Nausea and Vomiting
Nausea is an uneasy feeling in the upper part of the abdomen with a distressing urge to vomit. It may be a temporary sensation felt immediately before a bout of vomiting or it can persist without any vomiting occurring.
Vomiting is the sudden forceful ejection of the contents of the stomach when stomach contracts violently, emptying its contents into the esophagus and out through the mouth in one or several repeated bouts. It usually brings temporary relief from the feeling of nausea. When almost all the contents are emptied, vomiting may bring up clear fluids; it is called dry heaves. Vomiting usually leaves a burning sensation in the throat and the esophagus due to the irritation caused by the stomach acids which were brought up with the contents of the stomach.
Regurgitation is different from vomiting in that, the stomach contents are not forcefully ejected, but brought up slowly, in small quantities, usually without any accompanied nausea. Examples are regurgitation resulting from esophageal disorders such as Zenker’s diverticulum and achalasia, which results from a motility disorder of the esophagus.
The contents of vomit, called vomitus, consist of partially digested food, and digestive juices secreted by the stomach walls and the liver. When the presence of blood imparts a red color to the vomitus, it indicates a recent bleeding and it is called hemetemesis. A coffee grounds-like brown precipitate also indicates bleeding, but of earlier occurrence, the color change being caused by the action of digestive fluids on the blood. Yellowish green clear liquid in the vomitus is bile, which gives it a bitter taste.
Complications: Vomiting may bring temporary relief from nausea, but in addition to causing a burning sensation in the upper digestive tract, it may lead to complications such as:
- Aspiration of the contents of the vomit
- Severe loss of fluids leading to dehydration and chemical imbalance.
- forceful contraction causing tears in the esophageal wall
- Malnutrition in chronic cases
While vomiting, some of the vomitus may be aspirated when a person takes in a deep breath; it is more common if the patient is not fully conscious. The aspirated vomitus causes irritation to the lungs and may lead to inflammations and infections, even pneumonia.
Repeated forceful contractions of the stomach and the esophagus during vomiting can result in tears in the esophageal wall leading to bleeding. An example is Mallory-Weiss tear. If the tear is very large, and causes severe bleeding, it can be life threatening.
Along with the fluids lost through vomiting, mineral compounds of sodium, potassium, magnesium etc., are also lost, resulting in chemical imbalance which adversely affects various body functions. It can quickly become a life threatening condition, especially in babies and young children.
Vomiting, when it is a chronic condition, results in severe weight loss and malnutrition as in people who have bulimia.
Causes
Nausea and vomiting is generally associated with digestive disorders but it can result from the activation of the vomiting center in the brain. Injury to the head, motion sickness, certain drugs and toxins, sickening smells and distressing sights may cause nausea and vomiting.
Various digestive disorders cause vomiting, the most common among them being gastroenteritis which is an inflammation of the stomach due to viral or bacterial infections. Viral gastroenteritis is also called stomach flu which is highly contagious. Bacterial gastro enteritis is usually called food poisoning and it results from consuming food spoiled by bacterial activity.
Toxins ingested with food or otherwise (poisonous mushrooms, poisons contained in some plants of the nightshade family) can result in severe vomiting.
Physical obstructions in the digestive tract also cause vomiting because of the impediment to the smooth movement of food.
Certain disorders in organs connected to the digestive system such as pancreatitis, appendicitis, liver problems etc. may also have vomiting as symptom, in addition to pain.
Drugs used in chemotherapy for cancer, several pain medications like morphine belonging to the opioid group may cause vomiting. Excessive alcohol consumption often results in severe bouts of vomiting and retching which are known to cause esophageal tears.
Disorders of the brain or the nervous system including stroke, concussion due to accidents, inflammatory conditions like encephalitis and meningitis, and presence of tumors, have nausea and vomiting as symptoms.
Metabolic disorders like diabetes, and those resulting from liver and kidney failure, hormonal changes during early pregnancy, are some other reasons precipitating nausea and vomiting.
Damage to the balance keeping mechanism in the inner ear is the cause of vomiting due to motion sickness during travel and rollercoaster rides.
Mental stress or psychologic disorders sometimes result in psychogenic vomiting. Children often react to distressing events like starting or changing school by showing symptoms such as stomach pain and vomiting. People who suffer from anorexia nervosa and bulimia have intentional or habitual vomiting on eating food.
Evaluation
Nausea and vomiting are fairly common, and usually resolve by themselves, without medical intervention. However, vomiting may be a symptom of some serious disorder or damage caused to vital organs like brain, in which case, immediate medical care may help save lives. The warning signs listed below may help determine when medical attention should be sought.
