AN INTRODUCTION TO THE PROBLEM OF VOMITING IN ADULTS

ANTONIO COMIA, M.D., IDA MARIE LIM, M.D., PETER SY, M.D.

DEFINITION OF TERMS

Nausea – is the subjective feeling of the need to vomit that may or may not be followed by
vomiting.
Vomiting (emesis) – is the oral expulsion of upper gastrointestinal contents resulting from the
contraction of gut and thoracoabdominal wall musculature
Regurgitation – effortless passage of gastric contents into the mouth.
Rumination – repeated regurgitation of stomach contents, which are often rechewed and then
reswallowed.
Retching – consists of spasmodic and abortive respiratory movements with the glottis closed,
during which time inspiratory movements of the chest wall and diaphragm are opposed by
expiratory contractions of the abdominal musculature. During retching, the antrum of the
stomach contracts while the fundus and cardiac relax. The mouth is closed.

NEUROPHYSIOLOGIC PATHWAYS OF NAUSEA AND VOMITING

Figure 1. Afferent neural pathways and receptor populations involved in vomiting, as

determined by experimental animal studies, are shown. A series of brainstem structures
coordinate vomiting after activation of cortical, oral , vestibular, or peripheral afferents of
the chemoreceptor trigger zone (area postrema). Source: Mitchelson F. Pharmacological
agents affecting emesis. A review (part I). Drugs 1992; 43: 295.

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CAUSES OF NAUSEA AND VOMITING

Table 1. Causes of nausea and vomiting in adults.

MECHANISMS CATEGORIES CONDITIONS

Visceral Afferent Infections
Stimulation Mechanical Obstruction Gastric Outlet Obstruction : peptic ulcer
disease, benign tumors, malignancy, volvulus,
complications of caustic ingestion
Small intestinal obstruction:
Adhesions, hernia, Crohn’s disease,
carcinomatosis, benign tumors, polyps,
malignant tumors, intussusception
Dysmotility Gastroparesis: diabetic gastropathy,
medications, postviral postvagotomy
Small intestine : scleroderma, amyloidosis,
chronic intestinal pseudoobstruction, familial
myoneuropathies
Peritoneal irritation Peritonitis : perforated viscus, appendicitis,
spontaneous bacterial peritonitis
Viral gastroenteritis : Norwalk agent,
rotavirus
Food poisoning: toxins from bacillus cereus,
Staphylococcus aureus, Clostridium
perfringens
Hepatitis A or B
Acute systemic infections
Hepatobiliary or Acute pancreatitis
pancreatic disorders Cholecystitis or choledocholithisas
Periampullary malignancy with gastric outlet
obstruction
Topical gastrointestinal irritants Alcohol, NSAIDS, antibiotics
Postoperative Effect of anesthetics and sedative agents
Others Cardiac Disease : acute myocardial infection.
Congestive heart failure
Urologic Disease : stones , pyelonephritis
Central Nervous System Vestibular disorders Labyrinthitis, Meniere’s syndrome, motion
Disorders sickness, migraine
Increased intracranial pressure CNS tumors, subdural or subarachnoid
hemorrhage
Migraine
Infections Meningitis, encephalitis
Psychogenic Anticipatory vomiting, bulimia, psychiatric
disorders
Irritation of Antitumor chemotherapy
chemoreceptor trigger Drugs and medications Calcium channel blockers,opioids,
zone anticonvulsants, antiparkinsonism drugs,
B-blockers, antiarrhythmics, digoxin, nicotine
Radiation therapy
Systemic disorders Diabetic ketoacidosis, uemia, adrenocortical
crisis, parathyroid disease, hypothyroidism,
pregnancy, paraneoplastic syndrome,
hypertensive crisis

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 DIFFERENTIAL DIAGNOSES OF NAUSEA AND VOMITING

Table 2. Clinical considerations based on associated signs and symptoms.

CLINICAL FINDINGS CONSIDERATIONS

SYMPTOMS
Acute without abdominal pain
Acute with severe abdominal pain
Persistent vomiting
Vomiting in AM usually before breakfast
Vomiting immediately after meals
Vomiting of undigested food one to several
hours after meals
Headache, stiff neck, vertigo, facial parethesias
or weakness, projectile vomiting
Drowsiness, disorientation
History of past abdominal surgery
SIGNS
Character of vomitus
Fever, focal tenderness or rigidity, guarding or
rebound tenderness
Succusion splash
Weakness
Jaundice
Food poisoning, infectious gastroenteritis,
cholecystitis, pancreatitis or durgs
Paritoneal irritation, acute gastric or intestinal
obstruction, pancreatobiliary disease
Pregnancy, gastric outlet obstruction,
gastroparesis, intestinal dysmotility,
psychogenic disorders, and central nervous
system or systemic disorders
Pregnancy, uremia, alcohol intake the night
before, and increased ICP
Bulimia, or psychogenic causes, gastric outlet
obstruction
Gastroparesis, gastric outlet obstruction
Neurologic causes
Metabolic , septic, Hypoxic-ischemic
encephalopathy
Post-op obstruction or gastroparesis
Fecaloid/bilious – intestinal obstruction or
ileus
Undigested food- gastric outlet obstruction,
gastroparesis
Peritoneal irritation, acute gastric or intestinal
obstruction, or pancreatobiliary disease
Gastroparesis or gastric outlet obstruction
Metabolic derangements
Hepatitis, panceatobiliary disease

REFERENCES

1. Harrison’s Principles of Internal Medicine. McGraw Hill. 16th ed.

2. Yamada. Textbook of Gastroenterology. 4th ed.
3. Schwartz ' Principles of Surgery . 8th ed.