-Vomiting1

Team: 203, Medicine, UTM , 2nd year students

- Vomiting -

14th century illustration of vomiting from the Casanatense Tacuinum Sanitatis

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January 2013

-Summary2

1. Definition 2. Physiology 3. Pathogenesis 4. Causes 5. Vomiting of blood

6. Mechanism 7. Complications 8. Social Implications 9. Differential Diagnosis 10. Glossary 11. Bibliography

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January 2013

- Definition 3

VOMITING
= forceful expulsion of the contents of one's stomach through the mouth / the nose.

medically: Emesis informally: throwing up and numerous other terms (PUKE)

NAUSEA = uncomfortable feeling, known to be relieved by vomiting.

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January 2013

- Definition 4

Etiology & manifestation is different for the following:

Vomiting
Implies effort Containes mucus, digested food and gastric enzymes, acids

Regurgitation
Often effortless Contains Undigested food Used by birds to feed their young.

Rumination
Affection associated with depression, especially in infants Involves a cycle of regurgitation-ingestion Important weight loss.

!! They are NOT the same thing !!

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January 2013

- Physiology 5

It occurs after stimulation of:

the vomiting center (in the Brain Stem); (or) the Chemo-Receptor Trigger Zone (CTZ).

(through)

Pathways to stimulation: Psychological stress; Labyrinth of the inner ear; (eg. motion sickness) Chemical signals from bloodstream and CSF; Vagal & visceral nerves by G.I. irritation,
distension and delayed gastric emptying.
(eg. Radiation / Distension / Chemotherapy / Infection)

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January 2013

- Pathogenesis 6

It can be divided into:

A). Non-bilious B). Bilious C). G.E.R. :effortless and not associated with retching or autonomic symptoms.

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January 2013

CAUSES
7

A. Nonbilious:
1) Infectious/inflammatory. 2) Metabolic/endocrinologic

3) Neurologic.
4) Obstructive lesion 5) Psychological.

B. Bilious:
1) Distal obstructive lesion.

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January 2013

NON bilious causes :

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A.1. Infectious/inflammatory
9

Acute gastroenteritis:

-Viruses: Rotavirus -Bacteria: Sallmonella, Campylobacter, E.coli., Clostridium difficile, Giardia lamblia.

Diagnosis:

- stool culture (for ova and parasite); - rotazyme test; - detection for C difficile toxin

Other:

- Sepsis, C.N.S infection, U.T.I, and pneumonia; - Labyrinthitis and pancreatitis; - Inflammatory bowel disease.

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January 2013

A.2. Metabolic/Endocrinologic
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In-born errors of metabolism:

- It presents early in infancy and associated with symptoms of lethargy, hypo/hyper-tonia, seizures or coma. - Metabolic acidosis , hypoglycemia, hyperammonemia or ketosis and family history.
Diabetes mellitus:

due to ketoacidosis or gastroparesis.

Food related sensitivity:

- cow milk - soy protein intolerance - type 1 food allergy - celiac disease

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January 2013

A.3. Neurologic
11

(May occur in any condition that increases the intracranial pressure, seizures, autonomic disorders etc.)
Cyclic vomiting:

occurs at early age and is characterized by acute-onset periodic episodes of nausea and vomiting alternating with apparent periods of wellness with some identifiable precipitating events.
Those patients have increased incidence of migraine headaches and prevalence of epilepsy and irritable bowel syndrome.

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January 2013

A.4. Psychological
12
Rumination:

= serious condition that occurs in infants when there is a failure in reciprocal interaction between the infant and the caregiver. The failure to thrive does not improve with the traditional medical intervention but requires sensitive and interactive nurturing.
Bulimia: among teenagers.

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January 2013

Bilious causes :

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January 2013

B.1. Bilious vomiting

14

It is an omnious (premonitory) sign, that mandates immediate evaluation. Neonatal: Intestinal atresia, stenosis and malrotation (with/without volvulus)

need to be ruled out immediately.

In older child: malrotation with volvulus is a surgical emergency.

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January 2013

- Vomiting of blood 15

Bright red blood = implies active bleeding in the esophagus,

stomach, or proximal duodenum. Coffee-ground color = implies a recent history of bleeding. Yellow vomit = suggests bile. this indicates: the pyloric valve is open and bile is flowing into the stomach from the duodenum. (This is more common in older people.)

Minimal bleeding can be treated with histamine-2 blockers or antacids but larger hemorrhages require further intervention.

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January 2013

- Mechanism 16

PHASES: 1.The RETCHING phase: - abdominal muscles & diaphragm undergo a few rounds of coordinated contractions together (nothing has yet been expelled). 2.The EXPULSIVE phase: - intense pressure is formed in the stomach (vigorous contractions / last for extended periods of time - much longer than a normal muscular contraction). - the pressure is then suddenly released with the expulsion of gastric contents.

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January 2013

- Mechanism 17

NOTES:
The motor events involved, are mediated through the

vagal and sympathetic efferents (from the vomiting center.)

After the content is released => Endorfines are also released in the

body, so that pain / nausea etc. are all soothed.

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January 2013

- Complications 18

Aspiration of vomit
(In case of):

alcohol or anesthesia => Asphyxiation / Aspiration pneumonia;

Dehydration & Electrolyte imbalance
(In case of):

prolonged or excessive vomiting => Dehydration / Depletion of: HCO3- , CO2 , K+

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January 2013

- Complications 19

Mallory-Weiss tear
(In case of):

repeated / profuse vomiting => Erosions to the esophagus or small tears in the esophageal mucosa (Mallory-Weiss tear);
Dentistry
(In case of):

vomit acidity / digestive enzymes => destruction of tooth enamel, tissue degrading of the gums.

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January 2013

Differential Diagnosis 20

Differential Diagnosis

- GLOSSARY 21

Brain Stem = trunchiul cerebral CSF = cerebro spinal fluid CTZ = chemoreceptor trigger zone Depletion = expuizare, lipsa G.E.R.=gastro-esofageal reflux G.I. = gastro-intestinal

Hyperammonemia = niv. crescut de amoniac ketosis = niv. patologic crescut de corpi cetonici ketoacidosis = acidoza = ketoza

Ova = ovule / oua Retching = regurgitare Rumination = rumegare To thrive = a creste / dezvolta To undergo = a suferi / indura. U.T.I. = urinary tract infections Volvulus = rasucirea unei anse intestinale in jurul axului sau mezenteric

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January 2013

- Bibliography 22

Works Cited
Guyton, Arthur C. "Aspecte Fiziologice in Afectiunile

Gastrointestinale." TRATAT DE FIZIOLOGIE A OMULUI. 11th ed. Bucuresti: Ed. Medicala Callisto, 2007. 3-1117. Print. Dr. Doaa Al-Masri. Vomiting. Thesis. N.d. N.p.: n.p., n.d. Print. "Puke (disambiguation)." Wikipedia. Wikimedia Foundation, 01 Oct. 2013. Web. 8 Jan. 2013. "Vomiting Social Implications." Vomiting Social Implications. Online Article N.p., n.d. Web. 8 Jan. 2013.

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January 2013