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07-SEPTEMBER-2008 03:17:44 - Vomiting This article or section is missing citations or needs footnotes. Using inline citations helps guard against copyright violations and factual inaccuracies. June 2008 Heaving redirects here. For the up-and-down motion, see Heave. Puke redirects here. For the district in Albania, see Pukë District. For the punk rock album, see Puke Guttermouth album. Symptom/Sign: Vomiting Classifications and external resources ICD-10 R11. ICD-9 787 Vomiting also called throwing up, puking, barfing, and emesis is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Vomiting may result from many causes, ranging from gastritis or poisoning to brain tumors, or elevated intracranial pressure. The feeling that one is about to vomit is called nausea. It usually precedes, but does not always lead to vomiting. Antiemetics are sometimes necessary to suppress nausea and vomiting, and, in severe cases where dehydration develops, intravenous fluid may need to be administered to replace fluid volume. 14th century illustration of vomiting from the Casanatense Tacuinum Sanitatis 14th century illustration of vomiting from the Casanatense Tacuinum Sanitatis Vomiting is different from regurgitation, although the two terms are often used interchangeably. Regurgitation is the return of undigested food that has not yet reached the stomach back up the esophagus to the mouth. The causes of vomiting and regurgitation are generally different. Contents 1 Mechanism 1.1 Vomiting center 1.2 Vomiting act 2 Content 3 Complications 3.1 Aspiration of vomit 3.2 Dehydration and electrolyte imbalance 3.3 Mallory-Weiss tear 3.4 Dental 4 Causes 4.1 Digestive tract 4.2 Sensory system and brain 4.3 Other 5 Unusual types of vomiting 6 Related medication 6.1 Emetics 6.2 Antiemetics 7 Social implications 7.1 Nausea inducement in groups 7.2 Context 7.3 Sound 8 See also 9 References 10 External links Mechanism Vomiting center Vomiting is coordinated in the vomiting center in the lateral medullary reticular formation in the pons. Receptors on the floor of the fourth ventricle of the brain represent a chemoreceptor trigger zone, stimulation of which can lead to vomiting. The chemoreceptor zone lies outside the blood-brain barrier and can therefore be stimulated by blood-borne drugs that can stimulate vomiting or inhibit it. There are various sources of input to the vomiting center: The chemoreceptor trigger zone at the base of the fourth ventricle has numerous dopamine D2 receptors, serotonin 5-HT3 receptors, opioid receptors, Acetylcholine receptors, and receptors for substance P. Stimulation of different receptors are involved in different pathways leading to emesis, in the final common pathway substance P appears to be involved.1 The vestibular system which sends information to the brain via cranial nerve VIII vestibulocochlear nerve. It plays a major role in motion sickness and is rich in muscarinic receptors and histamine H1 receptors. Cranial nerve X vagus nerve, which is activated when the pharynx is irritated, leading to a gag reflex. Vagal and enteric nervous system inputs that transmit information regarding the state of the gastrointestinal system. Irritation of the GI mucosa by chemotherapy, radiation, distention, or acute infectious gastroenteritis activates the 5-HT3 receptors of these inputs. The CNS mediates vomiting arising from psychiatric disorders and stress. Vomiting act The vomiting act encompasses three types of outputs initiated by the chemoreceptor trigger zone: Motor, parasympathetic nervous system PNS, and sympathetic nervous system SNS. They are as follows: Increased salivation to protect the enamel of teeth from stomach acids excessive vomiting leads to dental erosion. This is part of the PNS output. Retroperistalsis, starting from the middle of the small intestine, sweeping up the contents of the digestive tract into the stomach, through the relaxed pyloric sphincter. A lowering of intrathoracic pressure by inspiration against a closed glottis, coupled with an increase in abdominal pressure as the abdominal muscles contract, propels stomach contents into the esophagus as the lower esophageal sphincter relaxes. The stomach itself does not contract in the process of vomiting, nor is there any retroperistalsis in the esophagus. Vomiting is ordinarily preceded by retching. Vomiting also initiates an SNS response causing both sweating and increased heart rate. The neurotransmitters that regulate vomiting are poorly understood, but inhibitors of dopamine, histamine, and serotonin are all used to suppress vomiting, suggesting that