Daniel Finkelstein and Oscar M, Laudanno
Nausea is the conscious, involuntary feeling of the impending desire to vomit. They are described as an unpleasant feeling of discomfort and restlessness, referring to the throat and epigastrium, with sweating, sialorrhea and modification of the respiratory rhythm, which occurs alone or followed by retching, and which can culminate in vomiting.
The pathogenesis is the same as that of vomiting, but with less intense reflexes. A decrease in the functional activity of the stomach is observed with alterations in the motility of the duodenum and the rest of the small intestine. Nausea can respond to functional causes, which generally appear in hypersensitive people, against unpleasant visual, olfactory or gustatory stimuli, or emotional disturbances, as well as organic causes, which are usually of gastroduodenal origin although they can also originate in changes in intracranial pressure or in pathologies of the rest of the abdomen and chest. Likewise, nausea can be caused by drugs and by stimulation of the vestibular apparatus.
When they appear permanently, it is called a nauseous state, which may originate in abdominal, pelvic or central nervous system conditions.
The methodology for studying the nauseous patient is based on the initial clinical impression, and it must be defined whether it is nausea of functional or organic origin. For this, the interrogation and the physical examination will guide towards a specific pathology. Laboratory, radiological and endoscopic studies will allow establishing the etiology.
The diagnosis of functional or psychic nausea is made by exclusion.
Vomiting is the violent expulsion of gastric contents through the mouth, preceded or not by nausea and retching.
In the act of vomiting there is an increase in abdominal pressure, the anthropyloric zone contracts and the lower esophageal sphincter relaxes. Along with this, an antiperistaltic wave would be produced in the esophagus that leads to the evacuation of the gastric contents through the mouth. The threshold of the vomiting center varies in different patients.
Causes of vomiting. They are varied and are listed in the table below.
According to its origin, it can be classified into:
- Central vomiting . No nausea or retching that precedes it; it occurs with changes of position. It is the sputtering vomit of endocranial hypertension.
- Peripheral vomiting . It is the gastroduodenal starting point, accompanied by nausea and retching. It may or may not calm discomfort and is seen in gastritis, gastric or duodenal ulcer, gastric cancer.
- Reflex vomit . The starting point is extra gastroduodenal; it is accompanied by other symptoms of the underlying disease. It does not calm the discomfort. It is observed in appendicitis, adnexitis, peritonitis.
According to its composition, vomiting can be:
- Food . Contains easily recognizable foods. Within this group is retentionist vomiting, which indicates the presence of a pyloric syndrome, in which the expelled material remains in the stomach for more than twelve hours, usually one or two days, and is never bilious.
- Mucous . It consists of a mixture of gastric juice and saliva. It is the typical vomit of the alcoholist, called morning pituita, generally unique. It can also appear in pregnancy.
- Bilious . It contains bile and is yellowish or greenish in color, depending on how long it stays in the stomach. Leaves a bitter taste in the mouth. It is almost always observed in liver and gallbladder conditions, duodenal stenosis, acute pancreatitis, migraine, or in states of repeated vomiting.
- Bloody . It occurs in pathologies that cause hematemesis (upper digestive hemorrhage). It can be red blood in the case of a recent hemorrhage, or dark, "in coffee grounds", in circumstances of gastric retention of blood.
- Sterraceous or fecaloid. It is one in which fecal matter is eliminated. It accompanies lower intestinal obstructions, or gastrocolic fistulas.
- With foreign bodies . Expulsion of gallstones occurs, due to cholecystogastric or cholecystoduodenal fistulas, parasites (ascaris and tapeworms), swallowed foreign bodies (pits, hairs: "trichobezoar").
Due to its frequency, vomiting is divided into isolated, in crisis (gastric intolerance) and unbearable (uremia, cancer, high ileus).
The timing of vomiting aids in diagnostic guidance. Morning vomiting is common observation in uremia, alcoholism (dry retching) and during the first trimester of pregnancy. The one that appears four hours after an ingestion and is copious indicates gastric retention. Postprandial vomiting can be a manifestation of gastritis or a pyloric spasm.
Interrogation and study methodology
Before a vomiting patient, a good questioning is important, which allows defining the initiation moment, the frequency, the time from the beginning, the composition, the concomitant symptoms and signs, the presence or not of nausea, and the temporal relationship with the intake. .
It is also interesting to know the existence of a surgical history or gastrointestinal, metabolic or capable of producing nausea and vomiting, the intake of medications or drugs, alcohol, and if the patient is a smoker. The association with general symptoms (weight loss, anorexia) should be questioned, as well as evaluating the psychological state and social history of the patient. The physical examination must be complete, with special emphasis on the presence of fever, jaundice, neurological abnormalities, and on the abdominal and cardiovascular examination.
Laboratory studies should include blood count, erythrocyte sedimentation, uremia, glycemia, calcaemia, ionogram, transaminases, alkaline phosphatase, amylasemia, bilirubin, blood gases (if an alteration of acid-base balance is suspected) and complete urine. In special situations, specific studies will be requested, such as pregnancy tests in case of amenorrhea.
An electrocardiogram and chest and direct radiographs of the standing and lying abdomen will be obtained.
For the rest of the studies, the orientation derived from a correct clinical evaluation (gastric aspiration, esophagus-gastro-duodenoscopy, contrast studies of the stomach and gallbladder and abdominal ultrasound) will be used. You can also study the composition of vomiting (occult blood).