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Encyclopedia > Vomit
Name of Symptom/Sign:
Vomiting
[[Image:{{{Image}}}|190px|center|]]
ICD-10 R11
ICD-O: {{{ICDO}}}
ICD-9 787
OMIM {{{OMIM}}}
MedlinePlus {{{MedlinePlus}}}
eMedicine {{{eMedicineSubj}}}/{{{eMedicineTopic}}}
DiseasesDB {{{DiseasesDB}}}

Vomiting (or emesis) is the forceful expulsion of the contents of one's stomach through the mouth. Although it probably evolved as a mechanism for expelling ingested poisons, vomiting may result from many causes not related to poisoning, ranging from gastritis to brain tumors, or elevated intracranial pressure (ICP). The feeling that one is about to vomit is called nausea. It usually, but not necessarily, precedes vomiting, but it does not always lead to vomiting. Antiemetics are sometimes necessary to suppress nausea and vomiting. The term symptom (from the Greek syn = con/plus and pipto = fall, together meaning co-exist) has two similar meanings in the context of physical and mental health: A symptom may loosely be said to be a physical condition which shows that one has a particular illness or disorder (see... In medicine, a sign is a feature of disease as detected by the doctor during physical examination of a patient. ... The following codes are used with International Statistical Classification of Diseases and Related Health Problems. ... The International Classification of Diseases for Oncology (ICD-O) is a domain specific extension of the International Statistical Classification of Diseases and Related Health Problems for tumor diseases. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... The Mendelian Inheritance in Man project is a database that catalogues all the known diseases with a genetic component, and - when possible - links them to the relevant genes in the human genome. ... MedlinePlus (medlineplus. ... eMedicine is an online clinical medical knowledge base that was founded in 1996. ... The Diseases Database is a free website that provides information about the relationships between medical conditions, symptoms, and medications. ... The stomach (Gaster) In anatomy, the stomach (in ancient Greek στόμαχος) is an organ in the gastrointestinal tract used to digest food. ... The skull and crossbones symbol traditionally used to label a poisonous substance. ... Gastritis is a medical term for inflammation of the lining of the stomach. ... A brain tumor is any intracranial mass created by an abnormal and uncontrolled growth of cells either normally found in the brain itself: neurons, glial cells (astrocytes, oligodendrocytes, ependymal cells), lymphatic tissue, blood vessels), in the cranial nerves (myelin producing Schwann cells), in the brain envelopes (meninges), skull, pituitary and... Nausea (Greek Ναυτεία) is the sensation of unease and discomfort in the stomach with an urge to vomit. ... An antiemetic is a drug that is effective against vomiting and nausea. ...


The medical branch investigating vomiting, emetics and antiemetics is called emetology.

Contents


Mechanism

Vomiting is co-ordinated in the vomiting center in the lateral medullary reticular formation in the medulla. Receptors on the floor of the fourth ventricle of the brain represent a chemoreceptor trigger zone, stimulation of which can lead to vomiting. The chemoreceptor zone lies outside the blood-brain barrier, and can therefore be stimulated by blood-borne drugs that can stimulate vomiting, or inhibit it. Position of medulla oblangata in the human brain The medulla oblongata is the lower portion of the brainstem. ... The fourth ventricle is one of the four connected fluid-filled cavities within the human brain. ... The blood-brain barrier is a physical barrier between the blood vessels in the central nervous system, and most parts of the central nervous system itself. ... Vomiting (or emesis) is the forceful expulsion of the contents of ones stomach through the mouth. ... Vomiting (or emesis) is the forceful expulsion of the contents of ones stomach through the mouth. ...


There are various sources of input to the vomiting center:

  • As stated earlier, the chemoreceptor trigger zone which lies in the fourth ventricle. This area has numerous dopamine D2 receptors, serotonin 5-HT3 receptors, and opoid receptors.
  • 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 receptors and histamine H1 receptors.
  • 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 CNS mediates vomiting arising from psychiatric disorders and stress.

