea b) seek medical care for - suspected poisoning - vomiting for > 24 hours - unable to keep any fluids down > 12 hours - headache or stiff neck - no urination in > 8 or hours - severe epigastric pain or other abdominal pain [7] 2) pharmaceutical agents (anti-emetics) a) dopamine receptor antagonists - phenothiazines - prochlorperazine (Compazine) 5-20 mg PO/IV/IM every 6-8h (NO better than placebo) [5] - chlorpromazine (Thorazine) - butyrophenones - haloperidol (Haldol) - droperidol (Inapsine) better than placebo [5] c) metoclopramide (Reglan) 10 mg IV every 2-3 hours, 10-30 mg PO QID (NO better than placebo) [5] b) 5-hydroxytrypamine-3 5HT-3 antagonists - preventative agents (premedication) for chemotherapy-induced nausea & vomiting - ondansetron (Zofran) - may help stop vomiting [6] - improves hydration in children [3,5,6] - granisetron (Kytril) c) corticosteroids a) dexamethasone b) methylprednisolone d) antihistamines - useful for inner ear dysfunction - dimenhydrinate - promethazine - cyclizine e) anticholinergics: useful for motion sickness - scopolamine (Transderm Scop, Hyoscine) - dimenhydrinate (Dramamine) - glycopyrrolate - hyocyamine (Levsin) f) octreotide (Sandostatin) decreases gastrointestinal secretion & motility g) ginger may be of benefit 3) combination therapy (palliative care) - suppository anti-emetic combination (BRD) - intravenous anti-emetic combination 4) avoid all foods for several hours - irritable stomachs respond to food with vomiting - begin refeeding with small quantities of clear liquid 5) specific therapy for underlying etiology - see management of nausea/vomiting by etiology - see nausea for intractable nausea & vomiting

Related

emesis management of nausea/vomiting by etiology

Specific

bilious vomiting copremesis; stercoraceous vomiting cyclic vomiting syndrome (CVS) morning sickness (nausea & vomiting of pregnancy) nausea/vomiting - chemotherapy induced post-operative nausea & vomiting

General

sign/symptom

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  2. Bruera & Neumann Canadian Medical Assoc. J (CAMJ):158:1717, 1998
  3. Freedman SB et al, Oral ondansetron for gastroenteritis in a pediatric emergency department N Engl J Med 2006; 354:1698 PMID: 16625009
  4. Braude D, Soliz T, Crandall C, Hendey G, Andrews J, Weichenthal L. Antiemetics in the ED: a randomized controlled trial comparing 3 common agents. Am J Emerg Med. 2006 Mar;24(2):177-82. PMID: 16490647
  5. Prescriber's Letter 14(8): 2007 Ondansetron (Zofran) in Children with Viral Gastroenteritis Detail-Document#: 230804 (subscription needed) http://www.prescribersletter.com
  6. The NNT: Ondansetron (Zofran) for Pediatric and Adolescent Gastroenteritis http://www.thennt.com/nnt/ondansetron-for-pediatric-gastroenteritis/ - Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD005506 PMID: 21901699 - Carter B, Fedorowicz Z Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework. BMJ Open 2012;2:e000622 http://bmjopen.bmj.com/content/2/4/e000622.long
  7. Tome J, Kamboj AK, Sweetse S A Practical 5-Step Approach to Nausea and Vomiting Mayo Clininc Proceedings. 2022 97(3):600-608. March 1 PMID: 35246289 https://www.mayoclinicproceedings.org/article/S0025-6196(22)00001-5/fulltext
  8. MedlinePlus: Nausea and vomiting - adults https://www.nlm.nih.gov/medlineplus/ency/article/003117.htm