notes by dr. Claudio Italiano
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.
Vomiting depends on:
- from diseases of the esophagus (see esophageal reflux)
- from gastritis and gastric affections
- intestinal stenosis
- peritoneal irritations (see
Peritonitis causes)
- 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.).
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.
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.
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:
- 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)
-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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