Vomiting

Vomiting
Vomiting
NAUSEA
subjective feeling of
vomiting
(unpleasant sensation of
impending vomiting)
vomiting
Oral expulsion of gastrointestinal
contents due to contractions of
GUT and thoraco abdominal wall
musculature
EARLY SATIETY
Sensation of gastric fullness before a meal is
completed
REGURGITATION
Effortless return of gastroesophageal
contents into the mouth
CAUSES OF VOMITING
SITE OF TRIGGER – NEUROLOGICAL
MECHANISM
chemical agents directly stimulate voitin g centre and chemoreceptor trigger
zone leading to stimulation of vagal nuclei
stimulation of cns structures via diseases such as infections/brain tumours that
Vomiting
act on vagal pathways
Example
migraine,cns infections,vestibular nerve lesions,toxins
SITE OF TRIGGER – PERIPHERAL
MECHANISM
stimulation of vagal and spinal afferent nerves by diseasesin peripheral organ
systems
Local dysfunction in periphearal organ systems that is sensed as nausea,which
may eventually evoke vomiting
Circulationg humoral factors from inflammatory or malignant conditions
Example
GI Mucosal inflammation, GI infections, GI obstruction
Pain including cardiac,abdominal or peripheral pain
Autoimmune disease,cancer
VOMITING-Mechanism
VOMITING
Direct stimulation of the chemoreceptor trigger zone- blood
Oral expulsion of gastrointestinal
borne emetic substances ex;opioids,chemotherapy
contents
Stimulation of thedue to contractions
vestibulocochlear ofthethe
cranial nerve from
vestibular system of the inner ear – motion sickess,infection
GUT and
Direct stimulation of the vomiting centre from sensory input
thoraco–abdominal
or higher wall
cortical centres - sensory input;nauseating
smells,sights,pai n,higher cortical
musculature.
centres,memory,anticipation,fear
Meningeal mechanoreceptors detect raised intracranial

pressure – intracranial bleed or infection causing raised ICP
CAUSES OF VOMITING
causes
GASTRO INTESTINAL DISORDERS : Peptic Ulcer Disease,Bowel
obstruction,Gastroperesis,Hepatitis,Cholecystitis,appendicitis,pancreatitis,
gastroenteritis
DRUGS : NSAIDS,Chemotherapeutic
Agents,digoxin,antibiotics,theophylline
SYSTEMIC ILLNESS
SEPSIS,MYOCARDIAL INFARCTION,RENAL FAILURE,ELECTROLYTE
IMBALANCE
CENTRAL NERVOUS SYSTEM : HEAD TRAUMA,RAISED
ICP,EPILEPSY,STROKE,MENINGITIS,MOTION SICKNESS
ENDOCRINE DISORDERS : DIABETES,ADDISON’S
DISEASE,THYROTOXICOSIS
PSYCHOGENIC VOMITING
Clinical History
1. Onset
Acute onset Chronic onset
Partial Mechanical Obstruction
Infections
Motility Disorders
Drugs
Endocrinopathy
Toxins
Metabolic Disorders
head trauma
Brain Tumour
visceral pain
Psychogenic Cause
2. Relation to meals
Vomiting within 5 mins after food – psychogenic vomiting
Vomiting more than 1 hour after food –Gastroperesis/Gastric Outlet Obstruction
Vomiting of materials eaten 12 hours before– Gastric Outlet Obstruction

3. Time
Early morning vomiting –

 Pregnancy
 Uremia
 Alcoholism
 Raised Intra Cranial Pressure

4.Associated Abdominal pain
Relief of Abdominal pain by vomiting

–
Antral or Small Bowel Obstruction

5. Content of Vomitus
Old food in vomitus – Gastric Outlet Obstruction /
Severe Gastroperesis
Undigested food – Achalasia /Zenker diverticulum
Presence of blood– Peptic ulcer disease/malignancy/

portal hypertension
Voluminous acidic vomiting– Gastrinoma
Feculent odour – Distal Intestinal or colonic obstruction/

bacterial overgrowth/gastrocolic fistula
6.Projectile vomiting/Nonprojectile
vomiting
Projectile vomiting
Vomiting without hypersalivation or nausea – suddenly occur without
any signs
• Increased Intracranial pressure or
• pyloric obstruction (GASTRIC OUTLET OBSTRUCTION)
NON PROJECTILE VOMITING –

– Regular Episodes Of Vomiting Are Often Preceded By A Wave Of Nausea
7. Associated symptoms
Fever–Infection / Inflammation
Weight loss – Malignancy/Gastric Outlet Obstruction

