Nausea and vomiting

Introduction

Introduction to nausea and vomiting

Nausea and vomiting (nauseaandvomiting) is one of the most common symptoms in the clinic. Nausea and vomiting can be caused by a variety of very different diseases and pathophysiological mechanisms, which may or may not be accompanied by each other. Nausea is a kind of mental activity of the human body. Various factors can cause nausea, viral acute gastroenteritis, bacterial acute gastroenteritis, acute viral hepatitis, appendicitis, cholecystitis, peritonitis, acute fallopian tube, pelvic inflammatory disease, etc. Causes the cause of nausea.

basic knowledge

Sickness ratio: 0.5%

Susceptible people: good for adult men and women

Mode of infection: non-infectious

Complications: electrolyte imbalance

Pathogen

Causes of nausea and vomiting

Infection (35%):

Nausea is a kind of mental activity of the human body. Various factors can cause nausea, viral acute gastroenteritis, bacterial acute gastroenteritis, acute viral hepatitis, appendicitis, cholecystitis, peritonitis, acute fallopian tube, pelvic inflammatory disease, etc. Causes the cause of nausea.

Abdominal other organ diseases (10%):

(1) Organ pain: pancreatitis, cholelithiasis, kidney stones, intestinal ischemia, ovarian cyst pedicle torsion. (2) gastrointestinal obstruction: pyloric obstruction (ulcer disease, gastric cancer, extraluminal mass compression), duodenal obstruction (duodenal cancer, pancreatic cancer), intestinal adhesions, intussusception, strangulation, Crohn's disease, intestinal tuberculosis, intestinal tumor, intestinal aphid, intestinal torsion, superior mesenteric artery compression syndrome, output sputum syndrome, gastrointestinal motility disorder (diabetic gastroparesis, non-diabetic gastroparesis), pseudo-intestine Obstruction (connective tissue disease, diabetic enteropathy, neoplastic intestinal neuropathy, amyloidosis, etc.).

Endocrine and metabolic diseases (15%):

Hyponatremia, metabolic acidosis, malnutrition, vitamin deficiency, diabetic acidosis, hyperthyroidism, hypothyroidism, hyperparathyroidism, hypopituitarism, adrenal insufficiency, various endocrine crisis, Uremia and the like.

Nervous system disease

Central nervous system infection (encephalitis, meningitis), brain tumors, insufficient blood supply to the brain, cerebral hemorrhage, craniocerebral trauma, brain parasitic diseases, etc.

2. Physical and chemical factors such as drugs

Anesthetics, digitalis, chemotherapy drugs, antibiotics, dopamine receptor agonists, non-steroidal anti-inflammatory drugs, theophylline, alcohol, radiation, etc.

3. Mental vomiting

Neurogenic polyphagia, anorexia nervosa.

4. Vestibular disease

Motion sickness, Meniere's disease, labyrinthitis of the inner ear.

5. Pregnant vomiting

Acute vomiting during pregnancy, acute fatty liver during pregnancy.

6. Other

Cardiopulmonary disorders (myocardial infarction, pulmonary infarction, hypertension, acute lung infection, pulmonary heart disease), urinary disorders (acute nephritis, acute pyelonephritis, uremia), periodic vomiting, postoperative nausea and vomiting, glaucoma, etc.

Pathogenesis

Nausea is a kind of mental activity in the human body. Many factors can cause nausea, such as internal organ pain, intracranial hypertension, labyrinth stimulation, certain mental factors, etc., gastric motility weakens or disappears when nausea occurs, emptying delay, duodenum And the proximal jejunal tension increased, reverse motility, resulting in duodenal contents refluxing into the stomach, nausea is often a prelude to vomiting.

Vomiting is a complex pathophysiological reflex process that includes:

1. Information is passed in

Autonomic nerve conduction (where vagus nerve fibers play a greater role than sympathetic nerve fibers).

2. Vomiting reflex center

It is currently believed that the two regions of the central nervous system are closely related to vomiting, one is the medullary vomiting center, and the other is the chemical trigger zone (CTZ).

