VOMIT - a complex -reflex act that leads to the eruption of stomach contents (sometimes with intestinal contents) through the mouth - occurs when peripheral or central stimuli affect the vomiting center of the brainstem and are often one of the main symptoms of serious 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 arises:
1. As a result of reflex excitation of the emetic center with 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. If the vomiting center is irritated by toxins or medicines. Vomiting can be caused by infections, exogenous intoxications such as carbon monoxide poisoning, poisonous mushrooms, alcohol, certain drugs (for example, cardiac glycosides, narcotic analgesics), etc., toxicosis of pregnant women, precomatose states (in diseases of the kidneys, liver), endocrine diseases (diabetes, adrenal insufficiency, thyrotoxicosis).
3. "Brain" vomiting is a consequence of direct irritation of the vomiting center in diseases of the central nervous system and occurs in hypertensive crises, disorders of cerebral circulation, brain edema, migraine, meningitis, tumors, abscesses, brain injuries.
Vomiting is almost always observed in acute diseases of the abdominal organs, with nausea usually preceded by vomiting, often abdominal pain. Vomiting of recently eaten food, bile is a characteristic symptom of acute gastritis. Usually single and double vomiting brings relief to the patient. Repeated debilitating vomiting in 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 vomiting of mucus, sometimes with an admixture of blood, accompanies acute erosive gastritis, which develop when strong acids and alkalis enter the stomach. The emergence of vomiting in combination with pain in the epigastric region, usually prevailing in the clinical picture, is characteristic of acute peptic ulcer disease and often requires emergency care. Compliance with bed rest, strict diet and the introduction of atropine in most cases significantly reduce these symptoms.
Abundant vomiting of the acidic contents of the stomach (decomposed remnants of a long-eaten food) that occurs 4-6 hours after a meal is the most important symptom of an organic narrowing of the output part of the stomach (pylorus) due to scarring of the ulcer or a malignant tumor. Carefully collected history and objective research data that reveal the exhaustion and dehydration of the patient in the presence of "splashing noise" in the stomach on an empty stomach, help diagnose organic pyloric stenosis. Patients with pyloric stenosis are often so depleted and dehydrated that they even require parenteral administration of glucose solution and isotonic sodium chloride solution even at the first treatment. In the future, they are subject to hospitalization in the surgical department for surgical treatment.
Extremely terrible symptom is bloody vomiting, indicating massive hemorrhage from the vessels of the stomach or esophagus.
The cause of bleeding can be erosion of the vessel with a gastric or duodenal ulcer, rupture of the varicose veins of the esophagus with cirrhosis of the liver with portal hypertension, disintegration of the stomach tumor , finally, vascular diseases and hemorrhagic diathesis. If bloody vomiting began after a severe coughing attack or following repeated bouts of vomiting, the rupture of the mucous membrane of the lower third of the esophagus may be the cause of bleeding (Mallori-Weiss syndrome). If vomiting immediately follows abundant gastric bleeding, the vomit consists of scarlet or freshly clotted blood. With less heavy bleeding, when the blood remains for some time in the stomach and the hemoglobin under the action of hydrochloric acid turns into hydrochloric acid hematin, the vomit takes on the characteristic form of coffee grounds.
Vomiting - the most important symptom of surgical diseases of the abdominal cavity. Usually it accompanies an attack of liver colic, acute cholecystitis and acute pancreatitis , being, along with pain, the main complaint of patients. At the same time, vomiting is combined with tenderness during palpation in the epigastric region and right hypochondrium, often with local symptoms of peritoneal irritation, and sometimes icteric sclera. In acute appendicitis, vomiting is also often observed in the early hours of the disease. Abundant vomiting with a foul odor, called fecal stench, is one of the main symptoms of intestinal obstruction. It should be emphasized that vomiting in these diseases often appears before the symptoms of peritoneal irritation and, along with pain, should be regarded as an early sign of an emergency condition caused by acute surgical pathology of the abdominal organs. At the same time, vomiting is a characteristic symptom of diffuse peritonitis in its late stage, when the diagnosis is beyond doubt, but it is rather difficult to establish the cause of peritonitis.
An attack of renal colic can also be accompanied by vomiting, often combined with bloating and abdominal pain. Such symptoms in right-sided colic sometimes lead to the erroneous diagnosis of acute cholecystitis or appendicitis.
Reflex vomiting is sometimes observed in the acute stage of myocardial infarction (especially when it is localized in the wall of the left ventricle) and is often the cause of diagnostic errors. The combination of vomiting with pain in the epigastric region with a gastralgic variant of myocardial infarction makes it even more difficult to establish a correct diagnosis. However, careful questioning of the nature of pain, the presence of painful angina attacks before the present painful attack, the identification of chest pain, in addition to epigastric localization, makes it possible to suspect the nature of the underlying disease, and to verify the diagnosis in an electrocardiographic study.