The vomiting act encompasses three types of outputs initiated by the medulla: Motor, Parasympathetic Nervous System (PNS) and Sympathetic Nervous System (SNS). Collectively, they are as follows: The dopamine receptors are a class of G-protein coupled receptors with dopamine as their endogenous ligand. ... The vestibulocochlear nerve is the eighth of twelve cranial nerves, and also known as the auditory nerve. ... The vagus nerve is tenth of twelve paired cranial nerves and is the only nerve that starts in the brainstem (somewhere in the medulla oblongata) and extends all the way down past the head, right down to the abdomen. ... The enteric nervous system (ENS) is an interdependent part of the autonomic nervous system. ... For the Physics term GUT, please refer to Grand unification theory The gastrointestinal or digestive tract, also referred to as the GI tract or the alimentary canal or the gut, is the system of organs within multicellular animals which takes in food, digests it to extract energy and nutrients, and... Gastroenteritis, or inflammation of the gastrointestinal tract, is an illness of fever, diarrhoea and/or vomiting caused by an infectious virus, bacterium or parasite. ... Anatomy and Physiology of the A.N.S. In contrast to the voluntary nervous system, the involuntary or autonomic nervous system is responsible for homeostasis, maintaining a relatively constant internal environment by controlling such involuntary functions as digestion, respiration, and metabolism, and by modulating blood pressure. ... The word sympathetic means different things in different contexts. ...

  • Increased salivation to protect the enamel of teeth from stomach acids (excessive vomiting does lead to caries). This is part of the PNS output.
  • 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 abdominal muscles contract, propels stomach contents into the esophagus without involvement of retroperistalsis. The lower esophageal sphincter relaxes. This is part of the motor output, and it is also important to note that the stomach itself does not contract in the process of vomiting.
  • Vomiting is ordinarily preceded by retching. The purpose of retching is to build up the pressure needed to expel the stomach contents from the body. In retching, the body makes movements similar to vomiting. These spasms build up pressure within the chest cavity. When a sufficient amount of pressure has been created, the diaphragm transfers the pressure from the chest to the abdomen, and this pressure then results in actual vomiting.
  • Vomiting also initiates a SNS response causing both sweating and increased heart rate.

The neurotransmitters 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. Contents of Saliva In animals, saliva is produced in and secreted from the salivary glands. ... Tooth enamel is the hardest and most mineralized substance of the body , and with dentin and cementum is one of the three major parts of the tooth. ... Types of teeth Molars are used for grinding up foods Carnassials are used for slicing food. ... Caries is a progressive destruction of any kind of bone structure, including the skull, the ribs and other bones. ... Diagram showing the small intestine In biology the small intestine is the part of the gastrointestinal tract between the stomach and the large intestine (colon). ... The space between the vocal cords is called the glottis. ... In anatomy, the abdomen is a part of the body; in humans, it is the region between the thorax and the pelvis. ... The esophagus (also spelled oesophagus/Å“sophagus), or gullet is the muscular tube in vertebrates through which ingested food passes from the mouth area to the stomach. ... The cardia is the anatomical term for the junction orifice of the stomach and the esophagus. ... Neurotransmitters are chemicals that are used to relay, amplify and modulate electrical signals between a neuron and another cell. ... Dopamine is a chemical naturally produced in the body. ... Histamine is a hemolytic protein involved in local immune responses as well as regulating physiological function in the gut and acting as a neurotransmitter. ... Serotonin (5-hydroxytryptamine, or 5-HT) is a monoamine neurotransmitter synthesised in serotonergic neurons in the central nervous system and enterochromaffin cells in the gastrointestinal tract. ... Antidiuretic hormone (ADH), or arginine vasopressin (AVP), is a peptide hormone produced by the hypothalamus, and stored in the posterior part of the pituitary gland. ...


