VOMITING

From Big Medical Encyclopedia

VOMITING (vomitus, emesis) — the complex-reflex act leading to eruption of contents of a stomach (sometimes together with contents of intestines) outside through a mouth (is more rare also through a nose).

The emetic act consists of consecutive movements of various muscular groups. It begins a deep breath with a phrenoptosis with the subsequent lowering of an epiglottis and podnyatiyekhm a throat and a soft palate that promotes isolation of respiratory tracts from emetic masses. The gatekeeper is laid off, the body of a stomach and an esophageal and gastric sphincter relax, a cardial part (cardia) is tightened up, the gullet extends and shortened. When the gatekeeper is densely closed, and the entrance to a stomach gapes, conditions for a retrograde exit of gastric contents are created. It is promoted by strong reductions of a diaphragm and muscles of a prelum abdominale. Sharply increasing intra belly and intragastric pressure causes eruption of contents of a stomach through a mouth. The stomach and a gullet play at the same time a passive role. Sometimes during R. there come the antiperistaltic movements of intestines that leads to hit of intestinal contents in a stomach.

In fiziol. R.'s relation is the protective alimentary system of reactions to hit in it (or education in it) the toxic or other damaging substances. The river is carried out as a compound reflex with participation of the emetic center, near the Crimea in the bottom of a bottom of the fourth ventricle of a brain there is a starting hemore-tseptivny zone. Coordination of motor reactions at R. is carried out by departments of a reticular formation myelencephalon (see), the connected with respiratory, vasomotor, tussive and other vegetative centers. Therefore R. is followed by certain reactions of breath, the blood circulatory system, a sialosis. Often precedes vomiting nausea (see).

The pathogeny

Excitement of the emetic center can be at increase in intracranial pressure (tumors, abscesses near the fourth ventricle), under the influence of mental incentives, at influence of impulses from a webby labyrinth of an inner ear, is reflex at irritation of various body parts. The starting hemore-tseptivny zone reacts directly to influence of the chemical substances (drugs, poisons, toxins) getting to blood.

Irritations of various body parts can become a source of an emetic reflex, however there are zones, irritation to-rykh most often causes an emetic reflex («emetic zones»). A throat, coronal (coronary) vessels, a peritoneum, mesenteric vessels, bilious channels, bark of a great brain concern to them. At most of people of R. arises at tactile stimulation of a mucous membrane of a back wall of a throat (gag reflex). Build-up of pressure in a stomach and in various departments of thin and thick guts can cause an emetic reflex, under a condition if pressure in a stomach and a duodenum exceeds 20 mm of mercury. Emetic impulses are sometimes combined with painful. Very strong pain (see) any genesis can cause River.

Afferent impulses reach the emetic center through the wandering and sympathetic nerves. The river arising in an experiment at stretching of a gut disappears after this-patikotomii, but remains after vagisection. The river caused by peroral administration of copper sulfate, staphylococcal toxin as well as R. at experimental peritonitis, remains after each of these operations, but disappears at animals, the Crimea both of these operations were performed. Efferent impulses from the emetic center go on cherepnomozgovy nerves (V, IX, X) to the sky, a throat, to a throat, a gullet, a stomach, a diaphragm and through a spinal cord on spinal nerves — to cross-striped muscles of a thorax and an abdominal wall. Destruction of a starting hemoretseptivny zone does not prevent R., voznikav yushchy at reception of copper sulfate inside, but eliminates R. at its intravenous administration. These observations demonstrate that nek-ry chemical substances cause R. as by means of the impulses coming to the emetic center, passing a he-moretseptivny zone, and at direct irritation of this zone. Row pharmakol. means (Apomorphinum), and also endogenous poisons (e.g., at uraemia) work only by means of the central mechanisms through a starting hemoretseptivny zone (see. Vomitives ). The described origins of R. allow to divide it into three main pathogenetic options: 1) central R. (nervous, brain); 2) hematogenous and toxic R.; 3) visceral, or actually reflex, River. Each option is inherent in a certain type of pathology and the wedge, features has the.

Diagnostic value

VOMITING is not a specific symptom of any nosological form. At the same time its emergence in a complex with other symptoms, assessment of features of manifestations, W. h a research of emetic masses, can significantly facilitate diagnosis of a disease or specify it, and also promote in some cases the correct assessment of weight of a condition of the patient.

