Vomiting (also called emesis) is forcefully throwing out food and fluids from the gut via the mouth. Nausea refers to the unpleasant sensation or feeling of wanting to vomit. Retching is the attempt to vomit without actually bringing out any vomitus. Nausea and vomiting are common symptoms and occur for a number of reasons.
GUT RELATED CAUSES
Inappropriate Food and Eating
Irritation of the gastrointestinal tract (GIT or gut) caused by food ingredients like germs, toxins, and irritants is the most common cause of nausea and vomiting. Gastritis and gastroenteritis (inflammation of the lining of the stomach, and stomach-intestine respectively) are seen due to ingestion of contaminated food and water containing bacteria/viruses/parasites (food poisoning/stomach flu/stomach bug), spicy/acidic/deep-fried foods, excessive alcohol consumption, or even by overeating. Associated symptoms may be a burning feeling/discomfort in the stomach area and abdominal cramps. Food poisoning or gastroenteritis is often accompanied by diarrhea, and sometimes fever.
Usually, no medication is required and the condition recovers spontaneously in 24-48 hours. Maintaining hydration is the key with a lot of fluids like plenty of water, buttermilk, coconut water, and oral rehydration powder solutions (ORS, etc.). A soft diet should be consumed with rice, lentils, curd, vegetables (boiled or cooked with minimal spice), and fruits. Eating slowly and having smaller, more frequent meals is recommended. Spicy foods, deep-fried items, and alcohol should be avoided till at least 3-5 days after symptoms subside. In cases of vomiting or diarrhea not improving in 24 hours, a course of antibiotics may be considered by the physician if suspecting bacterial/parasitic food poisoning. A stool test may also be performed if persisting diarrhea or dysentery (blood in stools) is present.
Food Allergies and Sensitivity
If nausea and vomiting occur recurrently, it is recommended to keep a dietary record to pick up sensitivity or allergies to certain food items. Lactose intolerance and gluten sensitivity are known causes, and these present with diarrhea, gas-bloating, abdominal cramps, and fatigue/weakness along with nausea-vomiting.
Lactose intolerance (milk protein allergy) can be diagnosed by lab tests that include a hydrogen breath test and a glucose blood test after consuming a drink with a standard amount of lactose. If the diagnosis is confirmed, it will be recommended to avoid milk and limit dairy products to small daily servings. Lactose-reduced milk and ice creams are also available. Lactase enzyme supplements may also be prescribed.
Gluten sensitivity (allergy to wheat proteins) is diagnosed by careful study of diet records, and trial of eliminating wheat items from the diet. A specific condition that is autoimmune where the body’s immune system attacks the intestine and causes inflammation on ingesting gluten is called celiac disease (celiac sprue or gluten-sensitive enteropathy). This condition can cause long-term damage to the gut resulting in malabsorption and nutritional deficiencies. A skin prick test may sometimes be used to diagnose gluten intolerance, while celiac disease can be diagnosed by a blood test for anti-gluten antibodies like ELISA. However, unlike celiac disease, gluten intolerance doesn’t usually cause long-term harm to the body. Gluten intolerance is managed by a gluten-free diet. Gluten-free common dietary items are now readily available in the market.
Other food items known to cause food allergies are eggs, peanuts/tree nuts, fish, shellfish (shrimp, crayfish, crab, lobster, clams, scallops, oysters, and mussels), mushrooms and soy. Understanding the responsible allergen, eliminating it from the diet, and planning nutritious meals accordingly is the solution.
Acid Reflux, Dyspepsia and Gastroparesis
Conditions causing acidity can also cause nausea and sometimes vomiting. This is seen in acid reflux disease and dyspepsia (indigestion). In gastroesophageal reflux disease (GERD), the stomach acid refluxes back into the esophagus (food pipe) causing heartburn symptoms and sometimes regurgitation of acidic fluid in the mouth. However, regurgitation should not be confused with vomiting, the latter being a forceful expulsion and not that common in GERD.
Dyspepsia manifests as discomfort in the stomach area, a feeling of bloating, and early post-meal fullness, along with nausea and rarely vomiting in some cases. The main cause of nausea and vomiting in dyspepsia is a combination of increased acid and slow transit of food out of the stomach. Vomiting is more common in people with diabetes who have a condition of slow emptying of the stomach food, called gastroparesis. Medicines like NSAIDs and some antibiotics and other drugs can also cause acidity, nausea, and sometimes vomiting.
