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Introduction

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Nausea, retching and hypersalivation frequently precede the act of vomiting, which is a highly integrated sequence of involuntary visceral and somatic motor events.

Harrison’s Principles of Internal Medicine, 1994

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Vomiting or emesis is a rather dramatic event with a diverse number of causes. It is usually preceded by nausea.

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Definitions

  • Haematemesis Vomiting of blood. It is presented in CHAPTER 55.

  • Nausea The unpleasant sickly sensation that can herald the onset of vomiting or can be present without vomiting.

  • Regurgitation The effortless passage of gastric contents into the mouth in the absence of nausea and without diaphragmatic muscular contractions.

  • Retching An involuntary act with all the movements of vomiting without the expulsion of gastric contents because the cardiac orifice remains closed.

  • Rumination The effortless regurgitation of recently ingested food into the mouth, followed by rechewing and reswallowing or spitting out.1

  • Vomiting The forceful expulsion of gastric contents through a relaxed upper oesophageal sphincter and out of the mouth.

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The clinical approach

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History

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A careful history is essential with an emphasis on drug intake, possible psychogenic factors, including self-induced emesis, weight loss, other GIT symptoms or symptoms suggestive of systemic disease.

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Examination

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If fever is present possible sources of infection (e.g. middle ear, meninges and urinary tract) should be checked.

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A careful abdominal examination is appropriate in most instances and this includes urinalysis. Look particularly for scars indicating previous surgery. Look for a succussion splash—this indicates pyloric obstruction.

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Key facts and checkpoints

  • Nausea and vomiting have a wide range of potential causes emanating from every body system.

  • The common cause of acute nausea and vomiting in most age groups is gastroenteritis.

  • The most common causes of vomiting in children are infections—viral (especially) and bacterial—including otitis media and urinary infection.

  • Drug ingestion is a common cause of nausea and vomiting; thus, a drug history is vital in assessment.

  • Vomiting is commonly associated with migraine and may be the only symptom of a variety of migraine. Children with cyclical vomiting syndrome may have a genetic association with migraine.

  • The nature of the vomitus provides a clue:

    • faecalent = intestinal obstruction

    • blood = bleeding from oesophagus, stomach or duodenum (mostly)

    • coffee-grounds = bleeding from stomach or duodenum

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A neurological examination needs to be considered, including ophthalmoloscopy. Consider raised intracranial pressure.

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No examination is complete without assessment of the patient’s physical fitness, including the level of hydration, especially in infants and the very old. In these age groups the history may be difficult to obtain and the consequences of fluid loss are more complicated. Always be mindful of the possibility of pregnancy in the female patient. Look for acid dental erosion as a marker of bulimia.

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Investigations

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These ...

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