Vomiting

Vomiting: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)

Vomiting is the forceful expulsion of gastric contents through the mouth. Characteristically preceded by nausea, vomiting results from a coordinated sequence of abdominal muscle contractions and reverse esophageal peristalsis.

A common sign of GI disorders, vomiting also occurs with fluid and electrolyte imbalances; infections; and metabolic, endocrine, labyrinthine, central nervous system (CNS), and cardiac disorders. It can also result from drug therapy, surgery, or radiation.

Vomiting occurs normally during the first trimester of pregnancy, but its subsequent development may signal complications. It can also result from stress, anxiety, pain, alcohol intoxication, overeating, or ingestion of distasteful foods or liquids.

History and physical examination

Ask your patient to describe the onset, duration, and intensity of his vomiting. What started it? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore any associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel elimination patterns or the appearance of stools, excessive belching or flatus, and bloating or fullness.

Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant and which contraceptive method she uses.

Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.

During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure, a life-threatening emergency. If this occurs in a patient with a CNS injury, quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.

Medical causes

Adrenal insufficiency

Common GI findings in the disorder include nausea and vomiting, anorexia, and diarrhea. Other findings include weakness, fatigue, weight loss, bronze skin, orthostatic hypotension, and a weak, irregular pulse.

Anthrax, GI

Initial signs and symptoms after ingestion of contaminated meat from an infected animal include nausea and vomiting, anorexia, and fever. Later, abdominal pain, severe bloody diarrhea, and hematemesis may occur.

Appendicitis

Nausea and vomiting may follow or accompany abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe, stabbing pain in the right lower quadrant. The patient generally has a positive McBurney’s sign—severe pain and tenderness at a point two-thirds the distance from the umbilicus to the right anterior superior spine of the ilium. Associated findings usually include abdominal rigidity and tenderness, anorexia, constipation or diarrhea, cutaneous hyperalgesia, fever, tachycardia, and malaise.

Bulimia

Most common in women ages 18 to 29, bulimia is characterized by polyphagia that alternates with self-induced vomiting, fasting, or diarrhea. It’s commonly accompanied by anorexia. The patient typically weighs less than normal but has a morbid fear of obesity. Self-induced vomiting may be evidenced by calloused knuckles and changes in teeth (enamel loss).

Cholecystitis (acute)

With this disorder, nausea and mild vomiting commonly follow severe right-upper-quadrant pain that may radiate to the back or shoulders. Associated findings include abdominal tenderness and, possibly, rigidity and distention, fever, and diaphoresis.

Cholelithiasis

Nausea and vomiting accompany severe unlocalized right-upper-quadrant or epigastric pain after ingestion of fatty foods. Other findings include abdominal tenderness and guarding, flatulence, belching, epigastric burning, pyrosis, tachycardia, and restlessness.

Cholera

Signs and symptoms of cholera include vomiting and abrupt watery diarrhea. Severe water and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Cirrhosis

Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, aching abdominal pain, and constipation or diarrhea. Later findings include jaundice, hepatomegaly, and abdominal distention.

Escherichia coli O157:H7

The signs and symptoms of this infection include nausea and vomiting, watery or bloody diarrhea, fever, and abdominal cramps. Children younger than age 5 and elderly people may develop hemolytic uremic syndrome, which causes red blood cell destruction and may eventually lead to acute renal failure.

Ectopic pregnancy

Nausea, vomiting, vaginal bleeding, and lower abdominal pain occur in this potentially life-threatening disorder.

Electrolyte imbalances

Such disturbances as hyponatremia, hypernatremia, hypokalemia, and hypercalcemia commonly cause nausea and vomiting. Other effects include arrhythmias, tremors, seizures, anorexia, malaise, and weakness.

Food poisoning

Vomiting, diarrhea, and fever are common findings in food poisoning, which is caused by ingestion of preformed toxins produced by bacteria typically found in foods, such as Bacillus cereus, Clostridium, and Staphylococcus.

Gastric cancer

This rare type of cancer may produce mild nausea, vomiting (possibly of mucus or blood), anorexia, upper abdominal discomfort, and chronic dyspepsia. Fatigue, weight loss, melena, and altered bowel elimination habits are also common.

Gastritis

Nausea and vomiting of mucus or blood are common in gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Epigastric pain, belching, and fever may also occur.

Gastroenteritis

This disorder causes nausea, vomiting (often of undigested food), diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, and abdominal pain and tenderness may also occur.