The treatment in such cases is acid suppressant drugs (proton pump inhibitors -PPIs like pantoprazole, rabeprazole) combined with medicines to propel food quickly and reduce nausea/vomiting (prokinetics – like domperidone, itopride). Diet and lifestyle modification are also equally important.
Inflammation or Obstruction of Abdominal organs
Conditions of acute inflammation and infection of abdominal organs can cause severe abdominal pain that is often accompanied by vomiting. Such conditions include appendicitis, pancreatitis, cholecystitis (gall bladder inflammation often due to stones), peritonitis, kidney stones, or urinary tract infections. Vomiting may be occasionally present in chronic bowel conditions like irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD).
Bowel obstruction can occur at various levels due to scarring, adhesions or strictures resulting from inflammation or ulceration, growths/tumors and sometimes due to twisting of the bowel (volvulus) or hernia. These can lead to ‘projectile vomiting’ that happens with a significant propelling force. Constipation, abdominal pain, bloating and not being able to pass gas, are other symptoms.
Liver inflammation (Hepatitis) and Cirrhosis can also cause nausea and vomiting.
Note: Vomiting may also be an atypical presentation for COVID-19 where the COVID virus causes viral gastroenteritis due to infection through the mouth. This may also be seen in other viral fevers.
Nausea and vomiting can also be seen in conditions not related to the gut. Vomiting occurs due to stimulation of the vomiting center and/or the chemoreceptor trigger zone (CTZ- sensitive to levels of chemicals/hormones/substances in the blood). The nerves from the gut (gastrointestinal tract) and abdominal organs when irritated are one such stimulus. The CTZ and vomiting center are situated in the brain stem and are triggered by multiple other stimuli that result in vomiting. These are elaborated below:
Back of the throat
- Severe cough especially in children when trying to bring out mucus/phlegm
- While examining the throat (gag reflex)
Inner ear vestibular system (senses changes in motion and balance)
- Motion sickness especially while traveling in curved roads (hilly regions)
- Sea (waves moving the boat/ship)
- Vertigo (benign paroxysmal positional vertigo, vestibular neuritis, Meniere’s disease)
- Ear infections (otitis media)
- First trimester of pregnancy (morning sickness)
- During menses time in some women
- Thyroid/parathyroid disorders
Toxins or drugs in blood
- Drugs: Chemotherapy, Opioid pain killers (morphine group), anesthetic drugs and some antidepressants
- Ketones (diabetic ketoacidosis)
- High levels of urea (uremia) in kidney failure
- Blood ammonia in liver failure
Changes in chemicals
These chemicals are called neurotransmitters (dopamine, serotonin, acetylcholine, histamine, opioids, and substance P) that modulate moods, emotions, stress and pain. Vomiting may be seen when there are changes in the levels of these chemicals as in –
- Extreme stress or emotional disturbance
- Severe anxiety, depression and other mental health illnesses
- Eating disorders (anorexia/bulimia nervosa)
- Migraine headaches
- Odors and disturbing visuals
- Conditions causing severe pain (like a heart attack)
- Head injury
- Brain tumors
- Infections (meningitis and encephalitis – accompanied by high fever).
Vomiting along with neurological symptoms like persistent headaches, convulsions, dizziness, vision/speech disturbance, decrease in memory/cognition or altered consciousness, are important alert signs after head injury and to investigate for brain hemorrhage or tumors.
ALERT SIGNS FOR MEDICAL INTERVENTION
- If vomiting is not reducing in 24 hours
- Recurrent episodes of vomiting
- Dehydration signs – Dry lips/tongue/skin, sunken eyes, increased thirst, palpitation, reduced urination/dark urine, mental confusion or decreased alertness, drowsiness, or dizziness.
- Blood in the vomit (hematemesis) – This may be seen with ulcers in the stomach/duodenum, liver disease (cirrhosis), tears in the esophagus, severe GERD or gastritis, gut/abdominal cancers, or due to swallowed blood from nosebleeds.
- Recent history of head injury
- Accompanying symptoms – high fever, severe abdominal pain, diarrhea/constipation lasting more than 24-48 hours, headache or neurological signs.
MEDICINES FOR NAUSEA-VOMITING
Medicines to reduce or stop nausea-vomiting (called anti-emetic drugs) should be given under a doctor’s advice and prescription. Vomiting is often the body’s way of getting rid of unwanted and harmful substances, therefore should not be always stopped with medication.
However, when vomiting is persistent, recurrent, or causing weakness, incapacitation and problems in nutrition, health, and quality of life, then antiemetics should be used. Conditions like motion sickness, and in those taking medicines for cancer, antiemetics may even be prescribed preventively.
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