Vomiting Definition
- Forcible ejection of contents of stomach through the mouth
- Accompanied by autonomic symptoms: pallor, sweating, tachycardia.
- Unlike regurgitation, which is effortless.
DDX
- Esophagus: anatomic problems, GERD, Swallowing problems/aspiration, Achalasia/Dysmotility, EOE/ Fundoplication.
- GI: anatomic problems, gastroparesis, pseudo-obstruction, Accommodation, CVS, Rumination, Mucosal Disease.
- Non-GI causes: metabolic, endocrine (DM, thyroid), UPJ obstruction, CNS (tumors, increased ICP), Rheumatologic, Toxins (including cannabinoids).
Mechanism of Vomiting
- chemoreceptor which triggers nausea/ vomiting is in Medulla oblongata.
Chemical messenger from GI tract: H-HT3.
Messenger from cortex thalamus: anxiety/pain.
Messenger from Vestibula: Histamine, M1 acetylcholine.
Messenger from chemoreceptor trigger zone: Mu, kappa, dopamine, neurokinin
Esophageal problem vs gastric problem
During a meal: rumination.
After a meal: reflux.
Before a meal: maybe not GI related.
Digested or not? if undigested, could be due to esophageal disease.
Dry: esophagus.
Just mucous: from the lungs.
Rule 1: Anatomy, rule out anatomy abnormalities
- Barium imaging: malrotation, SMA syndrome, duodenal and gastric webs.
- XR: esophageal/intestinal air fluid level, chronic lung disease
- EGD
-CT.
Esophageal vomiting
- Undigested food, Saliva,
- Not forceful to mildly forceful
- Can be episodic or constant.
- Heartburn, pain, dysphagia, cough, foul breast.
DDX: GERD, anatomic obstruction, fundoplication, primary vs secondary motility disorder (achalasia), metabolic/allergy
Tests: barium imaging, esophageal manometry, endoscopy.
Vomiting from esophageal stasis. Remember, pink = liquid. in achalasia the liquid is in the chest, didn’t make it to the stomach.
Treatment for Esophageal Vomiting
- Reduce stasis, decrease obstruction (dilation, surgery, botox). Increase peristalsis: cisapride.
- protect esophagus from damage: acid blockade, candida.
Gastric vomiting
- Partially digested food, yellow liquid
- Effortless or very forceful
- Cyclic or Episodic
- Pain, retching nausea
DDX: anatomic, gastroparesis, vagotomy after transplant, fundoplication, sensory abnormalities, poor accommodation, rumination, other: metabolic/allergy
Test: barium, gastric emptying, antroduodenal manometry, US
Rumination: purple starts moving into the esophagus with a reflux episode. hot pink starts in the stomach, pushes the reflux episode up into the mouth.
Treatment of gastric vomiting
- improves gastric emptyng: macrolides, botox, cisapride.
- reduce bolus entry to esophagus: baclofen (reduces transiet relaxations of LES-only medication to do this), fundoplication.
- Improve accommodation: periactin
- pain/nausea control: zofran, scopolamine
-bypass stomach: jejunal feedings;
Baclofen: only drug we have which reduces transient relaxations of the sphincter.
Small Bowel Vomiting
- Liquid, bilious
- effortless to very forceful
- episodic or cyclic
- pain, retching, nausea, distension.
DDX: anatomic (congenital, SMA), pseudo-obstruction, visceral hypersensitivity, SBBO
Treatment of SI vomiting
- gastrostomy, jejunostomy, ileostomy, intestinal resections, transplant
Medications for vomiting
Medications for CVS