Heart failure

Nausea and vomiting may occur, especially in right-sided heart failure. Associated findings include tachycardia, ventricular gallop, fatigue, dyspnea, crackles, peripheral edema, and jugular vein distention.

Hepatitis

Vomiting commonly follows nausea as an early sign of viral hepatitis. Other early findings include fatigue, myalgia, arthralgia, headache, photophobia, anorexia, pharyngitis, cough, and fever.

Hyperemesis gravidarum

Unremitting nausea and vomiting that last beyond the first trimester characterize this disorder of pregnancy. Vomitus contains undigested food, mucus, and small amounts of bile early in the disorder; later, it has a coffee-ground appearance. Associated findings include weight loss, headache, delirium and, possibly, thyroid dysfunction.

Increased intracranial pressure

Projectile vomiting that isn’t preceded by nausea is a sign of increased intracranial pressure. The patient may exhibit a decreased level of consciousness (LOC) and Cushing’s triad (bradycardia, hypertension, and respiratory pattern changes). He may also have a headache, widened pulse pressure, impaired movement, visual disturbances, pupillary changes, and papilledema.

Infection

Acute localized or systemic infection may cause vomiting and nausea. Other common findings include fever, headache, malaise, and fatigue.

Intestinal obstruction

Nausea and vomiting (bilious or fecal) are common in this type of obstruction, especially of the upper small intestine. Abdominal pain is usually episodic and colicky but can become severe and steady. Constipation occurs early in large intestinal obstruction and late in small intestinal obstruction. Obstipation, however, may signal complete obstruction. In partial obstruction, bowel sounds are typically high pitched and hyperactive; in complete obstruction, hypoactive or absent. Abdominal distention and tenderness also occur, possibly with visible peristaltic waves and a palpable abdominal mass.

Labyrinthitis

Nausea and vomiting commonly occur in this acute inner ear inflammation. Other findings include severe vertigo, progressive hearing loss, nystagmus and, possibly, otorrhea.

Listeriosis

After ingesting food contaminated with the bacterium Listeria monocytogenes, the patient develops nausea, vomiting, abdominal pain, diarrhea, fever, and myalgia. If the infection spreads to the nervous system, he may develop meningitis. Signs and symptoms may include fever, headache, nuchal rigidity, and altered LOC. This food-borne illness primarily affects pregnant women, newborns, and those with weakened immune systems.

Gender Cue: Listeriosis that occurs during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Ménière’s disease

This disorder results in sudden, brief, recurrent attacks of nausea and vomiting, dizziness, vertigo, hearing loss, tinnitus, diaphoresis, and nystagmus.

Mesenteric artery ischemia

This life-threatening disorder may cause nausea and vomiting and severe, cramping abdominal pain, especially after meals. Other findings include diarrhea or constipation, abdominal tenderness and bloating, anorexia, weight loss, and abdominal bruits.

Mesenteric venous thrombosis

Insidious or acute onset of nausea, vomiting, and abdominal pain occurs along with diarrhea or constipation, abdominal distention, hematemesis, and melena.

Metabolic acidosis

This imbalance may produce nausea, vomiting, anorexia, diarrhea, Kussmaul’s respirations, and decreased LOC.

Migraine headache

Prodromal signs and symptoms of migraine include nausea and vomiting, fatigue, photophobia, light flashes, increased noise sensitivity and, possibly, partial vision loss and paresthesia.

Motion sickness

Nausea and vomiting may be accompanied by headache, vertigo, dizziness, fatigue, diaphoresis, and dyspnea.

Myocardial infarction

Nausea and vomiting may occur, but the cardinal symptom is severe substernal chest pain, which may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, and restlessness also occur.

Norovirus infection

Violent vomiting may occur frequently and without warning in this infection. Children infected with noroviruses tend to experience acute-onset vomiting more often than adults. Additional symptoms include nausea, diarrhea, and abdominal pain or cramping. There are no drugs or vaccines for noroviruses, but symptomatic therapy may be necessary to replace fluids and correct electrolyte disturbances resulting from frequent vomiting and diarrhea. Young children, elderly people, and those who are otherwise ill are at increased risk for dehydration.

Pancreatitis (acute)

Vomiting, usually preceded by nausea, is an early sign of pancreatitis. Associated findings include steady, severe epigastric or left-upper-quadrant pain that may radiate to the back; abdominal tenderness and rigidity; hypoactive bowel sounds; anorexia; vomiting; and fever. Severe pancreatitis may result in tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities.

