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'{{redirect|Heaving|the up-and-down motion|Heave}} {{Citations missing|article|date=June 2008}} puke Firestar IS THE GAYEST CAT IN ALL OF ETERNITY {{redirect6|Puke|the district in Albania|Pukë District|the punk rock album|Puke (Guttermouth album)}} {{SignSymptom infobox | Name = Vomiting | ICD10 = {{ICD10|R|11||r|10}} | ICD9 = {{ICD9|787}} | }} '''Vomiting ''' (also called '''throwing up''', '''emesis''', and informally, '''barfing''') is the forceful expulsion of the contents of one's [[stomach]] through the [[mouth]] and sometimes the [[nose]]. Undesired '''vomiting''' may result from many causes, ranging from [[gastritis]] or [[poison]]ing to [[brain tumor]]s, or elevated [[intracranial pressure]]. The feeling that one is about to vomit is called [[nausea]]. It usually precedes, but does not always lead to vomiting. [[Antiemetic]]s are sometimes necessary to suppress nausea and vomiting, and, in severe cases where [[dehydration]] develops, [[intravenous]] fluid may need to be administered to replace fluid volume. [[Image:49-aspetti di vita quotidiana, vomito,Taccuino Sanitatis, Ca.jpg|thumb|300px|14th century illustration of vomiting from the Casanatense [[Tacuinum Sanitatis]]]] Vomiting is different from [[regurgitation (digestion)|regurgitation]], although the two terms are often used interchangeably. Regurgitation is the return of undigested food (that has not yet reached the stomach) back up the [[esophagus]] to the [[mouth]]. The causes of vomiting and regurgitation are generally different. ==Mechanism== === Vomiting === Receptors on the floor of the [[fourth ventricle]] of the brain represent a [[chemoreceptor trigger zone]], known as the area postrema, stimulation of which can lead to vomiting. The area postrema is a [[circumventricular organ]] and as such lies outside the [[blood-brain barrier]]; it can therefore be stimulated by blood-borne drugs that can [[Vomiting#Emetics|stimulate vomiting]] or [[Vomiting#Antiemetics|inhibit it]]. There are various sources of input to the vomiting center: *The chemoreceptor trigger zone at the base of the fourth ventricle has numerous [[dopamine receptors|dopamine D₂ receptors]], [[5-HT receptor|serotonin 5-HT₃ receptors]], [[opioid receptor]]s, [[acetylcholine receptor]]s, and receptors for [[substance P]]. Stimulation of different receptors are involved in different pathways leading to emesis, in the final common pathway substance P appears to be involved.<ref>Hornby PJ. Central neurocircuitry associated with emesis. Am J Med 2001;111:106S-12S. PMID 11749934.</ref> *The vestibular system which sends information to the brain via [[cranial nerve VIII]] (vestibulocochlear nerve). It plays a major role in [[motion sickness]] and is rich in [[Muscarinic acetylcholine receptor|muscarinic receptors]] and [[histamine receptor|histamine H₁ receptors]]. *[[Vagus nerve|Cranial nerve X]] (vagus nerve), which is activated when the [[pharynx]] is irritated, leading to a gag reflex. *Vagal and [[enteric nervous system]] inputs that transmit information regarding the state of the [[gastrointestinal system]]. Irritation of the GI mucosa by chemotherapy, radiation, distention, or acute infectious [[gastroenteritis]] activates the 5-HT₃ receptors of these inputs. *The [[Central nervous system|CNS]] mediates vomiting arising from psychiatric disorders and stress from higher brain centers. === Act === The vomiting act encompasses three types of outputs initiated by the chemoreceptor trigger zone: Motor, [[parasympathetic nervous system]] (PNS), and [[sympathetic nervous system]] (SNS). They are as follows: *Increased [[saliva]]tion to protect the [[tooth enamel|enamel]] of [[teeth]] from stomach acids (excessive vomiting leads to [[Erosion (dental)|dental erosion]]). This is part of the PNS output. *A deep breath is