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.
- Gastrointestinal Causes:
- 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
Drug | Indication | Dose | Common Side Effects |
---|---|---|---|
Ondansetron | Nausea and vomiting relief | 4–8 mg orally every 8 hours | Headache, constipation |
Metoclopramide | Gastrointestinal motility | 10 mg orally every 6–8 hours | Drowsiness, extrapyramidal symptoms |
Prochlorperazine | Severe nausea | 5–10 mg orally every 6–8 hours | Sedation, dry mouth |
Omeprazole | GERD or gastritis | 20–40 mg daily | Abdominal pain, headache |
Ciprofloxacin | Bacterial gastroenteritis | 500 mg orally twice daily for 5–7 days | Nausea, rash |
Table 2: Brand Names and Approximate Costs (USD)
Drug | Brand Names | Approx. Cost |
---|---|---|
Ondansetron | Zofran | $10–$30 per course |
Metoclopramide | Reglan | $10–$20 per course |
Prochlorperazine | Compazine | $10–$20 per course |
Omeprazole | Prilosec | $10–$20 per month |
Ciprofloxacin | Cipro | $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
- What causes vomiting in adults?
Answer: Common causes include infections, gastrointestinal disorders, medications, and neurological conditions. - How is vomiting treated?
Answer: Treatment depends on the cause but may include hydration, antiemetics, and addressing the underlying condition. - 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. - Can dehydration occur from vomiting?
Answer: Yes, especially if vomiting is frequent or severe. - Are antiemetics safe to use?
Answer: Most are safe for short-term use but should be taken under medical advice. - What foods help relieve vomiting?
Answer: Bland foods like crackers, rice, bananas, and clear broths are helpful. - Can stress cause vomiting?
Answer: Yes, stress and anxiety can trigger vomiting in some individuals. - 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. - How can I prevent vomiting while travelling?
Answer: Use motion sickness medications and avoid heavy meals before travelling. - Can vomiting cause long-term damage?
Answer: Persistent vomiting can lead to oesophageal damage, dehydration, and electrolyte imbalances. - What is haematemesis?
Answer: Vomiting blood, which may indicate gastrointestinal bleeding and requires urgent care. - Is vomiting during pregnancy normal?
Answer: Mild nausea and vomiting are common, but severe cases (hyperemesis gravidarum) require medical attention. - 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. - Can vomiting be prevented?
Answer: Practising good hygiene and avoiding triggers can help reduce risk. - 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.