Wikipedia

Vomiting

(Redirected fromEmetic)
Not to be confused withRegurgitation (digestion).
"Vomit", "Emesis", "Heaving", "Puke", and "Throw up" redirect here. For other uses, seeVomit (disambiguation).For the butterfly genus, seeEmesis (genus).For the 2021 Argentine film, seePussyCake.For the sailing terms, seeHeaving toandCareening.For the municipality of Albania, seePukë.For the style of graffiti, seeThrow up (graffiti).For other uses, seePuke (disambiguation).

Vomiting(also known asemesis,pukingandthrowing up)[a]is the involuntary, forceful expulsion of the contents of one'sstomachthrough themouthand sometimes thenose.[1]

Vomiting
Other namesEmesis, throwing up, puking, barfing, spewing, upchucking, heaving, hurling, ralphing, being sick
A Renaissance drawing with vivid colours depicting a woman holding the head of a man, who is bent over and expelling a brownish-red material from his mouth. A second woman stands at the left of the image in the doorway to the room, and appears to offer support. A crude representation of vomiting.
14th-century illustration of vomiting from the CasanatenseTacuinum Sanitatis
SpecialtyGastroenterology
SymptomsNausea
ComplicationsAspiration, electrolyte and water loss, damage to the enamel of the teeth, tear of the esophageal mucosa
Risk factorsHistory of migraine, history of PONV or motion sickness in a child's parent or sibling, better ASA physical status, intense preoperative anxiety, certain ethnicities or surgery types, decreased perioperative fluids, crystalloid versus colloid administration

Vomiting can be the result of ailments likefood poisoning,gastroenteritis,pregnancy,motion sickness,or hangover; or it can be an after effect of diseases such asbrain tumors,elevatedintracranial pressure,or overexposure toionizing radiation.[2]The feeling that one is about to vomit is callednausea;it often precedes, but does not always lead to vomiting. Impairment due toalcoholoranesthesiacan cause inhalation of vomit. In severe cases, wheredehydrationdevelops,intravenousfluid may be required.Antiemeticsare sometimes necessary to suppress nausea and vomiting. Self-induced vomiting can be a component of an eating disorder such asbulimia,and is itself now classified as an eating disorder on its own,purging disorder.

Complications

Vomiting

Aspiration

Vomiting is dangerous if gastric content enters therespiratory tract.Under normal circumstances thegag reflexandcoughingprevent this from occurring; however, these protective reflexes are compromised in persons who are under the influence of certain substances (includingalcohol) or even mildlyanesthetized.The individual may choke andasphyxiate[3]or developaspiration pneumonia.[4]

Dehydration and electrolyte imbalance

Prolonged and excessive vomiting depletes the body ofwater(dehydration), and may alter theelectrolytestatus. Gastric vomiting leads to the loss of acid (protons) and chloride directly. Combined with the resultingalkaline tide,this leads tohypochloremicmetabolic alkalosis(lowchloridelevels together with highHCO−
3andCO
2and increased bloodpH) and oftenhypokalemia(potassiumdepletion). The hypokalemia is an indirect result of thekidneycompensating for the loss of acid. With the loss of intake of food the individual may eventually becomecachectic.A less frequent occurrence results from a vomiting of intestinal contents, including bile acids andHCO−
3.

Mallory–Weiss tear

See also:Mallory–Weiss syndrome

Repeated or profuse vomiting may cause erosions to theesophagusor small tears in the esophageal mucosa (Mallory–Weiss tear). This may become apparent if fresh red blood is mixed with vomit after several episodes.

Dentistry

Recurrent vomiting, such as observed inbulimia nervosa,may lead to the destruction of thetooth enameldue to the acidity of the vomit.Digestive enzymescan also have a negative effect on oral health, by degrading the tissue of thegums.

