vomiting
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Introduction
Vomiting is the forceful expulsion of gastric contents through the mouth.
Etiology
- infectious diseases
- enterotoxins
- acute abdomen
- pharmaceutical agents
- alcohol
- increased intracranial pressure
- pregnancy, generally confined to 1st trimester
- gastric retention
- peptic ulcer disease
- upper GI bleeding:
- blood in the stomach may stimulate vomiting
- aerophagia
- metabolic & endocrine disorders
- labyrinthine diseases
- acute labyrinthitis, Meniere's disease
- cardiac disease
- pain
- autonomic dysfunction (common with advanced cancer)
- psychogenic
Pathology
- triggered by receptors in the stomach & CNS
- 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
- the vestibulocochlear nerve associated with movement
- cerebral cortex associated with anxiety
Clinical manifestations
- hematemesis from upper GI hemorrhage
- yellow vomit suggests bile
Laboratory
- pregnancy test
- basic metabolic panel
- urine chemistries
- urine potassium increased
- urine chloride decreased
- liver function tests, amylase, lipase
Diagnostic procedures
- gastric lavage until clear
- esophagogastroduodenoscopy (EGD)
Radiology
- plain abdominal radiograph: intestinal obstruction
- upper GI series - motility & mucosa of the proximal GI tract
- gastric emptying scan - gastroparesis
- computed tomography or magnetic resonance imaging of brain
Complications
- dehydration
- hypokalemia
- metabolic alkalosis
- aspiration pneumonitis
- malnutrition
- dental caries
- ruptured esophagus (Boerhaave's syndrome)
- Mallory-Weiss tear
Management
- hydration is probably the most effective antiemetic[5]
- oral sugar-containing fluids for home management
- 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]
- pharmaceutical agents (anti-emetics)
- 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]
- haloperidol (Haldol)
- phenothiazines
- metoclopramide (Reglan) 10 mg IV every 2-3 hours, 10-30 mg PO QID (NO better than placebo)[5]
- 5-hydroxytrypamine-3 5HT-3 antagonists
- preventative agents (premedication) for chemotherapy-induced nausea & vomiting
- ondansetron (Zofran)
- granisetron (Kytril)
- corticosteroids
- dexamethasone
- methylprednisolone
- antihistamines - useful for inner ear dysfunction
- anticholinergics: useful for motion sickness
- octreotide (Sandostatin) decreases gastrointestinal secretion & motility
- ginger may be of benefit
- dopamine receptor antagonists
- combination therapy (palliative care)
- suppository anti-emetic combination (BRD)
- intravenous anti-emetic combination
- avoid all foods for several hours
- irritable stomachs respond to food with vomiting
- begin refeeding with small quantities of clear liquid
- specific therapy for underlying etiology
- see management of nausea/vomiting by etiology
- see nausea for intractable nausea & vomiting
More general terms
More specific terms
- bilious vomiting
- copremesis; stercoraceous vomiting
- cyclic vomiting syndrome (CVS)
- morning sickness (nausea & vomiting of pregnancy)
- nausea/vomiting - chemotherapy induced
- post-operative nausea & vomiting
Additional terms
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
- ↑ Bruera & Neumann Canadian Medical Assoc. J (CAMJ):158:1717, 1998
- ↑ 3.0 3.1 Freedman SB et al, Oral ondansetron for gastroenteritis in a pediatric emergency department N Engl J Med 2006; 354:1698 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16625009
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/16490647
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Prescriber's Letter 14(8): 2007 Ondansetron (Zofran) in Children with Viral Gastroenteritis Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=230804&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 6.0 6.1 6.2 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: https://www.ncbi.nlm.nih.gov/pubmed/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 - ↑ 7.0 7.1 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: https://www.ncbi.nlm.nih.gov/pubmed/35246289 https://www.mayoclinicproceedings.org/article/S0025-6196(22)00001-5/fulltext
- ↑ MedlinePlus: Nausea and vomiting - adults https://www.nlm.nih.gov/medlineplus/ency/article/003117.htm