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ULY CLINIC

20 Septemba 2025, 03:42:16

Vomiting

Vomiting is the forceful expulsion of gastric contents through the mouth, usually preceded by nausea. It results from a coordinated sequence of abdominal muscle contractions and reverse esophageal peristalsis.

Vomiting is a common sign of gastrointestinal (GI) disorders, but may also occur in fluid and electrolyte imbalances; infections; metabolic, endocrine, labyrinthine, CNS, or cardiac disorders.
It can be triggered by drugs, surgery, radiation, stress, anxiety, pain, alcohol, overeating, or ingestion of distasteful foods.
Vomiting during the first trimester of pregnancy is often normal; persistent or late-onset vomiting may indicate complications.

History and Physical Examination

History

Onset, duration, frequency, and intensity of vomiting.
Triggers and relieving factors.
Associated symptoms: nausea, abdominal pain, anorexia, weight loss, changes in bowel habits, bloating, excessive belching or flatus.
Drug and alcohol history, systemic illnesses, infections, or recent surgery.
Pregnancy status and contraceptive use in women of childbearing age.

Vomitus Characteristics

Observing vomitus can provide clues to the underlying cause:

Vomitus Appearance	Possible Cause
Bile-stained (green)	Obstruction below the pylorus (e.g., duodenal lesion)
Bloody (bright red)	Upper GI bleeding, gastritis, peptic ulcer
Bloody (dark red, coffee-ground)	Esophageal or gastric varices, slowly bleeding gastric/duodenal lesion
Brown, fecal odor	Intestinal obstruction or infarction
Burning, bitter-tasting	Excess gastric acid
Undigested food	Gastric outlet obstruction (tumor or ulcer)

Physical Examination

Inspect abdomen for distention, rigidity, or tenderness.
Auscultate bowel sounds and bruits.
Palpate liver, spleen, and other abdominal organs.
Observe for projectile vomiting without nausea, which may indicate increased intracranial pressure.
Check vital signs for bradycardia, widened pulse pressure, or hypotension.

