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Vomiting, also known as emesis, puking ‘’’,barfing’’’, throwing up, among other terms, is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose.[1] Vomiting
Vomiting
can be caused by a wide variety of conditions; it may present as a specific response to ailments like gastritis or poisoning, or as a non-specific sequela of disorders ranging from brain tumors and elevated intracranial pressure to overexposure to ionizing radiation. The feeling that one is about to vomit is called nausea, which often precedes, but does not always lead to, vomiting. Antiemetics are sometimes necessary to suppress nausea and vomiting. In severe cases, where dehydration develops, intravenous fluid may be required. Self-induced vomiting can be a component of an eating disorder, such as bulimia nervosa, and is itself now an eating disorder on its own, purging disorder.[2] Vomiting
Vomiting
is different from regurgitation, although the two terms are often used interchangeably. Regurgitation is the return of undigested food back up the esophagus to the mouth, without the force and displeasure associated with vomiting. The causes of vomiting and regurgitation are generally different.

Contents

1 Complications

1.1 Aspiration 1.2 Dehydration
Dehydration
and electrolyte imbalance 1.3 Mallory–Weiss tear 1.4 Dentistry

2 Pathophysiology

2.1 Phases 2.2 Contents

3 Differential diagnosis

3.1 Digestive tract 3.2 Sensory system
Sensory system
and brain 3.3 Emetics 3.4 Social cues 3.5 Miscellanea 3.6 Other types

4 Treatment 5 Epidemiology 6 Social and cultural aspects 7 See also 8 References 9 External links

Complications Aspiration Vomiting
Vomiting
can be dangerous if the gastric content enters the respiratory tract. Under normal circumstances the gag reflex and coughing 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.[citation needed] Dehydration
Dehydration
and electrolyte imbalance Prolonged and excessive vomiting depletes the body of water (dehydration), and may alter the electrolyte status. Gastric vomiting leads to the loss of acid (protons) and chloride directly. Combined with the resulting alkaline tide, this leads to hypochloremic metabolic alkalosis (low chloride levels together with high HCO− 3 and CO 2 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. A less frequent occurrence results from a vomiting of intestinal contents, including bile acids and HCO− 3, which can cause metabolic acidosis.[citation needed] Mallory–Weiss tear See also: Mallory–Weiss syndrome 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 red blood is mixed with vomit after several episodes.[citation needed] Dentistry Recurrent vomiting, such as observed in bulimia nervosa, may lead to destruction of the tooth enamel due to the acidity of the vomit. Digestive enzymes can also have a negative effect on oral health, by degrading the tissue of the gums.[citation needed] Pathophysiology

14th-century illustration of vomiting from the Casanatense Tacuinum Sanitatis

Receptors on the floor of the fourth ventricle of the brain represent a chemoreceptor trigger zone, known as the area postrema, stimulation of which can lead to vomiting. The area postrema is a circumventricular organ and as such lies outside the blood–brain barrier; it can therefore be stimulated by blood-borne drugs that can stimulate vomiting or inhibit it.[3] 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 involved.[4][5] The vestibular system, which sends information to the brain via cranial nerve VIII (vestibulocochlear nerve), plays a major role in motion sickness, and is rich in muscarinic receptors and histamine H1 receptors.[6][7] The cranial nerve X (vagus nerve) is activated when the pharynx is irritated, leading to a gag reflex. The vagal and enteric nervous system inputs 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 that arises from psychiatric disorders and stress from higher brain centers.[8]

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:[citation needed]

Increased salivation to protect tooth enamel from stomach acids. (Excessive vomiting leads to dental erosion). This is part of the PNS output. The body takes a deep breath to avoid aspirating vomit. Retroperistalsis starts from the middle of the small intestine and sweeps up digestive tract contents into the stomach, through the relaxed pyloric sphincter. Intrathoracic pressure lowers (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 except for at the angular notch, nor is there any retroperistalsis in the esophagus. Vomiting
Vomiting
is ordinarily preceded by retching. Vomiting
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
Vasopressin
and neurokinin may also participate.[citation needed] Phases The vomiting act has two phases. In the retching 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 violent hiccups. In this retching phase, nothing has yet been expelled. In the next phase, also termed the expulsive 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. Individuals who do not regularly exercise their abdominal muscles may experience pain in those muscles for a few days. The relief of pressure and the release of endorphins into the bloodstream after the expulsion causes the vomiter to feel better.[citation needed] Contents Gastric secretions and likewise vomit are highly acidic. Recent food intake appears in the gastric vomit. Irrespective of the content, vomit tends to be malodorous.[citation needed] 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
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).[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[citation needed]