Content

As the stomach secretes acid, vomit contains a high concentration of hydronium ions and is thus strongly acidic. The potential physiological complications associated with excessive vomiting are mainly metabolic alkalosis (increased blood pH), hypokalemia (potassium depletion) and hypochloremia (chlorine depletion). The hypokalemia is an indirect result of the kidney compensating for the loss of acid. In chemistry, hydronium is the common name for the cation H3O+. // Nomenclature According to IUPAC ion nomenclature, it should be referred to as oxonium. ... For alternative meanings see acid (disambiguation). ... Alkalosis refers to a condition reducing hydrogen ion concentration of arterial blood plasma. ... The correct title of this article is pH. The initial letter is capitalized due to technical restrictions. ... Hypokalemia is a potentially fatal condition in which the body fails to retain sufficient potassium to maintain health. ... General Name, Symbol, Number potassium, K, 19 Chemical series alkali metals Group, Period, Block 1, 4, s Appearance silvery white Atomic mass 39. ... Hypochloremia is an electrolyte disturbance in which there is an abnormally depleted level of the chloride ion in the blood. ... General Name, Symbol, Number chlorine, Cl, 17 Chemical series halogens Group, Period, Block 17, 3, p Appearance yellowish green Atomic mass 35. ... Human kidneys viewed from behind with spine removed The kidneys are bean-shaped excretory organs in vertebrates. ...


The content of the vomitus (vomit) may be of medical interest. Fresh blood in the vomit is termed hematemesis ("blood vomiting"). Old blood bears resemblance to coffee grounds (as the iron in the blood is oxidized), and when this matter is identified the term "coffee ground vomiting" is used. Bile can enter the vomit during subsequent heaves due to duodenal contraction if the vomiting is severe. Fecal vomiting is often a consequence of intestinal obstruction, and is treated as a warning sign of this potentially serious problem ("signum mali ominis"); such vomiting is sometimes called "miserere". Red blood cells (erythrocytes) are present in the blood and help carry oxygen to the rest of the cells in the body Blood is a circulating tissue composed of fluid plasma and cells (red blood cells, white blood cells, platelets). ... Hematemesis or haematemesis is the vomiting of fresh red blood. ... General Name, Symbol, Number iron, Fe, 26 Chemical series transition metals Group, Period, Block 8, 4, d Appearance lustrous metallic with a grayish tinge Atomic mass 55. ... The most fundamental reactions in chemistry are the redox processes. ... Bile (or gall) is a bitter, greenish-yellow alkaline fluid secreted by the liver of most vertebrates. ... In anatomy of the digestive system, the duodenum is a hollow jointed tube connecting the stomach to the jejunum. ... Bowel obstruction is mechanical blockage of the intestines, preventing the normal transit of the products of digestion. ...


If the vomiting reflex continues for an extended period of time with no appreciable vomitus, the condition is known as non-productive emesis or dry heaves, which can become painful and debilitating.


Causes

Vomiting may be due to a large number of causes, and protracted vomiting has a long differential diagnosis. Differential diagnosis is the process by which a physician utilitizes the scientific method and the skills acquired in medical school, internship, and residency to take a history, examine the patient, and do the appropriate testing to determine the nature and extent of a disease process in a patient. ...


Digestive tract

Causes in the digestive tract: For the Physics term GUT, please refer to Grand unification theory The gastrointestinal or digestive tract, also referred to as the GI tract or the alimentary canal or the gut, is the system of organs within multicellular animals which takes in food, digests it to extract energy and nutrients, and...

Gastritis is a medical term for inflammation of the lining of the stomach. ... The human immunodeficiency virus (HIV) A virus is a microscopic parasite that infects cells in biological organisms. ... Infantile Pyloric stenosis is an uncommon pediatric condition where there is a congenital narrowing of the pylorus (the opening at the lower end of the stomach). ... Intestinal obstruction can be partial or complete blockage of the intestine, either large or small. ... Cholecystitis is inflammation of the gallbladder. ... Pancreatitis describes the condition of inflammation of the pancreas that causes mild to severe pain in the abdomen. ... Appendicitis is a condition characterised by inflammation of the appendix. ... Hepatitis is a gastroenterological disease, featuring inflammation of the liver. ... Pregnancy Pregnancy is the carrying of one or more embryos or fetuses by female mammals, including humans, inside their bodies. ...

