Medical history and physical examination: A comprehensive history and physical examination can often reveal the cause of nausea and vomiting, making further evaluation unnecessary. Doctors will ask about the individual's medical history, surgeries, and medications. A thorough history of recreational drug and alcohol use or abuse is equally important.
A complete physical examination will include a neurological examination and brain function tests. Acute symptoms generally are the result of infectious, inflammatory, or unknown causes. Evaluation first focuses on detecting any emergencies or complications that require hospitalization, such as bowel obstruction, cancer, opiate addiction, or increased pressure in the head.
Blood tests: Blood tests will be performed to determine if the individual is dehydrated. Blood tests may include electrolyte levels, such as sodium, potassium, and chloride. Tests for kidney function may also be performed, including blood urea nitrogen (BUN) and serum creatinine levels.
Diagnostic tests: Further testing, such as upper endoscopy or computed tomography of the abdomen, may be used by a doctor when an underlying condition, such as bowel obstruction or peptic ulcer, may be the cause of the nausea and vomiting. Upper endoscopy uses a long, narrow tube with a small attached camera that is threaded down the throat and esophagus into the stomach and duodenum. With this instrument, the doctor can view the upper digestive tract and identify an ulcer. If the doctor detects an ulcer, they may remove small tissue samples near the ulcer. Possible complications of upper endoscopy include bleeding and puncture of the stomach lining. However, such complications are rare. Most people will have nothing more than a mild sore throat after the procedure. The procedure takes 20-30 minutes. Because the individual will be sedated, they will need to rest at the endoscopy facility for 1-2 hours until the medication wears off. It is recommended to have a friend or loved one drive. Computerized tomography (CT) scan is an x-ray that uses computer technology and can be enhanced with the injection of a contrast dye. Computerized tomography (CT) scans allow for multiple X-rays to be taken from different angles to create a three-dimensional image of internal body structures. CT is used to show abnormalities in bones and soft tissue. CT scan can be used to look at the abdomen in individuals with severe nausea and vomiting to determine if bowel obstruction may be the cause.
signs and symptoms
is a subjective sensation that is difficult to define. It is an unpleasant feeling in the abdomen often associated with the sense of being ill and the urge to vomit. Vomiting (emesis)
is the forcible expulsion of stomach contents through the mouth. Retching
is a strong, belching-like, rhythmic movement that may or may not be followed by vomiting.
Other related symptoms include increased salivation, loss of color, sweating, tachycardia (increased heart rate), and the urge to defecate.
Usually, nausea and vomiting lasts only a short period of time (several minutes). Medical care should be sought if any of the following symptoms occurs with nausea and vomiting: very forceful vomiting; high fever, over 101 degrees Fahrenheit; severe headache or pain; diarrhea; blood in the vomited material, which may look red or brown, like coffee grounds; heavy sweating; or unusual weakness; if the nausea lasts for more than a few days; if there is a possibility of being pregnant; if home treatment is not working; if symptoms of dehydration are present, including thirst, cramping in the arms and legs, dizziness, restless or irritable behavior, decreased skin tone, dry mucous membranes (such as lips and mouth), sunken eyes, weakness, and fatigue; or a known injury has occurred (such as head injury or infection) that may be causing the vomiting.
Infants may have sunken eyes, a sunken fontanelle (soft spots), and absence of tears when crying vigorously. Infants and children (under six years of age) should be taken to a doctor if vomiting lasts more than a few hours, diarrhea is present, signs of dehydration occur, there is a fever higher than 100 degrees Fahrenheit, or if the child has not urinated for six hours.
risk factors and causes
It is thought that vomiting is controlled by the vomiting center located in the brain called the chemotrigger zone. Nausea is less well understood. The timing of the nausea or vomiting can indicate the cause. When it appears shortly after a meal, nausea or vomiting may indicate a mental disorder, such as bulimia, or a peptic ulcer. Nausea or vomiting one to eight hours after a meal may indicate food poisoning. Food borne diseases, such as Salmonella, may take eight to 72 hours after eating contaminated food to produce symptoms because of the incubation time.
