History of migraine, history of PONV or motion sickness in a child's parent or sibling, better ASA physical status, intense preoperative anxiety, certain ethnicities or surgery types, decreased perioperative fluids, crystalloid versus colloid administration
Vomiting (also known asemesis,puking andthrowing up)[a] is the involuntary, forceful expulsion of the contents of one'sstomach through themouth and sometimes thenose.[1]
Vomiting is dangerous if gastric content enters therespiratory tract. Under normal circumstances, thegag reflex andcoughing prevent this from occurring; however, these protective reflexes are compromised in persons who are under the influence of certain substances (includingalcohol) or even mildlyanesthetized. The individual may choke andasphyxiate[3] or developaspiration pneumonia.[4]
Dehydration and electrolyte imbalance
Prolonged and excessive vomiting depletes the body ofwater (dehydration), and may alter theelectrolyte status. Gastric vomiting leads to the loss of acid (protons)[clarification needed] and chloride directly. Combined with the resultingalkaline tide, this leads tohypochloremicmetabolic alkalosis (lowchloride levels together with highHCO− 3 andCO 2 and increased bloodpH) and oftenhypokalemia (potassium depletion). The hypokalemia is an indirect result of thekidney compensating for the loss of acid. With the loss of intake of food the individual may eventually becomecachectic. A less frequent occurrence results from a vomiting of intestinal contents, including bile acids andHCO− 3.
Repeated or profuse vomiting may cause erosions to theesophagus 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.
Dentistry
Recurrent vomiting, such as observed inbulimia nervosa or more rarelyanorexia nervosa, may lead to the destruction of thetooth enamel due to the acidity of the vomit.Digestive enzymes can also have a negative effect on oral health, by degrading the tissue of thegums.
Intrathoracic pressure lowers (byinspiration against a closedglottis), coupled with an increase in abdominal pressure as theabdominal muscles contract, propels stomach contents into theesophagus as thelower esophageal sphincter relaxes.[13] The stomach itself does not contract in the process of vomiting[14] except for at theangular notch, nor is there any retroperistalsis in the esophagus.
Vomiting also initiates anSNS response causing both sweating and increased heart rate.[12]
Phases
The vomiting act has two phases. In theretching 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 violenthiccups. In this retching phase, nothing has yet been expelled. In the next phase, also termed theexpulsive 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. As the mouth andnasal cavity are connected via the back of the throat, particularly forceful vomiting, or producing large quantities of vomit may result in material being ejected through thenostrils in addition to the mouth. Individuals who do not regularly exercise their abdominal muscles may experience pain in those muscles for a few days. The decrease in pressure and the release of endorphins into the bloodstream after the expulsion causes the vomiter to feel relief almost immediately after vomiting.[15]
Contents
Partially digested food, with arubber glove for scale
The content of the vomitus (vomit) may be of medical interest. Freshblood in the vomit is termedhematemesis ("blood vomiting"). Altered blood bears resemblance to coffee grounds (as theiron in the blood isoxidized) and, when this matter is identified, the termcoffee-ground vomiting is used.Bile can enter the vomit during subsequent heaves due toduodenal contraction if the vomiting is severe. Fecal vomiting is often a consequence ofintestinal obstruction or a gastrocolicfistula 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]
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 or green vomit suggests bile, indicating that thepyloric valve is open and bile is flowing into the stomach from the duodenum. This may occur during successive episodes of vomiting after the stomach contents have been completely expelled.[17]
Alcohol, which can be partially oxidized intoacetaldehyde that causes the symptoms ofhangover, including nausea, vomiting, shortness of breath, and fast heart rate.[22]
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 (formerly Norwalk virus or Norwalk agent)
Anemetic, such assyrup 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.[24] This presents no problem for the effectiveness of therodenticide as rodents are unable to vomit.[25] Inducing vomiting can remove the substance before it is absorbed into the body.Emetics can be divided into two categories, those which produce their effect by acting on the vomiting center in the medulla, and those which act directly on the stomach itself. Some emetics, such as ipecac, fall into both categories; they initially act directly on the stomach, while their further and more vigorous effect occurs by stimulation of the medullary center.[24]
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 inbinge drinking induce vomiting to make room in their stomachs for more alcohol consumption.
Participants inmilk chugging typically end up vomiting most of the milk they consume, as proteins in the ingested milk (such ascasein) rapidly denature and unravel on contact with gastric acid andprotease enzymes, rapidly filling the stomach. Once the stomach becomes full,stretch receptors in the stomach wall trigger signals to vomit to expel any further liquid the participant ingests.
People suffering fromnausea may induce vomiting in hopes of feeling better.