Medical causes

Cause	Onset	Key Features	Associated Findings	Pathophysiology	Management
Adrenal insufficiency	Gradual	Vomiting, nausea, anorexia, diarrhea	Weakness, fatigue, weight loss, bronze skin, hypotension	Cortisol and aldosterone deficiency	Hormone replacement (hydrocortisone, fludrocortisone), treat underlying cause
Anthrax (GI)	Acute	Vomiting after ingestion	Fever, abdominal pain, bloody diarrhea	Toxin-mediated intestinal injury	Supportive care, antibiotics (ciprofloxacin, doxycycline)
Appendicitis	Acute	Nausea, vomiting following abdominal pain	RLQ pain, McBurney’s sign, rigidity, anorexia, fever	Inflammation of appendix	Surgical appendectomy, supportive care
Cholecystitis (acute)	Acute	Nausea, mild vomiting	RUQ pain radiating to back/shoulder, tenderness, fever	Gallbladder inflammation	Antibiotics, cholecystectomy
Cholelithiasis	Acute/after meals	Nausea, vomiting after fatty food	RUQ/epigastric pain, belching, flatulence	Gallstones causing biliary colic	Pain management, dietary modification, cholecystectomy if recurrent
Cholera	Acute	Profuse vomiting and diarrhea	Severe dehydration, hypotension, muscle cramps	Enterotoxin-mediated secretory diarrhea	Aggressive rehydration, antibiotics if severe
Cirrhosis	Gradual	Nausea, vomiting, anorexia	Jaundice, hepatomegaly, abdominal distention	Chronic liver injury	Treat underlying cause, supportive care
Electrolyte imbalances	Acute/gradual	Nausea, vomiting	Arrhythmias, tremors, seizures, weakness	Altered cellular ion balance	Correct electrolyte abnormalities
E. coli O157:H7 infection	Acute	Vomiting, diarrhea	Fever, abdominal cramps, hemolytic uremic syndrome in children	Toxin-mediated intestinal injury	Supportive care, monitor renal function
Food poisoning	Acute	Vomiting shortly after ingestion	Diarrhea, fever	Preformed bacterial toxins	Supportive care, hydration
Gastric cancer	Gradual	Mild nausea, vomiting	Weight loss, anorexia, upper abdominal discomfort	Malignant obstruction or ulceration	Surgical, chemotherapy, palliative care
Gastritis	Acute/gradual	Nausea, vomiting of mucus/blood	Epigastric pain, belching, fever	Inflammation of gastric mucosa	Acid suppression, remove irritants (NSAIDs, alcohol)
Gastroenteritis	Acute	Vomiting, diarrhea	Abdominal cramps, fever, malaise	Viral or bacterial infection of GI tract	Hydration, symptomatic care
Heart failure	Gradual	Nausea, vomiting	Fatigue, dyspnea, edema, tachycardia	Venous congestion, gut edema	Optimize heart failure therapy
Hepatitis	Acute	Nausea, vomiting	Fatigue, myalgia, jaundice	Viral liver infection	Supportive care, antiviral if indicated
Hyperemesis gravidarum	Acute/first trimester	Unremitting nausea and vomiting	Weight loss, dehydration, headache	Unknown; hormonal changes	Hydration, antiemetics, nutritional support
Increased intracranial pressure	Acute	Projectile vomiting without nausea	LOC changes, headache, Cushing’s triad	Raised intracranial pressure	Urgent neuroimaging, ICP-lowering measures
Intestinal obstruction	Acute	Bilious/fecal vomiting	Abdominal distention, colicky pain, constipation/obstipation	Mechanical blockage or impaired motility	Decompression, surgery if complete obstruction
Labyrinthitis	Acute	Vomiting with vertigo	Hearing loss, nystagmus	Inner ear inflammation	Supportive care, vestibular suppressants
Listeriosis	Acute	Vomiting, diarrhea	Fever, myalgia, meningitis in CNS involvement	Listeria infection	Antibiotics (ampicillin), supportive care
Mesenteric venous thrombosis	Acute/insidious	Vomiting, abdominal pain	Diarrhea or constipation, hematemesis, melena	Intestinal ischemia	Anticoagulation, surgical intervention if necrosis
Migraine headache	Acute/prodrome	Nausea, vomiting	Photophobia, fatigue, visual disturbances	Neurovascular changes	Analgesics, triptans, hydration
Motion sickness	Acute	Nausea, vomiting	Dizziness, fatigue, diaphoresis	Vestibular mismatch	Antihistamines, behavioral strategies
Norovirus	Acute	Vomiting, watery diarrhea	Abdominal cramps, low-grade fever	Viral gastroenteritis	Hydration, supportive care
Pancreatitis (acute)	Acute	Nausea followed by vomiting	Epigastric/left upper quadrant pain, rigidity, fever	Pancreatic inflammation	NPO, fluids, analgesia, treat underlying cause
Peritonitis	Acute	Nausea, vomiting	Severe abdominal pain, rigidity, hypotension, fever	Peritoneal inflammation/infection	Antibiotics, surgical source control
Preeclampsia	Acute	Nausea, vomiting	Hypertension, edema, headache, visual changes	Endothelial dysfunction	Delivery if indicated, antihypertensives, seizure prophylaxis
Q fever	Acute	Vomiting, nausea	Fever, headache, malaise, chest pain	Rickettsial infection	Doxycycline or other appropriate antibiotics
Renal/urologic disorders	Acute/chronic	Nausea, vomiting	Dysuria, flank pain, hematuria	Uremia, obstruction, infection	Treat underlying cause, supportive care
Rhabdomyolysis	Acute	Nausea, vomiting	Muscle pain/weakness, dark urine	Myoglobin-induced renal injury	Aggressive hydration, treat underlying cause
Typhus	Acute	Vomiting, nausea	Fever, headache, myalgia, rash	Rickettsial infection	Doxycycline or chloramphenicol, supportive care
Drugs	Acute/subacute	Nausea, vomiting	Variable depending on drug	Direct mucosal irritation, CNS stimulation	Stop/adjust offending drug, antiemetics
Radiation therapy	Acute/subacute	Nausea, vomiting	Fatigue, mucositis	Gastric mucosa damage	Antiemetics, supportive care
Postoperative	Acute	Nausea, vomiting	Depends on surgery type	Anesthetic, GI motility disruption	Antiemetics, hydration, early mobilization

Special considerations

Monitor hydration status and electrolytes.
Correct underlying medical or surgical causes.
Provide antiemetic therapy as appropriate.
For severe or persistent vomiting, ensure nutritional support and safety.

Patient counseling

Encourage small, frequent meals and adequate hydration.
Avoid triggering foods or medications if possible.
Advise immediate reporting of blood in vomitus, projectile vomiting, or signs of dehydration.
During pregnancy, stress the importance of early medical evaluation for persistent vomiting.

Pediatric pointers

Vomiting may indicate infection, obstruction, or metabolic disorders.
Assess hydration and electrolytes promptly.
Refer to pediatric specialist for persistent, bilious, or bloody vomiting.

Geriatric pointers

Older adults may have blunted symptoms of infection or obstruction.
Dehydration develops more rapidly.
Assess for polypharmacy or drug-induced vomiting.

References

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Camilleri M. Nausea and vomiting. N Engl J Med. 2001;345:1875–1881.
DiBaise JK. Gastrointestinal complications of systemic disease. Med Clin North Am. 2019;103:337–353.
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American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Nausea and Vomiting of Pregnancy. Washington (DC): ACOG; 2018.