these play a role in the initiation or maintenance of a vomiting cycle. Vasopressin and neurokinin may also participate. Content Gastric secretions and likewise vomit are highly acidic. Recent food intake will be reflected in the gastric vomit. Irrespective of the content, vomit tends to be malodorous. The content of the vomitus vomit may be of medical interest. Fresh blood in the vomit is termed hematemesis blood vomiting. Altered blood bears resemblance to coffee grounds as the iron in the blood is oxidized and, when this matter is identified, the term coffee ground vomiting is used. Bile can enter the vomit during subsequent heaves due to duodenal contraction if the vomiting is severe. Fecal vomiting is often a consequence of intestinal obstruction or a gastrocolic fistula and is treated as a warning sign of this potentially serious problem signum mali ominis; such vomiting is sometimes called miserere. If the vomiting reflex continues for an extended period with no appreciable vomitus, the condition is known as non-productive emesis or dry heaves, which can be painful and debilitating. Complications Aspiration of vomit Vomiting can be very dangerous if the gastric content gets into the respiratory tract. Under normal circumstances the gag reflex and coughing will prevent this from occurring, however these protective reflexes are compromised in persons under the influences of certain substances such as alcohol or anesthesia. The individual may choke and asphyxiate or suffer an aspiration pneumonia. Dehydration and electrolyte imbalance Prolonged and excessive vomiting will deplete the body of water dehydration and may alter the electrolyte status. The loss of acid and chlorine leads to hypochloremic metabolic alkalosis low chloride levels together with high HCO3 and increased blood pH and often hypokalemia potassium depletion. The hypokalemia is an indirect result of the kidney compensating for the loss of acid. With the loss of intake of food the individual may eventually become cachectic. Mallory-Weiss tear Repeated or profuse vomiting may cause erosions to the esophagus or small tears in the esophageal mucosa Mallory-Weiss tear. This may become apparent if fresh blood is admixed with vomit after several episodes. Dental Recurrent vomiting, such as observed in bulimia nervosa, may lead to destruction of the tooth enamel due to the acidity of the vomit. Causes Vomiting may be due to a large number of causes, and protracted vomiting has a long differential diagnosis. Digestive tract Causes in the digestive tract: Gastritis inflammation of the gastric wall, usually by viruses Pyloric stenosis in babies, this typically causes a very forceful projectile vomiting and is an indication for urgent surgery Bowel obstruction Acute abdomen and/or peritonitis Ileus Cholecystitis, pancreatitis, appendicitis, hepatitis Food allergies In children, it can be caused by an allergic reaction to cow's milk proteins milk allergy Sensory system and brain Causes in the sensory system: Movement: motion sickness which is caused by overstimulation of the labyrinthine canals of the ear Ménière's disease Causes in the brain: Concussion Cerebral hemorrhage Migraine Brain tumors, which can cause the chemoreceptors to malfunction Benign intracranial hypertension and hydrocephalus Metabolic disturbances these may irritate both the stomach and the parts of the brain that coordinate vomiting: Hypercalcemia high calcium levels Uremia urea accumulation, usually due to renal failure Adrenal insufficiency Hypoglycemia Pregnancy: Hyperemesis, Morning sickness Drug reaction vomiting may occur as an acute somatic response to: alcohol being sick while being drunk or being sick the next morning, suffering from the after-effects, i.e., the hangover. opioids selective serotonin reuptake inhibitors many chemotherapy drugs some entheogens such as peyote or ayahuasca Other Self-induced Eating disorders anorexia nervosa or bulimia nervosa To remove a poison in case such has been ingested some poisons should not be vomited as they may be more toxic when inhaled or aspirated; it is, in general, considered better to ask for help before inducing vomiting Some people who are engaged in binge drinking will induce vomiting in order to make room in their stomachs for further alcohol consumption. In the United Kingdom, this practice is known as tactical chundering, or hitting the reset button. In the United States, it is known as boot and rally or pulling the trigger. After surgery postoperative nausea and vomiting Disagreeable sights, smells or thoughts such as decayed matter, others' vomit, thinking of vomiting, etc. Extreme