Pathophysiology

Receptors on the floor of thefourth ventricleof the brain represent achemoreceptor trigger zone,known as thearea postrema,stimulation of which can lead to vomiting.[2]The area postrema is acircumventricular organand as such lies outside theblood–brain barrier;it can therefore be stimulated by blood-borne drugs that canstimulate vomitingorinhibit it.[5]

There are various sources of input to the vomiting center:

The vomiting act encompasses three types of outputs initiated by the chemoreceptor trigger zone: Motor,parasympathetic nervous system(PNS), andsympathetic nervous system(SNS). They are as follows:

Phases

The vomiting act has two phases. In theretching phase,the abdominal muscles undergo a few rounds of coordinated contractions together with the diaphragm and the muscles used in respiratory inspiration. For this reason, an individual may confuse this phase with an episode of violenthiccups.In this retching phase, nothing has yet been expelled. In the next phase, also termed theexpulsive phase,intense pressure is formed in the stomach brought about by enormous shifts in both the diaphragm and the abdomen. These shifts are, in essence, vigorous contractions of these muscles that last for extended periods of time—much longer than a normal period of muscular contraction. The pressure is then suddenly released when the upper esophageal sphincter relaxes resulting in the expulsion of gastric contents. As the mouth andnasal cavityare connected via the back of the throat, particularly forceful vomiting, or producing large quantities of vomit may result in material being ejected through thenostrilsin addition to the mouth. Individuals who do not regularly exercise their abdominal muscles may experience pain in those muscles for a few days. The decrease in pressure and the release of endorphins into the bloodstream after the expulsion causes the vomiter to feel relief almost immediately after vomiting.[15]

Contents

Partially digested food, with arubber glovefor scale

Gastric secretionsand likewise vomit are highlyacidic.Recent food intake appears in the gastric vomit. Irrespective of the content, vomit tends to bemalodorous.[citation needed]

The content of the vomitus (vomit) may be of medical interest. Freshbloodin the vomit is termedhematemesis( "blood vomiting" ). Altered blood bears resemblance to coffee grounds (as theironin the blood isoxidized) and, when this matter is identified, the termcoffee-ground vomitingis used.Bilecan enter the vomit during subsequent heaves due toduodenalcontraction if the vomiting is severe. Fecal vomiting is often a consequence ofintestinal obstructionor a gastrocolicfistulaand is treated as a warning sign of this potentially serious problem (signum mali ominis).[citation needed]

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.[citation needed]

Color of vomit[16]
  • Bright red in the vomit suggests bleeding from the esophagus
  • Dark red vomit with liver-like clots suggests profuse bleeding in the stomach, such as from a perforated ulcer
  • Coffee-ground-like vomit suggests less severe bleeding in the stomach because the gastric acid has had time to change the composition of the blood
  • Yellow or green vomit suggests bile, indicating that thepyloric valveis open and bile is flowing into the stomach from the duodenum. This may occur during successive episodes of vomiting after the stomach contents have been completely expelled.[17]

Causes

Vomiting may be due to a large number of causes, andprotractedvomiting has a longdifferential diagnosis.[citation needed]

Digestive tract

Causes in thedigestive tract

Sensory system and brain

Causes in thesensory system:[citation needed]

Causes in thebrain:[citation needed]

Metabolicdisturbances (these may irritate both the stomach and the parts of the brain that coordinate vomiting):[citation needed]

Pregnancy:[21]

Drug reaction(vomiting may occur as an acutesomaticresponse to):[citation needed]

High altitude:

Illness(sometimes colloquially known as "stomach flu"—a broad name that refers to gastric inflammation caused by a range of viruses and bacteria):[citation needed]

Psychiatric/behavioral:

Emetics

Anemetic,such assyrup of ipecac,is a substance that induces vomiting when administered orally or by injection. An emetic is used medically when a substance has been ingested and must be expelled from the body immediately. (For this reason, many toxic and easily digestible products such as rat poison contain an emetic.[24]This presents no problem for the effectiveness of therodenticideas rodents are unable to vomit.)[25]Inducing vomiting can remove the substance before it is absorbed into the body. Emetics can be divided into two categories, those which produce their effect by acting on the vomiting center in the medulla, and those which act directly on the stomach itself. Some emetics, such as ipecac, fall into both categories; they initially act directly on the stomach, while their further and more vigorous effect occurs by stimulation of the medullary center.[24]

Saltwater andmustardwater, which act directly on the stomach, have been used since ancient times as emetics.[26]Care must be taken with salt, asexcessive intake can potentially be harmful.[27][28] Copper sulfatewas also used in the past as an emetic.[29][30]It is now considered too toxic for this use.[31]