3. Efferent nerves, including the vagus nerve, sympathetic nerves, body nerves and cranial nerves.

Usually, the vomiting caused by the impulse of the splanchnic nerve endings is called reflex vomiting. The vomiting caused by CTZ stimulation is called central vomiting. The medullary vomiting center is located in the dorsolateral side of the medullary reticular formation, near the vagus nerve nucleus. From the afferent impulses of the digestive and splanchnic nerves, cerebral cortex, vestibular organs, optic nerve, pain receptors and CTZ, the chemoreceptor triggering zone (CTZ) is located in the posterior polar region at the bottom of the fourth ventricle, a bilateral region with dense dopamine The receptor, dopamine receptor plays an important role in the vomiting-mediated process of CTZ, because the application of apomorphine, levodopa, bromocriptine and other dopamine receptor agonists can cause vomiting, and its antagonist, metoclopramide Amine (gastric ampoules), morphine and other drugs have anti-vomiting effects, and neurotransmitters such as serotonin, norepinephrine, neuropeptide substances and r-aminobutyric acid in the chemosensory triggering region may also participate in the vomiting and reflex process. CTZ mainly receives vomiting stimulation signals from the chemical and drug aspects of the blood circulation, and sends out nerve impulses that cause vomiting, but CTZ itself cannot It is necessary to cause vomiting in the medullary vomiting center and its mediated vomiting, but the relationship between the two is still unknown. CTZ is outside the blood-cerebrospinal fluid barrier, and many drugs or metabolic disorders can act on CTZ. Drugs such as anesthetics, chemical drugs, ergot derivatives, ipecac syrup, etc. and certain polypeptide substances in the body such as thyroid hormone releasing hormone, substance P, angiotensin, gastrin, vasopressin, vascular intestinal peptide, etc. Acting on CTZ causes nausea and vomiting. In addition, nausea and vomiting caused by certain diseases such as uremia, hypoxemia, ketoacidosis, radiation sickness, and motion sickness are also associated with CTZ.

The efferent nerve transmits vomiting signals to various effect organs, causing nausea and vomiting. When vomiting begins, the pylorus is closed, and the contents of the stomach cannot be discharged into the duodenum. At the same time, the cardia is loose, the cardia rises, the abdominal muscles, the diaphragm and The intercostal muscle contraction, intragastric pressure and intra-abdominal pressure increase, and the lower esophageal sphincter relaxes, causing the contents of the stomach to be excreted.

Prevention

Nausea and vomiting prevention

1, early detection of early diagnosis of the primary disease is the key to the prevention and treatment of this disease.

2, try to avoid the invasion of cold and dampness or turbidity, avoid mental stimulation, avoid eating cockroaches, not overeating, avoid eating cold and spicy scent. Those who have severe vomiting should rest in bed.

3, should explain to the patient the nature of the disease, pathogenesis and prognosis, eliminate tension and can actively cooperate with doctors to achieve satisfactory results.

Complication

Nausea and vomiting complications Complications electrolyte disorder

Severe vomiting caused by esophageal or gastric mucosal rupture, often occurs after severe vomiting. Most people think that vomiting causes reflex pyloric sphincter contraction and sinus contraction, and sputum and abdominal muscle contraction, the stomach contents are greatly impacted. Force and high pressure act on the gastric cardia and esophageal junction. At the same time, because the esophagus is in the iliac contraction state, its distal end may have localized expansion. When the intragastric pressure reaches 13-20 kPa, it may cause mucosal tear. Severe cases can cause hemorrhagic shock and even death.

Repeated vomiting can lead to complications of dehydration, water and electrolyte disorders.

Symptom

Symptoms of nausea and vomiting Common symptoms Gastrointestinal dysfunction Abdominal mass Abdominal muscles Intestinal tension Fecal eggs are found... Abdominal pain Reproductive urinary tract crisis Nausea Prerenal renal insufficiency Bowels frequent vomiting and constipation

1. Accompanied by vomiting vomiting with fever, attention should be paid to acute infectious diseases; vomiting with unclean diet or collective disease in the same food, should consider food or drug poisoning; vomiting with chest pain, common in acute myocardial infarction or acute Pulmonary infarction, etc.; vomiting with abdominal pain, common in abdominal organ inflammation, obstruction and rupture; abdominal pain in the temporary relief after vomiting, suggesting peptic ulcer, acute gastritis and gastrointestinal obstructive disease; abdominal pain can not be relieved after vomiting Common in biliary tract disorders, urinary tract disorders, acute pancreatitis, etc.; vomiting with headache, in addition to considering the symptoms of intracranial hypertension, should also consider migraine, rhinitis, glaucoma and refractive errors; vomiting with dizziness, should be considered Vestibular, labyrinth disease, insufficient blood supply to the basal vertebral artery, insufficient blood supply to the inferior cerebellar artery, and cranial nerve damage caused by certain drugs (aminosteroid antibiotics).

