Persistent Nausea or Vomiting
Feeling sick (nausea) and being sick (vomiting) are common experiences. Many people experience them for a day or two because of problems like tummy bugs and food poisoning. This leaflet is about nausea and vomiting which goes on for longer than a day or two.
Adult patients who are usually well should seek medical advice if they vomit for more than 48 hours, feel weak or unwell with vomiting, or vomit repeatedly for more than 24 hours and can't keep fluid down. Patients who were already unwell, or who are frail, very young or elderly, should not wait this long. Anyone who vomits blood or has other problems like difficulty swallowing, severe head or tummy pain or a high temperature and rash should get medical advice urgently.
What are nausea and vomiting?
Nausea means feeling sick, and is a sensation which ranges from feeling off your food and mildly unwell at the thought of food to an overwhelming sense of the need to vomit.
Vomiting (sometimes called emesis) means being sick, so that your stomach contents are ejected forcefully through your mouth (and sometimes your nose). In some cases of vomiting, liquid from just beyond the stomach, which is yellowish and bitter, is also ejected. Vomiting is not quite the same as regurgitation, which is not forceful.
Whilst they commonly go together, nausea often occurs without vomiting, and vomiting sometimes occurs without nausea.
What are persistent nausea and vomiting?
Most cases of nausea and vomiting are short-lived - less than 24 hours - or have an obvious short-term cause (such as sea-sickness, a tummy bug, or drinking too much alcohol).
- Nausea and vomiting are called 'persistent' if they last more than 24 hours or come and go over a period of more than 24 hours.
- Vomiting is considered severe if you vomit more than 10 times in 24 hours, if you vomit every time you try to drink something in 24 hours, or if you have unusually forceful vomiting.
Why do we get nausea and vomiting?
Nausea and vomiting are controlled by a combination of the vomiting centre in your brain, and areas within your gut. The vomiting centre in the brain responds to many signals, such as toxic substances in the blood, circulating hormones in pregnancy, signals from the balance organs, signals from the 'thinking brain' (such as memories, thoughts and feelings), high levels of adrenaline (in a 'fight or flight' situation), noxious smells, and pain.
Everyone experiences nausea and vomiting at some time. Vomiting is protective to the stomach and intestines, and in our distant ancestors' time probably protected them from poisonous or contaminated substances they might have swallowed by mistake. Vomiting also protects the digestive system if it is inflamed or infected.
Nausea and vomiting can also occur because of conditions which directly affect the way the brain triggers nausea and vomiting. One example of this is travel sickness, where the nausea and vomiting are triggered by the body's balance systems in the ears, eyes and brain. Another example would be the nausea we feel in response to certain toxic substances like some drugs and alcohol.
What is the difference between acute and persistent nausea and vomiting?
Acute nausea and/or vomiting usually mean lasting less than 24-48 hours. They are most commonly due to gastric infection or food poisoning and are self-limiting (ie each stops by itself). This sort of nausea and vomiting does not usually need any intervention unless it is very severe, the vomit is unusual (for example, bloody) or the person affected is a baby or young child and not managing fluids, or if lack of fluid in the body (dehydration) is a problem. See separate leaflet called Nausea and Vomiting for more information on the acute conditions.
Persistent nausea and vomiting is that which lasts for 48 hours or more. It can have the same causes as acute nausea and vomiting, but simple infections and food poisoning start to look less likely as time goes on, and other possible causes come to the fore. Some are more serious than others, and many cause other symptoms too.
What can cause persistent nausea and/or vomiting?
There are many possible causes of persistent nausea and/or vomiting. Some of these are common and some are rare. Some are serious. Many of the conditions listed here would be expected to cause other symptoms in addition to nausea and vomiting. They include:
- Pregnancy, particularly early pregnancy morning sickness:
- 3 out of every 4 pregnant women experience at least some nausea during the first 12 weeks of pregnancy. About 1 in 100 have severe nausea and vomiting (hyperemesis gravidarum) and this may last until much longer in the pregnancy.
- Nausea and/or vomiting may return in late pregnancy, when a combination of tummy inflammation and pressure of the baby on your tummy may cause it to return.
- Infections of many types - but particularly:
- Urinary tract infection (a common cause of vomiting in children and elderly people). Vomiting is sometimes the only symptom.
- Kidney infection (pyelonephritis).
- Gastrointestinal infection (you may also have diarrhoea). This usually recovers within 48 hours but some infections such as rotavirus (which also causes diarrhoea) and giardia (which tends to cause nausea and flatulence without vomiting) can last a week or more.
- Chest infection, particularly in elderly patients.
- Stomach problems - for example:
- Gastro-oesophageal reflux disease (GORD). This condition is acid reflux and oesophagitis. It also tends to cause pain at the top of the stomach and (in reflux) a sense of burning or acid behind the breastbone. Reflux can also occur in babies.
- Stomach ulcers. These are seen in severe liver disease and gastric cancer, and usually cause severe pain and intolerance of food.
- Gastroparesis (delayed stomach emptying). This is more common in people with diabetes, people who have had weight-loss surgery and in Parkinson's disease.
- Pyloric stenosis (in babies).
- Liver disease - for example, hepatitis A, hepatitis B, liver cirrhosis. There will be other symptoms, including yellowing of the skin and the whites of the eyes (jaundice) and, usually, pain over the liver.
- Kidney problems - for example, chronic kidney disease, which typically causes nausea when severe, and kidney stones (which may also cause pain).
- Intestinal problems:
- Intestinal infection - for example, salmonella, giardia.
- Intestinal inflammation - for example, Crohn's disease.
