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Vomiting
•! Definitions:
o! Vomiting (emesis): Forceful oral expulsion of gastric contents associated with
contraction of the abdominal and chest wall musculature, frequently preceded by
nausea and abdominal pain.
o! Nausea: The unpleasant sensation of the imminent need to vomit, usually referred to
the throat or epigastrium; a sensation that may or may not ultimately lead to the act of
vomiting.
o! Regurgitation: The act by which food is brought back into the mouth without the
abdominal and diaphragmatic muscular activity that characterizes vomiting.
o! Retching: Spasmodic respiratory movements against a closed glottis with contractions
of the abdominal musculature without expulsion of any gastric contents, "dry heaves".
•! Mechanisms:
o! Neurophysiological Emesis: Vomiting
Area of Postrema (vomiting center):
a.! Has the “Chemoreceptor trigger
zone” ! CTZ lies outside the BBB Neurophysiological Somatomotor
b.! Anatomically, located in the brain
stem at the caudal extremity of the
floor of the fourth ventricle. Vagal
Diaphragm
Afferents
c.! Triggered by: systemic chemicals descend,
through the following pathways: intercostal
Area of contraction
Postrema
"! Vagal Afferents:
Vestibular Abdominal
#! Mechanical or chemosensory System muscle
sensations. contraction,
gastric
#! Examples of sensations that Amygdala contents goes
up
trigger this pathway: over
distension, food poisoning, mucosal Abdominal
irritation, cytotoxic drugs, and radiation. muscles
relaxes

"! Vestibular System: Retching

#! When vestibular input is in conflict with visual
sensations.
Abdominal
#! Plays a role in motion sickness. muscle
#! E.g.: Irritation or labyrinthine inflammation, contraction,
diaphragms
motion-sickness up

"! Amygdala: EXPULSION

OF GASTRIC
#! Receives input from the olfactory bulb and CONTENT
olfactory cortex.

o! Somatomotor Events of Emesis (emptying out the stomach, characterized by cycles of

retching followed by the forceful expulsion of gastric contents):

1.! Diaphragm descends and the intercostal muscles contract while the glottis is closed.
2.! The abdominal muscles contract and the gastric contents are forced into upper
gastric vault and lower esophagus.
3.! The abdominal muscle relaxes and the esophageal refluxates.
4.! Several cycles of retching.
5.! Abdominal contraction with elevation of diaphragm results in forceful expulsion of
gastric contents.
!
•! Causes:
o! Food poisoning (toxins):

Organism Food at risk Vomiting

Causes

Bacillus Cereus Reheated or fried rice

Food
Staph aureus Cream, unrefrigerated meat Poisining

Clostridium Beef, turkey, chicken

perfringens Obstructive

Vibrio Shellfish
parahemolyiticus Pain induced

o! Pain-induced:
#! Any deep visceral pain Cerebral
(central)
#! E.g.: Acute appendicitis, MI, Renal stone pain
o! Obstructive:
#! Pyloric or intestinal obstruction

o! Cerebral or Central:
#! Psychogenic: anxiety, bad odor, sight of blood, and tension.
#! Fever.
#! Pregnancy.
#! Drugs: digitalis, salicylates, morphine, alcohol…
#! Increased intracranial pressure.
#! Disturbance of electrolytes: ketosis, uremia.
#! Labyrinthine Disturbances.

Significant Notes
Clues with
Vomiting

Nausea: •! Usually precede the vomiting

•! Vomiting without nausea usually projectile (pyloric
obstruction\ increased Intracranial pressure)

Large Vomitus: •! Pyloric obstruction: brownish, foul smelling containing food

vomitus
•! Intestinal obstruction: Fecal vomiting

Pain relief: •! Vomiting that is relieves immediately the abdominal pain:

PUD

Timing: •! During the meal or soon after the meal$ pyloric obstruction
•! Delayed vomiting (>1hour): PUD, gall bladder disease,
gastroparesis, intestinal obstruction
•! Morning Vomiting: Pregnancy, Alcoholics, uremia
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References:
1.! http://www.uptodate.com/contents/approach-to-the-infant-or-child-with-nausea-and-
vomiting?source=search_result&search=vomiting&selectedTitle=1%7E150
2.! Clinical Approach to Diagnosis Major Sign and Symptoms by Dr. Salah Ibrahim.
3.! Crash course Gastrointestinal System 4th edition.
4.! Crash course Gastroenterology 4th edition.

Written By: Roaa Amer Reviewed By: Haifa Al Issa

Format editor: Roaa Amer Lama Al Luhidan