taken to avoid [[aspiration]] of vomit. *[[Retroperistalsis]], starting from the middle of the [[small intestine]], sweeping up the contents of the digestive tract into the stomach, through the relaxed pyloric sphincter. *A lowering of intrathoracic pressure (by [[inspiration]] against a closed [[glottis]]), coupled with an increase in abdominal pressure as the [[abdomen|abdominal muscles]] contract, propels stomach contents into the [[esophagus]] as the [[cardia|lower esophageal sphincter]] relaxes. The stomach itself does not contract in the process of vomiting except for at the annular notch, nor is there any retroperistalsis in the esophagus. *Vomiting is ordinarily preceded by [[retching]]. *Vomiting also initiates an [[Sympathetic nervous system|SNS]] response causing both sweating and increased heart rate. The [[neurotransmitter]]s that regulate vomiting are poorly understood, but inhibitors of [[dopamine]], [[histamine]], and [[serotonin]] are all used to suppress vomiting, suggesting that these play a role in the initiation or maintenance of a vomiting cycle. [[Vasopressin]] and [[neurokinin]] may also participate. === Phases === The vomiting act has two phases. In the retching phase, the abdominal muscles undergo a few rounds of coordinated contractions together with the diaphragm and the muscles used in respiratory inspiration. In this retching phase nothing has yet been expelled. In the next phase, also termed the expulsive phase, intense pressure is formed in the stomach brought about by enormous shifts in both the diaphragm and the abdomen. These shifts are, in essence, huge contractions of these muscles that last for extended periods of time - much longer than a normal period of muscular contraction. The pressure is then suddenly released when the esophagus relaxes resulting in the expulsion of gastric contents. For people not in the habit of exercising the abdominal muscles, they may be painful for the next few days. The relief of pressure and the release of endorphins into the bloodstream after the expulsion causes the vomiter to feel better. Often this feeling is only temporary, however.{{Fact|date=October 2008}} ==Content== [[Gastric acid|Gastric secretions]] and likewise vomit are highly [[acidic]]. Recent food intake will be reflected in the gastric vomit. Irrespective of the content, vomit tends to be [[odor|malodorous]]. The content of the ''vomitus'' (vomit) may be of medical interest. Fresh [[blood]] in the vomit is termed [[hematemesis]] ("blood vomiting"). Altered blood bears resemblance to coffee grounds (as the [[iron]] in the blood is [[oxidation|oxidized]]) and, when this matter is identified, the term "[[coffee ground vomiting]]" is used. [[Bile]] can enter the vomit during subsequent heaves due to [[duodenum|duodenal]] contraction if the vomiting is severe. [[Fecal vomiting]] is often a consequence of [[intestinal obstruction]] or a gastrocolic [[fistula]] and is treated as a warning sign of this potentially serious problem ("signum mali ominis"); such vomiting is sometimes called "miserere." If the vomiting reflex continues for an extended period with no appreciable vomitus, the condition is known as ''non-productive emesis'' or ''dry heaves'', which can be painful and debilitating. ==Complications== ===Aspiration of vomit === Vomiting can be dangerous if the gastric content gets into the respiratory tract. Under normal circumstances the [[gag reflex]] and [[coughing]] will prevent this from occurring, however these protective reflexes are compromised in persons under the influences of certain substances such as [[ethanol|alcohol]] or [[anesthesia]]. The individual may choke and [[asphyxiation|asphyxiate]] or suffer an [[aspiration pneumonia]]. === Dehydration and electrolyte imbalance === Prolonged and excessive vomiting will deplete the body of water (dehydration) and