Vomiting

Vomit redirects here. For other uses, see Vomit

(disambiguation).
Emesis redirects here. For the buttery genus, see
Emesis (genus).
Heaving redirects here. For the up-and-down motion,
see Heave.
Puke redirects here. For other uses, see Puke (disambiguation).

chloride directly. Combined with the resulting alkaline

tide, this leads to hypochloremic metabolic alkalosis (low
chloride levels together with high HCO
3 and CO
2 and increased blood pH) and often hypokalemia
(potassium depletion). The hypokalemia is an indirect
result of the kidney compensating for the loss of acid.
With the loss of intake of food the individual may eventually become cachectic. A less frequent occurrence reVomiting (known medically with the Greek term eme- sults from a vomiting of intestinal contents, including bile
sis and informally as throwing up and numerous other acids and HCO
terms) is the involuntary, forceful expulsion of the con- 3, which can cause metabolic acidosis.
tents of ones stomach through the mouth and sometimes
the nose.[1] Vomiting can be caused by a wide variety
1.3 Mallory-Weiss tear
of conditions; it may present as a specic response to
ailments like gastritis or poisoning, or as a non-specic
sequela of disorders ranging from brain tumors and el- Repeated or profuse vomiting may cause erosions to
evated intracranial pressure to overexposure to ionizing the esophagus or small tears in the esophageal mucosa
radiation. The feeling that one is about to vomit is called (Mallory-Weiss tear). This may become apparent if fresh
nausea, which often precedes, but does not always lead red blood is mixed with vomit after several episodes.
to, vomiting. Antiemetics are sometimes necessary to
suppress nausea and vomiting. In severe cases, where
1.4 Dentistry
dehydration develops, intravenous uid may be required.
Vomiting is dierent from regurgitation, although the two
terms are often used interchangeably. Regurgitation is the
return of undigested food back up the esophagus to the
mouth, without the force and displeasure associated with
vomiting. The causes of vomiting and regurgitation are
generally dierent.

1
1.1

Recurrent vomiting, such as observed in bulimia nervosa,

may lead to destruction of the tooth enamel due to the
acidity of the vomit. Digestive enzymes can also have a
negative eect on oral health, by degrading the tissue of
the gums.

2 Pathophysiology

Complications

Receptors on the oor of the fourth ventricle of the brain

represent a chemoreceptor trigger zone, known as the
area postrema, stimulation of which can lead to vomiting.
The area postrema is a circumventricular organ and as
such lies outside the bloodbrain barrier; it can therefore
be stimulated by blood-borne drugs that can stimulate
vomiting or inhibit it.

Aspiration of vomit

Vomiting can be dangerous if the gastric content enters

the respiratory tract. Under normal circumstances the gag
reex and coughing prevent this from occurring, however
these protective reexes are compromised in persons under the inuences of certain substances such as alcohol or
There are various sources of input to the vomiting center:
anesthesia. The individual may choke and asphyxiate or
suer an aspiration pneumonia.
The chemoreceptor trigger zone at the base of the
fourth ventricle has numerous dopamine D2 recep1.2 Dehydration and electrolyte imbalance
tors, serotonin 5-HT3 receptors, opioid receptors,
acetylcholine receptors, and receptors for substance
Prolonged and excessive vomiting depletes the body of
P. Stimulation of dierent receptors are involved
water (dehydration), and may alter the electrolyte status.
in dierent pathways leading to emesis, in the nal
Gastric vomiting leads to the loss of acid (protons) and
common pathway substance P appears involved.[2]
1

2 PATHOPHYSIOLOGY
Intrathoracic pressure lowers (by inspiration against
a closed glottis), coupled with an increase in abdominal pressure as the abdominal muscles contract,
propels stomach contents into the esophagus as the
lower esophageal sphincter relaxes. The stomach
itself does not contract in the process of vomiting
except for at the angular notch, nor is there any
retroperistalsis in the esophagus.
Vomiting is ordinarily preceded by retching.
Vomiting also initiates an SNS response causing
both sweating and increased heart rate.
The neurotransmitters that regulate vomiting are poorly
understood, but inhibitors of dopamine, histamine, and
serotonin are all used to suppress vomiting, suggesting
that these play a role in the initiation or maintenance of
a vomiting cycle. Vasopressin and neurokinin may also
participate.

