Vomiting in Adults

1. Introduction

  • Definition: Vomiting, or emesis, is the forceful expulsion of stomach contents through the mouth, usually caused by the activation of the vomiting centre in the brainstem.
  • Epidemiology: Vomiting is a common symptom with a wide range of underlying causes, from minor gastrointestinal disturbances to life-threatening conditions.
  • Significance: While occasional vomiting is often harmless, persistent or severe vomiting may lead to dehydration, electrolyte imbalances, and underlying medical emergencies.

2. Causes and Risk Factors

  • Causes:
    • Gastrointestinal Causes:
      • Gastroenteritis (viral, bacterial, or parasitic).
      • Gastric outlet obstruction, peptic ulcers, or GERD.
      • Appendicitis, pancreatitis, or intestinal obstruction.
    • Neurological Causes:
      • Migraine, increased intracranial pressure, or vestibular disorders (e.g., vertigo).
      • Head injury or stroke.
    • Metabolic and Endocrine Causes:
      • Diabetic ketoacidosis (DKA), adrenal insufficiency, or hypercalcaemia.
      • Pregnancy-related nausea and vomiting (hyperemesis gravidarum).
    • Medications and Toxins:
      • Chemotherapy, antibiotics, or excessive alcohol.
      • Food poisoning or ingestion of toxins.
    • Psychogenic Causes:
      • Anxiety, stress, or eating disorders.
  • Risk Factors:
    • Recent infection or exposure to contaminated food or water.
    • History of motion sickness or migraine.
    • Pregnancy or hormonal changes.
    • Use of medications known to cause nausea and vomiting (e.g., opioids, NSAIDs).

3. Pathophysiology

  • Vomiting is triggered by stimulation of the vomiting centre in the medulla oblongata.
    • Peripheral Triggers: Irritation of the gastrointestinal tract (e.g., toxins, infection) stimulates the vagus nerve.
    • Central Triggers: Activation of the chemoreceptor trigger zone (CTZ) by drugs, toxins, or metabolic changes.
    • Vestibular Triggers: Inner ear dysfunction affects the vestibular nuclei, leading to vomiting.

4. Symptoms and Features

  • Associated Symptoms:
    • Nausea, abdominal pain, bloating, or diarrhoea (gastrointestinal causes).
    • Dizziness, headache, or visual disturbances (neurological causes).
    • Dry mouth, fatigue, and decreased urine output (signs of dehydration).
  • Red Flag Symptoms:
    • Severe abdominal pain, high fever, or jaundice.
    • Blood in vomit (haematemesis) or coffee-ground appearance.
    • Persistent vomiting (>48 hours) or signs of dehydration.
    • Altered mental status, stiff neck, or severe headache.

5. Complications

  • Dehydration and electrolyte imbalances (e.g., hypokalaemia, metabolic alkalosis).
  • Aspiration pneumonia from inhaling vomit into the lungs.
  • Mallory-Weiss tears (oesophageal tears due to forceful vomiting).
  • Worsening of underlying conditions (e.g., obstruction or infection).

6. Diagnosis

  • Clinical Features: Detailed history (onset, duration, triggers, associated symptoms) and physical examination.
  • Laboratory Tests:
    • Basic metabolic panel to assess dehydration and electrolyte imbalances.
    • Blood glucose and ketone levels (for suspected DKA).
    • Liver function tests (for biliary or hepatic causes).
  • Imaging:
    • Abdominal ultrasound or CT scan for obstruction, appendicitis, or other structural causes.
    • Brain imaging (CT or MRI) for neurological causes (e.g., stroke, raised intracranial pressure).
  • Additional Tests:
    • Stool analysis (if diarrhoea is present).
    • Pregnancy test for women of childbearing age.

7. Management Overview

  • Goals: Identify and treat the underlying cause, relieve symptoms, and prevent complications like dehydration.
  • Approach: Symptomatic management for mild cases and targeted therapy for specific causes.

8. Treatment Options with Cost (USD)

  • Symptomatic Relief:
    • Oral rehydration solutions (ORS): ~$10–$20 per pack.
    • Antiemetics (e.g., ondansetron, metoclopramide): ~$10–$30 per course.
  • Condition-Specific Treatments:
    • Proton pump inhibitors (e.g., omeprazole for GERD): ~$10–$20 per month.
    • Antibiotics for infections (e.g., ciprofloxacin for bacterial gastroenteritis): ~$15–$40 per course.

9. Advanced Treatment Options with Cost (USD)

  • Hospitalisation:
    • Intravenous (IV) fluids for severe dehydration: ~$500–$1,000.
    • Parenteral nutrition for prolonged vomiting: ~$1,000–$3,000 per day.
  • Surgical Intervention:
    • Surgery for intestinal obstruction or perforation: ~$10,000–$20,000.