may alter the electrolyte status. Gastric vomiting leads to the loss of acid (protons) and chlorine directly. Combined with the resulting [[alkaline tide]], this leads to [[hypochloremia|hypochloremic]] [[metabolic alkalosis]] (low [[chloride]] levels together with high [[bicarbonate|HCO₃]] and CO₂ and increased blood [[pH]]) and often [[hypokalemia]] ([[potassium]] depletion). The hypokalemia is an indirect result of the [[kidney]] compensating for the loss of acid. With the loss of intake of food the individual may eventually become [[cachexia|cachectic]]. A less frequent occurrence results from a vomiting of intestinal contents, including bile acids and HCO₃^- which can lead to [[metabolic acidosis]]. ===Mallory-Weiss tear=== Repeated or profuse vomiting may cause erosions to the [[esophagus]] or small tears in the esophageal mucosa ([[Mallory-Weiss tear]]). This may become apparent if fresh red blood is mixed with vomit after several episodes. ===Dentistry=== Recurrent vomiting, such as observed in [[bulimia nervosa]], may lead to destruction of the [[tooth enamel]] due to the acidity of the vomit. [[Digestive enzymes]] can also have a negative effect on oral health, by degrading the tissue of the [[gums]]. ==Causes== Vomiting may be due to a large number of causes, and protracted vomiting has a long [[differential diagnosis]]. ===Digestive tract=== ;Causes in the [[digestive tract]] * [[Gastritis]] (inflammation of the gastric wall, usually by [[virus]]es) * [[Pyloric stenosis]] (in babies, this typically causes a very forceful "projectile vomiting" and is an indication for urgent surgery) * [[Bowel obstruction]] * Over-eating * [[Acute abdomen]] and/or [[peritonitis]] * [[Ileus]] * [[Cholecystitis]], [[pancreatitis]], [[appendicitis]], [[hepatitis]] * In children, it can be caused by an allergic reaction to cow's milk proteins (Milk allergy or [[lactose intolerance]]) ===Sensory system and brain=== ;Causes in the [[sensory system]] * Movement: [[motion sickness]] (which is caused by overstimulation of the labyrinthine canals of the ear) * [[Ménière's disease]] ;Causes in the brain * [[Concussion]] * [[Cerebral hemorrhage]] * [[Migraine]] * [[Brain tumor]]s, which can cause the chemoreceptors to malfunction * [[Benign intracranial hypertension]] and [[hydrocephalus]] ;Metabolic disturbances (these may irritate both the stomach and the parts of the brain that coordinate vomiting) * [[Hypercalcemia]] (high [[calcium in biology|calcium]] levels) * [[Uremia]] ([[urea]] accumulation, usually due to [[renal failure]]) * [[Adrenal insufficiency]] * [[Hypoglycemia]] ;Pregnancy * [[Hyperemesis gravidarum|Hyperemesis]], [[Morning sickness]] ;Drug reaction (vomiting may occur as an acute [[somatic]] response to) * [[alcohol]] (being sick while being [[drunkenness|drunk]] or being sick the next morning, suffering from the after-effects, i.e., the [[hangover]]). * [[opioid]]s * [[selective serotonin reuptake inhibitors]] * many [[chemotherapy]] drugs * some [[entheogen]]s (such as [[peyote]] or [[ayahuasca]]) ;Illness * [[Norwalk virus]] ===Miscellanea=== * Self-induced ** [[Eating disorder]]s ([[anorexia nervosa]] or [[bulimia nervosa]]) ** To remove a poison in case such has been ingested (some poisons should not be vomited as they may be more toxic when inhaled or aspirated; it is, in general, considered better to ask for help before inducing vomiting) ** Some people who are engaged in [[binge drinking]] will induce vomiting in order to make room in their stomachs for further alcohol consumption. In the United Kingdom, this practice is known as ''tactical chundering,'' or ''hitting the reset button''. In the United States, it is known as ''boot and rally'' or ''pulling the trigger''. * After [[surgery]] ([[postoperative nausea and vomiting]]) * Disagreeable sights, smells or thoughts (such as decayed