Gastric vomiting: relation to pain and time of day
Gastric vomiting rarely occurs in isolation: it is usually accompanied by pronounced nausea, increased salivation (hypersalivation), and abdominal pain. The key sign distinguishing gastric pathology from other conditions is the onset of clear relief and abatement of pain after the act of vomiting.
A thorough history-taking allows the episode to be linked to a specific disease:
- Morning vomiting on an empty stomach: if the masses contain a large amount of mucus, it indicates chronic gastritis (especially in patients with alcohol dependence). If acidic contents are discharged, it points to nocturnal gastric hypersecretion.
- At the peak of pain: vomiting acidic contents, bringing long-awaited relief, is a classic manifestation of peptic ulcer disease.
- Long-eaten food: if the patient vomits food consumed 1–2 days prior, this indicates content stasis against the background of pyloric stenosis.
Macroscopic assessment of emesis
Visual inspection and evaluation of the odor of discharged masses can immediately point to the development of severe complications.
- Admixture of blood. The appearance of «coffee-ground» vomiting is a marker of gastrointestinal bleeding. The specific color is due to the chemical reaction between hemoglobin from the shed blood and hydrochloric acid of the gastric juice.
- Putrid odor. Occurs upon prolonged retention and decomposition of food masses in the stomach, which is typical for decompensated pyloric stenosis.
- Fecal odor. Indicates the reflux of intestinal contents into the stomach via antiperistalsis. This severe condition indicates the formation of a gastrocolic fistula — a pathological communication between the stomach and the transverse colon.
Central-origin vomiting
So-called «cerebral vomiting» requires clear differentiation from gastric and esophageal types. It is caused not by GI pathology, but by direct stimulation of the vomiting center.
Features:
- Develops abruptly and suddenly.
- The patient experiences no preceding nausea.
- Does not bring relief.
The main causes include increased intracranial pressure, meningeal irritation, as well as hysteria and other central nervous system dysfunctions.
Symptomatology of eructation and its complications
Eructation is the sudden involuntary expulsion of gas or a small amount of gastric contents (regurgitation) into the oral cavity.
- Belching of air (aerophagia): associated with swallowing excess air. Often observed during fast eating, various neuroses, and digestive tract disorders.
- With odor (during stasis): the odor of rancid butter indicates fermentation processes in the stomach, while the «rotten egg» odor (hydrogen sulfide) indicates protein putrefaction.
- Taste changes: sour eructation indicates a hypersecretory state (increased acid production). Bitter eructation is a sign of duodenogastric reflux, in which bile from the duodenum is refluxed into the stomach (sometimes perceived simply as a bitter taste in the mouth).
Complications: regurgitation carries the risk of aspiration of food masses into the respiratory tract. Clinically, this manifests as coughing and choking, and in severe cases leads to aspiration pneumonia. Patients with alcoholism are at increased risk for this complication.
Appetite dynamics in gastric pathology
Changes in appetite serve as an important diagnostic marker:
- Decreased appetite: typical of chronic gastritis proceeding with reduced secretory function.
- Anorexia: complete lack of appetite. If accompanied by a persistent aversion to certain products (primarily meat), this is a pathognomonic sign of gastric cancer.
- Increased appetite: often accompanies peptic ulcer disease, especially when the defect is localized in the duodenal bulb.
- Pica (pica chlorotica): an irresistible urge to eat non-food substances such as coal or chalk. This condition indicates severe iron deficiency in the body and occurs in chlorosis (anemia) or during pregnancy.
Briefly: answers to topical questions
Where is the vomiting center located and what receptor zones stimulate it?
The vomiting center is located in the medulla oblongata. Its innervation is provided by $M_1$ cholinergic receptors.
Stimulation pathways (receptor zones):
- Vestibular apparatus (contains $M_1$ cholinergic receptors and $H_1$ histamine receptors);
- Peripheral stimulation (pharyngeal and gastric mucosal receptors, $5-HT_3$ receptors);
- Chemoreceptor trigger zone (located on the floor of the IV ventricle, contains $D_2$ dopamine and $5-HT_3$ serotonin receptors, responds to chemical agents in the blood/CSF).
What types of eructation exist according to the mechanism of occurrence in norm and pathology?
In sources, eructation is classified as follows:
- Belching of air (aerophagia) — occurs when swallowing excess air (in neuroses, fast eating, GI diseases).
- Eructation with odor (during food stasis):
- With a rancid butter odor (or odorless) — the result of fermentation;
- With a «rotten egg» odor (hydrogen sulfide) — the result of protein putrefaction.
- By taste characteristics:
- Sour — a sign of hypersecretory states (increased acidity);
- Bitter — a sign of duodenogastric reflux (bile reflux from the duodenum).
Gastric vomiting brings Relief, central vomiting Leaves everything as it was. Bitter eructation is bile, sour is acid, and rotten is protein putrefaction.
Class and exam questions
How to quickly distinguish vomiting in peptic ulcer disease from «cerebral» vomiting?
In ulcer, vomiting is preceded by nausea, occurs at the peak of abdominal pain, and afterwards the patient feels clear relief. «Cerebral» vomiting appears suddenly, without nausea, and does not reduce symptom intensity.
What does a fecal odor of vomitus indicate?
It indicates the presence of a gastrocolic fistula. Due to antiperistalsis, the contents of the transverse colon are refluxed back into the stomach.
Why can eructation be dangerous?
Eructation may be accompanied by regurgitation — the reflux of gastric contents into the oral cavity. This creates a risk of aspiration of food masses into the respiratory tract with the subsequent development of aspiration pneumonia.
What is pica chlorotica?
This is a pathological perversion of appetite in which a person consumes non-food substances (e.g., chalk). The symptom indicates iron deficiency in the body.
What else to study on this topic
- Pathogenesis of hematin hydrochloride formation in gastrointestinal bleeding
- Mechanisms of gastrocolic fistula formation
- Etiology and consequences of duodenogastric reflux
- Physiology of antiperistalsis in intestinal obstruction and fistulas
- Mechanism of aspiration pneumonia development in patients with alcoholism
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