Digestive Health

Updated 16 March 2016

Nausea and vomiting

Nausea and vomiting have many possible causes, and are not always related to disease of the gastro-intestinal tract.

0

Description

Nausea is an unpleasant feeling in the pit of the stomach that one is about to vomit. Vomiting is a reflex where the vomiting centre in the brain tells the intestines to reverse their peristaltic movements in order to force the contents of the stomach out through the mouth.

Causes

There are many possible causes for nausea and vomiting, which is not always related to conditions of the gastro-intestinal (GIT) tract.

Sometimes no cause can be found for vomiting, an action which is induced in the brain in a specific location called the vomiting centre.

The body’s vomiting centre can be stimulated by physical or psychological causes.

Physical

- Most common causes relate to something you have eaten or have eaten too much of. If you have nausea and vomiting, take note of what you have eaten in the last few hours, especially chicken or sea food. If you are taking any prescription or over the counter drugs be sure to mention this to your doctor.

- Diseases of the oral cavity, tonsillitis, post nasal drip and sinusitis.

- Chemicals and toxins

Infections 

lead to the production of certain chemicals that can cause fever (pyrogens) and also stimulate the vomiting centre. These include:

Bacterial and viral infections such as salmonella that can cause either gastro-intestinal or systemic infections

- Rota virus, especially in children

- Parasitic infections such as malaria

- Meningitis

- Encephalitis

- Sinusitis

- Severe pain or shock

- Trauma, especially post-concussion which needs close monitoring

- Unpleasant smells or pictures

- Disturbances in the inner ear in conditions such as altitude sickness, Meniere’s disease, motion sickness and labyrinthitis. Sometimes middle-ear infection in children can cause vomiting, but then it is caused by an irritated nerve that runs through the middle ear

Diseases of the internal organs (viscera) which include:

- Gastro-intestinal disease such as gastritis, peptic ulcer, stomach cancer, gut obstruction, appendicitis and mesenteric adenitis

- Disease of the liver or gallbladder such as cholecystitis, hepatitis and cirrhosis

- Pancreatitis

- Heart diseases such as myocarditis, severe hypertension, heart attack (myocardial infarction) and congestive heart failure.

- Brain conditions such as stroke (cerebrovascular accident), brain tumours, epilepsy and any condition when there is a lack of oxygen and nutrients getting to the brain.

- Certain endocrine problems (e.g. hyperparathyroidism, hyperthyroidism and diabetes mellitus) produce chemical imbalances that stimulate the vomiting centre

- The waste products that accumulate in the body with renal failure and other electrolyte disturbances can stimulate the vomiting centre in the brain

- Some drugs and hormones can stimulate the vomiting centre, causing nausea and vomiting. These include digoxin, morphine, estrogens, iron preparation and aminophyllin.

- Other conditions such as morning sickness, haemolytic anaemia, alcoholism and radiotherapy. 

- Congenital malformations of the gastro-intestinal tract such as pyloric stenosis and gastro-oesophageal reflux, especially in the first six weeks of life.

Psychological and psychiatric causes of vomiting and nausea include:

- Attention- seeking in children

- Shock,  for example after witnessing a traumatic incident

- Bulimia nervosa and self- induced vomiting

How vomiting and nausea progress

Nausea and vomiting are mild and self-limiting most of the time.

Once the vomiting centre in the brain is stimulated, the peristaltic movement of the intestines goes into reverse. The person first experiences a nauseous feeling in the pit of the stomach, producing large quantities of saliva that contain a lot of mucus.

The person may also feel weak and sweaty. The glottis closes and breathing stops, which prevents the vomit from entering the lungs.

This is followed by an involuntary contraction of the stomach muscles during which the stomach contents are forcefully expelled through the mouth.

More severe cases of vomiting may cause fluid and electrolyte loss. In such cases it is not practical to do oral rehydration and treatment at home, so it may require being hospitalised to have intravenous therapy.

Prevalence

Psychogenic or functional nausea and vomiting have many causes and can occur in different ways. This kind of vomiting happens either voluntarily or involuntarily. For instance some people start vomiting involuntarily in a very stressful situation. If an individual perceives a certain kind of food as repulsive, he or she may vomit involuntarily when eating that food. In other cases people deliberately induce vomiting to avoid difficult situations or evoke sympathy.

Cancer treatment: People who receive cancer treatment often feel nauseous afterwards. Radiation therapy causes certain by-products that stimulate the 

- vomiting centre in the brain, while the drugs used for chemotherapy directly stimulate the vomiting centre.

Children and babies: Children are more prone to vomiting for trivial reasons such as a mild fever. Most infants tend to bring up small amounts of milk when winded, and this is usually not a cause for concern. It often helps to change the feeding conditions, for example by reducing the feed, changing the milk formula or changing the nipple size on baby’s feeding bottle.

Pregnancy: Some women experience nausea and vomiting during the first six to eleven weeks of pregnancy, in the first trimester. Others have no problems, while a few unlucky women suffer from nausea later in pregnancy.