The research of emetic masses is desirable in each case of R. Organolepticheski determine one-time and the general (at repeated R.) the volume of emetic masses, their consistence, color, a smell, presence of the remains of food, their structure, existence patol. impurity (blood, slime, large amount of bile, pus, worms). Depending on character of emetic masses distinguish R. svezhesjedenny food, R. the eaten food (so-called congestive R.), bilious, bloody, fecal, purulent R. long ago, etc. Undigested food in emetic masses can testify to a gastric akhiliya or to R. of an esophageal origin, napr, at an achalasia of a gullet. The ruble a pure gastric juice of high acidity allows to suspect Zollinger's syndrome — Ellisona (see. Zollingera — Ellisona a syndrome ). The putrefactive smell of emetic masses can be observed at the breaking-up carcinoma of the stomach, a smell of alcohol — at an alcoholic poisoning, a smell of acetone — at atsetonemichesky R. (see. Acetonemia ). Fecal R. is characteristic for impassability of intestines (see). Bloody R. (see. Hematemesis ) always confirms bleeding in went. - kish. a path also demands urgent diagnosis of the reason of bleeding (an ulcer, erosion etc.). Bile is almost always present at emetic masses at strong R.; at a number of diseases preferential bilious River is possible.

If the organoleptic research is not enough, make necessary laboratory researches of emetic masses — bacteriological (e.g., at acute food toxicoinfections), cytologic, chemical, etc. At suspicion of poisoning with poisons carry out court. - a medical chemical research.

Important diagnostic value has definition of communication of R. with meal. This communication can be characterized by allocation of the following types of R.: morning, or R. on an empty stomach (vomitus matutinus), early (comes soon after food), late (comes several hours later after food), night and, at last, R. which is not connected with meal (cyclic R.) etc.

The pathogenetic diagnosis of R. is based on set of signs of a basic disease taking into account features of emergence of R., character of emetic masses, R.'s communication with meal.

The central vomiting can arise because of organic diseases of c. N with — at meningitis, encephalitis, abscesses and tumors brain (see), and also at defeats of a webby labyrinth of an inner ear, at glaucoma. In its basis there can be acute vascular crises at a hypertension, migraine. A specific place is held by psychogenic R. at hysterical neurosis (hysterical vomiting), and also in usual R.'s option at other disturbances of century of N of.

In the analysis of the reasons of psychogenic R. mean, as at healthy faces reaction on unpleasant food or on stressful irritants quite often is followed by R. and that tendency of people to R. is very individual. It is known that women are more subject to R., than men, children — more than adults. Attribute to usual psychogenic R. the following features: the long anamnesis (sometimes R. begins in school days), quite often R. meets and at relatives, usually arises soon after the beginning of food or at once after its end, she easily is called at introduction of a finger to a throat, can be independently suppressed, seldom happens in the public place, disturbs the most sick a little and worries his relatives more, is sometimes combined with nervous anorexia (see). In some cases at psychogenic frustration not R. is observed, and regurgitation (see), at a cut inherent R. are absent of reduction of belly muscles.

Cyclic R. is described by hl. obr. at children. It is characterized by causeless returnable - long attacks of heavy R. with a headache, abdominal pains, fever. Psychogenic factors, perinatal and post-natal injuries of a brain are considered as cyclic R.'s reasons.

The central R., especially at organic pathology of c. the N of page, often arises without the previous nausea that is used at differential diagnosis. Eruption of emetic masses, sudden for the patient, frequent «fountain» (the patient does not manage to choose the place for R.) is characteristic of the central R. as if that can serve as the reason of the wrong assumption of a pyloric stenosis. Emetic masses usually consists from svezhesjeden-ache food without patol. impurity. The specified signs are not, however, absolute.