Chemotherapy induced nausea and vomiting: Chemotherapy medications are commonly used to treat various types of cancers. Some chemotherapy medications cause more nausea and vomiting than others, including cisplatin (Platinol®) and cyclophosphamide (Cytoxan®). These two drugs cause nausea and vomiting in greater than 90% of those receiving the drug when no nausea treatment is given.
Chemotherapy induced nausea and vomiting can be divided into several categories. Acute nausea and vomiting usually occurs a few minutes to several hours after the chemotherapy is initiated and goes away within the first 24 hours. The vomiting will be at its worst usually after five to six hours. Delayed vomiting develops more than 24 hours after chemotherapy is given. It might occur with cisplatin (Platinol®) or cyclophosphamide (Cytoxan®). Cisplatin-related vomiting will be at its worst usually from 48-72 hours following chemotherapy and can last six to seven days. Anticipatory nausea/vomiting is learned from previous experiences with vomiting. Anticipatory nausea and vomiting occurs as a result of an unpleasant experience with chemotherapy. It occurs as the individual is preparing for the next dose of chemotherapy, usually within 30-60 minutes before the chemotherapy is started. The individual anticipates that nausea and vomiting will occur as it did before. Breakthrough vomiting occurs despite treatment to prevent it. It requires more anti-nausea and vomiting treatment. Refractory vomiting occurs after one, a few, or several chemotherapy treatments even though the individual is being treated to prevent or control nausea and vomiting. The anti-nausea and vomiting treatment is no longer effective. The individual no longer responds to treatment to prevent nausea and vomiting.
Diabetes: Diabetes can cause nausea, especially when blood sugar levels are poorly controlled. Blood sugar levels of 100-125 milligrams/deciliter indicates an individual has a form of pre-diabetes called impaired fasting glucose (IFG), meaning that the individual is more likely to develop type 2 diabetes but does not have the condition yet. A level of 126 milligrams/deciliter is diabetes. Diabetes can lead to a condition of the stomach called gastroparesis, which also can cause nausea and difficulty eating. Gastroparesis causes stomach contents to not be emptied quickly enough, resulting in nausea.
Emotional stress: Sensitive individuals under extreme emotional stress may become nauseous and vomit.
Gallstones: Gallstones are solid deposits of cholesterol or calcium salts that form in the gallbladder or nearby bile ducts. Gallstones may cause nausea, vomiting, indigestion, and abdominal pain.
Gastroenteritis: Gastroenteritis is inflammation of the lining of the stomach and intestines. Gastroenteritis is typically caused by a viral infection or bacteria from contaminated food or water. In addition to nausea and vomiting, the individual may have watery diarrhea and abdominal cramps.
Gastroesophageal reflux disease (GERD): Gastroesophageal reflux disease (GERD) is irritation to the esophagus that causes inflammation. GERD is often due to stomach acid that backs up into the esophagus Stomach acid in the lower esophagus can trigger nausea and regurgitation of food. It may also be associated with vomiting. Foods and beverages that may cause GERD include alcoholic beverages, soft drinks, tea, and coffee.
Headache: An intense headache, such as a migraine, can cause nausea and vomiting. A rare cause of headache and nausea with vomiting is a brain tumor.
Kidney failure: Nausea and vomiting may develop if the kidneys are not able to rid the body or toxins effectively, such as in nephritis.
Liver disease: If the liver becomes inflamed, called hepatitis, the individual may experience nausea and vomiting. If the liver is damaged to the point of liver failure, waste products are not removed effectively and nausea and vomiting may result. Hepatitis can result from a viral infection, chronic alcohol abuse, and certain medications, including acetaminophen (Tylenol®).