2. Ways and characteristics of vomiting

Jet vomiting is more common in intracranial inflammation, edema hemorrhage, space-occupying lesions, meningeal inflammation and adhesions, etc. caused by increased intracranial pressure, usually without nausea, in addition, glaucoma and the eighth pair of cranial neuropathy can also occur with jet vomiting Vomiting is not laborious, occurs after meals, and the amount of vomit is small, seen in mental vomiting.

Should pay attention to the amount of vomit, traits and odor, large amount of vomit, and contain rot foods suggest pyloric obstruction with gastric retention, gastroparesis and upper intestinal obstruction; vomit is coffee-like or bloody in upper gastrointestinal bleeding, containing Incompletely digested foods suggest esophageal vomiting (cardiac achalasia, esophageal fistula, esophageal cancer, etc.) and neuropathic vomiting; those with bile, common in frequent severe vomiting, duodenum below the duodenal papilla Intestinal or small bowel obstruction, cholecystitis, cholelithiasis and subtotal gastrectomy, sometimes seen in hyperemesis of pregnancy, syncope; vomit has acid odor, or stomach contents have fecal odor suggesting low intestinal obstruction, Paralytic ileus, colonic obstruction and valvular insufficiency or gastric colon fistula.

3. The relationship between vomiting and eating

Vomiting occurs during eating or early eating, usually in pyloric canal or psychotic vomiting; vomiting after eating or after several meals, seen in pyloric obstruction, intestinal obstruction, gastroparesis or superior mesenteric artery compression leading to duodenal hoarding; Vomiting in the morning is more common in pregnancy vomiting, sometimes in uremia, chronic alcoholism and intracranial hypertension.

Examine

Nausea and vomiting check

It mainly includes laboratory tests related to inflammation, endocrine metabolism and water, salt and electrolyte metabolism disorders.

Can be used for B-ultrasound, gastroscope, ERCP, endoscopic ultrasound, CT, magnetic resonance and other special examinations. B-ultrasound: Vibrations of 20,000-100 million vibrations per second. Sound waves that are inaudible to human ears are called ultrasonic waves. An imaging discipline that uses the physical properties of ultrasound for diagnosis and treatment, called ultrasound medicine.

Diagnosis

Diagnosis of nausea and vomiting

Diagnostic criteria

1. History:

(1) History of drug or radiation exposure: Commonly used drugs that cause vomiting include certain antibiotics, digitalis, theophylline, chemotherapy drugs, anesthetics, alcohol, deep radiation therapy, radium irradiation therapy and 60 cobalt irradiation therapy, often causing nausea. Vomiting.

(2) Others: Vomiting can be one of the manifestations of many systemic diseases, including diabetes, hyperthyroidism or hypothyroidism, endocrine diseases such as adrenal insufficiency, connective tissue diseases such as scleroderma, insufficient blood supply to the brain, and cerebral hemorrhage. Brain tumors, meningitis, brain trauma and other central nervous diseases, uremia and other kidney diseases.

2. Clinical manifestations:

3. Physical examination:

(1) General situation: attention should be paid to the mind, nutritional status, dehydration, circulatory failure, anemia and fever.

(2) Abdominal signs: should pay attention to stomach type, gastric peristaltic wave, vibrating water and other pyloric obstruction performance; bowel sounds hyperthyroidism, intestinal type and other acute intestinal obstruction performance; abdominal muscle tension, tenderness, rebound pain and other acute abdomen performance In addition, you should also pay attention to the presence or absence of abdominal lumps, sputum and so on.

(3) Other:

1 eye examination pay attention to nystagmus, intraocular pressure measurement, there is no optic disc edema in the fundus.

2 with or without pathological reflex and peritoneal irritation.

Differential diagnosis

Acute infection

There are many causes of acute gastroenteritis, such as bacterial infection, viral infection, chemical and physical stimulation, allergic factors and stress factors. Acute non-typhoid Salmonella infection is a common cause of vomiting, acute gastroenteritis. The resulting vomiting is often accompanied by fever, headache, myalgia, abdominal pain, diarrhea, etc. In addition, nausea and vomiting are also prodromal symptoms of acute viral hepatitis. Some viral infections can cause epidemic vomiting. The main clinical features are: sudden Frequent nausea and vomiting, more common in the morning, often accompanied by dizziness, headache, muscle aches, sweating, etc., the disease recovered quickly, usually vomiting stopped in about 10 days, but may relapse after 3 weeks.