matter, others' vomit, thinking of vomiting), etc. * Extreme pain, such as intense [[headache]] or [[myocardial infarction]] (heart attack) * Violent emotions * [[Cyclic vomiting syndrome]] (a poorly-understood condition with attacks of vomiting) * High doses of [[ionizing radiation]] will sometimes trigger a vomit reflex in the victim * Violent fits of [[coughing]], [[hiccups]], or [[asthma]] * [[Nervousness]] * Performing physical activity (such as swimming) short time after a meal. * Getting struck hard in the stomach. * Overexertion (doing too much strenuous exercise can lead to vomiting shortly afterwards). ==Unusual types== '''Fecal vomiting''' is a kind of [[emesis]] in which [[fecal]] matter is expelled from the [[intestines]] into the [[stomach]], by spasmodic contractions of the gastric muscles, and then subsequently forcefully expelled from the stomach up into the [[esophagus]] and out through the mouth and sometimes [[nasal passage]]s. Alternative medical terms for fecal vomiting are ''copremesis'' and ''stercoraceous vomiting''.<ref>[http://medical-dictionary.thefreedictionary.com/fecal+vomiting fecal vomiting - definition of fecal vomiting in the Free Online Medical Dictionary, Thesaurus and Encyclopedia<!-- Bot generated title -->]</ref> It was also referred to as ''miserere'' in medieval times.{{Fact|date=January 2009}} ==Related medication== ===Emetics=== An ''emetic'', such as [[syrup of ipecac]], is a substance that induces vomiting when administered orally or by injection. An emetic is used medically where a substance has been ingested and must be expelled from the body immediately (for this reason, many toxic and easily digestible products such as rat poison contain an emetic). Inducing vomiting can remove the substance before it is absorbed into the body. Ipecac abuse can cause detrimental health effects. [[Copper sulfate]] was also used in the past as an emetic.<ref name="pmid4385403">{{cite journal |author=Holtzmann NA, Haslam RH |title=Elevation of serum copper following copper sulfate as an emetic |journal=Pediatrics |volume=42 |issue=1 |pages=189–93 |year=1968 |month=July |pmid=4385403 |doi= |url=http://pediatrics.aappublications.org/cgi/content/abstract/42/1/189}}</ref> It is now considered too toxic for this use.<ref name="isbn0-8385-8172-2">{{cite book |author=Olson, Kent C. |title=Poisoning & drug overdose |publisher=Lange Medical Mooks/McGraw-Hill |location=New York |year=2004 |pages=175 |isbn=0-8385-8172-2 |oclc= |doi= |accessdate=}}</ref> ===Antiemetics=== An [[antiemetic]] is a [[medication|drug]] that is effective against vomiting and [[nausea]]. Antiemetics are typically used to treat [[motion sickness]] and the [[Adverse effect (medicine)|side-effects]] of some [[opioid]] [[analgesic]]s and [[chemotherapy]] directed against [[cancer]]. Antiemetics act by inhibiting the receptor sites associated with emesis. Hence, anticholinergics, antihistamines, dopamine antagonists, serotonin antagonists, and cannabinoids are used as anti-emetics. ==Social implications== ===Nausea inducement in groups=== It is quite common that, when one person vomits, others nearby will become nauseated, particularly when smelling the vomit of others, often to the point of vomiting themselves. It is believed that this is an [[evolution|evolved]] trait among [[primates]]. Many primates in the wild will tend to browse for food in small groups. Should one member of the party react adversely to some ingested food, it may be advantageous (in a survival sense) for other members of the party also to vomit. This tendency in human populations has been observed at drinking parties, where excessive consumption of [[alcohol]]ic beverages may result in a number of party members vomiting nearly simultaneously, this being triggered by the initial vomiting of a single member of the party. This phenomenon has