In case of intoxication, vomiting is usually preceded by nausea , characterized by persistent, repeated vomiting with liquid and at first abundant vomit. The appearance of vomiting is possible with various infectious diseases (influenza, pneumonia , meningitis) at the height of fever and intoxication. Excessive vomiting of food, and then liquid, combined with intoxication, cramping abdominal pain, high fever, usually multiple diarrhea (fetid foamy stool of a greenish color), sometimes vascular insufficiency, is typical of foodborne toxicoinfections.
Of the emergency conditions that manifest, among other symptoms, persistent vomiting, it is necessary to indicate intoxication with drugs of opium, nicotine and especially large doses of alcohol. Morning vomiting is characteristic; alcohol smell is sometimes observed; in severe cases, it is combined with impaired consciousness, depression of the respiratory center, vascular insufficiency. Patients need vigorous detoxification therapy in combination with the introduction of vascular agents.
Vomiting is an early symptom in some prismic states. Increasing renal failure with developing uremia is usually accompanied by persistent excruciating vomiting, combined with other symptoms of uremia: disorders of the central nervous system, oliguria, pruritus, the smell of ammonia from the mouth, diarrhea, anemia. Hepatic precoma is also often accompanied by vomiting. The presence and intensification of jaundice, the appearance or increase of ascites, a decrease in the size of the liver, the development of encephalopathy, and the 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 correct assessment of vomiting as a symptom of diabetic precoma is that vigorous rational therapy with insulin, the introduction of fluids, sodium chloride eliminate acidosis , prevent the development of coma and remove the patient from the precomatose state. Vomiting in diabetic precoma is usually combined with pain in the epigastric region, lethargy and adynamia of the patient; polyuria, thirst, dry skin and mucous membranes, the smell of acetone from the mouth. Anamnestic indications of diabetes mellitus and detection of insulin injections on the arms, abdomen, and thighs greatly simplify the diagnosis.
Patients with increasing adrenal insufficiency in hypocorticism, Addison's disease usually experience vomiting, which is combined with pain in the abdomen, often diarrhea, severe weakness, hypotension and, especially, Addison's disease, skin pigmentation, most pronounced on open parts of the body - face, neck, hands, palms and friction places of clothing. Timely administration to patients with increasing adrenal insufficiency of adrenal cortex hormones, sodium chloride, and liquid leads to an improvement in the condition and cessation of vomiting.
Vomiting combined with diarrhea, abdominal pain, agitation, tachycardia - one of the main symptoms of thyrotoxic crisis, also requiring emergency care, the introduction of parenteral fluids, saline solutions, glucose with insulin, cardiac drugs, steroid hormones, prescription of thyrostatic drugs.
Vomiting without prior nausea and abdominal pain is a frequent symptom of acute vascular and inflammatory diseases of the brain. With cerebral dyscirculation, it appears at the height of a headache without prior nausea, is combined with vestibular disorders, increases with head turns, does not bring relief. The combination of vomiting with headaches, fluctuations in blood pressure, and even more so the detection of focal neurological symptoms help establish the correct diagnosis. Vomiting in combination with hemicrania suggests a migraine , when combined with severe dizziness, hearing loss, Meniere's disease can be suspected. In the case of high fever, headache, the addition of meningeal symptoms, inflammation of the meninges can be diagnosed. Trauma to the skull and concussion are 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, characteristics of vomitus, taking into account other manifestations of the disease in order to ascertain the nature of the underlying disease for timely assistance. If necessary, in a hospital environment conduct laboratory research of vomit: bacteriological (with food toxicoinfections), forensic chemical (if you suspect poisoning with poisons).
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 intoxication of the body. In case of disturbed consciousness, aspiration of vomit is possible, leading to the development of aspiration pneumonia, and with abundant aspiration - to asphyxia. Persistent debilitating vomiting can provoke tears of the mucous membrane with the development of massive gastric bleeding.
Symptomatic drug therapy for stopping vomiting includes the use of antispasmodics (no-spa 2 ml of 2% solution), m-holinoblokatorov (atropine 0.5 - 1 ml of 0.1% solution) or metoclopramide, which normalizes motility of the gastrointestinal tract 2 ml). These drugs are administered intravenously or intramuscularly. When indomitable vomiting and the ineffectiveness of the above treatment, prescribe antipsychotics (for example, ethaperazine 4 —8 mg orally 3–4 times a day). When signs of intoxication appear, detoxification therapy is indicated, with severe hypovolemia, intravenous administration of fluids and electrolytes, and with blood pressure fluctuations, therapy aimed at its normalization. The need for hospitalization is determined by the nature of the underlying disease: A patient with bloody vomiting is subject to immediate hospitalization in the surgical department, where esophagogastroduodenoscopy is urgently carried out with diagnostic and sometimes therapeutic purposes. Before being sent to the hospital, strict bed rest, hunger, and the implementation of accessible hemostatic measures are necessary.