2. nausea and vomiting caused by organ pain

Reflex vomiting, such as acute intestinal obstruction, bile duct stones, ureteral stones, intestinal torsion, ovarian cyst torsion, etc., acute visceral inflammation (appendicitis, pancreatitis, cholecystitis, diverticulitis, peritonitis, severe Crohn's disease and ulcerative colon Inflammation, etc.) are often accompanied by nausea and vomiting. Patients often have corresponding signs, such as abdominal muscle tension, tenderness, rebound tenderness, changes in bowel sounds, etc. Laboratory tests show elevated white blood cells, and some patients have elevated serum amylase ( Pancreatitis) or elevated bilirubin (cholelithiasis).

3. Mechanical obstruction

(1) pyloric obstruction: acute pyloric or duodenal ampullary ulcer can cause pyloric congestion and edema, sphincter spasm caused by pyloric obstruction, manifested as nausea, vomiting, abdominal pain, vomiting often occurs 3 to 4 hours after eating, abdominal pain after vomiting Relieve, after anti-ulcer treatment and control diet, nausea and vomiting symptoms can disappear.

The pyloric obstruction caused by the scar of chronic duodenal ulcer is characterized by a feeling of fullness in the upper abdomen after eating, delayed vomiting, large amount of vomit, sour odor, may contain overnight food, and the stomach and peristaltic waves of the upper abdomen may be dilated. Smell and sound the sound of water.

Advanced tumors in the pyloric region of the antrum can also cause pyloric obstruction, manifested as nausea and vomiting, loss of appetite, anemia, weight loss, fatigue, and upper abdominal pain.

(2) duodenal compression or stenosis: lesions causing duodenal stenosis include duodenal cancer, Crohn's disease, intestinal tuberculosis, etc., diseases causing extraluminal compression include pancreatic head, pancreatic body cancer and mesentery Upper arterial compression syndrome, this type of vomiting is characterized by delayed vomiting after meals, accompanied by upper abdominal fullness discomfort, sometimes accompanied by upper abdominal cramps, vomit often with bile, rapid relief of abdominal symptoms after vomiting, mesentery Upper arterial compression syndrome occurs mostly in recent weight loss, bed rest, lordosis, vomiting can disappear after anteversion or chest and knee position, and gastrointestinal angiography shows vertical sharp cut on the right side of the midline of the duodenum. The stomach and proximal duodenum dilate, and patients sometimes need to be loosened or short-circuited.

(3) intestinal obstruction: tumors in the intestine, tuberculosis and Crohn's disease, etc., or intestinal adhesions can cause intestinal emptying disorders, leading to intestinal obstruction, often manifested as abdominal pain, bloating, nausea and vomiting and anal stop defecation Exhaust, vomiting repeated attacks are more severe, early vomiting is food, gastric juice or bile, after the vomit is brown or light green, late fecal-like, with foul odor, abdominal pain after vomiting is often not significantly reduced, check the intestinal type , tenderness is obvious, can be licked and mass, bowel sounds hyperthyroidism, combined with abdominal X-ray film and other examinations, can make a diagnosis.

4. Endocrine or metabolic diseases

Many endocrine diseases can cause nausea and vomiting, such as gastroparesis, connective tissue disease, hyperthyroidism, hypothyroidism, pituitary kidney kidney crisis, diabetic acidosis, etc., nausea and vomiting is the early main cause of a small number of patients with hyperthyroidism Symptoms, hyponatremia can cause nausea and vomiting reflexively. In addition, nausea and vomiting often occur in the early stage of uremia, accompanied by loss of appetite, hiccup, diarrhea and other gastrointestinal symptoms, according to the clinical characteristics of various diseases and auxiliary examination, Can identify the cause of nausea and vomiting.

5. Drug vomiting

Drugs are one of the most common causes of nausea and vomiting. Drugs and/or their metabolites, on the one hand, stimulate the CTZ receptors (such as dopamine receptors), thereby generating impulses and transmitting them to the vomiting center, causing nausea and vomiting. Such as chemotherapy drugs, anesthetics, digitalis drugs, etc.; on the other hand, it can stimulate the gastrointestinal tract, make the gastrointestinal nerves excited, and send impulses to the vomiting center, causing vomiting center excitement, nausea and vomiting, such as partial chemotherapy Drugs, non-steroidal anti-inflammatory drugs and certain antibiotics.