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 vomit suggests bile, indicating that the pyloric valve is open and bile is flowing into the stomach from the duodenum (this is more common in older people)

Differential diagnosis Vomiting
Vomiting
may be due to a large number of causes, and protracted vomiting has a long differential diagnosis.[citation needed] Digestive tract Causes in the digestive tract

Gastritis
Gastritis
(inflammation of the gastric wall) Gastroenteritis Gastroesophageal reflux disease Celiac disease[9] Non-celiac gluten sensitivity[10] Pyloric stenosis
Pyloric stenosis
(in babies, this typically causes a very forceful "projectile vomiting" and is an indication for urgent surgery) Bowel obstruction Overeating Acute abdomen and/or peritonitis Ileus Food allergies (often in conjunction with hives or swelling) Cholecystitis, pancreatitis, appendicitis, hepatitis Food poisoning In children, it can be caused by an allergic reaction to cow's milk proteins (Milk allergy or lactose intolerance)

Sensory system
Sensory system
and brain Causes in the sensory system:[citation needed]

Movement: motion sickness (which is caused by overstimulation of the labyrinthine canals of the ear)[citation needed] Ménière's disease

Causes in the brain:[citation needed]

Concussion Cerebral hemorrhage Migraine Brain tumors, which can cause the chemoreceptors to malfunction Benign intracranial hypertension
Benign intracranial hypertension
and hydrocephalus

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

Hypercalcemia
Hypercalcemia
(high calcium levels) Uremia
Uremia
(urea accumulation, usually due to renal failure) Adrenal insufficiency Hypoglycemia Hyperglycemia

Pregnancy:[citation needed]

Hyperemesis, morning sickness

Drug reaction (vomiting may occur as an acute somatic response to):[citation needed]

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)

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]

Norovirus
Norovirus
(formerly Norwalk virus or Norwalk agent) Swine influenza

Psychiatric/behavioral

Bulimia Nervosa Purge disorder

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 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). Inducing vomiting can remove the substance before it is absorbed into the body. Ipecac abuse can cause detrimental health effects.[citation needed] Salt
Salt
water and mustard water have been used since ancient times as emetics.[11] Care must be taken with salt, as excessive intake can potentially be harmful.[12][13] Copper sulfate was also used in the past as an emetic.[14][15] It is now considered too toxic for this use.[16] Hydrogen peroxide
Hydrogen peroxide
is used as an emetic in veterinary practice.[17][18] 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, often to the point of vomiting themselves. It is believed that this is an evolved trait among primates. 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 of alcoholic beverages may 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 films Monty Python's The Meaning of Life (1983) and Stand By Me (1986).[19] 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.[20] 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.[21] 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.[citation needed]

Special
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 bags are 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 an eating disorder such as bulimia 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 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 disgust is triggered by the sound of vomiting to protect those nearby from possibly diseased food.[22] Miscellanea

Self-induced

Eating disorders
Eating disorders
(anorexia nervosa or bulimia 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 in binge drinking induce vomiting to make room in their stomachs for more alcohol consumption. People suffering from nausea may induce vomiting in hopes of feeling better.

After surgery (postoperative nausea and vomiting) Disagreeable sights or disgust, 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 Cyclic vomiting syndrome (a poorly understood condition with attacks of vomiting) High doses of ionizing radiation sometimes trigger a vomit reflex. Violent fits of coughing, hiccups, or asthma Anxiety Depression Overexertion (doing too much strenuous exercise can lead to vomiting shortly afterward). Rumination syndrome, an underdiagnosed and poorly understood disorder that causes sufferers to regurgitate food shortly after ingestion.