Sensory system and brain

Causes in the sensory system: (See also sense) A sensory system is a part of the nervous system that consists of sensory receptors, neural pathways, and those parts of the brain responsible for processing the information. ...

  • Movement: motion sickness (which is caused by overstimulation of the labyrinthine canals of the ear)
  • Ménière's disease

Causes in the brain: Motion sickness is a condition in which the endolymph (the fluid found in the semicircular canals of the inner ears) becomes stirred up, causing confusion between the difference between apparent perceived movement (none or very little), and actual movement. ... Ménière’s disease (or syndrome, since its cause is unknown) was first described by French physician Prosper Ménière in 1861. ...

Metabolic disturbances (these may irritate both the stomach and the parts of the brain that coordinate vomiting): Your brain floats within your skull surrounded by cerebrospinal fluid (CSF). ... Bottles of cachaça, a Brazilian alcoholic beverage. ... A hangover or veisalgia is the unpleasant physical effects following heavy consumption of alcohol or the use of drugs. ... A cerebral hemorrhage is bleeding directly into the brain parenchyma (tissue) itself, otherwise known as hemorrhagic stroke. ... A brain tumor is any intracranial mass created by an abnormal and uncontrolled growth of cells either normally found in the brain itself: neurons, glial cells (astrocytes, oligodendrocytes, ependymal cells), lymphatic tissue, blood vessels), in the cranial nerves (myelin producing Schwann cells), in the brain envelopes (meninges), skull, pituitary and... This article is actively undergoing a major edit. ...

Opioids, many chemotherapy drugs and a host of other drugs may cause nausea and vomiting. Hypercalcaemia is an elevated calcium level in the blood. ... Calcium plays a vital role in the anatomy, physiology and biochemistry of organisms and of the cell, particularly in signal transduction pathways. ... Uremia is a toxic condition resulting from renal failure, when kidney function is compromised and urea, a waste product normally excreted in the urine, is retained in the blood. ... Urea is an organic compound of carbon, nitrogen, oxygen and hydrogen, with the formula CON2H4 or (NH2)2CO. Urea is also known as carbamide, especially in the recommended International Non-proprietary Names (rINN) in use in Europe. ... Renal failure is the condition where the kidneys fail to function properly. ... In medicine, adrenal insufficiency is the inability of the adrenal gland to produce adequate amounts of cortisol in response to stress. ... Hypoglycemia is a medical term referring to a pathologic state produced by a lower than normal amount of sugar (glucose) in the blood. ... An opioid is any agent that binds to opioid receptors found principally in the central nervous system and gastrointestinal tract. ... Chemotherapy is the use of chemical substances to treat disease. ...


Other

Anorexia nervosa is an eating disorder characterized by voluntary starvation and exercise stress. ... Bulimia nervosa, more commonly known as bulimia, is a psychological condition in which the subject engages in recurrent binge eating followed by intentionally doing one or more of the following in order to compensate for the intake of the food and prevent weight gain: vomiting inappropriate use of laxatives, enemas... Sexual fetishism, first described as such by Sigmund Freud though the concept and certainly the activity is quite ancient, is a form of paraphilia where the object of affection is a specific inanimate object or part of a persons body. ... This article needs to be cleaned up to conform to a higher standard of quality. ... Binge drinking is commonly defined as drinking alcohol solely for the purpose of intoxication. ... A typical modern surgical operation Surgery (from the Greek cheirourgia meaning hand work) is the medical specialty that treats diseases or injuries by operative manual and instrumental treatment. ... Postoperative nausea and vomiting is an unpleasant complication affecting about a third of the 10% of the population undergoing general anaesthesia each year. ... A headache (medically known as cephalgia) is a condition of mild to severe pain in the head; sometimes upper back or neck pain may also be interpreted as a headache. ... A myocardial infarction occurs when an atherosclerotic plaque slowly builds up in the inner lining of a coronary artery and then suddenly ruptures, totally occluding the artery and preventing blood flow downstream. ... Morning sickness, also called nausea and vomiting of pregnancy (NVP), or pregnancy sickness, affects between 50 and 95 percent of all pregnant women. ... Hyperemesis gravidarum (from the Latin for extreme vomiting of the pregnant woman) is a severe form of morning sickness. ... Cyclic Vomiting Syndrome (CVS) is a digestive disorder whose symptoms are recurring attacks of nausea, vomiting and abdominal pain for both children & adults. ...