14th-century illustration of vomiting from the Casanatense

Tacuinum Sanitatis

The vestibular system, which sends information to

the brain via cranial nerve VIII (vestibulocochlear
nerve), plays a major role in motion sickness, and
is rich in muscarinic receptors and histamine H1 receptors.
The cranial nerve X (vagus nerve) is activated when
the pharynx is irritated, leading to a gag reex.
The vagal and enteric nervous system inputs
transmit information regarding the state of the
gastrointestinal system. Irritation of the GI mucosa
by chemotherapy, radiation, distention, or acute infectious gastroenteritis activates the 5-HT3 receptors of these inputs.
The CNS mediates vomiting that arises from psychiatric disorders and stress from higher brain
centers.[3]

2.1 Phases
The vomiting act has two phases. In the retching phase,
the abdominal muscles undergo a few rounds of coordinated contractions together with the diaphragm and the
muscles used in respiratory inspiration. For this reason,
an individual may confuse this phase with an episode of
violent hiccups. In this retching phase nothing has yet
been expelled. In the next phase, also termed the expulsive phase, intense pressure is formed in the stomach
brought about by enormous shifts in both the diaphragm
and the abdomen. These shifts are, in essence, vigorous
contractions of these muscles that last for extended periods of time - much longer than a normal period of muscular contraction. The pressure is then suddenly released
when the upper esophageal sphincter relaxes resulting in
the expulsion of gastric contents. Individuals who do not
regularly exercise their abdominal muscles may experience pain in those muscles for a few days. The relief
of pressure and the release of endorphins into the bloodstream after the expulsion causes the vomiter to feel better.

The vomiting act encompasses three types of outputs

initiated by the chemoreceptor trigger zone: Motor,
2.2 Contents
parasympathetic nervous system (PNS), and sympathetic
nervous system (SNS). They are as follows:
Gastric secretions and likewise vomit are highly acidic.
Recent food intake appears in the gastric vomit. Irrespec Increased salivation to protect tooth enamel from tive of the content, vomit tends to be malodorous.
stomach acids. (Excessive vomiting leads to dental
The content of the vomitus (vomit) may be of medical inerosion). This is part of the PNS output.
terest. Fresh blood in the vomit is termed hematemesis
The body takes a deep breath to avoid aspirating (blood vomiting). Altered blood bears resemblance to
coee grounds (as the iron in the blood is oxidized) and,
vomit.
when this matter is identied, the term "coee ground
Retroperistalsis, starts from the middle of the small vomiting" is used. Bile can enter the vomit during subintestine and sweeps up digestive tract contents into sequent heaves due to duodenal contraction if the vomthe stomach, through the relaxed pyloric sphincter. iting is severe. Fecal vomiting is often a consequence

3.2

Sensory system and brain

of intestinal obstruction or a gastrocolic stula and is 3.2

treated as a warning sign of this potentially serious problem (signum mali ominis).

Sensory system and brain

If the vomiting reex continues for an extended period

with no appreciable vomitus, the condition is known as
non-productive emesis or dry heaves, which can be painful
and debilitating.
Color of vomit
Bright red in the vomit suggests bleeding from the
esophagus
Dark red vomit with liver-like clots suggests profuse
bleeding in the stomach, such as from a perforated
ulcer
Coee ground-like vomit suggests less severe bleeding in the stomach, because the gastric acid has had
time to change the composition of the blood
Yellow vomit suggests bile. This indicates that the
pyloric valve is open and bile is owing into the
stomach from the duodenum. (This is more common in older people.)

Dierential diagnosis

Vomiting may be due to a large number of causes, and

protracted vomiting has a long dierential diagnosis.