Warning signs: people should seek medical attention when the following warning signs are present:
- Severe dehydration characterized by reduced production of urine, weakness, dryness of the mouth and throat and excessive thirst
- Confusion, disoriented feeling, stiffness of neck and severe or uncharacteristic headache indicative of problems with the brain.
- Acute or recurring abdominal pain or bloating of abdomen
- Symptoms of peritonitis such as sensitivity or pain while moving or touching the abdomen.
- When severe vomiting is associated with equally severe diarrhea
- When bright colored blood is present in the vomit (hemetemesis)
- Vomiting following an injury to the head or after an accident
When to see a doctor: Those who have the above warning signs should seek immediate medical attention. If vomiting persists for more than a day, people should consult a doctor without delay even if the warning signs are absent. People can consult the doctor over the phone so that the doctor can advise them to either come to the hospital or not, depending on their symptoms and medical history. For adult patients, doctor may recommend home remedies such as over the counter medication and taking plenty of fluids.
For babies and young children, vomiting more than a few times can lead to sudden deterioration of their condition; hence, it is advisable to see a doctor as early as possible and continue to administer oral rehydration therapy. If oral rehydration is not tolerated, it is essential to seek emergency medical care for them.
When a person comes to the doctor with nausea and vomiting, doctor may want to know all the details about the foods and drinks recently consumed, with special emphasis on any change of diet, any change in the source of food and water, recent travel, alcohol usage or any other detail of special interest.
A physical examination is done during which the doctor checks the abdomen for pain, tenderness and bloating. In addition to that, the doctor may check the patient for symptoms of dehydration such as low blood pressure, abnormal increase in heart rate, weakness, dry mouth and cracking lips. Signs of disorientation, confusion, and reduced alertness, are also taken note of, if present.
Doctor may ask about the previous medical history, especially about existing conditions such as diabetes, liver disorders, kidney disease, migraines which may have significance in diagnosis as well as in determining the diagnostic tests required. Other conditions of special significance are radiation therapy or chemotherapy the patient may be undergoing as part of the treatment for cancer, and the possibility of a female patient being pregnant.
Certain drugs like acetaminophen and toxins in poisonous mushrooms are late acting and their symptoms such as vomiting may appear only several days later. It is essential that doctor is informed about any such incident in the recent past. Doctor may also be interested in knowing about the incidence of vomiting and diarrhea among the patient’s family and friends which usually indicates viral gastritis.
If the patients have undergone any abdominal surgery previously, it is also important in arriving at a diagnosis as they have an increased risk of developing obstructions in the digestive tract due to adhesions and scar tissue formations.
People, who have conditions like migraine with the usual symptom of vomiting, may be evaluated to see if the present bout of vomiting is due to a new abnormality or just a recurrence of the existing disorder.
Testing: For sporadic incidents of vomiting, tests may not be required and the vomiting may even stop without medication.
People who have had severe vomiting for over a day may have to undergo blood and urine tests to determine liver function and the electrolyte levels in the body. Women and girls of reproductive age are tested for pregnancy in addition to other blood tests and urine tests.
If any abnormality of the digestive system is suspected by the doctor, based on the symptoms and physical examination conducted, viewing tests like upper endoscopy or imaging tests such as x-rays or ultrasound screening are done.
Treatment
The cause of vomiting is treated with appropriate medications and procedures. If bacterial infections are present, antibiotics may be necessary. To remove ingested poisons, stomach wash or gastric lavage may have to be done.
Rehydration therapy should be started as soon as possible to avoid complication due to dehydration. If oral administration of small amounts of liquid is tolerated, specially prepared rehydration solutions can be given to replenish the body with fluids as well as the electrolytes lost through vomiting. If vomiting continues, oral administration may not be effective and intravenous drips are given. Anti nausea and anti emetic drugs are prescribed to control further vomiting.
Antihistamines are prescribed for vomiting due to motion sickness. Dimenhydrinate is an antihistamine used to prevent vomiting. Scopolamine patches also may be used.
Metoclopramide and prochlorperazine are other drugs usually prescribed. When vomiting is severe, as in people undergoing chemotherapy, granisetron, dolasetron aprepitant or ondansetron may be given. Pregnant women suffering from morning sickness should not take any antiemetic medication without doctor’s prescription.
When the patient is sufficiently recovered from vomiting, liquid diet can be started in small quantities, an ounce or two at a time; and then gradually increased, depending on the patient’s tolerance. In addition to plain water, weak tea or broth can be given. Alcohol as well as carbonated drinks should not be given during the recuperation period. Solid food can be introduced slowly, and when it is well tolerated, the patient can return to normal diet.
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Yasser Elnahas
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