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Nausea and Vomiting

2nd gastrointestinal department


Si xi-jian

Mechanisms of
emesis

CTZ & Emetic Center (Vomiting center)


Emetic Center at lateral brainstem and
reticular formation back receive impulse from cerebral
cortex digestive organs heart&vessel and
chemoreceptor trigger zone CTZ .

CTZ fourth cerebral ventricle bottom Intrinsic or


extrinsic chemical substance morphine digitalis
metabolic product

CTZ & Emetic Center (Vomiting


center)

Neurotransmitters in CTZ & Emetic


Center
Neurotransmitters involved in
stimulating the emetic center, chemoreceptor trigger zone and GI tract
include
5-HT, acetylcholine, histamine,
dopamine (opiates and receptors for
benzodiazepines are also found here)

Classification of
vomiting
1. Reflective vomiting

2.Central vomiting

3. Neurological vomiting

Reflective vomiting
Pharyngeal Mechanisms
Gastrointestinal
Mechanisms
Disease of biliary tract
Peritoneal and mesentery
the five sense organs
Cardiovascular diseases
kidney
Pelvic

Pharyngal Reflexion

Gastrointestinal Mechanisms

Liver Gall
bladder pancre
as

Others

Central vomiting
Intra-cranial infection
Cerebrovascular disorders
Craniocerebral injury
Epilepsy
Metabolic disorders
Drugs

Intra-cranial infection

Cerebrovascular
disorders
Craniocerebral injury

Metabolic disorders
Ketosis acidos
is
Early
pregnancy

Uremia

Liver
coma

Brain edema and


high intracranial
pressure
from any cause

Drug

Antibiotics
Anticarcinoma
Digitalis
morphia
Excite Emetic Center or act on
Gastrointestinal smooth muscle movement

Neurologic and Psychogenic causes

Gastrointestinal tract
neurosis
apositia

Characteristics of Nausea and


Vomiting
1. Time
2. Timing with meals
3. Character of
vomiting
4. Characters of
vomitus

Early
pregnancy
Functional
indigestion

Mornin
g
vomitin
g

Nose&pharyn
x disease

Alcohol

GERD

achalasia of
cardia

pylorus
obstructio
n

Night&overnight
vomiting

Timing with
meals
Immediate after meal Neurologic &

Psychogenic group onset: consider food


poisoning
>1h
after meal Stomach lack
peristalsis &evacuation disturbance

Very long after several meals or over-night


Pylorus obstruction

Character of
vomiting
Neurologic & high intracranial pressure
No obvious nausea very
frequent propellant
vomiting
Characters
of vomitus

No sour erosive smell achalasia of cardia or


achlorhydria
Foul fermentive smell gastric
stasis
Foul smell like stool low intestinal
obstruction
No bile pylorus
obstruction
Long duration or large amount liquid
and electrolyte lose

Accompanying
symptoms
Abdominal pain diarrhea food
poison intestinal contagious disease;
rhythmic pain peptic ulcers
Right upper quadrant pain with
fever jaundice cholecystitis bile duct
stones
infection
Headache
dizzy visual
abnormality ejective vomiting high
intracranial pressure glaucoma
Vertigo nystagmus vestibular
dysfunction
Women of childbearing age(menopause)
pregnancy?
Timing with drug from drugs

CAUSES OF
NAUSEA/VOMITING

Early pregnancy
Psychogenesis
vomiting
Bulimia( )
Pyloric channel ulcer
Acute gastritis
Gastric retention(
Viral gastroenteritis
Toxic gastroenteritis

Myocardial infarction
Peritonitis
Acute obstruction
Neurological
emergency
Drug toxicity
Cancer therapy
Drug withdrawal

Review
1. How vomiting is classified? And
identify which kind vomiting does one
diseases vomiting belongs to.
2. What is propellant vomiting?
3. What does different smell of vomitus
suggest?
4. What does accompanying symptoms
suggest?

Break

Nausea and Vomiting

Goals

Definition
Outline the disease associated with nausea
and vomiting.
Characterize Nausea and Vomiting caused by
prominent disorders
Discriminate the accompanying symptoms.
Suggest diagnostic strategies of the
symptoms.

Definition of Nausea and


Vomiting

Nausea the inclination or


feeling of imminent desire to
vomit, usually felt in the
throat or epi-gastrum.
Vomiting the forceful oral
expulsion of gastric contents
via retro-peristalsis.
Nausea-Vomiting:
simultaneity or separateness

Definition of emesis. (Three


phases)
1. Nausea --->
2. Retching - the labored
rhythmic contraction of
respiratory and abdominal
musculature that frequently
precedes or accompanies
vomiting --->
3. Vomiting.

Mechanism
Vagal
excitation
Nause
a
Retching

Vomitin
g

Differ from food


reflux
vomit Have
nausea feeling
and retching
movement.

Food
reflux No
such feeling
and
movement.
(infant hug
e meal

ICP

ICP=Inductively Coupled Plasma

3
4

History taking

Onset situation inducement fast or


slow abdominal surgery
history menstrual history
Onset time morning night association
with taking food activity posture
Vomitus character smell
Accompanying symptoms
Diagnose treatment & symptom ongoing

History/Background
a) Age
b) GI history required
c) Food intolerance
d) Timing with meals
e) Consistency

f) Content

g) Odor
h) Frequency
i) Fever
j) Weight loss
k) Precipitating
factors
l) Myalgias ,
visual disturbances,
headache, pain
outside abdomen

PHYSICAL EXAM

Vital signs
Skin
HEENT
head,eyes,ear,nose,thro
at)
Abdomen
Neurological

LABORATORY

Rule out obstruction and peritonitis


HCG
Urinalysis
Electrolytes, BUN, creatinine, glucose
Transaminases, amylase
EKG, head CT, upper GI &/or
endoscopies