VOMITING

Vomiting - a complex reflex act leading to the eruption of the contents of the stomach (sometimes together with the contents of the intestine) through the mouth - occurs when exposed to peripheral or central stimuli on the emetic center of the brainstem and is often one of the main symptoms of severe diseases requiring emergency care. In most cases, vomiting is a protective reaction of the body aimed at removing toxic or irritating substances from it. It occurs:

1. As a result of reflex excitation of the emetic center by drugs, for example, with strong local irritation of the peritoneum or mesentery, with obstruction of tubular structures with muscle walls (bile duct, intestine, ureter, etc.).

2. When irritating the vomiting center with toxins or medications. The cause of vomiting can be infections, exogenous intoxications - carbon monoxide poisoning, poisonous fungi, alcohol, certain medications (for example, cardiac glycosides, narcotic analgesics), etc., toxicosis of pregnant women, precomatric states (with kidney and liver diseases), endocrine diseases (Diabetes mellitus, adrenal insufficiency, thyrotoxicosis).

3. "Brain" vomiting is the result of direct irritation of the emetic center in diseases of the central nervous system and occurs with hypertensive crisis, disorders of cerebral circulation, brain edema, migraine, meningitis, tumors, abscesses, brain traumas.

Vomiting is almost always observed with acute diseases of the abdominal cavity, with this vomiting usually preceded by nausea , often - pain in the abdomen. Vomiting recently eaten by food, bile is a characteristic symptom of acute gastritis. Usually, one- and two-time vomiting brings relief to the patient. Multiple debilitating vomiting with acute gastritis leads to dehydration and loss of sodium, potassium and chlorine, which in turn increases vomiting and significantly worsens the condition of patients. Persistent painful vomiting of mucus, sometimes with an admixture of blood, accompanies acute erosive gastritis, which develop when strong acids and alkalis enter the stomach. The appearance of vomiting in combination with pain in the epigastric region, usually prevailing in the clinical picture, is typical for peptic ulcer exacerbation and often requires urgent care. Adherence to bed rest, strict diet and the introduction of atropine in most cases significantly reduce these symptoms.

Abundant vomiting of acid contents of the stomach (decomposed remains of long-eaten food), which occurs 4-6 hours after ingestion, is the most important symptom of organic narrowing of the ventricle (pylorus) in connection with cicatrization of the ulcer or with a malignant tumor. Carefully collected history and data of objective research, revealing the depletion and dehydration of the patient in the presence of "splash noise" in the stomach on an empty stomach, help diagnose the organic stenosis of the pylorus. Patients with stenosis of the pylorus are often so depleted and dehydrated that even with the first treatment they need parenteral administration of glucose solution and isotonic sodium chloride solution. Later they are subject to hospitalization in the surgical department for surgical treatment.

An extremely formidable symptom is a bloody vomiting, indicating a massive hemorrhage from the vessels of the stomach or esophagus.

The cause of bleeding may be erosion of the vessel with ulcer of the stomach or duodenum, rupture of the varicose veins of the esophagus with cirrhosis of the liver with portal hypertension, decomposition of the stomach tumor , finally, vascular diseases and hemorrhagic diathesis. If bloody vomiting began after a severe cough or after repeated attacks of vomiting, the cause of bleeding may be a rupture of the mucous membrane of the lower third of the esophagus (Mallory-Weiss syndrome). If vomiting follows immediately from heavy gastric bleeding, vomitus consists of scarlet or just curled blood. With less abundant bleeding, when the blood remains in the stomach for a while and the hemoglobin under hydrochloric acid turns into hydrochloric acid, the vomit becomes a characteristic type of coffee grounds.

Vomiting is the most important symptom of surgical diseases of the abdominal cavity. Usually it accompanies an attack of hepatic colic, acute cholecystitis and acute pancreatitis , being along with the pain the main complaint of patients. In this case, vomiting is combined with pain in palpation in the epigastric region and in the right hypochondrium, often with local symptoms of irritation of the peritoneum, sometimes with a scleral icterism. In acute appendicitis, vomiting is also often observed during the first hours of the illness. Abundant vomiting with a bad smell, called for the stench of stool, is one of the main symptoms of intestinal obstruction. It should be emphasized that vomiting with these diseases often appears before the symptoms of irritation of the peritoneum and along with pain should be regarded as an early sign of an emergency condition caused by acute surgical pathology of the abdominal cavity organs. At the same time, vomiting is a characteristic symptom of diffuse peritonitis in its late stage, when the diagnosis is clear, but the cause of peritonitis is difficult to establish.

The attack of renal colic can also be accompanied by vomiting, which is often accompanied by swelling and abdominal pain. Such symptomatology with right-side colic sometimes leads to erroneous diagnosis of acute cholecystitis or appendicitis.

Reflex vomiting is sometimes observed in the acute stage of myocardial infarction (especially when it is located in the wall of the left ventricle) and is often the cause of diagnostic errors. The combination of vomiting and pain in the epigastric region with a gestralgic variant of myocardial infarction makes it even more difficult to establish the correct diagnosis. However, careful inquiry about the nature of the pain, the presence before the present painful attack of the period of frequent episodes of angina pectoris, revealing, in addition to epigastric localization, chest pains, it is possible to suspect the nature of the underlying disease, and in the electrocardiographic study to verify the diagnosis.