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 (typically poison) has been ingested and must be expelled from the body immediately. Inducing vomiting can remove the substance before it is absorbed into the body. Syrup of ipecac (derived from the Ipecacuanha plant), is an emetic - a substance used to induce vomiting. ... The skull and crossbones symbol traditionally used to label a poisonous substance. ...


Antiemetics

An antiemetic is a drug that is effective against vomiting and nausea. Antiemetics are typically used to treat motion sickness and the side effects of some opioid analgesics and chemotherapy directed against cancer. An antiemetic is a drug that is effective against vomiting and nausea. ... A medication is a licenced drug taken to cure or reduce symptoms of an illness or medical condition. ... Nausea (Greek Ναυτεία) is the sensation of unease and discomfort in the stomach with an urge to vomit. ... Motion sickness is a condition in which the endolymph (the fluid found in the semicircular canals of the inner ears) becomes stirred up, causing confusion between the difference between apparent perceived movement (none or very little), and actual movement. ... Side-effect can mean: Side-effect (computer science), a state change caused by a function call Adverse drug reaction, an unintended consequence specifically arising from drug therapy Therapeutic effect (medicine), a desirable consequence of any kind of medical treatment, even though resulting as an unintended, unexpected consequence of the treatment... An opioid is any agent that binds to opioid receptors found principally in the central nervous system and gastrointestinal tract. ... An analgesic (colloquially known as painkiller) is any member of the diverse group of drugs used to relieve pain and to achieve analgesia. ... Chemotherapy is the use of chemical substances to treat disease. ... When normal cells are damaged beyond repair, they are eliminated by apoptosis. ...


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 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 alcoholic 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. A speculatively rooted phylogenetic tree of all living things, based on rRNA gene data, showing the separation of the three domains, bacteria, archaea, and eukaryotes, as described initially by Carl Woese. ... For the ecclesiastical use of this term, see primate (religion) Families 13, See classification A primate is any member of the biological order Primates, the group that contains all lemurs, monkeys, and apes, including humans. ... In general usage, alcohol (from Arabic al-kukhūl الكحول = the spirit, the chemical.) refers almost always to ethanol, also known as grain alcohol, and often to any beverage that contains ethanol (see alcoholic beverage). ...


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. On airplanes and boats, special bags are supplied for sick passengers to vomit into. Alternatively, a special disposable bag is available containing absorbent material that solidifies the vomit quickly, 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 abnormality. Bulimia nervosa, more commonly known as bulimia, is an eating disorder. ...


In language

As with other physiological processes involving body wastes, vomiting has taboo aspects. This is shown by the large number of colourful euphemisms for vomiting. (see: toilet humour) A taboo is a strong social prohibition (or ban) relating to any area of human activity or social custom declared as sacred and forbidden; breaking of the taboo is usually considered objectionable or abhorrent by society. ... A euphemism is an expression intended by the speaker to be less offensive, disturbing, or troubling to the listener than the word or phrase it replaces, or in the case of doublespeak to make it less troublesome for the speaker. ... Toilet humour (also potty humour) is a type of humour dealing with bodily toilet functions. ...