Other types

Projectile vomiting refers to vomiting that ejects the gastric contents with great force.[23] It is a classic symptom of infantile hypertrophic pyloric stenosis, in which it typically follows feeding and can be so forceful that some material exits through the nose.[24]

Treatment 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 medications such as opioids and chemotherapy.[citation needed] Antiemetics act by inhibiting the receptor sites associated with emesis. Hence, anticholinergics, antihistamines, dopamine antagonists, serotonin antagonists, and cannabinoids are used as antiemetics.[25] Evidence to support the use of antiemetics for nausea and vomiting among adults in the emergency department is poor.[26] It is unclear if any medication is better than another or better than no active treatment.[26] Epidemiology Nausea and/or vomiting are the main complaints in 1.6% of visits to family physicians in Australia.[27] Social and cultural aspects Herodotus, writing on the culture of the ancient Persians and highlighting the differences with those of the Greeks, notes that to vomit in the presence of others is prohibited among Persians.[28][29] See also

Bulimia nervosa Emetophilia Cancer and nausea Emetophobia

References

^ Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. p. 830. ISBN 0-07-148480-9.  ^ "New Eating Disorder: No Binge, Just Purge". 20 September 2007.  ^ Holland, James F.; Kufe, Donald W.; Weichselbaum, Ralph R.; Pollock, Raphael E.; Frei III, Emil; Gansler, Ted S.; Bast Jr., Robert C. (2003). Cancer medicine (6. [ed.]. ed.). Hamilton, Ontario [u.a.]: Decker. ISBN 9781550092134.  ^ Hornby, PJ (2001). "Central neurocircuitry associated with emesis". The American Journal of Medicine. 111 Suppl 8A (8): 106S–112S. doi:10.1016/S0002-9343(01)00849-X. PMID 11749934.  ^ Naylor, RJ; Inall, FC (January 1994). "The physiology and pharmacology of postoperative nausea and vomiting". Anaesthesia. 49 Suppl: 2–5. doi:10.1111/j.1365-2044.1994.tb03575.x. PMID 8129158.  ^ Matsuoka, I; Ito, J; Takahashi, H; Sasa, M; Takaori, S (1984). "Experimental vestibular pharmacology: a minireview with special reference to neuroactive substances and antivertigo drugs". Acta Oto-Laryngologica Supplementum. 419: 62–70. PMID 6399658.  ^ Li–gui, Huang; En–tong, Wang; Wei, Chen; Wei–xi, Gong (June 2011). "Role of Histamine
Histamine
H1 Receptors in Vestibular Nucleus in Motion Sickness". Journal of Otology. 6 (1): 20–25. doi:10.1016/S1672-2930(11)50003-0.  ^ Ray Andrew P.; Chebolu Seetha; Ramirez Juan; Darmani Nissar A (2009). "Ablation of Least Shrew Central Neurokinin
Neurokinin
NK1 Receptors Reduces GR73632-Induced Vomiting". Behavioural Neuroscience. 123 (3): 701–706. doi:10.1037/a0015733.  ^ "Symptoms & Causes of Celiac Disease NIDDK". National Institute of Diabetes and Digestive and Kidney
Kidney
Diseases. June 2016. Archived from the original on 24 April 2017. Retrieved 24 April 2017.  ^ Volta U, Caio G, Karunaratne TB, Alaedini A, De Giorgio R (2017). "Non-coeliac gluten/wheat sensitivity: advances in knowledge and relevant questions". Expert Review of Gastroenterology
Gastroenterology
& Hepatology (Review). 11 (1): 9–18. doi:10.1080/17474124.2017.1260003. PMID 27852116. A lower proportion of NCG/WS patients (from 30% to 50%) complain of upper gastrointestinal tract manifestations, e.g. vomiting, nausea, gastroesophageal reflux disease, aerophagia and aphthous stomatitis. (NCG/WS: Non-coeliac gluten/wheat sensitivity)  ^ Decker, W. J. (1971). "In Quest of Emesis: Fact, Fable, and Fancy". Clinical Toxicology. 4 (3): 383–387. doi:10.3109/15563657108990490. PMID 4151103.  ^ Moder, K. G.; Hurley, D. L. (1991). "Fatal hypernatremia from exogenous salt intake: report of a case and review of the literature". Mayo Clinic Proceedings. 65 (12): 1587–94. doi:10.1016/S0025-6196(12)62194-6. PMID 2255221.  ^ Salt: a natural antidepressant? The Scotsman. April 6, 2009. ^ Holtzmann NA, Haslam RH (July 1968). "Elevation of serum copper following copper sulfate as an emetic". Pediatrics. 42 (1): 189–93. PMID 4385403.  ^ Wang, S. C.; Borison, Herbert L. (1951). "Copper Sulphate Emesis: A Study of Afferent Pathways from the Gastrointestinal Tract". American Journal of Physiology. 164 (2): 520–526.  ^ Olson, Kent C. (2004). Poisoning & drug overdose. New York: Lange Medical Mooks/McGraw-Hill. p. 175. ISBN 0-8385-8172-2.  ^ "Drugs to Control or Stimulate Vomiting". Merck Veterinary manual. Merck & Co., Inc. 2006.  ^ "How to Induce Vomiting
Vomiting
(Emesis) in Dogs". Petplace.com. Retrieved 2014-05-03.  ^ 9 Best Vomit Scenes On Film, screenjunkies.com ^ Shanon, B. (2002). The antipodes of the mind: Charting the phenomenology of the ayahuasca experience. Oxford: Oxford University Press. ^ Andritzky, W. (1989). "Sociopsychotherapeutic functions of ayahuasca healing in Amazonia". Journal of Psychoactive Drugs. 21 (1): 77–89. doi:10.1080/02791072.1989.10472145. PMID 2656954.  ^ [1] University of Salford. January 28, 2007. Archived February 24, 2009, at the Wayback Machine. ^ "vomiting - definition of vomiting in the Medical dictionary - by the Free Online Medical Dictionary, Thesaurus and Encyclopedia". Medical-dictionary.thefreedictionary.com. Retrieved 2014-05-03.  ^ Mark Feldman; Lawrence S. Friedman; Lawrence J. Brandt, eds. (2009). Sleisenger & Fordtran's gastrointestinal and liver disease pathophysiology, diagnosis, management (PDF) (9th ed.). St. Louis, Mo.: MD Consult. p. 783. ISBN 1-4160-6189-4.  ^ Mitchelson, F (March 1992). "Pharmacological agents affecting emesis. A review (Part I)". Drugs. 43 (3): 295–315. doi:10.2165/00003495-199243030-00002. PMID 1374316.  ^ a b Furyk, JS; Meek, RA; Egerton-Warburton, D (28 September 2015). "Drugs for the treatment of nausea and vomiting in adults in the emergency department setting". Cochrane Database of Systematic Reviews. 9: CD010106. doi:10.1002/14651858.CD010106.pub2. PMID 26411330.  ^ Helena Britt; Fahridin, S (September 2007). "Presentations of nausea and vomiting" (PDF). Australian Family Physician. 36 (9): 673–784. PMID 17885697.  ^ electricpulp.com. "HERODOTUS iii. DEFINING THE PERSIANS – Encyclopaedia Iranica". www.iranicaonline.org.  ^ "Internet History Sourcebooks". sourcebooks.fordham.edu. 