Peptic ulcer

Nausea and vomiting may follow sharp, burning or gnawing epigastric pain, especially when the stomach is empty or after ingestion of alcohol, caffeine, or aspirin. Attacks are relieved by eating or taking antacids. Hematemesis or melena may also occur.

Peritonitis

Nausea and vomiting usually accompany acute abdominal pain in the area of inflammation. Other findings include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness; weakness; pale, cold skin; diaphoresis; hypotension; signs of dehydration; and shallow respirations.

Preeclampsia

Nausea and vomiting are common in this disorder of pregnancy. Rapid weight gain, epigastric pain, generalized edema, elevated blood pressure, oliguria, a severe frontal headache, and blurred or double vision also occur.

Q fever

Signs and symptoms of this rickettsial infection include nausea and vomiting, fever, chills, severe headache, malaise, chest pain, and diarrhea. Fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Renal and urologic disorders

Cystitis, pyelonephritis, calculi, and other renal and urologic disorders can cause vomiting. Accompanying findings reflect the specific disorder. Persistent nausea and vomiting are typical findings in patients with acute or worsening chronic renal failure.

Rhabdomyolysis

Signs and symptoms of this disorder include nausea and vomiting, muscle weakness or pain, fever, malaise, and dark urine. Acute renal failure, the most commonly reported complication of rhabdomyolysis, results from renal structure obstruction and injury during the kidneys’attempt to filter the myoglobin from the bloodstream.

Thyrotoxicosis

Nausea and vomiting may accompany the classic findings of severe anxiety, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, tachycardia, and palpitations. Other findings include exophthalmos, ventricular or atrial gallop, and an enlarged thyroid gland.

Typhus

Typhus is a rickettsial disease transmitted to humans by fleas, mites, or body louse. Initial symptoms include headache, myalgia, arthralgia, and malaise, followed by an abrupt onset of nausea, vomiting, chills, and fever. A maculopapular rash may be present in some cases.

Ulcerative colitis

Nausea, vomiting, and anorexia may occur, but the most common sign is recurrent diarrhea with blood, pus, and mucus. Fever, chills, and weight loss are other common signs and symptoms.

Other causes

Drugs

Drugs that commonly cause vomiting include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium, chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, and overdoses of cardiac glycosides and theophylline. Syrup of ipecac, a mixture of ipecac fluid extract, glycerin, and syrup, is used to treat drug overdoses by inducing vomiting.

Radiation and surgery

Radiation therapy may cause nausea and vomiting if it disrupts the gastric mucosa. Postoperative nausea and vomiting are common, especially after abdominal surgery.

Special considerations

Draw blood to determine fluid, electrolyte, and acid-base balance because prolonged vomiting can cause dehydration, electrolyte imbalances, and metabolic alkalosis. Have the patient breathe deeply to ease his nausea and help prevent further vomiting. Keep his room fresh and clean smelling by removing bedpans and emesis basins promptly after use. Elevate his head or position him on his side to prevent aspiration of vomitus. Continuously monitor vital signs and intake and output (including vomitus and liquid stools). If necessary, administer I.V. fluids or have the patient sip clear liquids to maintain hydration.

Because pain can precipitate or intensify nausea and vomiting, administer pain medications promptly. If possible, give them by injection or suppository to prevent exacerbating associated nausea. If an opioid is used to treat pain, monitor bowel sounds, flatus, and bowel movements carefully because they may slow GI motility and exacerbate vomiting. If you administer an antiemetic, be alert for abdominal distention and hypoactive bowel sounds, which may indicate gastric retention. If this occurs, insert a nasogastric tube.

Pediatric pointers

In a neonate, pyloric obstruction may cause projectile vomiting, and Hirschsprung’s disease may cause fecal vomiting. Intussusception may lead to vomiting of bile and fecal matter in an infant or toddler. Because an infant may aspirate vomitus as a result of his immature cough and gag reflexes, position him on his side or abdomen and clear any vomitus immediately.

Geriatric pointers

Although elderly patients can develop several of the disorders mentioned earlier, always rule out intestinal ischemia first—it’s especially common in this age-group and has a high mortality.

Patient counseling

Advise patients to replace fluid losses to avoid dehydration. If vomiting is persistent, administer an antiemetic; consider hospitalizing the patient for I.V. fluid replacement or parenteral nutrition therapy. Advise patients suffering from migraine headaches that vomiting may be a prodromal symptom and that they should take antimigraine medication.

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Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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