Vomiting

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 the vomiting? 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 habits or 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. Ask which contraceptive method she’s using.

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 CNS injury, you should quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.

Medical causes

Adrenal insufficiency

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

Anthrax (GI)

Initial signs and symptoms after eating contaminated meat from an infected animal include vomiting, loss of appetite, nausea, and fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

Vomiting and nausea 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 on palpation about 2" (5 cm) from the right anterior superior spine of the ilium, on a line between that spine and the umbilicus. Associated findings usually include abdominal rigidity and tenderness, anorexia, constipation or diarrhea, cutaneous hyperalgesia, fever, tachycardia, and malaise.

Cholecystitis (acute)

With cholecystitis, 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 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.

Electrolyte imbalances

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

Escherichia coli (E. coli)

O157:H7. The signs and symptoms of this infection include vomiting, watery or bloody diarrhea, nausea, fever, and abdominal cramps. In children younger than age 5 and the elderly, hemolytic uremic syndrome may develop in which the red blood cells are destroyed, and this may ultimately lead to acute renal failure.

Food poisoning

Vomiting is a common finding of food poisoning, caused by preformed toxins produced by bacteria typically found in foods, such as Bacillus cereus, Clostridium, and Staphylococcus. Diarrhea and fever also usually occur.

Gastric cancer

This rare 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 habits are also common.

Gastritis

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

Gastroenteritis

Gastroenteritis 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 with 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, and delirium. Thyroid dysfunction may be associated with this condition.

Increased intracranial pressure

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

Intestinal obstruction

Nausea and vomiting (bilious or fecal) are common with intestinal 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, bowel sounds are typically 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 with this acute inner ear inflammation. Other findings include severe vertigo, progressive hearing loss, nystagmus, and possibly otorrhea.

Listeriosis

After the ingestion of food contaminated with the bacterium Listeria monocytogenes, vomiting, fever, myalgias, abdominal pain, nausea, and diarrhea occur. If the infection spreads to the nervous system, meningitis may develop. Signs and symptoms may include fever, headache, nuchal rigidity, and change in LOC. The food-borne illness primarily affects pregnant women, neonates, and those with weakened immune systems.

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

Mesenteric venous thrombosis

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

Migraine headache

Nausea and vomiting are prodromal signs and symptoms, with 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.

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. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.

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 with preeclampsia, a disorder of pregnancy. Rapid weight gain, epigastric pain, generalized edema, elevated blood pressure, oliguria, severe frontal headache, and blurred or double vision also occur.

Q fever

Signs and symptoms of Q fever, a rickettsial infection, include vomiting, fever, chills, severe headache, malaise, chest pain, nausea, 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 disorders of this system 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 vomiting, muscle weakness or pain, fever, nausea, malaise, and dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidney’s attempt to filter the myoglobin from the bloodstream.

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 vomiting, nausea, chills, and fever. A maculopapular rash may be present in some cases.

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 is a mixture of ipecac fluid extract, glycerin, and syrup. It’s used to treat 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. (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 these 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 down 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, whereas 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 patients of this age-group, and it has a high mortality rate.

Pictures

Book Source Details

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

Other Book Chapters Related to Stomach pain

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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.

More About Causes of Stomach pain

• Back to symptom: Stomach pain: Introduction (review 45 causes)
• Next Book Extract About Stomach pain: Abdominal Distention (A Pocket Manual of Differential Diagnosis)
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More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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