- Nausea or vomiting that occurs in the first trimester of pregnancy is usually mild and medication should be avoided. The nausea is caused by hormones that the placenta produces. Morning sickness usually occurs early in the morning, but may occur at any time of the day and is caused by hormones produced by the placenta.

- A more rare form of vomiting in pregnant women is called hyperemesis gravidarum. Factors that play a part in this condition are psychological factors and personality traits, multiple pregnancies and high levels of a hormone call human chorionogonadotropin.

- This condition involves persistent vomiting, which is so severe that women become starved and dehydrated. Such women fail to gain weight and may develop severe liver damage. Hyperemesis gravidarum should initially be treated in hospital.

Motion sickness: Motion or travel sickness can cause nausea and/or vomiting when travelling by road, train, sea or air. Children are especially prone to travel sickness.

When to see a doctor

- If vomiting persists for longer than 24 hours

- If a child under the age of 9 months stays ill for longer than half a day. A child at this age may lose a dangerous amount of body fluid in a very short time

- If signs of dehydration develop, such as a dry tongue, severe thirst, fast breathing, sunken eyes, dry skin or if less urine than normal is passed. Make a note of the usual pattern of nappy changes your baby has and how many changes there have been in the last 12 hours. 

- If the person has had diarrhoea or vomiting very recently and he/she becomes confused.

Also see your doctor if vomiting and/or nausea accompany any of these symptoms:

- Fever, temporary hearing loss, vomiting and pulling of the ear in young children, especially after a cold – there may be a middle-ear infection.

- Neurological signs such as numbness and loss of speech, which may indicate a stroke. This can also occur in severe migraines.

- Blood or a coffee ground-like substance in the vomit, which may indicate a bleeding peptic ulcer.

- Jaundice (eyes and skin turn yellow, and may be accompanied by dark urine, light-coloured stools and general itching). This may indicate hepatitis.

- Mild fever, headache, vomiting, muscular pain, sudden chills and intense shivering some time after visiting a malaria area.

- Disturbed vision, feeling of numbness, pins and needles and headache, which may indicate migraine.

- Cramping pain, swollen abdomen and constipation, which may indicate bowel obstruction.

- Generalised abdominal pain that later shifts to lower right side and loss of appetite, which may indicate appendicitis.

- Pain in the right upper side of the abdomen that radiates to between the shoulder blades or the right shoulder, a possible indication of cholecystitis.

- Sudden onset of severe abdominal pain after a big meal, especially if the person has gallbladder disease or drinks heavily, which may indicate pancreatitis.

- Repeated projectile vomiting in an infant, or increasing amounts of vomit, which may indicate pyloric stenosis or gastro-oesophageal reflux.

- Fever in an infant, which may indicate an infection.

- Black, tarry stools (called malena). This signals blood that has been altered in the digestive tract and may indicate an ulcer or cancer of the gastro-intestinal tract. These types of stools may also be present if taking iron preparations.

- Severe headaches, sleepiness, lethargy and/or a stiff neck, accompanied by a fever may indicate meningitis or encephalitis.

- A severe headache with nausea and /or vomiting plus a change in the level of consciousness could indicate a brain bleed. 

- If the person has had diarrhoea or vomiting very recently and he/she becomes confused.

Also see your doctor if vomiting and/or nausea accompany any of these symptoms:

- Fever, temporary hearing loss, vomiting and pulling of the ear in young children, especially after a cold – there may be a middle-ear infection.

- Neurological signs such as numbness and loss of speech, which may indicate a stroke. This can also occur in severe migraines.

- Blood or a coffee ground-like substance in the vomit, which may indicate a bleeding peptic ulcer.

- Jaundice (eyes and skin turn yellow, and may be accompanied by dark urine, light-coloured stools and general itching). This may indicate hepatitis.

- Mild fever, headache, vomiting, muscular pain, sudden chills and intense shivering some time after visiting a malaria area.

- Disturbed vision, feeling of numbness, pins and needles and headache, which may indicate migraine.

- Cramping pain, swollen abdomen and constipation, which may indicate bowel obstruction.

- Generalised abdominal pain that later shifts to lower right side and loss of appetite, which may indicate appendicitis.

- Pain in the right upper side of the abdomen that radiates to between the shoulder blades or the right shoulder, a possible indication of cholecystitis.

- Sudden onset of severe abdominal pain after a big meal, especially if the person has gallbladder disease or drinks heavily, which may indicate pancreatitis.

- Repeated projectile vomiting in an infant, or increasing amounts of vomit, which may indicate pyloric stenosis or gastro-oesophageal reflux.

- Fever in an infant, which may indicate an infection.

- Black, tarry stools (called malena). This signals blood that has been altered in the digestive tract and may indicate an ulcer or cancer of the gastro-intestinal tract. These types of stools may also be present if taking iron preparations.

- Severe headaches, sleepiness, lethargy and/or a stiff neck, accompanied by a fever may indicate meningitis or encephalitis.

- A severe headache with nausea and /or vomiting plus a change in the level of consciousness could indicate a brain bleed. 

