Vomiting R11

Synonyms

Emesis; vomitus; vomiting;

Initial descriptor

The ROME- criteria, important for the diagnosis of cyclic vomiting, were first developed by the ROME- Foundation in 2006 and revised in subsequent years (Venkatesan 2019).

Vomiting is the oral expulsion of gastrointestinal contents (Kasper 2015) contrary to the normal peristalsis of the gastrointestinal tract. Vomiting is not an actual disease, but merely a symptom (Oechsle 2019).

• Motion sickness:

For prophylaxis of motion sickness, for example, a scopolamine patch (taking into account contraindications such as benign prostatic hypertrophy, glaucoma) can be used (Herold 2022).

• Cyclic vomiting:

Prophylactically, a tricyclic antidepressant such as amitriptyline should be used as the 1st choice agent according to the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association. Dosage recommendation: 75 - 100 mg / d or 1 - 1.5 mg / kg bw (Venkatesan 2019).

One differentiates between the following forms of vomiting:

- Peripheral vomiting:

This is usually accompanied by persistent nausea and is often associated with strenuous retching. It occurs, for example, in infections of the gastrointestinal tract and in ileus (Oechsle 2019).

- Central vomiting:

Central vomiting usually occurs spontaneously, without preceding nausea. It is gushing or explosive and occurs in association with craniocerebral trauma, brain tumors, meningitis, toxic effects of alcohol, bacteria, anesthetic gases, medications, and liver failure (Oechsle 2019).

- Mechanical vomiting:

This is found when there is irritation of the pharynx or soft palate and can occur unintentionally (e.g., during inspection of the oral cavity, tooth brushing, etc.) or intentionally (Oechsle 2019).

- Habitual vomiting:

Habitual vomiting occurs due to mechanical and psychological factors, such as in the context of bulimia. Even in infants, vomiting that occurs at regular intervals is sometimes found without any apparent reason (Oechsle 2019).

- Functional vomiting:

In this case, episodes of vomiting occur one or more times per week without the presence of an eating disorder or mental illness (Kasper 2015).

- Psychological vomiting:

This can be triggered by excitement, fear, disgust, odors, restlessness, and to gain attention, etc. (Oechsle 2019).

- Cyclic vomiting (CVS [Venkatesan 2019]):

Cyclic vomiting is found in children and adults. It is often associated with migraine headaches (Kasper 2015).

Here, one differentiates on the one hand between a mild course with < 4 episodes / year and a ≤ 2 day duration, without the need for inpatient treatment and on the other hand between a severe course with ≥ 4 episodes / year, a ≥ 2 day duration, long convalescence after the episodes and visit to the emergency room or need for hospitalization (Venkatesan 2019).

- Anticipatory vomiting:

In anticipation of an unpleasant event due to tastes, smells, memory, this form of vomiting may occur (Oechsle 2019).

- Hormonal vomiting:

This occurs due to a hormonal change, such as during pregnancy as so-called emesis gravidarum or due to a migraine attack caused by hormonal causes (Oechsle 2019).

- Cannabis hyperemesis syndrome:

The syndrome manifests as cyclic vomiting and often occurs in men who consume large amounts of cannabis over many years (Kasper 2015).

- Gastroparesis:

This involves delayed gastric emptying, which can lead to nausea and vomiting. Gastroparesis is often found after vagotomy, mesenteric vascular insufficiency, scleroderma, amyloidosis, pancreatic cancer, diabetes mellitus (Kasper 2015).

- Idiopathic gastroparesis:

The idiopathic form of gastroparesis sometimes occurs after a viral infection; otherwise, no evidence of etiopathogenesis is found (Frieling 2017).

- Functional dyspepsia:

Complaints persisting for more than 3 months without evidence of an organic cause (Kasper 2015 / Madisch 2018).

• Functional dyspepsia:

The prevalence is between 10-20%. This makes functional dyspepsia one of the most common functional disorders of the gastrointestinal tract (Madisch 2018).

• Emesis gravidarum:

Occurs in up to 90% of pregnant women predominantly in the 1st half of pregnancy. Desiccosis and electrolyte imbalances exist in approximately 2% of pregnant women (Herold 2022).

