Vomiting, hematemesis and melena: causes

notes by  dr. Claudio Italiano

vedi anche novitÓ su www.unmedicopertutti.it/vomito.htm

cf anche la cattiva digestione nausea emorragie

cfr visita e cura del paziente con vomito

Vomiting is a very frequent symptom, observable in the most various morbid processes, without however representing a constant feature, because it is subject to individual variations, so the gastroenterologist often equates anorexia and nausea to vomiting. Vomiting, however, is not a symptom of gastrointestinal disorders: it also appears in uremia due to intestinal insufficiency and alkalosis, renal colic, cardiac infarct, bulimia and anorexia and, if "vomit jet" or "mouth of barrel ", in acute cerebral vasculopathies.

Causes of vomiting

Vomiting depends on:
- from diseases of the esophagus (see esophageal reflux)
- from gastritis and gastric affections
- intestinal stenosis
- peritoneal irritations (see acute surgical abdomen)
- stenosis and occlusion of extra-intestinal hollow organs
- central vomiting, for example in stroke, "barrel mouth".
More than vomiting, it is esophageal regurgitation, especially if there are diverticula or carcinoma of the esophagus; sometimes the patient with hernia jatale esophageal and gastro-oesophageal reflux wakes up in the morning and finds the pillow wet with saliva mixed with blood and residues of the ingested food that has been regurgitated. However, vomiting of gastric diseases is the most frequent; the subject with erosive gastritis sometimes feels a sense of nausea and vomits the greasy; at other times it feels a sense of stomach swelling (swollen belly). In the case of frequent and abundant vomiting, one must think of a pyloric stenosis; eye because the gastric lesions are not like the duodenal ones and hide serious pitfalls (digestive cancer, pancreatic cancer, calculosis, gastric carcinoma, ulcer-cancer, stenosing cancer of the antrum and pylorus, etc.).

Lesione ulcerata vegetante del colon discendente

Colonoscopy: patient with a vegetative ulcerated lesion of the descending colon neostoma with late vomiting due to subocclusion with a low stop, to the colon.

In intestinal strictures vomit is early, the stenosis is higher, while in ileal stenosis it takes 4 hours and vomit is missing in the large colon obstructions. Initially the vomit of the stenosis is yellowish, then brownish and finally fecaloid in the most serious cases, it is a surgical emergency (fecal vomiting, miserere nobis!). Classic example consists of inguinal hernias, clogged or choked; in the case of the throttling we will have peritoneal irritation and a premature vomiting, as well as in other diseases with peritoneal irritation: peritonitis, appendicitis, torsion of an ovarian cyst, pancreatic necrosis, perforation of an ulcer, stenosis and occlusion of biliary excretory pathways with or without jaundice or urinary for example for calculations, as well as for female genital organs.


Central vomiting, on the other hand, is related to bulbar stimulation and can cause apomorphine intoxication. Mostly it is caused by exogenous or endogenous intoxication, e.g. from drugs (digital) or from uremia or hepatic coma. In the same category should be considered the gravidic hyperemesis, intracranial hypertension or Meniere's syndrome and the patient with vertigo that vomits; the same applies to certain forms of headache or migraine that benefit from the use of intestinal motor drugs such as metoclopramide. Finally we remember the acute enterocolitis or the ingestion of bacterial toxins and therefore the food toxins are accompanied by vomiting, for ex. when we eat creams or mayonnaise or anything else that has been manipulated or contaminated by toxin-producing bacteria.

Hematemesis

It means the "vomit of blood", with emission of brown colored material ("coffee bottom") is a serious condition, which is associated with particular gastric diseases and the esophagus. in the great majority of cases it depends on gastric or duodenal ulcer, due to the erosion of blood vessels from the bottom of an ulcerative crater, gastric carcinoma, but it is necessary to carry out the investigations and to exclude whether or not it is esophageal varices. The latter depend on a condition of obstacle to the outflow of blood that from the intestine, through the system of the portal vein, must reach the liver, be "filtered", and move to the systemic circulation through the hepatic veins and the upper cavity system up to the right atrium. In these cases, however, a condition of liver disease (eg cirrhosis, severe active chronic hepatitis, etc.) can cause hypertension in the portal circulation and, consequently, the blood supply occurs due to collaterals, in fact the esophageal veins. These go to "sfiancamento" and give rise to varicose veins. When, instead, the blood is digested, the feces are dyed black and it is called "feci picee" or "melena"; they are sometimes accompanied by putrefactive diarrheal discharges. Beware, however, that even subjects who have eaten blueberries or taken colloidal bismuth (antiulcer) or iron per os may have black stools.

Age of the patient and vomiting

If the patient is elderly (> 60 years), lower hemorrhage is more common, due to colon cancer, diverticulosis, intestinal ischemia; in the young we think of colon polyps, inflammatory bowel disease and infectious colitis. If, however, there is a recent history of taking anti-inflammatory drugs, then urinating for "fan gastritis"; in other cases, in the liver patient, with problems of hemorrhagic diathesis (platelet <70,000 platelets / mm3, prothrombin activity <40%) we are oriented towards a problem of esophageal varices and a congestive gastropathy, due substantially to a condition of portal hypertension.

In summary, if the patient has hemorrhages from the gastroenterentric tube, this can be caused by:

- hemorrhages of the upper part;
- bleeding from the nose or pharynx;
- hemoptysis (literally "sputum of blood", probably from respiratory origin);
- Mallory-Weiss syndrome (from repeated vomiting with lower esophageal lesion);
- esophageal rupture (Boerhaave syndrome)
- erosive processes (gastritis, duodenitis, esophagitis)
- peptic ulcer of the esophagus, stomach ulcer and duodenum
- esophageal varices
- Neoplasms (carcinomas, lymphomas, leiomyomas)
- lower digestive haemorrhages
hemorrhoids
- Anal fissures
- inflammatory bowel diseases
- neoplasms (carcinomas and polyps)
- diverticular diseases
- enteritis or ischemic colitis
- pseudomemebanous enterocolitis
- amyloidosis
- Meckel's diverticulum


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cfr anche gastroenterology index