Gematogenno - toxic vomiting is observed at the diseases which are characterized by formation of toxic products of the broken metabolism, napr at uraemia, a dekompensirovanny diabetes mellitus (atsetonemichesky R.), a liver failure, at a porphyria, a thyrotoxicosis, a gi-perparatireoidizm, adrenal insufficiency, at patients with diarrhea. It is caused by the exogenous poisons which are also circulating in blood at poisonings (carbon monoxide gas, chlorine, alcohol, etc.), medicinal intoxications (drugs of a foxglove, X-ray contrast means, cytostatics, streptocides, iron preparations, nek-ry drugs, Apomorphinum, etc.). It is necessary to carry R. at various inf to the same look. diseases when she is called by the toxins of the bacterial nature circulating in blood, viruses, various metabolites.

The previous expressed nausea, frequency of emetic acts (sometimes unrestrained R.), liquid is characteristic of the hematogenous and toxic R. caused by exogenous poisons and in the beginning plentiful emetic masses, to-rye at repeated R. often consists of small portions of the liquid painted by bile. The ruble at endogenous intoxications can remind more on the manifestations central. R.'s combination to other symptoms of intoxication — dehydration, development of acidosis (if there is no expressed hypochloraemia from R.), sometimes fever, disturbance of consciousness is characteristic up to development coma (see).

Visceral vomiting is caused by reflex excitement of the emetic center from peripheral receptors; most often it is observed at pathology went. - kish. a path it is also connected definitely with meal though R. which is not connected with meal is possible (e.g., at an acute appendicitis).

Morning R. (till a breakfast, on an empty stomach) is characteristic for hron. gastritis (especially because of alcoholism), it is sometimes observed at an aggravation of a peptic ulcer, a duodenitis, is followed by a plentiful sialosis. In some cases morning R. can come owing to irritation of a back wall of a throat the bronchial secret which collected in a night. Early R. accompanies dysfunctions of a stomach, neurotic states, but is observed also at a carcinoma of the stomach, gastritises, diverticulums of a gullet. Late R. meets at piloroduodenal-ny ulcers, a duodenitis, gastritises the increased gastric secretion. Night R. occurs sometimes at patients with a peptic ulcer, in some cases she is called randomly for simplification of pains, can be observed also at food poisonings, at diseases of bilious or uric ways.

The river long ago the eaten food (more than for 7 hours to R.), as well as capotement at a palpation of epigastriß area later 5 hours after meal or water, demonstrates disturbance of gastric evacuation. It is characteristic of a pyloric stenosis (see. Pylorostenosis ), post-bulbar stenoses. Sometimes R. the eaten food and disturbances of evacuation of a stomach can have long ago the functional nature as, e.g., at severe forms of a diabetes mellitus when the atony of a stomach from «congestive» R., reflex paresis of a stomach develops at cholelithiasis and nek-ry others patol. processes, at treatment of patients with cholinolytics.

The bilious R. which is characterized by abundance of bile in emetic masses is observed at complications after stomach operations (a syndrome of the bringing loop, a reflux gastritis, a round ulcer of an anastomosis), during the narrowing of a duodenum below a big nipple of a duodenum, sometimes at bilious colic. It is accompanied by pains in epigastriß area, nausea, at patients comes to light weight loss, an iron deficiency anemia.

Complications

Persistent R. causes a number of metabolic shifts in an organism. Often repeating R., especially at children, the old men weakened patients causes dehydration (see. Dehydration of an organism ), a hypovolemia (see. Oligemiya ), hypopotassemia (see), hyponatremia (see), hypochloraemia (see) with development of metabolic alkalosis (see). These exchange frustration lead to disturbances of cordial activity, function of kidneys, and sometimes and to disorders of consciousness, paralyzes. Indicators of a hematocrit raise, the level of a renin and Aldosteronum increases in plasma, the clearance of creatinine decreases, the content of residual nitrogen in blood (hloro-privny uraemia) increases. Long and strong R. can cause formation of anguishes of a mucous membrane, most often in a transition range from a gullet on a stomach, with massive bleedings — a so-called syndrome of Mallori — Weiss (see. Mallori — Weiss a syndrome ). At the weakened faces (especially at children and at elderly), and also at patients with the broken consciousness aspiration of emetic masses with the subsequent additional complications is possible.

Treatment

Treatment shall be whenever possible etiological that does not exclude carrying out in need of symptomatic therapy. At poisonings (see) carry out gastric lavage (see) and other measures desintoxication (see). At stenoses went. - kish. a path, his tumors and nek-ry other forms of organic pathology operational treatment is shown. Carry out treatment of the diseases which are followed by the central or hematogenous and toxic R., aggravations hron. diseases of the alimentary system.