- A severe headache, with visual changes plus nausea and vomiting following a climax during sexual activity could indicate vascular disease, like an aneurysm (weakness in the blood vessel wall).

- Recent bump on the head and vomiting afterwards.

- Pregnancy and an inability to keep food down.

- Chest pain that radiates into the jaw or left arm, sweating, shortness of breath, which may indicate angina or a heart attack (myocardial infarct).

- Chest pain, fever, shortness of breath and palpitations, which may indicate myocarditis or pericarditis.

- A headache that is worse after lying down, when coughing and sneezing, and vomiting that occurs early in the morning. It may indicate raised pressure within the brain.

- If you think the medication you are taking is making you ill.

What to tell your doctor

When you decide to consult a health professional about nausea and/or vomiting, make sure you take note of the following:

 The amount vomited – vomiting large quantities of food and other gastric secretions later in the day may indicate gastric outlet obstruction

- The colour of the vomit:

- bright red blood suggests bleeding from the oesophagus

- dark red vomit with liver-like clots suggests profuse bleeding in the stomach, such as of a peptic ulcer

- coffee ground-like vomit suggests less acute bleeding in the stomach, because the gastric acid has had time to change the composition of the blood

- yellow vomit suggests bile and is an indication that the pyloric valve is open en bile is flowing into the stomach (this is more common in older people)

- If the vomit is sour and contains recent food

- The relationship to eating

- The time of day that it occurs – vomiting in the morning may indicate pregnancy, alcoholism or anxiety

- If vomiting is preceded by nausea or if it occurs suddenly – the absence of nausea may indicate raised pressure in the brain

- If vomiting relieves abdominal pain (it may be due to a peptic ulcer) 

- If there is persistent vomiting without weight loss, which may indicate of a psychological problem

Complications

- The problem with vomiting alone is that body water is lost, as well as electrolytes such as sodium and chloride. If untreated, this may lead to dehydration. Dehydration is marked by thirst, dry mouth, fast breathing, sunken eyes and a reduction in the amount of urine passed.

- If a person vomits for a long time, the oesophagus may tear. This could lead to massive bleeding and the vomiting of big amounts of bright red blood, a condition which is called Mallory Weiss syndrome.

- In prolonged or repeated vomiting, the hydrochloric acid in the gastric juices may damage the enamel of the teeth.

Treatment

It is most important to try and keep up the body’s supply of water by taking in as much clear fluid as possible. Rehydration liquids are an excellent choice, as they also contain electrolytes, but remember to take a small quantity at a time.

If dehydration does occur, or if the person is not able to keep any fluids down, he/she will have to be hospitalised and treated with intravenous water, electrolytes and glucose.

If an unconscious person vomits, he or she can inhale the vomit, which can lead to aspiration pneumonia, or even worse choking to death on the vomit. For that reason you should always turn an unconscious person on his or her side and make sure that the airway remains open.

The next stage is to try and treat or eliminate the cause of the vomiting. It will be necessary to consult a health professional. For example, if it is caused by non-cytotoxic drugs, the health professional may reduce the dose, change the route via which the drug is taken, or change the kind of medication.

If the health professional suspects a peptic ulcer, the person will be referred for a gastroscopy to confirm the diagnosis.

Medication 

- There are numerous over-the-counter (OTC) preparations available to treat nausea and vomiting.

- Suppositories are easier to administer, especially in children, with Cyclizine (Valoid) being very useful. Paracetamol suppositories are also very effective if there is also fever present.

- Always check the package insert for dosage and contra-indications.

For the treatment or prevention of travel or motion sickness, try the following:

- Promethazine (Brunazine, Daralix)

- A mixture of sugar and phosphoric acid (Emetrol, Emex)

- Cyclizine (Valoid,Triazine, Aculoid, Nauzine)

- Cinnarizine (Stugeron)

- Buclizine (Vomifene).

For rehydration, try one of these solutions:

- Darrowped

- Electrona

- Electropak

- Hydrol powder

- Rehidrat

- Scripto-lyte

- Commercial drinks such as Game, Energade, Powerade or Lucozade.

Reviewed by Dr Saville Furman, MBChB MFGP (SA).Family Physician, Part time lecturer in family medicine and primary care at UCT, Red Cross Children’s Hospital and Groote Schuur hospital, Cape Town. February 2015.

Previously reviewed by Prof Don du Toit.

 

Read Health24’s Comments Policy

Comment on this story
0 comments
Comments have been closed for this article.

Ask the Expert

Digestive Health Expert

Dr. Estelle Wilken is a Senior Specialist in Internal Medicine and Gastroenterology at Tygerberg Hospital. She obtained her MBChB in 1976, her MMed (Int) in 1991 and her gastroenterology registration in 1995.

Still have a question?

Get free advice from our panel of experts

The information provided does not constitute a diagnosis of your condition. You should consult a medical practitioner or other appropriate health care professional for a physical exmanication, diagnosis and formal advice. Health24 and the expert accept no responsibility or liability for any damage or personal harm you may suffer resulting from making use of this content.

* You must accept our condition

Forum Rules