Vomiting, Adult

Basics

Description

  • The forceful expulsion of gastric and intestinal contents through the mouth due to autonomic and somatic motor responses
  • Coordinated by the vomiting center in the medulla:
    • Inputs include the GI tract, pharynx, vestibular system, visceral organs, cerebral cortex, and the chemoreceptor trigger zone (CTZ)
    • The CTZ, located outside the blood–brain barrier, detects medications, toxins, and hormones in the bloodstream
  • Once activated, the vomiting center stimulates the vagus, phrenic, and spinal nerves resulting in:
    • Retching: rhythmic contractions of diaphragm, intercostal and abdominal muscles, along with retrograde peristalsis of stomach and small intestine
    • Vomiting: Forceful contraction of diaphragm and abdominal muscles, along with retrograde contraction of the esophagus
  • The vomiting center is mediated by dopamine (D2), serotonin (5-HT3), acetylcholine (M1), histamine (H1), cannabinoid (CB1), substance P (NK-1), prostaglandin, and opioid receptors:
    • Medications that provide symptomatic treatment of vomiting antagonize these receptors

Etiology

  • Mechanical/motility:
    • Gastric outlet obstruction
    • Gastroparesis
    • Bowel obstruction:
      • Adhesions
      • Strictures
      • Volvulus
      • Foreign body
      • Incarcerated hernia
      • Intussusception
      • Mass (intra- or extraluminal)
      • SMA syndrome
    • Ileus
    • Intestinal pseudo-obstruction (Ogilvie syndrome)
    • Overdistention
  • Gastrointestinal (GI):
    • Appendicitis
    • Cholecystitis/biliary colic
    • Gastritis/peptic ulcer disease
    • Gastroenteritis (viral/bacterial/parasitic/enterotoxin)
    • GI bleeding
    • Hepatitis
    • Inflammatory bowel disease
    • Ischemic bowel
    • Intestinal edema
    • Pancreatitis
    • Perforated viscus
    • Peritonitis
  • Genitourinary:
    • Gonadal torsion
    • Nephrolithiasis
    • UTI/pyelonephritis
  • Pregnancy
  • Neurologic:
    • Elevated intracranial pressure (ICP)
    • Intracranial hemorrhage
    • Meningitis/encephalitis
    • Migraine
    • Tumor
    • Vestibular (labyrinthitis, posterior stroke, peripheral vertigo, motion sickness)
  • Psychologic:
    • Eating disorders
    • Malingering/factitious disorders
    • Intense emotion, pain, or stress
  • Metabolic:
    • Adrenal insufficiency (addisonian crisis)
    • Diabetic ketoacidosis (DKA)
    • Electrolyte disorders
    • Hypoparathyroid, hyperparathyroid
    • Hypothyroid, hyperthyroid
    • Porphyria
    • Uremia/renal failure
    • Hypercalcemia
    • Pheochromocytoma
  • Toxicologic:
    • Alcohols
    • Medication overdose (notably acetaminophen, aspirin, NSAIDs, digoxin, theophylline, cholinergic medications)
    • Cannabinoid hyperemesis syndrome
    • Withdrawal (alcohol, opiate, benzodiazepine)
    • Organophosphate exposure
    • Caustic chemical ingestion
    • Carbon monoxide exposure
    • Toxic plant/mushroom ingestion
    • Radiation exposure
  • Therapeutic medication use:
    • Antibiotics
    • Aspirin/NSAIDs
    • Chemotherapy
    • Opiates
    • Anesthesia (post-op nausea and vomiting)
    • Estrogen-based contraceptives
  • Miscellaneous:
    • Acute coronary syndrome (ACS)
    • Increased intraocular pressure
    • Hypotension/shock
    • Traumatic injuries to chest/abdomen
    • Starvation
    • Functional disorders

There's more to see -- the rest of this topic is available only to subscribers.