Doctors

Introduction to nausea and vomiting

Nausea and vomiting are symptoms of an underlying disease and not a specific illness. Nausea is the sensation that the stomach wants to empty itself, while vomiting (emesis) or throwing up, is the act of forcible emptying of the stomach.

Vomiting is a violent act in which the stomach has to overcome the pressures that are normally in place to keep food and secretions within the stomach. The stomach almost turns itself inside out - forcing itself into the lower portion of the esophagus (the tube that connects the mouth to the stomach) during a vomiting episode.

What causes nausea or vomiting?

There are numerous causes of nausea and vomiting. These symptoms may be due to the following:

• acute gastritis
  
  
• central causes (signals from the brain)
  
  
• association with other illnesses remote from the stomach
  
  
• medications and medical treatments
  
  
• mechanical obstruction of the bowel

Acute gastritis

Acute gastritis (gastro=stomach + it is= inflammation) is often caused by an offending agent which irritates the lining of the stomach. Examples of these include:

• Infections: Infections are often the cause, whether it is a common virus or an infection that is contracted from travel. There may be associated crampy upperabdominal pain, fever ,and chills may be present. Common viral infections includenoroviruses and rotavirus. Parasitic infections often are associated with diarrheabut may also have a component of nausea and vomiting. Infection by bacteria in the Helicobacter family (like H. Pylori) can also be the infectious agent.
  
  
• Stomach flu: Stomach flu is a non-specific term used to describe vomiting and diarrhea associated with a viral infection. It should not be confused with influenza, whose symptoms include fever, chills, cough, and myalgias (muscle pain).
  
  
• Food poisoning: Food poisoning may cause significant vomiting and usually is caused by a bacterial toxin. Symptoms begin within a couple hours of eating contaminated or poorly prepared food and may last for 1-2 days. Sources of food poisoning include Salmonella, Campylobacter, Shigella, E. coli, Listeria, orClostridium botulinum (botulism).
  
  
• Other stomach irritants: alcohol, smoking, and non steroidal anti-inflammatory medications such as aspirin and ibuprofen may irritate the stomach lining.
  
  
• Peptic ulcer disease: Peptic ulcer disease can range from mild irritation of the stomach lining to the formation of a defect in the protective lining of the stomach called an ulcer.
  
  

• Gastroesophageal reflux disease (GERD, reflux esophagitis): Nausea or vomiting is also associated with irritation of the lining of the esophagus

  Central causes (signals from the brain that cause nausea and vomiting)

  • Headache: especially migraine, is commonly associated with nausea and vomiting.
    
    
  • Inner ear: Motion sickness, labyrinthitis,benign postural vertigo, or Meniere's disease
    
    
  • Head injury: Any illness or injury that increases the pressure inside the skull can cause vomiting. This rise in intracranial pressure may be due to brain swelling from trauma (for example, concussion or head trauma), infection (meningitis or encephalitis),tumor, or abnormal electrolyte and water balance in the bloodstream.
    
    
  • Noxious stimulus: Certain smells or sounds can cause centrally mediated nausea and vomiting. Whether it is the pain of a broken bone or the emotional shock of observing an event, vasovagal events can cause significant symptoms. In a vasovagal episode, the vagus nerve (one of the nerves that helps control basic body functions like heart rate, breathing, and blood pressure) is overly stimulated and cause the heart rate to slow and blood vessels to dilate. This decreases the blood flow to the brain and causes fainting, known as a syncopal episode.

  • Association with illness

    • Diabetes: Persons with diabetes may develop nausea because ofgastroparesis, a condition in which the stomach fails to empty properly and is likely due to the generalized neuropathy (failure of the nerves in the body to send proper signals to and from the brain) that is a complication of the disease.

    People with diabetes can also develop nausea and vomiting should their blood sugars become abnormally high or low (hyperglycemia or hypoglycemia) because the sugar and insulin balance is disturbed.

    • Diseases or illness: Many illnesses associated with the intra-abdominal organs have symptoms of nausea and vomiting. These include digestive organ diseases, for example:
      
      
      • hepatitis,
        
        
      • gallbladder disease,
        
        
      • pancreatitis
        
        
      • inflammatory bowel disease
        
        
      • kidney diseases (for example, kidney stones, infection, kidney failure)
        
        
      • some forms of cancer.
        
        
    • Vomiting as an atypical symptom of another disease: Some illnesses will cause nausea and vomiting, even though there is no direct involvement of the stomach or gastrointestinal tract.
      
      
      • Heart attack victims may experience nausea and vomiting as an atypical presentation of angina, especially if the myocardial infarction affects the inferior or lower part of the heart.
        
        
      • Lung infections, for example, pneumonia and bronchitis, may also cause nausea and vomiting, especially if the area of lung involved is near the diaphragm, the muscle that separates the chest form the abdomen.
        
        
    • Sepsis: An overwhelming body infection spread through the bloodstream may also be associated with nausea and vomiting.
      
      
    • Eating disorders: Patients with bulimia will have self-induced vomiting, purging as part of their psychiatric illness

    • Medications and medical treatments

      • Side effects from medications: The side effect of many medications include stomach irritation and/or nausea and vomiting. Anti-cancer dugs are notorious irritants (for example,chemotherapy treatment). Narcotic pain medications, anti-inflammatory medications (including both steroids like prednisone and non-steroidal medications like ibuprofen) and antibiotics all have nausea and vomiting listed as common side effects.
        