The causes of vomiting are very diverse:

• Gastrointestinal disorders such as:
  • Inflammatory diseases due to e.g:
    • Pancreatitis
    • peritonitis
    • acute gastroenteritis (occurs additionally with diarrhea )
    • ulcer disease (Herold 2022)
  • visceral pain such as:
    • in the context of biliary colic (Herold 2022)
  • Passenger disorders due to e. g.:
    • stenosis
    • subileus
    • ileus
    • diabetic gastroparesis (Herold 2022)
    • pyloric obstruction (Kasper 2015)
  • coffee-ground-like or bloody vomiting at:
    • upper gastrointestinal bleeding (Herold 2022)
  • Regurgitation of food in the case of e.g:
    • achalasia
    • Zenker diverticulum (Herold 2022)
  • postoperative:
    • "nausea and vomiting" = PONV
    • after Billroth II surgery as syndrome of the feeding loop (Herold 2022).
• in the context of severe pain conditions such as:
  • Renal colic
  • Myocardial infarction
  • Glaucoma attack
  • pedunculated ovarian cyst
  • testicular torsion (Herold 2022)
  • migraine (occurs together with photophobia and unilateral headache)
  • Special form (rarely occurring): cycling vomiting syndrome (CVS) (Herold 2022)
• vestibular causes such as:
  • Neuronitis vestibularis
  • M. Meniere's
  • motion sickness (Herold 2022)
• CNS disorders due to e. g.:
  • Meningitis
  • Encephalitis
  • increased intracranial pressure
  • craniocerebral trauma (Herold 2022)
• Uremia
• diabetic ketoacidosis (Herold 2022)
• intoxication caused by e. g.:
  • Alcohol
  • food (Herold 2022)
• during pregnancy as so-called emesis gravidarum (Herold 2022)
• drug-induced by e. g.:
  • Cytostatic drugs
  • Digitalis
  • and many other drugs (Herold 2022)
• psychogenic eating disorders such as
  • Bulimia
  • Anorexia nervosa (Herold 2022)
• Exposure to ionizing radiation: This occurs from an exposure of > 0.5 Gy (Herold 2022)

Central vomiting is triggered by irritation of the vomiting center in the medulla oblongata (Oechsle 2019).

In peripheral vomiting, the coordination of vomiting occurs through the brainstem. Several brainstem nuclei and medullary nuclei, which regulate breathing, facial and tongue movements, among others, are involved in the coordination, as are the neurotransmitters / hormones neurokinin NK1, serotonin 5- HT3 and vasopressin (Oechsle 2019 / Kasper 2015).

This triggers reactions in the pharynx, somatic musculature and intestine. Contractions of the musculature in the thoracoabdominal wall and intestine occur with an increase in intrathoracic and intraabdominal pressure. The cardia of the stomach herniates above the diaphragm and the larynx moves upward, allowing the gastric contents to empty (Kasper 2015).

The nausea that precedes vomiting in most cases is likely caused by involvement of the cerebral cortex. The exact mechanisms are not yet known (Kasper 2015).

In many cases, vomiting is preceded as a prodrome:

- nausea

- hypersalivation

- retching (Mörk 2000)

Diagnostic indications can be:

• Medical history:
  • temporal relationship:
    • morning vomiting e.g. in the context of alcoholism and pregnancy
  • postprandial vomiting e.g. in:
    • ulcer disease
    • gastric outlet stenosis
  • Vomiting in a gush without pre-existing nausea in e.g:
    • increase of intracranial pressure
    • neurogenic cause
    • Afferent- loop- syndrome after Billroth II- surgery (Herold 2022)

• Inspection
  • Caffeine-saturated vomiting / vomiting of blood in the case of:
    • Gastrointestinal hemorrhage proximal to the Treitz ligament
  • bilious vomiting in e.g.:
    • Afferent loop syndrome
    • Stenosis proximal to the papilla duodeni Vateri
  • Miserere (flaccid vomiting) in:
    • Ileus (Herold 2022)
  • Vomiting of undigested food in:
    • Achalasia
    • Zenker diverticulum (Kasper 2015)

• Associated symptoms:
  • colic such as:
    • Renal colic
    • Biliary colic
  • Diarrhea in:
    • Gastroenteritis
  • ringing in the ears, dizziness in case of
    • M. Meniere's disease
  • disturbance of consciousness in
    • Intoxications
  • Meningismus, headache in case of e.g.:
    • Increased intracranial pressure
    • Meningitis
  • Visual disturbance, eye pain in case of:
    • Glaucoma
  • Amenorrhea in
    • pregnancy
  • Glucose markedly elevated in:
    • diabetic ketoacidosis
  • Creatinine markedly elevated in:
    • uremia (Herold 2022)

• cyclic vomiting:

The diagnosis is made using the ROME- criteria. The current criteria are the ROME- IV- criteria. These are:

- Onset: acute and duration: < 1 week.