3.1

Digestive tract

Causes in the digestive tract

Gastritis (inammation of the gastric wall)
Gastroenteritis
Gastroesophageal reux disease
Pyloric stenosis (in babies, this typically causes a
very forceful projectile vomiting and is an indi- Intoxication is one cause of vomiting.
cation for urgent surgery)
Causes in the sensory system
Bowel obstruction
Overeating
Acute abdomen and/or peritonitis
Ileus

Movement: motion sickness (which is caused by

overstimulation of the labyrinthine canals of the ear)
Mnires disease

Food allergies (often in conjunction with hives or Causes in the brain

swelling)
Concussion
Cholecystitis, pancreatitis, appendicitis, hepatitis
Cerebral hemorrhage
Food poisoning
Migraine
In children, it can be caused by an allergic reaction
Brain tumors, which can cause the chemoreceptors
to cows milk proteins (Milk allergy or lactose intolerance)
to malfunction

3 DIFFERENTIAL DIAGNOSIS
Benign intracranial hypertension and hydrocephalus 3.4

Social cues

Metabolic disturbances (these may irritate both the stomach and the parts of the brain that coordinate vomiting)
Hypercalcemia (high calcium levels)
Uremia (urea accumulation, usually due to renal failure)
Adrenal insuciency
Hypoglycemia
Hyperglycemia
Pregnancy
Hyperemesis, Morning sickness

A drunk man vomiting, while a young slave is holding his forehead. Brygos Painter, 500-470 BC

Drug reaction (vomiting may occur as an acute somatic

response to)
It is quite common that, when one person vomits, others nearby become nauseated, particularly when smelling
alcohol (being sick while being drunk or being sick the vomit of others, often to the point of vomiting themthe next morning, suering from the after-eects, selves. It is believed that this is an evolved trait among
i.e., the hangover)
primates. Many primates in the wild tend to browse for
food in small groups. Should one member of the party
opioids
react adversely to some ingested food, it may be advanta selective serotonin reuptake inhibitors
geous (in a survival sense) for other members of the party
to also vomit. This tendency in human populations has
many chemotherapy drugs
been observed at drinking parties, where excessive con some entheogens (such as peyote or ayahuasca)
sumption of alcoholic beverages may cause a number of
party members to vomit nearly simultaneously, this beIllness (sometimes colloquially known as stomach u ing triggered by the initial vomiting of a single member
a broad name that refers to gastric inammation caused of the party. This phenomenon has been touched on in
by a range of viruses and bacteria)
popular culture: Notorious instances appear in the lms
Monty Pythons The Meaning of Life (1983) and Stand By
Norovirus (formerly Norwalk virus or Norwalk Me (1986).[12]
agent)
Intense vomiting in ayahuasca ceremonies is a com Swine inuenza
mon phenomenon. However, people who experience la
purga after drinking ayahuasca, in general, regard the
practice as both a physical and spiritual cleanse and of3.3 Emetics
ten come to welcome it.[13] It has been suggested that the
consistent emetic eects of ayahuasca in addition to
An emetic, such as syrup of ipecac, is a substance that in- its many other therapeutic properties was of medicinal
duces vomiting when administered orally or by injection. benet to indigenous peoples of the Amazon, in helping
An emetic is used medically where a substance has been
to clear parasites from the gastrointestinal system.[14]
ingested and must be expelled from the body immediately
(for this reason, many toxic and easily digestible products There have also been documented cases of a single ill
such as rat poison contain an emetic). Inducing vomiting and vomiting individual inadvertently causing others to
can remove the substance before it is absorbed into the vomit, when they are especially fearful of also becoming
body. Ipecac abuse can cause detrimental health eects. ill, through a form of mass hysteria.
Most people try to contain their vomit by vomiting into
a sink, toilet, or trash can, as vomit is dicult and unpleasant to clean. On airplanes and boats, special bags
are supplied for sick passengers to vomit into. A special
Copper sulfate was also used in the past as an emetic.[7][8] disposable bag (leakproof, puncture-resistant, odorless)
It is now considered too toxic for this use.[9]
containing absorbent material that solidies the vomit
Hydrogen peroxide is used as an emetic in veterinary quickly is also available, making it convenient and safe
practice.[10][11]
to store until there is an opportunity to dispose of it conSalt water and mustard water have been used since ancient times as emetics.[4] Care must be taken with salt, as
excessive intake can potentially be harmful.[5][6]