pain, such as intense headache or myocardial infarction heart attack Violent emotions including laughing Cyclic vomiting syndrome a poorly-understood condition with attacks of vomiting High doses of ionizing radiation will sometimes trigger a vomit reflex in the victim Violent fits of coughing or hiccups Nervousness Unusual types of vomiting Fecal vomiting or antiperistalsis is a kind of emesis in which fecal matter is expelled from the intestines into the stomach, by spasmodic contractions of the gastric muscles, and then subsequently forcefully expelled from the stomach up into the esophagus and out through the mouth and sometimes nasal passages. Alternative medical terms for fecal vomiting are copremesis and stercoraceous vomiting.2 It was also referred to as miserere in medieval times.citation needed Related medication Emetics An emetic, such as syrup of ipecac, is a substance that induces vomiting when administered orally or by injection. An emetic is used medically where a substance has been ingested and must be expelled from the body immediately. Inducing vomiting can remove the substance before it is absorbed into the body. Ipecac abuse can lead to detrimental health effects. Antiemetics An antiemetic is a drug that is effective against vomiting and nausea. Antiemetics are typically used to treat motion sickness and the side-effects of some opioid analgesics and chemotherapy directed against cancer. Antiemetics act by inhibiting the receptor sites associated with emesis. Hence, anticholinergics, antihistamines, dopamine antagonists, serotonin antagonists, and cannabinoids are used as anti-emetics. Social implications Nausea inducement in groups It is quite common that, when one person vomits, others nearby will become nauseated, particularly when smelling the vomit of others, often to the point of vomiting themselves. It is believed that this is an evolved trait among primates. Many primates in the wild will tend to browse for food in small groups. Should one member of the party react adversely to some ingested food, it may be advantageous in a survival sense for other members of the party also to vomitcitation needed. This tendency in human populations has been observed at drinking parties, where excessive consumption of alcoholic beverages may result in a number of party members vomiting nearly simultaneously, this being triggered by the initial vomiting of a single member of the party. This phenomenon has been touched on in popular culture: Notorious instances appear in the films Monty Python's The Meaning of Life 1983 and Stand By Me 1986, while, in the computer game Theme Hospital, it is referred to as a 'vomit wave' and can spread through the hospital quickly. Intense vomiting in ayahuasca ceremonies is a common phenomenon. However, people who experience la purga after drinking ayahuasca, in general, regard the practice as both a physical and spiritual cleanse and often come to welcome it. 3 It has been suggested that the consistent emetic effects of ayahuasca - in addition to its many other therapeutic properties - was of medicinal benefit to indigenous peoples of the Amazon, in helping to clear parasites from the gastrointestinal system. 4 There have also been documented cases of a single ill and vomiting individual inadvertently causing others to vomit, when they are especially fearful of also becoming ill, through a form of mass hysteria. Context Most people try to contain their vomit by vomiting into a sink, toilet, or trash can, as both the act and the vomit itself are widely considered embarrassing; vomit is also difficult to clean. On airplanes and boats, special bags are supplied for sick passengers to vomit into. A special disposable bag containing absorbent material that solidifies the vomit quickly is available, also, making it convenient and safe to keep leakproof, puncture-resistant, odorless until there is an opportunity to dispose of it conveniently. People who vomit chronically e.g., as part of an eating disorder such as bulimia nervosa may devise various ways to hide this disorder. Sound According to an online study of 30 traditionally bad sounds, the sound of vomiting is the worst sound in the world.5 Professor Cox of the University of Salford's Acoustic Research Centre said that We are pre-programmed to be repulsed by horrible things such as vomiting, as it is fundamental to staying alive to avoid nasty stuff. It is thought that the thought of disgust is triggered by the sound of vomiting to protect food from those possibly diseased nearby.6 See also Emetophilia Emetophobia References July 2007 ^ Hornby PJ. Central neurocircuitry associated with emesis. Am J Med 2001;111:106S-12S. PMID 11749934. ^ fecal vomiting - definition of fecal vomiting in the Free Online Medical Dictionary, Thesaurus and Encyclopedia ^ Shanon, B. 2002. The antipodes of the mind: Charting the phenomenology of the ayahuasca experience. 