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Saturday, August 23, 2025

Being sick


Vomiting (Being Sick)

Introduction

Vomiting (emesis) is the forceful expulsion of gastric contents through the mouth, usually preceded by nausea and accompanied by retching.

  • It is a protective reflex to remove harmful substances.

  • However, recurrent or persistent vomiting can lead to dehydration, electrolyte imbalance, and malnutrition.

  • The causes are wide-ranging: gastrointestinal, central nervous system, metabolic, infectious, or drug-induced.

Physiology of Vomiting

Vomiting is coordinated by the vomiting center in the medulla oblongata, which receives input from:

  • Chemoreceptor trigger zone (CTZ): Sensitive to toxins, drugs, metabolic changes.

  • Vestibular system: Motion sickness.

  • Visceral afferents: GI tract irritation, obstruction.

  • Higher centers: Stress, emotions, smells.

Causes of Vomiting

1. Gastrointestinal Causes

  • Gastroenteritis (viral, bacterial, food poisoning).

  • Gastritis, peptic ulcer disease.

  • Gastroesophageal reflux disease (GERD).

  • Gallstones, cholecystitis, pancreatitis.

  • Appendicitis.

  • Intestinal obstruction (tumor, adhesions, hernia, volvulus).

  • Hepatitis, liver disease.

2. Neurological Causes

  • Raised intracranial pressure (tumor, hemorrhage, meningitis).

  • Migraine.

  • Motion sickness.

  • Head trauma.

3. Metabolic / Endocrine Causes

  • Diabetic ketoacidosis (DKA).

  • Uremia (kidney failure).

  • Addison’s disease.

  • Hypercalcemia.

  • Pregnancy (morning sickness, hyperemesis gravidarum).

4. Infections

  • Systemic (sepsis, malaria, meningitis).

  • Local GI infections.

5. Drug / Toxin Induced

  • Chemotherapy drugs.

  • Alcohol, opioids, digoxin, antibiotics.

  • Food poisoning, ingestion of toxins.

6. Cardiac Causes

  • Myocardial infarction (may present with nausea, vomiting).

7. Psychological / Functional

  • Eating disorders (bulimia).

  • Psychogenic vomiting.

Clinical Features

  • Nausea (urge to vomit).

  • Retching (involuntary spasms without expulsion).

  • Vomiting (expulsion of gastric contents).

Associated symptoms depending on cause:

  • Abdominal pain, diarrhea, fever → gastroenteritis, infection.

  • Severe abdominal distension, constipation → intestinal obstruction.

  • Headache, visual changes → raised intracranial pressure, migraine.

  • Chest pain → myocardial infarction.

  • Weight loss, chronic nausea → cancer, chronic GI disease.

Complications of prolonged vomiting:

  • Dehydration (dry mouth, reduced urine).

  • Electrolyte imbalance (low potassium, metabolic alkalosis).

  • Mallory–Weiss tear (esophageal bleeding).

  • Aspiration pneumonia.

Diagnostic Approach

1. History

  • Onset, frequency, volume, contents (bilious, bloody, undigested food).

  • Relation to meals.

  • Associated symptoms: pain, diarrhea, headache, chest pain.

  • Pregnancy possibility.

  • Medication and alcohol history.

  • Recent travel or food exposure.

2. Examination

  • General: hydration status, fever, blood pressure, heart rate.

  • Abdominal exam: tenderness, distension, bowel sounds.

  • Neurological exam: papilledema, focal deficits.

  • Cardiac exam if chest pain.

3. Investigations

  • Basic labs: CBC, electrolytes, renal/liver function, glucose.

  • Urine tests: pregnancy test, ketones.

  • Stool culture (if infection suspected).

  • Imaging:

    • Abdominal ultrasound (gallstones, appendicitis).

    • Abdominal X-ray / CT (bowel obstruction).

    • Brain CT/MRI if raised intracranial pressure suspected.

  • ECG: rule out myocardial infarction.

  • Endoscopy: if peptic ulcer, cancer suspected.

Management and Treatment

A. General Measures

  • Identify and treat underlying cause.

  • Rehydration (oral or IV fluids).

  • Correct electrolyte imbalances.

  • Nil by mouth until cause clarified if severe vomiting.

B. Pharmacological Treatment (Symptomatic Relief)

1. Antiemetics

  • Dopamine antagonists (for general vomiting):

    • Metoclopramide 10 mg orally/IV every 8 h.

    • Domperidone 10 mg orally three times daily.

  • 5-HT3 receptor antagonists (chemotherapy, post-op, severe cases):

    • Ondansetron 4–8 mg orally/IV every 8–12 h.

  • Antihistamines (motion sickness, vestibular causes):

    • Cyclizine 50 mg orally/IV every 8 h.

    • Promethazine 25 mg orally or IM every 6–8 h.

  • Anticholinergics (motion sickness):

    • Hyoscine hydrobromide 300 mcg orally or transdermal patch every 72 h.

  • Neurokinin-1 (NK1) antagonists (chemotherapy-induced):

    • Aprepitant 125 mg orally before chemo, then 80 mg daily × 2 days.

2. For Specific Causes

  • Gastroenteritis: Supportive, hydration ± antibiotics if bacterial.

  • Pregnancy (hyperemesis gravidarum):

    • Pyridoxine (Vitamin B6) 10–25 mg orally three times daily.

    • Doxylamine 12.5 mg orally at night.

    • Ondansetron if severe.

  • Migraine-related vomiting:

    • Sumatriptan 50–100 mg orally at onset.

    • Metoclopramide 10 mg orally/IV.

  • Raised intracranial pressure: Treat underlying cause (surgery, steroids e.g., Dexamethasone 4 mg IV every 6 h).

  • DKA: IV fluids, insulin therapy.

  • MI: Standard ACS protocol (Aspirin 325 mg chewed, nitrates, oxygen, morphine).

C. Procedural / Surgical Treatment

  • Endoscopy for upper GI bleeding.

  • Surgery for bowel obstruction, perforation, tumors.

  • Neurosurgical intervention for intracranial mass.

Complications

  • Dehydration, shock.

  • Electrolyte imbalances (hypokalemia, hyponatremia).

  • Aspiration pneumonia.

  • Esophageal rupture (Boerhaave’s syndrome, rare but life-threatening).

  • Malnutrition in chronic cases.

Prognosis

  • Acute viral gastroenteritis or food poisoning: Excellent, self-limiting.

  • Pregnancy-related nausea: Usually resolves by mid-pregnancy.

  • Chronic disease (cancer, obstruction, intracranial): Prognosis depends on underlying cause.

  • Massive or persistent vomiting: Risk of life-threatening complications if untreated.

Patient Education

  • Vomiting is common but persistent, severe, or recurrent vomiting needs medical review.

  • Stay hydrated — small sips of clear fluids.

  • Avoid solid food until vomiting settles, then start bland diet (bananas, rice, toast).

  • Avoid alcohol, caffeine, and fatty foods during recovery.

  • Seek urgent care if vomiting is:

    • Severe and persistent.

    • Associated with blood, severe abdominal pain, headache, chest pain, high fever, or confusion.

    • In pregnancy and leading to dehydration.



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