5
After surgery (postoperative nausea and vomiting)
Disagreeable sights or disgust, smells or thoughts
(such as decayed matter, others vomit, thinking of
vomiting), etc.
Extreme pain, such as intense headache or
myocardial infarction (heart attack)
Violent emotions
Cyclic vomiting syndrome (a poorly understood
condition with attacks of vomiting)
High doses of ionizing radiation sometimes trigger
a vomit reex.
Violent ts of coughing, hiccups, or asthma
Anxiety
Depression
Overexertion (doing too much strenuous exercise
can lead to vomiting shortly afterwards).

Special bags are often supplied on boats for sick passengers to

vomit into.

veniently.

Rumination syndrome, an underdiagnosed and

poorly understood disorder that causes suerers to
regurgitate food shortly after ingestion.

4 Other types

People who vomit chronically (e.g., as part of an eating

[16]
is a
disorder such as bulimia nervosa) may devise various Fecal vomiting (aka stercoraceous vomiting)
kind of vomiting, or emesis, in which partially or fully
ways to hide this disorder.
digested matter is expelled from the intestines into the
An online study of peoples responses to horrible stomach, by a combination of liquid and gas pressure and
sounds found vomiting the most disgusting. Profes- spasmodic contractions of the gastric muscles, and then
sor Trevor Cox of the University of Salford's Acoustic subsequently forcefully expelled from the stomach up into
Research Centre said that We are pre-programmed to the esophagus and out through the mouth and sometimes
be repulsed by horrible things such as vomiting, as it is nasal passages. Though it is not usually fecal matter that
fundamental to staying alive to avoid nasty stu. It is is expelled, it smells noxious. Alternative medical terms
thought that disgust is triggered by the sound of vomiting for fecal vomiting are copremesis and stercoraceous vomto protect those nearby from, possibly diseased, food.[15] iting.[17] Copremesis like all emesis may lead to aspiration. However, if contents of the large intestine are aspirated, severe or even fatal aspiration pneumonia results,
3.5 Miscellanea
secondary to the massive number of bacteria normally
present distal to the ileocecal valve. Projectile vomit Self-induced
ing refers to vomiting that ejects the gastric contents with
[16]
Eating disorders (anorexia nervosa or bulimia great force. It is a classic symptom of infantile hypertrophic pyloric stenosis, in which it typically follows feednervosa)
ing and can be so forceful that some material exits through
To eliminate an ingested poison (some poisons the nose.[18]
should not be vomited as they may be more
toxic when inhaled or aspirated; it is better to
ask for help before inducing vomiting)

5 Treatment

Some people who engage in binge drinking induce vomiting to make room in their stomachs An antiemetic is a drug that is eective against vomitfor more alcohol consumption.
ing and nausea. Antiemetics are typically used to treat
People suering from nausea may induce motion sickness and the side-eects of medications such
vomiting in hopes of feeling better.
as opioids and chemotherapy.

Antiemetics act by inhibiting the receptor sites asso- [9]

ciated with emesis. Hence, anticholinergics, antihistamines, dopamine antagonists, serotonin antagonists,
and cannabinoids are used as anti-emetics.
[10]

Epidemiology

Nausea and/or vomiting are the main complaints in 1.6%

of visits to family physicians in Australia.[19]

See also
Airsickness bag
Emetophilia

EXTERNAL LINKS

Olson, Kent C. (2004). Poisoning & drug overdose. New

York: Lange Medical Mooks/McGraw-Hill. p. 175.
ISBN 0-8385-8172-2.
Drugs to Control or Stimulate Vomiting. Merck Veterinary manual. Merck & Co., Inc. 2006.

[11] How to Induce Vomiting (Emesis) in Dogs.

place.com. Retrieved 2014-05-03.