Motion sickness: Motion sickness is a normal response to real, perceived, or anticipated movement. Individuals tend to experience motion sickness on a moving boat (seasickness), train, airplane, automobile, or amusement park rides. Although this condition is fairly common and only a minor nuisance for the occasional traveler, it may be incapacitating for people with an occupation that requires constant movement, such as a flight attendant, pilot, astronaut, or ship crew member. Symptoms generally consist of dizziness, fatigue, and nausea, which may progress to vomiting. Fortunately, most symptoms disappear once the journey is over. Treatment can include over-the-counter (OTC) antihistamines including dimenhydrinate (Dramamine®) and integrative therapies including acupressure and ginger (Zingiber officinale).
Pancreatitis: Pancreatitis is a condition where digestive enzymes attack the pancreas rather than break down food in the small intestine. Pancreatitis causes mild to severe abdominal pain, often accompanied by nausea, vomiting, and fever.
Peptic ulcers: Peptic ulcers are lesions that develop on the lining of the stomach, upper small intestine, or esophagus. The classic symptom of peptic ulcer is burning pain anywhere from the navel to the breastbone, but peptic ulcers may cause nausea and vomiting as well.
Pregnancy: It is estimated that 50-90% of pregnant women experience nausea during the first trimester, while 25-55% experience vomiting. The hormonal changes of early pregnancy have been thought to cause nausea and vomiting. For most women, nausea begins between the 2nd and 5th week and ends between the 8th and 14th week post-conception. For 35% of pregnant women, nausea and vomiting are severe enough that they lose time from work.
Radiation therapy nausea and vomiting: Whether radiation therapy causes nausea and vomiting depends on the part of the body being treated, the amount of radiation given, and how often the treatment is given. When the area of the body being treated includes a large part of the abdomen, specifically, the small intestine (or small bowel), there is a greater chance of nausea and vomiting occurring. About 50% of the people with cancer who receive standard doses of radiation to their abdomen will have nausea and vomiting. These symptoms can occur one to two hours after treatment and can last for several hours. Of those being treated with total body radiation therapy used in bone marrow transplants, about 60-90% will develop nausea and vomiting if not given preventative medicines. These people may also receive high doses of chemotherapy to prepare for the transplant. The combination of radiation therapy and chemotherapy increases the chance of nausea and vomiting. Individuals who receive one large dose of radiation therapy (500 rem or more) have a greater chance of nausea and vomiting than those who receive radiation therapy in smaller doses (less than 100 rem).
Toxins: Toxins in the blood, including alcohol, nicotine, and medications (such as antibiotics), can cause nausea and vomiting. Withdrawal from addictive substances, such as narcotic pain relievers and heroin, can lead to nausea and vomiting.
Underlying conditions: Nausea and vomiting are usually harmless, but in some cases may be a sign of a more serious illness. Some examples of serious conditions that may result in nausea or vomiting include concussions or brain injuries, meningitis (infection of the membrane linings of the brain), intestinal blockage, appendicitis, and brain tumors.
Dehydration: Another concern is dehydration. Adults have a lower risk of becoming dehydrated because they can usually detect the symptoms of dehydration, including increased thirst and dry lips or mouth. Children have a greater risk of becoming dehydrated, especially if they also have diarrhea. Young children are often unable to communicate symptoms of dehydration. Adults caring for sick children should be aware of these visible signs of dehydration: dry lips and mouth, sunken eyes, and rapid breathing or pulse. In infants, decreased urination and a sunken fontanelle (soft spot on the head) may occur.
Hyperemesis gravidarum: Recurrent vomiting in pregnancy can lead to a serious condition called hyperemesis gravidarum, where the mother may develop fluid and mineral imbalances that can endanger her life or that of her unborn child. Hyperemesis gravidarum is characterized by persistent vomiting, protein in the urine, severe weight loss, and dehydration. This condition affects approximately 0.5-2% pregnant women and, if left untreated, can lead to coma, convulsions, and fetal loss. Up to 60% of women who suffer from hyperemesis gravidarum develop depression. Treatment may involve anti-nausea medications (such as 5-HT3 inhibitors), intravenous (IV) fluids (such as normal saline), enteral nutrition (such as Osmolite® or Ensure®). Enteral nutrition is a way to provide food to the body through a tube placed in the nose, the stomach, or the small intestine.