Symptomatic therapy consists in selection of a diet, purpose of the means suppressing R. (see. Antiemetics ), and corrections of the complications arising at R. Apply derivatives of a fenotiazin (aminazine, etaperazin, Torecanum, etc.), antihistamines (Dimedrol, etc.), and also drugs of others pharmakol. groups (Scopolaminum, haloperidol, Metoclopramidum). Aminazin (see) it is most effective at R. caused by drugs of a foxglove, antibiotics, alcohol, infections, endogenous intoxications. At R. connected using drugs administration of antihistaminic drugs since fenotiazina can exponentiate effect of morphine is preferable. For postoperative R.'s prevention recommend to use antihistamines, and for its treatment — aminazine. The increasing application at R. of various genesis is found by Metoclopramidum (cerucal), to-ry is almost deprived of side effects. Antiemetic action also high doses of a pyridoxine possess (rat anti-acrodynia factor), to-ry appoint inside or intravenously 50 — 100 mg to once a day. In cases when R. is caused by an inflammation of a mucous membrane of a stomach and her irritation, appointment in anaesthesin and drugs (Bellasthesinum, Pavethesinum) supporting him, drugs of bismuth, and also drugs containing aluminum hydroxide is shown (Almagelum, etc.) to-rye are shown also at R. connected about a reflux gastritis since they well adsorb bile. At persistent R. intravenous administration of liquids, solutions of electrolytes is shown.

Vomiting of pregnant women

Vomiting of pregnant women — one of frequent displays of early toxicosis of pregnancy (see. Toxicoses of pregnant women ), prichinno connected with the developing fetal egg.

Pathogeny The ruble of pregnant women is studied is incomplete. The role of a hormonal imbalance is conventional. It is established that the expressed forms of early toxicosis meet more often at polycarpous pregnancy (see) and vesical drift (see). Temporary coincidence of peak of secretion is noted chorionic gonadotrophin (see) also began R. Besides, at the pregnant women suffering from R. the change of function of bark of adrenal glands which is expressed in decrease in secretion of corticosteroids is quite often noted. Rubles of pregnant women consider as well as allergic reaction in response to hit of elements of a trophoblast in a blood stream of mother.

It is accepted to distinguish three severity of R. of pregnant women: I \easy, II — moderately severe and III — heavy (excessive P.). The I severity — R. arises to 5 times a day, happens on an empty stomach or is caused meal and off-flavors. The II severity — emergence of symptoms of intoxication and R.'s increase to 10 times a day. The III severity — within a day repeated excessive, so-called unrestrained, R.; patients completely do not hold food, there is a bystry decrease in body weight, there is a number of metabolic disturbances.

Treatment Rubles of pregnant women of the I degree will see off on an outpatient basis under control of dynamics of body weight of the pregnant woman and at repeated researches of urine on content of acetone in it. Appoint frequent fractional food, rinsing of a mouth cementitious matters; recommend frequent change of a surrounding situation (walk, etc.) - At the expressed nausea appoint Aeronum.

R.'s treatment pregnant II and III severity is carried out in a hospital; it shall be complex, including impact on the broken function of c. N of page, recovery of nutritive loss and liquid, normalization of electrolytic balance and acid-base equilibrium. In case of unsuccessfulness of treatment of R. of pregnant women abortion is necessary. Indications for abortion: ongoing R., resistant subfebrile temperature, the expressed tachycardia, the progressing decrease in body weight, a proteinuria, a cylindruria, an acetonuria, jaundice.

At heavy R. of pregnant women the small-for-date fetus can develop. Therefore such pregnant women should be carried to group of high risk. They need timely hospitalization, treatment, and the subsequent — dispensary observation in clinic for women.

Vomiting at children

Vomiting at children is observed considerably more often than at adults, and comes that easier, than the child is younger. R.'s reasons at children are diverse.