- 1. at least 3 discrete episodes in the last year, 2 of them in the last six months. The two episodes must be at least one week apart.

- 2. no vomiting is found between episodes. Other mild symptoms may be present.

Criteria must have been met in the past 6 months, with symptoms occurring at least 3 months prior to diagnosis.

Inquiries should also be made about possible migraine episodes in the family (Venkatesan 2019).

The following examinations are indicated depending on the symptoms:

- X-ray thorax

- Abdominal X-ray

- Chest CT (in case of suspicion of perforation)

- ECG

- Endoscopic examinations

- Cranial CT (Herold 2022)

- Mesenteric angiography

- Gastric scintigraphy in gastroparesis

- Small intestine barium imaging in case of e.g. partial intestinal obstruction

- Small bowel manometry (Kasper 2015)

Laboratory screening, with appropriate further investigations in case of pathological values (Herold 2022).

- Regurgitation:

Regurgitation is the arbitrary, effortless passage of gastric contents into the mouth (Kasper 2015).

- Rumination:

This refers to the arbitrary repeated regurgitation of food remnants that are chewed and swallowed again (Kasper 2015).

- Gastroesophageal reflux disease (GERD).

- Aspiration (during vomiting the glottis is open [Kretz 2006])

- electrolyte imbalance

- dehydration

- metabolic alkalosis

- Boerhaave syndrome (esophageal rupture)

- Mallory- Weiss- syndrome (occurrence of mucosal rupture and hemorrhage in the esophageal-cardiac region)

(Herold 2022)

Acute vomiting is usually self-limited and requires no further treatment. If it occurs in conjunction with diarrhea, the focus is on adequate fluid and electrolyte administration (Layer 2008).

• Symptomatic therapy:
  • Antiemetics (for details, see "Internal Therapy" [Herold 2022]).
• Inpatient treatment for severe dehydration (Kasper 2015).
• Causal therapy depending on the cause of the symptomatology (Herold 2022).

• Cannabis hyperemesis syndrome:

Vomiting disappears with discontinuation of cannabis (Kasper 2015).

• Antiemetics such as.
  • Dopamine antagonists (e.g. domperidone, metoclopramide)
  • Antihistamines (e.g., Vomex A as suppositories or i.v.)
  • 5- HT3- receptor antagonists (e.g., granisetron, ondansetron [Herold 2022]).

If the effect of an antiemetic is insufficient, antiemetics can be combined (Layer 2008).

• Substitution of missing electrolytes in hypokalemia and metabolic alkalosis (Kasper 2015).

• Vomiting caused by chemotherapy or radiotherapy:

The usual antiemetics usually prove ineffective in this case. 5-HT3- receptor antagonists such as Zofran, and also NK1- receptor antagonists such as rolapitant, aprepitant (Weihrauch 2020) and corticosteroids such as dexamethasone (Oechsle 2019) have proven effective.

• Central vomiting:

Provided this is caused by intracranial pressure elevation, it responds well to steroids such as dexamethasone or prednisolone (Layer 2008).

• Opiate-induced vomiting:

MCP and low-dose haloperidol (3 - 5 tr. at baseline) can be used here (Oechsle 2019).

• Vomiting in mechanical obstruction:

In this case, a gastric tube to drain the gastric contents has proven beneficial. The drainage bag should always be below the level of the stomach.

Medication can be used to inhibit peristalsis and gastrointestinal secretion by:

- Butylscopolamine, recommended dosage: 40 - 120 mg s. c. or i. v. / d

- Octreotide, dosage recommendation: 3 x 50 µg to 3 x 200 µg s. c. / d.

MCP is contraindicated in the presence of mechanical obstruction (Oechsle 2019).

• Cyclic vomiting:

In the acute attack, the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association conditionally recommend the use of serotonin antagonists such as ondansetron or triptans such as sumatriptan (Venkatesan 2019).

In the prodromal stage:

Dosage recommendation ondansetron: 8 mg sublingually or rectally.

Dosage recommendation Sumatriptan: 20 mg as nasal spray or 6 mg s. c., the dose can be repeated after 2 h if necessary, but should be limited to a maximum of 6 doses / week (Venkatesan 2019).

• Postoperative vomiting:

Various drugs can be used for postoperative vomiting such as:

- Serotonin- antagonists such as ondansetron, dolasetron, granisetron.

Dosage recommendation: Ondansetron e.g. Zofran 4 - 8 mg i. v.

- Dexamethasone e.g. Fortecortin

Dosage recommendation: 150 µg / kg bw to a maximum of 8 mg i. v. for induction of anesthesia (Kretz 2006).

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