        
      • Radiation therapy: Nausea and vomiting is associated with radiation therapy.

      Bowel obstruction

      Abdominal pain and distention, nausea and vomiting, and inability to pass flatus (gas) or have a bowel movement are hallmarks of bowel obstruction. Due to a variety of potential reasons, the small intestine becomes blocked and doesn't allow contents to pass through to the colon. This acts like a dam in which food, fluid, and secretions back up, causing the symptoms of an obstruction.

      Pregnancy

      Vomiting in pregnancy is especially common in the first trimester and is due to hormone level changes in the bloodstream.

      What about vomiting in infants?

      It may be hard to decide if an infant is vomiting or spitting up. If the episodes occur shortly after feeding and only a small amount comes up, this may be spitting up.

      • Forceful vomiting: In the first two or three months, if the vomiting is forceful after eating (imagine it flying across the room), this may be a sign of pyloric stenosis, or an abnormal narrowing of the area at which the stomach empties into the small intestine. The vomiting is impressive, and if the healthcare provider suspects this diagnosis, it can be confirmed by ultrasound. The treatment is an operation to open the narrowing.
        
        
      • Vomiting associated with pain: if the infant cries uncontrollably, and if the stool is bloody or red, the diagnosis may be an intussusception (the pushing of one segment of the bowel into an adjacent segment). These infants should be evaluated by their healthcare provider.
        
        
      • Viral infection: If there is associated diarrhea that is not bloody, then a viral infection is a possibility. Alternatively, there may be an issue with intolerance to the type of baby formula. Infants and children are at greater risk of dehydration if the vomiting episodes last for more than 24 hours. Contact should be made with the healthcare provider for further advice in this situation.

      • What can I do at home for nausea or vomiting?

        It is important to rest the stomach and yet still avoid dehydration. Clear fluids should be attempted for the first 24 hours of an illness, and then the diet should be advanced as tolerated.

        Clear fluids are easy for the stomach to absorb and include:

        • water,
          
          
        • sports drinks,
          
          
        • clear broths,
          
          
        • popsicles, and
          
          
        • Jello.

        It is important not to take too much fluid at one time since stretching the stomach may cause the nausea to worsen. One to two ounces of fluid at a time, taken every 10-15 minutes, may be all that the stomach will be able to tolerate.

        Milk products should be avoided for the first 24-48 hours during an episode of nausea and vomiting. The enzyme that helps digest milk is located in cells lining the stomach. With vomiting, the body can become relatively lactose intolerant. Abdominal pain, bloating, vomiting, and diarrhea may occur.

        When should I call the doctor regarding nausea and vomiting?

        If the symptoms last for more than 24 hours, if the diagnosis is uncertain, if there is concern about dehydration, or if the patient has underlying medical conditions that make them more fragile, medical care should be accessed sooner, rather than later.

        Infants and children are more susceptible to dehydration and may not have as much reserve as an adult. If there is concern about dehydration or the inability to tolerate fluids, a healthcare provider should be contacted.

        If nausea and vomiting are associated with pain, fever, vomiting blood, or having bloody or black, tarry bowel movements, medical care should be sought immediately.

        Vomiting is a symptom of an illness and is not a disease in itself. If the symptom persists for more than 24-48 hours, it may be wise to contact a medical care provider.

        How is the source of nausea or vomiting diagnosed?

        The healthcare provider will try to find the underlying illness that is causing the symptoms of nausea and vomiting. At the same time, steps will be taken to treat the symptoms and prevent dehydration.

        Any testing will likely be directed to finding the underlying diagnosis. However, blood tests may be taken to assess whether the electrolyte balance in the body has been disturbed due to dehydration from continued vomiting.

        A urinalysis may be done. Concentrated urine is associated with dehydration as the kidneys try to hold on to water in the body.Ketones in the urine are also a sign of dehydration.

        How is nausea or vomiting treated?

        Symptomatic treatment may occur while the underlying illness is being investigated because ideally, nausea and vomiting should resolve when the cause of the symptoms resolves.

        Nausea and vomiting are often made worse when the patient is dehydrated, resulting in a vicious cycle. The nausea makes it difficult to drink fluid, making the dehydration worse, which then increases the nausea. Intravenous fluids may be provided to correct this issue.

        There are a variety of anti-nausea medications (antiemetics) that may be prescribed. They can be administered in different ways depending upon the patient's ability to take them. Medications are available by pill, liquid, or tablets that dissolve on or under the tongue, by intravenous or intramuscular injection, or by rectal suppository.

        Common medications used to control nausea and vomiting include promethazine(Phenergan), prochlorperazine (Compazine), droperidol (Inapsine) metoclopramide(Reglan), and ondansetron (Zofran). The decision as to which medication to use will depend on the specific situation.

        Nausea and Vomiting At A Glance

        • Nausea and vomiting are symptoms, not a disease. The underlying cause of the illness should be identified and treated.
          
          
        • Symptom control is important both for comfort's sake and to prevent dehydration.
          
          
        • Dehydration in itself can worsen the nausea and vomiting.
          
          
        • Medication may be available to control symptoms.
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