The river at newborns during the first hours after the birth can be caused by swallowing amniotic waters in the course of childbirth; at it there is a danger aspirations (see). In further R. at children of this period it can be observed as in connection with diseases (encephalopathy, sepsis, meningitis, etc.), and at anomalies of the alimentary system (brakhiezofagus, phrenic hernia, a diverticulum, a stenosis, an atresia of a gullet, an atresia and a stenosis of a small bowel, the meconium Ilheus developing at a mucoviscidosis), anomalies of an urinary system (a cystosis of kidneys, an inborn hydronephrosis), disbolism (an adrenogenital syndrome with loss of salt, a galactosemia, etc.). In all cases of emergence of R. it is necessary to aim at detection and other symptoms either preceding it, or developing in parallel with it, or appearing after it.

The Nek-ry anomalies of the alimentary system which are not posing direct hazard to life of the child or not korrigirovanny in the operational way continue to remain R.'s reason with children of chest age. The river is observed at invagination, obturatsionny and paralytic impassability of intestines (see. Impassability of intestines ). R. «fountain» is frequent happens at a pyloric stenosis (see. Pylorostenosis ). Functional disturbances — a cardiospasm, a pylorospasm can be non-constant R.'s cause at babies. Especially often R. at children of chest age is observed at inflammatory diseases of the alimentary system and at the toxicoses caused by various reasons. Besides, the hypervitaminosis of D can be R.'s cause at babies (see. Hypervitaminoses ), the rare reason — intolerance of cow's milk.

At children of the first weeks and months of life of R. it is necessary to distinguish from the vomiting which is often observed at them, a cut has functional character and usually stops after 6 months R. at children at this age arises at disturbance of the general state, the chair can be also broken, changes in other bodies are possible; during R. tension of a prelum abdominale, blanching of the person, a cold snap of extremities, pulse frequent, small is observed. During the vomiting all these signs are absent.

The river at children aged after 1 year quite often accompanies development acute inf. diseases, especially at high temperature in an initial stage of a disease. And at this age of R. often takes place at diseases of the alimentary system. Especially expressed she is at acute toxicoinfections (see. Toxicoinfections food ). Frequent painful R. is observed at acute peritonitis (see), to-ry can develop at necrotic ulcer changes in intestines. Often there is R. at appendicitis (see), to-ry at small children not always develops typically.

Esophageal R. (ejection of the food or liquid which did not reach a stomach) meets at diverticulums and esophageal stenoses, paralysis of muscles of the sky after diphtheria, and also at quinsies owing to impossibility to swallow food.

At the senior children of R. can be display of acute or chronic gastritis, a duodenitis, cholecystitis, a peptic ulcer, pancreatitis; besides, as well as at adults, at them the central or hematogenous and toxic R. at the corresponding diseases can be observed.

Neurogenic vomiting meets at children more often of preschool age at a neuropathy, hysteria, sometimes as manifestation of negative emotions; children can cause it randomly.

In diagnosis of a disease character of emetic masses matters. The ruble not turned milk is at an atresia of a gullet, anomalies of a stomach, kardio-and a pylorospasm. The milk which turned, sometimes partially digested in emetic masses is observed at a pylorostenosis. Impurity of bile is possible at anomalies of development of a small or large intestine, at mekoniyevy impassability. The fecal vomit is noted at the started intestinal impassability, peritonitis. Bloody R. (see. Hematemesis ) it is possible at various diseases at children, since the period of a neonatality. The river is more often observed by a coffee thick at children of early age at the heavy infections proceeding with toxicosis (see. Toxic syndrome ), is more rare along with a tar-like chair at the bleeding Mekkel's diverticulum (see. Mekkelya diverticulum ).

R.'s treatment at children is carried out as well as at adults. At functional R. along with strictly adjustable feeding the segmented physical therapy (erythema doses of UV rays on an anticardium), fight against a meteorism gives good effect. Conservative treatment is carried out only at confidence that the organic reasons are absent.

The nosotrophy is of great importance during R.'s act since aspiration of emetic masses in respiratory tracts can cause damages of lungs. At newborns and children of early age it is necessary to turn the head on one side and to hold it in such situation before the termination R. Detyam of more advanced age it is necessary to give sedentary or semilying edgewise position at R., to incline the head down, supporting and fixing it.



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A. V. Frolkis; V. P. Bisyarina (ped.), V. P. Smetnik (gin.).

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