External links

Wikimedia Commons has media related to Vomiting.

Wikiquote has quotations related to: Vomiting

Look up vomiting in Wiktionary, the free dictionary.

Cyclical Vomiting
Vomiting
Syndrome  "Emetics". The American Cyclopædia. 1879. 

v t e

Symptoms and signs: digestive system and abdomen (R10–R19, 787,789)

Upper

Nausea Vomiting Heartburn Aerophagia Dysphagia

oropharyngeal esophageal

Odynophagia Halitosis Xerostomia Hypersalivation Burping

Wet burp

Defaecation

Flatulence Fecal incontinence

Encopresis

Blood: Fecal occult blood Rectal tenesmus Constipation Obstructed defecation Diarrhea Rectal discharge

Psoas sign Obturator sign Rovsing's sign Hamburger sign Heel tap sign Aure-Rozanova's sign Dunphy sign Alder's sign Lockwood's sign Rosenstein's sign

Abdomen

Abdominal pain

Acute abdomen Colic Baby colic Abdominal guarding Rebound tenderness

Abdominal distension

Bloating Ascites Tympanites Shifting dullness Bulging flanks Fluid wave test

Abdominal mass Hepatosplenomegaly

Hepatomegaly Splenomegaly

Jaundice Mallet-Guy sign Puddle sign

Authority control

LCCN: sh85144382 GND: 4015109-8 SUDOC: 027256154 BNF: cb119338174 (data) NDL: 0056