With intoxication, vomiting is usually preceded by nausea , characterized by persistent, repeated vomiting of liquid and initially abundant emetic masses. The occurrence of vomiting is possible with various infectious diseases ( influenza , pneumonia , meningitis ) at the height of fever and intoxication. Abundant vomiting of food, and then fluid, combined with intoxication, cramping abdominal pain, high fever, usually multiple diarrhea (stinking frothy stools of greenish color), sometimes vascular insufficiency, is typical of foodborne infections.

Of the urgent conditions, manifested, in addition to other symptoms, persistent vomiting, it is necessary to indicate the intoxication with drugs of opium, nicotine and especially large doses of alcohol. Morning vomiting is characteristic; Sometimes there is a smell of alcohol; In severe cases it is combined with a violation of consciousness, depression of the respiratory center, vascular insufficiency. Patients need vigorous detoxification therapy in combination with the administration of vascular agents.

Vomiting is an early symptom in some prskomatoznyh states. Increasing renal failure with developing uremia is usually accompanied by persistent agonizing vomiting, combined with other symptoms of uremia: disorders of the central nervous system, oliguria, skin itching, odor of ammonia from the mouth, diarrhea, anemia. Hepatic precoma is also often accompanied by vomiting. Presence and increase of jaundice, appearance or increase of ascites, decrease in liver size, development of encephalopathy, characteristic hepatic smell from the mouth help to establish the correct diagnosis.

It is especially important to know that vomiting is usually accompanied by decompensation of diabetes mellitus, increasing insular insufficiency with the development of acidosis. The importance of a correct evaluation of emesis as a symptom of diabetic precoma is that energetic rational insulin therapy, administration of fluids, sodium chloride eliminate acidosis , prevent the development of coma and remove the patient from the precomatum state. Vomiting with diabetic precoma usually combines with pain in the epigastric region, lethargy and adynamics of the patient; Polyuria, thirst, dryness of the skin and mucous membranes, the smell of acetone from the mouth. Anamnestic indications for diabetes mellitus and the detection of traces of insulin injections on the hands, abdomen, thighs greatly simplify the diagnosis.

In patients with increasing adrenal insufficiency in hypocorticism, addison's disease, vomiting is usually observed, which is combined with abdominal pain, often with diarrhea, severe weakness, arterial hypotension, and, most notably, Addison's disease, with skin pigmentation most pronounced on exposed parts of the body - Face, neck, hands, palm folds and places of friction with clothes. The timely administration of hormones to the adrenal cortex, sodium chloride, and fluid leads to an improvement in the condition and cessation of vomiting, with adrenal insufficiency of the hormones.

Vomiting, combined with diarrhea, abdominal pain, agitation, tachycardia is one of the main symptoms of thyrotoxic crisis, which also requires emergency care, parenteral fluids, saline solutions, glucose with insulin, cardiac agents, steroid hormones, and thyroid medication.

Vomiting without previous nausea and abdominal pain is a common symptom of acute vascular and inflammatory diseases of the brain. In cerebral dyscirculation, it appears at the height of the headache without previous nausea, is combined with vestibular disorders, increases with the turns of the head, and does not bring relief. The combination of vomiting with headaches, fluctuations in blood pressure, and even more so the detection of focal neurologic symptoms help to establish the correct diagnosis. Vomiting in combination with hemicrania suggests migraine , when combined with severe dizziness, hearing loss, Meniere's disease can be suspected. In case of high fever, headache, joining of meningeal symptoms, inflammation of the meninges can be diagnosed. Trauma to the skull, concussion is also usually accompanied by vomiting.

Thus, vomiting is not a specific symptom of any particular disease, but in all cases, vomiting as a symptom requires clarification of the circumstances of its occurrence, the characteristics of the vomit, the recording of other manifestations of the disease in order to clarify the nature of the underlying disease for timely assistance. If necessary, under laboratory conditions, a laboratory study of vomiting is carried out: bacteriological (for foodborne infections), forensic (if poisonous poisoning is suspected).

It is important to emphasize that vomiting, being one of the symptoms of various diseases, often significantly worsens the condition of patients, increases dehydration and loss of electrolytes, leads to the development of metabolic alkalosis, thereby deepening the intoxication of the body. In the case of mental disorders, aspiration of emetic masses, leading to the development of aspiration pneumonia, and, if abundant aspiration, to asphyxia, is possible. Persistent debilitating vomiting can provoke tearing of the mucous membrane with the development of massive gastric bleeding.

Symptomatic drug therapy for the reduction of vomiting includes the use of antispasmodics (no-sppa 2 ml of a 2% solution), m-holinoblockers (atropine 0.5-1 ml 0.1% solution) or normalizing the motility of the gastrointestinal tract metoclopramide (raglan, cerucal, 2 ml). These drugs are administered intravenously or intramuscularly. With indomitable vomiting and ineffectiveness of the above treatment, antipsychotics are prescribed (for example, etaperazine 4-8 mg orally 3 to 4 times a day). When there are signs of intoxication, disintoxication therapy is shown, with pronounced hypovolemia - intravenous fluids and electrolytes, with fluctuations in blood pressure - therapy aimed at its normalization. The need for hospitalization is determined by the nature of the underlying disease: A patient with bloody vomiting is immediately hospitalized in the surgical department, where esophagogastroduodenoscopy is urgently performed with a diagnostic and sometimes therapeutic purpose. Prior to referral to hospital, strict bed rest, hunger, and available haemostatic measures are necessary.