Overexertion (doing too much strenuous exercise can lead to vomiting shortly afterwards).
Other types
Projectile vomiting is vomiting that ejects the gastric contents with great force.[34] It is a classic symptom ofinfantile hypertrophic pyloric stenosis, in which it typically follows feeding and can be so forceful that some material exits through the nose.[35]
Antiemetics act by inhibiting the receptor sites associated with emesis. Hence, anticholinergics, antihistamines, dopamine antagonists, serotonin antagonists, and cannabinoids are used as antiemetics.[36]
Evidence to support the use ofantiemetics for nausea and vomiting among adults in theemergency department is poor.[37] It is unclear if any medication is better than another or better than no active treatment.[37]
Epidemiology
Nausea and/or vomiting are the main complaints in 1.6% of visits to family physicians in Australia.[38]
Society and culture
Herodotus, writing on the culture of theancient Persians and highlighting the differences with those of theGreeks, notes that to vomit in the presence of others is prohibited among Persians.[39][40]
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, and often to the point of vomiting themselves. It is believed that this is anevolved trait amongprimates. 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 ofalcoholic 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 filmsMonty Python's The Meaning of Life (1983) andStand by Me (1986).[41]
Intense vomiting inayahuascaceremonies is a common phenomenon. However, people who experience "la purga" after drinking ayahuasca, in general, regard the practise as both a physical and spiritual cleanse and often come to welcome it.[42] It has been suggested that the consistent emetic effects of ayahuasca—in addition to its many other therapeutic properties—was of medicinal benefit toindigenous peoples of theAmazon, in helping to clearparasites from the gastrointestinal system.[43]
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 ofmass hysteria.[citation needed]
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]
An online study of people's responses to "horrible sounds" found vomiting "the most disgusting". Professor Trevor Cox of theUniversity of Salford's Acoustic Research Centre said, "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 thatdisgust is triggered by the sound of vomiting to protect those nearby from possibly diseased food.[44]
Psychology
Emetophilia is sexual arousal from vomiting, or watching others vomit.[45]Emetophobia is a phobia that causes overwhelming, intense anxiety pertaining to vomiting.
^Informally known as (chieflyU.S.)upchucking,barfing,heaving, and (chieflyBrit.)being sick orgetting sick
References
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^abHauser, Joshua M.; Azzam, Joseph S.; Kasi, Anup (2022-09-26)."Antiemetic Medications". StatPearls Publishing.PMID30335336.Archived from the original on 2023-03-30. Retrieved2023-07-12.
^Robson, Philip (1999).Forbidden Drugs (2nd ed.). New York: Oxford University Press. p. 49.ISBN0-19-262955-7.Archived from the original on March 26, 2023. RetrievedAugust 9, 2021.
^Chambers, David; Huang, Christopher; Matthews, Gareth (January 15, 2015).Basic Physiology for Anaesthetists. Cambridge, United Kingdom: Cambridge University Press. p. 277.ISBN978-1-107-63782-5.Archived from the original on December 28, 2023. RetrievedAugust 9, 2021.
^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.ISBN978-1-55009-213-4.
^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.PMID6399658.
^abcdeAnthony L. Kovac (March 29, 2016)."2: Mechanisms of nausea and vomiting". In Tong Joo Gan; Habib, Ashraf S. (eds.).Postoperative Nausea and Vomiting: A Practical Guide. Cambridge, United Kingdom: Cambridge University Press. p. 13.ISBN978-1-107-46519-0.Archived from the original on October 22, 2023. RetrievedAugust 8, 2021.
^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 & Hepatology (Review).11 (1):9–18.doi:10.1080/17474124.2017.1260003.PMID27852116.S2CID34881689.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)
^Iatrakis, George M.; Sakellaropoulos, Gerasimos G.; Kourkoubas, Anthony H.; Kabounia, Stavroula E. (1988). "Vomiting and Nausea in the First 12 Weeks of Pregnancy".Psychother Psychosom.49 (1):22–24.doi:10.1159/000288062.PMID3237957.
^Rostron, Chris; Barber, Jill, eds. (March 2021).Pharmaceutical Chemistry (2nd ed.). New York, NY: Oxford University Press. p. 8.ISBN978-0-19-877978-0.Archived from the original on December 28, 2023. RetrievedAugust 9, 2021.
^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.PMID2255221.
^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.PMID2656954.
^Aggrawal, Anil (2009).Forensic and Medico-legal Aspects of Sexual Crimes and Unususal Sexual Practices. Boca Raton: CRC Press. p. 373.ISBN978-1-4200-4308-2.
