NAUSEA AND VOMITING - Full extract 

It was about 1 AM when the phone went. Mr Smith was very concerned about his daughter, Penny, whom he had found slumped on the toilet floor, vomiting profusely. 

I quickly got dressed and hurried over to see what the problem was. By this stage Penny was leaning over the toilet bowl dry-retching. " God, I feel awful," she said, several times over. Her parents hovered nearby, both looking very agitated. " She was like this when her friends brought her home," said Mrs Smith, wringing her hands. " But I think she's getting worse. She even sounds a bit confused." 

She was quite unsteady and needed help to walk to her bedroom. There was a strong smell of alcohol on her breath. " Penny, how much have you been drinking?" I asked. " I've had rum. I've had some beer. And I'm drunk as a skunk." She started to giggle but her parents were far from amused. 

Examining her, there was nothing else to find. Her chest was clear and there was no tenderness in the abdomen. Her blood pressure and pulse were also normal. I have known Penny since she was at kindergarten. It was an opportune time for a cup of tea with her parents. 

I checked on Penny before I left. She had stopped vomiting and aside from the drowsiness was fine. I was able to ascertain that she had not taken any drugs or other substances. I suggested that Mr and Mrs Smith observe Penny closely overnight ask her to give me a call in the morning. 

She did ring to say that she had a king-size hangover but was otherwise okay. I advised her to call in for a check-up and maybe talk a little about alcohol. She hasn't been in yet. 

Nausea is the feeling that vomiting could easily occur. Pallor and sweating are often present and there may be some increased salivation. Vomiting is the forceful emptying of the stomach contents. It is a universal symptom that affects us all from time to time, and it can be an important clue to a number of underlying medical problems. 

Several physiological events occur with vomiting. Among other changes is a relaxation at the top of the stomach and a strong contraction of the diaphragm and abdominal muscles. It is controlled by two closely-linked areas in the base of the brain. The main vomiting centre can be stimulated by disturbances in many areas, including the stomach, bowel and inner ear. An area immediately adjacent to the vomiting centre is sensitive to various substances like medications and can either stimulate or inhibit the vomiting centre. 

There are numerous causes of vomiting, far too many to mention. Viral gastroenteritis is the most common and is often accompanied by diarrhoea and a fever. Other infections like tonsillitis, middle ear infections, and urinary infections are often associated with vomiting. Vomiting may also occur as a toxic effect of alcohol and food-poisoning, and as a side-effect of certain drugs like antibiotics and some painkillers. The vomiting of early pregnancy also has to be kept in mind. Migraine, heart conditions, bowel obstruction and gallbladder disease can cause vomiting, as can any condition that causes severe pain, for instance kidney stones and heart attack. Psychological factors can also cause vomiting to occur. Bulimia is an eating disorder characterized by self-induced vomiting.

A careful history and examination are necessary to establish the cause of the vomiting. Enquiries are made whether there are other symptoms like abdominal pain, fever or diarrhoea, and whether any medications are being taken. A description of the type of vomiting and what's in it are important. The presence of blood in the vomit is especially significant. The person is then carefully examined to rule out any serious underlying problems. Among the many things that are looked for are signs of dehydration, pallor and tenderness in the abdomen. 

Most people with a bout of vomiting require no special investigations or treatment. With viral gastroenteritis the vomiting usually subsides over a day or so with rest and extra fluids. Some adults require an anti-nausea injection to settle the vomiting. However, they are not recommended for children; absorption is variable and adverse side-effects can occur. When young children have gastroenteritis it is very important to watch the fluid balance to see that dehydration is not occurring. Any sign of drowsiness, floppiness or reduced urine output should be immediately discussed with the doctor in case admission to hospital is required. In people of any age, persistent or severe vomiting should always be checked.

Sometimes the vomiting can be recurrent, over weeks or months. A check with the doctor is required. Referral for further investigation is likely so that the precise cause of the vomiting can be established. It is only then that specific treatment can be arranged. 

Health tip: 
* Vomiting can be an important clue to many underlying medical conditions. When it persists or is associated with other symptoms see your doctor for advice.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: December 11, 2004