Pet-

[12] 9 Best Vomit Scenes On Film, screenjunkies.com

[13] Shanon, B. (2002). The antipodes of the mind: Charting
the phenomenology of the ayahuasca experience. Oxford:
Oxford University Press.
[14] Andritzky, W. (1989).
Sociopsychotherapeutic
functions of ayahuasca healing in Amazonia.
Journal of Psychoactive Drugs 21 (1):
7789.
doi:10.1080/02791072.1989.10472145.
PMID
2656954.

Cancer and nausea

[15] University of Salford. January 28, 2007.

Emetophobia

[16] vomiting - denition of vomiting in the Medical dictionary - by the Free Online Medical Dictionary, Thesaurus and Encyclopedia.
Medicaldictionary.thefreedictionary.com. Retrieved 2014-05-03.

References

[1] Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)).
New York: McGraw-Hill Companies. p. 830. ISBN 007-148480-9.
[2] Hornby, PJ (2001). Central neurocircuitry associated with emesis. The American Journal of Medicine.
111 Suppl 8A (8): 106S112S. doi:10.1016/S00029343(01)00849-X. PMID 11749934.
[3] Ray Andrew P., Chebolu Seetha, Ramirez Juan, Darmani Nissar A (2009). Ablation of Least Shrew Central
Neurokinin NK1 Receptors Reduces GR73632-Induced
Vomiting. Behavioural Neuroscience 123 (3): 701706.
doi:10.1037/a0015733.
[4] Decker, W. J. (1971). In Quest of Emesis: Fact, Fable, and Fancy. Clinical Toxicology 4 (3): 383387.
doi:10.3109/15563657108990490. PMID 4151103.
[5] Moder, K. G.; Hurley, D. L. (1991). Fatal hypernatremia
from exogenous salt intake: report of a case and review
of the literature. Mayo Clin Proc. 65 (12): 158794.
doi:10.1016/S0025-6196(12)62194-6. PMID 2255221.
[6] Salt: a natural antidepressant? The Scotsman. April 6,
2009.
[7] Holtzmann NA, Haslam RH (July 1968). Elevation of
serum copper following copper sulfate as an emetic. Pediatrics 42 (1): 18993. PMID 4385403.
[8] Wang, S. C.; Borison, Herbert L. (1951). Copper Sulphate Emesis: A Study of Aerent Pathways from the
Gastrointestinal Tract. Am J Physiol - Legacy Content
164 (2): 520526.

[17] fecal vomiting - denition of fecal vomiting in the

Free Online Medical Dictionary, Thesaurus and Encyclopedia. Medical-dictionary.thefreedictionary.com. Retrieved 2014-05-03.
[18] Sleisenger, edited by Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt; consulting editor, Marvin H.
(2009). Sleisenger & Fordtrans gastrointestinal and liver
disease pathophysiology, diagnosis, management (9th ed.).
St. Louis, Mo.: MD Consult. p. 783. ISBN 1-41606189-4.
[19] Helena Britt;
Fahridin, S (September 2007).
Presentations of nausea and vomiting. Aust Fam
Physician 36 (9): 673784. PMID 17885697.

9 External links
Cyclical Vomiting Syndrome

"Emetics". The American Cyclopdia. 1879.

10
10.1

Text and image sources, contributors, and licenses

Text

Vomiting Source: http://en.wikipedia.org/wiki/Vomiting?oldid=636490304 Contributors: AxelBoldt, Zundark, The Anome, Taral, Zoe,
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Hamamelis, Towelie7778, WerewolfHunter65, Sonicsouts, Anish1411, Answerman22, Tobby72, Cameron1994, Recognizance, Antonbartelpuke, Citation bot 1, Javert, El estremeu, RedBot, Connaugh12, SpaceFlight89, Sjd7901, Winxclublovers411, Stephendwan, Lotje,
Inferior Olive, Diannaa, Jimb0onwheelz, Idajork, 7mike5000, Uanfala, Chrisx930, Mandolinface, GoingBatty, Tommy2010, ZroBot,
PBS-AWB, Terribleidea, Hazard-SJ, Captain Screebo, Dark-X, Helpful Pixie Bot, Lionhead99, Regulov, PhnomPencil, Nikos 1993, Zach
Vega, Cobone, GlassWax, Arcandam, SoledadKabocha, Coolbeans443, J.C.FMS1995, Monkbot and Anonymous: 586