(PSYCHOGENIC VOMITING – STABLE WEIGHT MAINTANED)
Headache,Altered mentation/convulsion/diplopia– Intracranial causes

of vomiting
Vertigo/Tinnitus/Deafness– Vestibular Dysfunction
Abdominal distension/abdominal pain/constipation– small bowel

obstruction
Prior abdominal surgery – Mechanical Obstruction/ Post
Gastrectomy Syndrome
History of NSAIDs intake

Physical Examination
Assessment of Intra vascular fluid loss
Fever suggests Infection /Inflammation
Loss of dental enamel in oral cavity suggests

bulimia
Icterus indicates Hepato biliary disease

Neurological Examination
Impaired mentation,focal neurological

deficit,neck stiffness & papilledema – CNS DISEASE
Autonomic and Peripheral neuropathy may be

associated with Gastro intestinal motility disorders
Abdominal distension – Ileus or Intestinal
Obstruction
Abdominal tenderness –
Inflammation/Infection/Luminal Distension
Succusion splash on side to side movement –
Gastric Outlet obstruction /Gastroperesis
Look for any mass,hepatomegaly or splenomegaly
Absence of bowel sounds– Ileus
Hyperactive,high pitched bowel sounds with a
distended abdomen – Mechanical Intestinal
obstruction
Diagnostic procedures
Blood investigations
Imaging studies
Endoscopy study
Functional Study
Blood investigations
Leucocytosis – inflammation
Anemia – either blood loss or chronic inflammation
Hypokalemia and elevated blood urea nitrogen with
normal creatinine – dehydration
Metabolilc alkalosis – results from loss of hydrogen
ions in the vomitus and contractions of the
extracellular space from dehydration
Endocrine and metabolic parameters
Amylase ,lipase and liver chemistry in pancreatic or
hepatobiliary disorders
Imaging studies
Plain x ray abdomen – small iontestinal airfluid levels
with absent colonic air suggests obstruction
Diffuse distension suggests Ileus
USG Abdomen/ CT Abdomen – for suspected

hepatobiliary or pancreatic disorders
Barium meal – for partial obstruction

ENDOSCOPY
UGI SCOPY – For suspected gastric outlet obstruction
.
Retained food in the absence of obstruction indicates
GASTROPARESIS
COLONOSCOPY– in suspected ileocaecal TB

FUNCTIONAL STUDY
GASTROPARESIS– delayed emptying of either solid or
liquid
EGG– in suspected ileocaecal TB
ANTRAL DUODENAL MANOMETRY – for intestinal

pseudo obstruction
Management
Intravenous fluid resuscitation – moderate to
severe dehydration,secondary to persistent
vomiting
Medical management– for the underlying cause
ANTIEMETICS AND PROKINETIC AGENTS

Vomiting

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Vomiting

Meningeal mechanoreceptors detect raised intracranial

Vomiting within 5 mins after food – psychogenic vomiting

Vomiting more than 1 hour after food –Gastroperesis/Gastric Outlet Obstruction

Vomiting of materials eaten 12 hours before– Gastric Outlet Obstruction

Early morning vomiting –

 Raised Intra Cranial Pressure

Relief of Abdominal pain by vomiting

Antral or Small Bowel Obstruction

Undigested food – Achalasia /Zenker diverticulum

Presence of blood– Peptic ulcer disease/malignancy/

Voluminous acidic vomiting– Gastrinoma

Feculent odour – Distal Intestinal or colonic obstruction/

NON PROJECTILE VOMITING –

Weight loss – Malignancy/Gastric Outlet Obstruction

Headache,Altered mentation/convulsion/diplopia– Intracranial causes

Vertigo/Tinnitus/Deafness– Vestibular Dysfunction

Abdominal distension/abdominal pain/constipation– small bowel

History of NSAIDs intake

Assessment of Intra vascular fluid loss

Fever suggests Infection /Inflammation

Loss of dental enamel in oral cavity suggests

Icterus indicates Hepato biliary disease

Impaired mentation,focal neurological

Autonomic and Peripheral neuropathy may be

USG Abdomen/ CT Abdomen – for suspected

Barium meal – for partial obstruction

COLONOSCOPY– in suspected ileocaecal TB

EGG– in suspected ileocaecal TB

ANTRAL DUODENAL MANOMETRY – for intestinal

Medical management– for the underlying cause

ANTIEMETICS AND PROKINETIC AGENTS

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