10. Pharmacological Treatment

  • First-line: Antiemetics like ondansetron or prochlorperazine for symptomatic relief.
  • Second-line: Metoclopramide or promethazine for persistent symptoms.
  • Condition-Specific:
    • Proton pump inhibitors or H2 blockers for GERD.
    • Antibiotics for bacterial infections.

11. Medication Tables

Table 1: Doses and Side Effects

DrugIndicationDoseCommon Side Effects
OndansetronNausea and vomiting relief4–8 mg orally every 8 hoursHeadache, constipation
MetoclopramideGastrointestinal motility10 mg orally every 6–8 hoursDrowsiness, extrapyramidal symptoms
ProchlorperazineSevere nausea5–10 mg orally every 6–8 hoursSedation, dry mouth
OmeprazoleGERD or gastritis20–40 mg dailyAbdominal pain, headache
CiprofloxacinBacterial gastroenteritis500 mg orally twice daily for 5–7 daysNausea, rash

Table 2: Brand Names and Approximate Costs (USD)

DrugBrand NamesApprox. Cost
OndansetronZofran$10–$30 per course
MetoclopramideReglan$10–$20 per course
ProchlorperazineCompazine$10–$20 per course
OmeprazolePrilosec$10–$20 per month
CiprofloxacinCipro$15–$40 per course

12. Lifestyle Interventions

  • Stay hydrated by sipping clear fluids (e.g., water, ORS, clear broths).
  • Eat small, bland meals and avoid fatty, spicy, or acidic foods.
  • Avoid alcohol, caffeine, and smoking, which can irritate the stomach lining.
  • Rest and avoid sudden movements to reduce nausea.

13. Monitoring Parameters

  • Monitor hydration status (e.g., urine output, mucous membranes).
  • Evaluate for symptom improvement and resolution of underlying causes.
  • Regularly assess for side effects of medications like sedation or extrapyramidal symptoms.

14. Patient Counseling Points

  • Explain the importance of staying hydrated and recognising signs of dehydration.
  • Advise on avoiding trigger foods and identifying early signs of serious conditions (e.g., severe abdominal pain or haematemesis).
  • Stress the importance of completing prescribed treatments, such as antibiotics.
  • Encourage seeking prompt medical attention if symptoms worsen or persist.

15. Special Populations

  • In Pregnant Women: Use pregnancy-safe antiemetics like doxylamine-pyridoxine or ondansetron if needed.
  • In Elderly: Avoid sedating medications and monitor closely for dehydration or complications.
  • In Immunocompromised Patients: Aggressively investigate infections or systemic causes of vomiting.

16. Prevention

  • Practise good hygiene to reduce the risk of infections (e.g., handwashing, safe food preparation).
  • Avoid overuse of alcohol, NSAIDs, or other stomach-irritating substances.
  • Treat underlying conditions like GERD or migraines to prevent recurrent episodes.
  • Stay hydrated and avoid prolonged fasting.

17. FAQs

  1. What causes vomiting in adults?
    Answer: Common causes include infections, gastrointestinal disorders, medications, and neurological conditions.
  2. How is vomiting treated?
    Answer: Treatment depends on the cause but may include hydration, antiemetics, and addressing the underlying condition.
  3. When should I see a doctor for vomiting?
    Answer: If vomiting persists >48 hours, is accompanied by severe symptoms, or there is blood in vomit.
  4. Can dehydration occur from vomiting?
    Answer: Yes, especially if vomiting is frequent or severe.
  5. Are antiemetics safe to use?
    Answer: Most are safe for short-term use but should be taken under medical advice.
  6. What foods help relieve vomiting?
    Answer: Bland foods like crackers, rice, bananas, and clear broths are helpful.
  7. Can stress cause vomiting?
    Answer: Yes, stress and anxiety can trigger vomiting in some individuals.
  8. Is vomiting always a sign of a serious condition?
    Answer: No, it is often caused by minor issues like viral gastroenteritis, but persistent or severe vomiting warrants medical evaluation.
  9. How can I prevent vomiting while travelling?
    Answer: Use motion sickness medications and avoid heavy meals before travelling.
  10. Can vomiting cause long-term damage?
    Answer: Persistent vomiting can lead to oesophageal damage, dehydration, and electrolyte imbalances.
  11. What is haematemesis?
    Answer: Vomiting blood, which may indicate gastrointestinal bleeding and requires urgent care.
  12. Is vomiting during pregnancy normal?
    Answer: Mild nausea and vomiting are common, but severe cases (hyperemesis gravidarum) require medical attention.
  13. How do I know if vomiting is due to an infection?
    Answer: Infections are often associated with fever, diarrhoea, or recent exposure to contaminated food or water.
  14. Can vomiting be prevented?
    Answer: Practising good hygiene and avoiding triggers can help reduce risk.
  15. What is the difference between nausea and vomiting?
    Answer: Nausea is the sensation of needing to vomit, while vomiting is the physical expulsion of stomach contents.