10.2

Images

File:3205_-_Milano,_Duomo_-_Giorgio_Bonola_-_Miracolo_di_Marco_Spagnolo_(1681)_-_Foto_Giovanni_Dall'Orto,
_6-Dec-2007.jpg Source:
http://upload.wikimedia.org/wikipedia/commons/f/fd/3205_-_Milano%2C_Duomo_-_Giorgio_Bonola_
Public domain
-_Miracolo_di_Marco_Spagnolo_%281681%29_-_Foto_Giovanni_Dall%27Orto%2C_6-Dec-2007.jpg License:
Contributors: Own work, Giovanni Dall'Orto, 7 December 2007 Original artist: Creator:Giorgio Bonola (ca. 1657-1700)
File:49-aspetti_di_vita_quotidiana,_vomito,Taccuino_Sanitatis,_Ca.jpg Source: http://upload.wikimedia.org/wikipedia/commons/
e/e3/49-aspetti_di_vita_quotidiana%2C_vomito%2CTaccuino_Sanitatis%2C_Ca.jpg License: Public domain Contributors: book scan
Original artist: unknown master

10

TEXT AND IMAGE SOURCES, CONTRIBUTORS, AND LICENSES

File:Commons-logo.svg Source: http://upload.wikimedia.org/wikipedia/en/4/4a/Commons-logo.svg License: ? Contributors: ? Original

artist: ?
File:Nationalmuseet_-_Cophenaghen_-_brygos_vomiting1.jpg Source:
http://upload.wikimedia.org/wikipedia/commons/c/c9/
Nationalmuseet_-_Cophenaghen_-_brygos_vomiting1.jpg License: CC-BY-SA-3.0 Contributors: Own work Original artist: Stefano
Bolognini
File:Padlock-silver.svg Source: http://upload.wikimedia.org/wikipedia/commons/f/fc/Padlock-silver.svg License: CC0 Contributors:
http://openclipart.org/people/Anonymous/padlock_aj_ashton_01.svg Original artist: This image le was created by AJ Ashton. Uploaded
from English WP by User:Eleassar. Converted by User:AzaToth to a silver color.
File:Question_book-new.svg Source: http://upload.wikimedia.org/wikipedia/en/9/99/Question_book-new.svg License: Cc-by-sa-3.0
Contributors:
Created from scratch in Adobe Illustrator. Based on Image:Question book.png created by User:Equazcion Original artist:
Tkgd2007
File:Sea-sickness_bag,_Merseyside_Maritime_Museum.png Source:
http://upload.wikimedia.org/wikipedia/commons/b/bd/
Sea-sickness_bag%2C_Merseyside_Maritime_Museum.png License: CC BY-SA 3.0 Contributors: Own work Original artist: Rept0n1x
File:Vomiting_Erbrechen_drunk.jpg Source: http://upload.wikimedia.org/wikipedia/commons/4/4a/Vomiting_Erbrechen_drunk.jpg
License: CC BY-SA 3.0 Contributors: Own work Original artist: Usien
File:Wikiquote-logo.svg Source: http://upload.wikimedia.org/wikipedia/commons/f/fa/Wikiquote-logo.svg License: Public domain
Contributors: ? Original artist: ?
File:Wikisource-logo.svg Source: http://upload.wikimedia.org/wikipedia/commons/4/4c/Wikisource-logo.svg License: CC BY-SA 3.0
Contributors: Rei-artur Original artist: Nicholas Moreau
File:Wiktionary-logo-en.svg Source: http://upload.wikimedia.org/wikipedia/commons/f/f8/Wiktionary-logo-en.svg License: Public domain Contributors: Vector version of Image:Wiktionary-logo-en.png. Original artist: Vectorized by Fvasconcellos (talk contribs), based
on original logo tossed together by Brion Vibber

10.3

Content license

Creative Commons Attribution-Share Alike 3.0