2002. Oxford: Oxford University Press. ^ Andritzky, W. 1989. Sociopsychotherapeutic functions of ayahuasca healing in Amazonia. Journal of Psychoactive Drugs. 211, 77-89. ^ Acoustics audio video, University of Salford ^ Sound101.org. External links Wikimedia Commons has media related to: Vomiting Wikiquote has a collection of quotations related to: Vomiting Look up Vomiting in Wiktionary, the free dictionary. Cyclical Vomiting Syndrome v d e Digestive system - Digestive disease - Gastroenterology primarily K20-K93, 530-579 Upper GI tract Esophagus Esophagitis Candidal - Boerhaave syndrome - UES Zenker's diverticulum - LES Barrett's esophagus, Mallory-Weiss syndrome - Esophageal motility disorder Nutcracker esophagus, Achalasia, Diffuse esophageal spasm, GERD - Esophageal stricture - Megaesophagus Stomach Gastritis Atrophic, Ménétrier's disease, Gastroenteritis - Peptic gastric ulcer/Dieulafoy's lesion - Dyspepsia - Pyloric stenosis - Achlorhydria - Gastroparesis - Gastroptosis - Portal hypertensive gastropathy - Gastric antral vascular ectasia - Gastric dumping syndrome - Gastric volvulus Intestinal/ enteropathy Small intestine/ duodenum/jejunum/ileum Enteritis Duodenitis, Jejunitis, Ileitis Peptic duodenal ulcer Malabsorption: Coeliac - Tropical sprue - Blind loop syndrome - Whipple's - Short bowel syndrome - Steatorrhea Large intestine appendix/colon Appendicitis - Colitis Pseudomembranous, Ulcerative, Ischemic Functional colonic disease IBS, Intestinal pseudoobstruction/Ogilvie syndrome Megacolon/Toxic megacolon - Diverticulitis/Diverticulosis Large and/or small Enterocolitis Necrotizing - IBD Crohn's disease vascular: Abdominal angina - Mesenteric ischemia - Angiodysplasia Bowel obstruction: Ileus - Intussusception - Volvulus - Fecal impaction Constipation - Diarrhea Rectum/anus Proctitis Radiation proctitis - Proctalgia fugax - Rectal prolapse - Anal fissure/Anal fistula - Anal abscess Accessory Liver Hepatitis Viral hepatitis, Autoimmune hepatitis, Alcoholic hepatitis - Cirrhosis PBC - Fatty liver NASH - vascular Hepatic veno-occlusive disease, Portal hypertension, Nutmeg liver - Alcoholic liver disease - Liver failure Hepatic encephalopathy, Acute liver failure - Liver abscess - Hepatorenal syndrome - Peliosis hepatis Gallbladder Cholecystitis - Gallstones/Cholecystolithiasis - Cholesterolosis - Rokitansky-Aschoff sinuses - Postcholecystectomy syndrome Bile duct/ other biliary tree Cholangitis PSC, Ascending - Cholestasis/Mirizzi's syndrome - Biliary fistula - Haemobilia - Gallstones/Cholelithiasis common bile duct Choledocholithiasis, Biliary dyskinesia Pancreatic Pancreatitis Acute, Chronic, Herary - Pancreatic pseudocyst - Exocrine pancreatic insufficiency - Pancreatic fistula Hernia Diaphragmatic: Congenital diaphragmatic - Hiatus Abdominal hernia: Inguinal Indirect, Direct - Umbilical - Incisional - Femoral Obturator hernia - Spigelian hernia Peritoneal Peritonitis Spontaneous bacterial peritonitis - Hemoperitoneum - Pneumoperitoneum GI bleeding Upper Hematemesis, Melena - Lower Hematochezia See also congenital, neoplasia v d e Symptoms and signs: digestive system and abdomen R10-R19, 787 Abdominal and pelvic pain Abdominal pain - Acute abdomen - Colic Other Nausea/Vomiting - Heartburn - Dysphagia Oropharyngeal, Esophageal flatulence and related Abdominal distension, Bloating, Burping, Tympanites Fecal incontinence Encopresis hepatosplenomegaly Hepatomegaly, Splenomegaly Jaundice - Ascites - Fecal occult blood - Halitosis see also noncongenital, congenital Retrieved from http://en..org/wiki/Vomiting Categories: Reflexes | Symptoms | Digestive disease symptoms | Body fluids | VomitingHidden categories: Articles with statements since June 2008 | All articles with statements | Articles with statements since April 2008 | Articles with statements since May 2008 | Articles needing additional references from July 2007 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages العربية বাংলা Bosanski Català Česky Dansk Deutsch Español Esperanto Ù?ارسی Français í•œêµì–´ Hrvatski Ã?slenska Italiano עברית Latina Lietuvių МакедонÑ?ки Nederlands 日本語 ‪Norsk bokmÃ¥l‬ Polski Português РуÑ?Ñ?кий Simple English SlovenÄ?ina СрпÑ?ки / Srpski Suomi Svenska SlovenÅ¡Ä?ina తెలà±?à°—à±? УкраїнÑ?ька Walon ä¸æ–‡ This page was last modified on 28 August 2008, at 08:09
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