6. Central nervous system diseases

Cerebrovascular disease, cervical spondylosis and increased intracranial pressure caused by various causes can cause nausea and vomiting.

(1) Cerebrovascular disease: common diseases include migraine and vertebrobasilar insufficiency. Migraine may be related to vasomotor dysfunction caused by vasoactive substances such as serotonin and bradykinin. Common causes are emotional agitation, insomnia, and drinking. And excessive smoking, etc., the main clinical manifestations of paroxysmal unilateral headache, vomiting is often sprayed, vomiting stomach contents, headache can be alleviated after vomiting, accompanied by pale, cold sweat, visual changes and lethargy, application The ergot derivative preparation can quickly relieve symptoms, vertebral-basal artery insufficiency can also occur nausea and vomiting, and there are dizziness, visual impairment, ataxia, headache, disturbance of consciousness and other manifestations.

(2) increased intracranial pressure: cerebrovascular rupture or obstruction, central nervous system infections (such as acute encephalitis, meningitis) and intracranial tumors can cause increased intracranial pressure and vomiting, which is characterized by nausea before vomiting or Slight nausea, vomiting is spray-free and diet-free, vomit is mostly stomach contents, often accompanied by severe headache and varying degrees of disturbance of consciousness, headache is not obvious after vomiting; cerebrovascular accident often has severe headache, vomiting, disturbance of consciousness , hemiplegia, etc.; in addition to headache, vomiting, but also with chills, fever, severe cases can occur shock; vomiting of brain tumors often occur when the headache is severe, headache can be temporarily relieved after vomiting, often accompanied by different Degree of symptoms of brain damage.

7. Pregnant vomiting

Nausea and vomiting is one of the most common clinical manifestations during pregnancy. 50% to 90% of pregnant women have nausea, 25% to 55% of pregnant women have vomiting, nausea and vomiting often occur in early pregnancy and disappear after 15 weeks of pregnancy. Vomiting is more common in the morning fasting, often caused by sleep disorders, fatigue, emotional excitement, etc. If pregnant women are pregnant for the first time, they are more likely to have pregnancy vomiting, pregnancy vomiting generally does not cause water and electrolyte balance or nutritional disorders, and does not endanger pregnant women. And the safety and health of the fetus; about 3.5% of pregnant women with hyperemesis can cause severe water-electrolyte disorders and ketoacidosis, pregnancy vomiting is more likely to occur in multiple pregnancies, hydatidiform moles and young and mentally unstable women, The mechanism of pregnancy vomiting is still unclear and may be related to endocrine factors and mental factors.

8. Mental vomiting

Psychotic vomiting is common in young women, with more obvious mental and psychological disorders, including neurological vomiting, anorexia nervosa and polyphagia, vomiting and mental stress, anxiety or mental stimulation are closely related, vomiting often occurs at the beginning of eating Or at the end of eating, no nausea, vomiting effortless, vomiting is not much, often food or mucus, spit and eat, patients can self-control or induce vomiting, except for anorexia nervosa because of fear or refusal to eat can be extremely Loss and malnutrition, outside the amenorrhea, many patients with neurological vomiting have normal appetite and nutritional status, and sometimes patients even eat more food leads to overnutrition.

9. Inner ear vestibular disease

The nausea and vomiting caused by vestibular disease in the inner ear is characterized by sudden onset of vomiting, intense, sometimes jet-like, with dizziness, headache, tinnitus, hearing loss, etc. Common diseases include motion sickness, labyrinthitis and Meniere's disease (Meniere's Disease) and so on.

(1) motion sickness: the main clinical manifestations are dizziness, nausea and vomiting, etc., nausea is often more obvious, vomiting often occurs after dizziness, mostly sprayed, accompanied by upper abdominal discomfort, cold sweat, pale, runny, etc. The mechanism of motility is still unclear, probably due to some factors stimulating the vestibular part of the inner ear, and the reflex caused by the vomiting center.

(2) labyrinthitis: is a common complication of acute and chronic otitis media, the main clinical manifestations in addition to nausea and vomiting, accompanied by paroxysmal vertigo, nystagmus and so on.

(3) Meniere's disease: The most prominent clinical manifestations are paroxysmal vertigo, accompanied by nausea and vomiting, tinnitus, deafness, nystagmus, etc. Vomiting often occurs after vertigo, can be sprayed, accompanied by nausea, vertigo after vomiting No significant reduction.

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