In other animals

  • Whales vomit regularly (every 7 to 10 days) as a means of the ordinary digestive process, to expel inedible things they have swallowed.
  • The domestic cat is well known for its tendency to vomit, particularly when attempting to dislodge hairballs from its throat or upper gastrointestinal tract. Chronic vomiting in cats may indicate underlying liver or kidney dysfunction and should be investigated by a veterinarian. Dogs also vomit often (frequently after eating grass) and are also known for eating their own vomit, a fact even cited in the Bible: KJV Proverbs 26:11 "As a dog returneth to his vomit, so a fool returneth to his folly."
  • Owls will expel the undigestible bones and fur of their meals after partial digestion of the nutritious parts rather than passing them through the digestive tract.
  • Some adult birds regurgitate food to feed their young, triggered by a feather or a beak of their young. The food can be either incompletely digested or partially predigested, depending on the species. Some bird species may also use regurgitation as a form of defense, vomiting when wounded or molested. When an intruder or a predator comes near a fulmar on its nest, the bird vomits oil up to 3 feet at the enemy.
  • When in danger, the sea cucumber may eject its entire digestive tract. The animal is able to re-grow another one.
  • Some large mammals, including horses, rarely vomit. Many rodents lack the ability to vomit, which is why mice and rats are easily killed by poisoning.

Whales are the largest species of exclusively aquatic mammals, members of the order Cetacea, which also includes dolphins and porpoises. ... Trinomial name Felis silvestris catus (Linnaeus, 1758) This article is about the domestic cat. ... For the Physics term GUT, please refer to Grand unification theory The gastrointestinal or digestive tract, also referred to as the GI tract or the alimentary canal or the gut, is the system of organs within multicellular animals which takes in food, digests it to extract energy and nutrients, and... Trinomial name Canis lupus familiaris (Linnaeus, 1758) The dog is a canine mammal of the Order Carnivora. ... The King James Version (KJV) is an English translation of the Holy Bible, commissioned for the benefit of the Church of England at the behest of King James I of England. ... The Book of Proverbs is a book of the Tanakh/Old Testament. ... For uses of the word Owl as a three letter acronym, see OWL. Families Strigidae Tytonidae An owl is any of some 220+ species of solitary, mainly nocturnal birds of prey in the order Strigiformes. ... Orders Many - see section below. ... Closeup on a single white feather A feather is one of the epidermal growths that forms the distinctive outer covering, or plumage, on a bird. ... The beak - otherwise known as the bill - is the only device a bird has for consuming food. ... It has been suggested that this article or section be merged with predation. ... Species Fulmar (Linnaeus, 1761) Southern Fulmar (Smith,A, 1840) The two Fulmars are closely related seabirds occupying the same niche in different oceans. ... A foot (plural: feet) is a non-SI unit of distance or length, measuring around a third of a metre. ... Orders Subclass Apodacea  Apodida  Molpadiida Subclass Aspidochirotacea  Aspidochirotida  Elasipodida Subclass Dendrochirotacea  Dactylochirotida  Dendrochirotida The sea cucumber is an echinoderm of the class Holothuroidea, with an elongated body and leathery skin. ...

See also

Emetophobia is an excessive or irrational fear of vomiting. ... This article needs to be cleaned up to conform to a higher standard of quality. ... Regurgitation is the passive flow of stomach contents back into the esophagus and mouth. ...

External links

  • Emetophobia FAQ
  • Cyclical Vomiting Syndrome

  Results from FactBites:
 
MedlinePlus Medical Encyclopedia: Nausea and vomiting (1083 words)
Sneezing ejects the intruders from the nose, coughing from the lungs and throat, diarrhea from the intestines, and vomiting from the stomach.
Vomiting is a forceful action accomplished by a fierce, downward contraction of the diaphragm.
Vomiting is a complex, coordinated reflex orchestrated by the vomiting center of the brain.
Discovery Health :: Diseases & Conditions :: vomiting (549 words)
Vomiting is when the stomach contents are ejected through the mouth.
For instance, ear infections are a common cause of vomiting in infants.
Sometimes, the cause of vomiting is obvious to the healthcare professional from the history and physical exam.
  More results at FactBites »

 
 

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