been touched on in popular culture: Notorious instances appear in the films ''[[Mr Creosote|Monty Python's The Meaning of Life]]'' (1983) and ''[[Stand by Me (film)|Stand By Me]]'' (1986), while, in the computer game [[Theme Hospital]], it is referred to as a 'vomit wave' and can spread through the hospital quickly. Intense vomiting in [[ayahuasca]] [[ceremony|ceremonies]] is a common phenomenon. However, people who experience "la purga" after drinking ayahuasca, in general, regard the practice as both a physical and spiritual cleanse and often come to welcome it. <ref>Shanon, B. (2002). The antipodes of the mind: Charting the phenomenology of the ayahuasca experience. (2002). Oxford: Oxford University Press.</ref> It has been suggested that the consistent emetic effects of ayahuasca — in addition to its many other therapeutic properties — was of medicinal benefit to [[indigenous people]]s of the [[Amazon Basin|Amazon]], in helping to clear [[parasite]]s from the gastrointestinal system. <ref>Andritzky, W. (1989). Sociopsychotherapeutic functions of ayahuasca healing in Amazonia. Journal of Psychoactive Drugs. 21(1), 77-89.</ref> There have also been documented cases of a single ill and vomiting individual inadvertently causing others to vomit, when they are especially fearful of also becoming ill, through a form of [[mass hysteria]]. ===Context=== Most people try to contain their vomit by vomiting into a sink, toilet, or trash can, as both the act and the vomit itself are widely considered embarrassing; vomit is also difficult to clean. On airplanes and boats, special bags are supplied for sick passengers to vomit into. A special disposable bag containing absorbent material that solidifies the vomit quickly is available, also, making it convenient and safe to keep (leakproof, puncture-resistant, odorless) until there is an opportunity to dispose of it conveniently. People who vomit chronically (e.g., as part of an [[eating disorder]] such as [[bulimia nervosa]]) may devise various ways to hide this disorder. ===Sound=== According to an online study of 30 traditionally bad sounds, the sound of vomiting is the worst sound in the world.<ref>[http://www.acoustics.salford.ac.uk/news/news2.htm Acoustics audio video, University of Salford<!-- Bot generated title -->]</ref> Professor Cox of the [[University of Salford]]'s Acoustic Research Centre said that "We are pre-programmed to be repulsed by horrible things such as vomiting, as it is fundamental to staying alive to avoid nasty stuff." It is thought that the thought of disgust is triggered by the sound of vomiting to protect food from those possibly diseased nearby.<ref>{{cite web | work= | title=Sound101.org |url=http://www.sound101.org/horriblesound.php?factoid=disgust}}</ref> ==See also== *[[Emetophilia]] *[[Emetophobia]] == References == {{Refimprove|date=July 2007}} {{reflist|2}} ==External links== {{commons|Vomiting}} {{wikiquote}} {{Wiktionary}} *[http://www.cvsa.org.uk Cyclical Vomiting Syndrome] {{Gastroenterology}} {{Digestive system and abdomen symptoms and signs}} [[Category:Reflexes]] [[Category:Symptoms]] [[Category:Digestive disease symptoms]] [[Category:Body fluids]] [[Category:Vomiting| ]] [[ar:قيء]] [[bn:বমি]] [[bs:Povraćanje]] [[bg:Повръщане]] [[ca:Èmesi]] [[cs:Zvracení]] [[da:Opkast]] [[de:Erbrechen]] [[el:Έμετος]] [[es:Vómito]] [[eo:Vomado]] [[fa:استفراغ]] [[fr:Vomissement]] [[gl:Vómito]] [[ko:구토]] [[hr:Povraćanje]] [[is:Uppköst]] [[it:Vomito]] [[he:הקאה]] [[la:Vomitus]] [[lv:Vemšana]] [[lt:Vėmimas]] [[hu:Hányás]] [[mk:Повраќање]] [[ml:ഛര്‍ദ്ദി]] [[nl:Braken (lichaamsfunctie)]] [[ja:嘔吐]] [[no:Oppkast]] [[pl:Wymioty]] [[pt:Emese]] [[qu:Aqtuy]] [[ru:Рвота]] [[simple:Vomit]] [[sk:Zvracanie]] [[sl:Bljuvanje]] [[sr:Повраћање]] [[fi:Oksentaminen]] [[sv:Kräkning]] [[te:వాంతి]] [[th:อาเจียน]] [[uk:Блювання]] [[wa:Rivômixhaedje]] [[zh:呕吐]]'