Hydrogen peroxideis used as an emetic in veterinary practice.[32][33]

Self-induced

  • Eating disorders(anorexia nervosaorbulimia nervosa)
  • To eliminate an ingested poison (some poisons should not be vomited as they may be more toxic when inhaled or aspirated; it is better to ask for help before inducing vomiting)
  • Some people who engage inbinge drinkinginduce vomiting to make room in their stomachs for more alcohol consumption.
  • Participants inmilk chuggingtypically end up vomiting most of the milk they consume, as proteins in the ingested milk (such ascasein) rapidly denature and unravel on contact with gastric acid andproteaseenzymes, rapidly filling the stomach. Once the stomach becomes full,stretch receptorsin the stomach wall trigger signals to vomit to expel any further liquid the participant ingests.
  • People suffering fromnauseamay induce vomiting in hopes of feeling better.

Miscellaneous

Other types

  • Projectile vomitingis vomiting that ejects the gastric contents with great force.[34]It is a classic symptom ofinfantile hypertrophic pyloric stenosis,in which it typically follows feeding and can be so forceful that some material exits through the nose.[35]

Treatment

Anantiemeticis adrugthat is effective against vomiting andnausea.Antiemetics are typically used to treatmotion sicknessand theside effectsof medications such asopioidsandchemotherapy.

Antiemetics act by inhibiting the receptor sites associated with emesis. Hence, anticholinergics, antihistamines, dopamine antagonists, serotonin antagonists, and cannabinoids are used as antiemetics.[36]

Evidence to support the use ofantiemeticsfor nausea and vomiting among adults in theemergencydepartment is poor.[37]It is unclear if any medication is better than another or better than no active treatment.[37]

Epidemiology

Nauseaand/or vomiting are the main complaints in 1.6% of visits to family physicians in Australia.[38]

Society and culture

Herodotus,writing on the culture of theancient Persiansand highlighting the differences with those of theGreeks,notes that to vomit in the presence of others is prohibited among Persians.[39][40]

Social cues

A drunk man vomiting, while a young slave is holding his forehead.Brygos Painter,500–470 BC

It is quite common that, when one person vomits, others nearby become nauseated, particularly when smelling the vomit of others, and often to the point of vomiting themselves. It is believed that this is anevolvedtrait amongprimates.Many primates in the wild 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 to also vomit. This tendency in human populations has been observed at drinking parties, where excessive consumption ofalcoholic beveragesmay cause a number of party members to vomit 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 filmsMonty Python's The Meaning of Life(1983) andStand by Me(1986).[41]

Intense vomiting inayahuascaceremoniesis a common phenomenon. However, people who experience "la purga" after drinking ayahuasca, in general, regard the practise as both a physical and spiritual cleanse and often come to welcome it.[42]It has been suggested that the consistent emetic effects of ayahuasca—in addition to its many other therapeutic properties—was of medicinal benefit toindigenous peoplesof theAmazon,in helping to clearparasitesfrom the gastrointestinal system.[43]

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 ofmass hysteria.[citation needed]

Special bags are often supplied on boats for sick passengers to vomit into.

Most people try to contain their vomit by vomiting into a sink, toilet, or trash can, as vomit is difficult and unpleasant to clean. On airplanes and boats,special bagsare supplied for sick passengers to vomit into. A special disposable bag (leakproof, puncture-resistant, odorless) containing absorbent material that solidifies the vomit quickly is also available, making it convenient and safe to store until there is an opportunity to dispose of it conveniently.[citation needed]

People who vomit chronically (e.g., as part of aneating disordersuch asbulimia nervosa) may devise various ways to hide this disorder.[citation needed]

An online study of people's responses to "horrible sounds" found vomiting "the most disgusting". Professor Trevor Cox of theUniversity of Salford's Acoustic Research Centre said, "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 thatdisgustis triggered by the sound of vomiting to protect those nearby from possibly diseased food.[44]

Psychology

Emetophiliais sexual arousal from vomiting, or watching others vomit.[45]Emetophobiais a phobia that causes overwhelming, intense anxiety pertaining to vomiting.

See also

Notes

  1. ^Informally known as (chieflyU.S.)upchucking,barfing,heaving,and (chieflyBrit.)being sickorgetting sick

References

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