- Intestinal discomfort and motility problems - for example, irritable bowel syndrome.
- Food intolerance - for example, lactose intolerance, coeliac disease. These often cause quite vague symptoms and may go undetected for years.
- Gastrointestinal blockage - for example, twisted bowel, severe constipation, bowel cancer.
- Pancreatitis, which is often caused by gallstones.
- Psychological problems - for example:
- Nervousness (for example, stage fright).
- Bulimia nervosa, which leads to repeated, self-induced vomiting. Other eating disorders commonly cause nausea and may lead to vomiting.
- Cyclical vomiting syndrome - recurrent vomiting in a healthy person, usually a child. There may be tummy pain and a family history of migraine.
- Toxic substances - for example:
- Food poisoning, although this usually lasts less than 48 hours unless you continue to ingest the affected food.
- Poisoning with toxic substances. This may include medicines (either in overdose or in the stated dose), and accidental poisoning - for example, from chemicals, foraged mushrooms.
- Side-effects of medication (either prescribed, or 'over the counter'). Almost any medicine CAN cause nausea, although most don't cause nausea in most people. Medicines that commonly cause nausea include opiates such as codeine and morphine, many antibiotics such as metronidazole and erythromycin, some hormonal contraceptives, some antidepressants, non-steroidal anti-inflammatory medicines and iron tablets.
- Chemotherapy. Chemotherapy medicines vary in their tendency to cause nausea and vomiting.
- Chronic alcohol overuse. Alcohol can inflame both the stomach and the liver, and can also cause nausea and vomiting by a direct chemical effect on the brain.
- Neurological conditions - for example:
- Headache, particularly migraine. All pain can cause nausea and vomiting. Migraine is particularly prone to cause it even when the headache is relatively mild.
- Concussion, which occurs after a head injury that bruises the brain, and can last several weeks.
- Meningitis - causes severe headache, often with neck stiffness and intolerance of light.
- Brain swelling or injury of any cause.
- Brain tumour, which tends to cause persistent and unremitting headache, nausea and sometimes vomiting.
- Metabolic conditions - for example:
- Diabetes, particularly if poorly controlled. Diabetic ketoacidosis (when breakdown products called ketones circulate in the blood) occurs most commonly on patients who are on insulin, and is usually caused by being unwell and not using enough insulin. It can cause persisting, increasing vomiting.
- Addison's disease. This rare condition develops over several months and also causes severe fatigue, weight loss, low blood pressure and other symptoms.
- Hypercalcaemia. A high calcium level is most commonly due to parathyroid gland overactivity, but it can also be caused by certain cancers.
- Uraemia. A condition where there is a build-up of waste products in the blood, usually because the kidneys are not working properly.
- Conditions affecting the inner ear:
- Labyrinthitis. This condition is often viral and can last for several days.
- Ménière's disease. This is a chronic condition affecting the inner ear, which can cause episodes of nausea and vomiting together with tinnitus and hearing loss.
- Some cancers can cause persistent nausea and vomiting, as can their treatment.
When should I contact my doctor about nausea and vomiting?
You should contact your doctor if you have persistent nausea and vomiting for more than 48 hours, or if you feel weak or unwell, both to discover the reason for it and to find out whether there is any treatment that might help. In some cases you should do this urgently. This includes:
- Bringing up (vomiting) blood or bile.
- Weight loss.
- Severe tummy (abdominal) pain.
- High temperature (fever), neck stiffness, a rash, reluctance to look at light.
- Increasing weakness/loss of consciousness.
- Continuous or worsening vomiting after 48 hours.
- The symptoms presenting in a small child or a frail elderly person.
- The person lacking fluid in the body (being dehydrated):
- Dehydration is more likely to occur in children under the age of 1 year (and especially those under 6 months of age), particularly if they also have diarrhoea. This is because babies don't need to lose much fluid to become dehydrated. In children you should have a lower threshold for contacting your doctor about persistent nausea and vomiting.
- If your child is under 6 years old you should contact your doctor if:
- They have both vomiting and diarrhoea.
- They have projectile vomiting.
- You suspect dehydration.
- They have been vomiting repeatedly for more than two or three hours.
- They have a high temperature (fever) with vomiting.
- They have not urinated in more than six hours.
- They complain of severe headache or stiff neck.
- They have a rash, particularly if it does not blanch on pressing with a glass.
- They seem less responsive or confused.
- They have severe tummy pain.
What will the doctor want to know?
The doctor will want to know whether you also have any other symptoms, particularly any that may suggest an underlying serious condition. They will determine whether the nausea and vomiting are making you ill in themselves, and ask questions directed towards finding the cause. For instance:
- Did it start suddenly or develop over time? Did anything trigger it?
- How long has it lasted?
- When do you vomit?
- Do you ever vomit blood or bile (bitter yellow, orange or greenish fluid)?
- Do you have diarrhoea? Are you opening your bowels normally?
- Is anyone else around you affected?
- Do you have a high temperature (fever), weight loss or tummy (abdominal) pains?
- Do you have headaches or visual disturbances when (or before) you are sick?
- How much alcohol do you drink?
- Could you be pregnant?
- Have you started any new medication recently?
- Are you taking any over-the-counter or herbal medicines?
- Have you had a head injury?
- Have you recently returned from abroad?
Your doctor will examine you, checking you for signs of lack of fluid in the body (dehydration) and for clues as to the cause of your symptoms. He/she will check your temperature, and examine your chest and abdomen. You may be asked to produce a urine sample and have a blood test to rule out metabolic conditions such as diabetes, and possibly to check for pregnancy. Further tests may be advised.
Can nausea and vomiting cause any problems?
Most nausea and vomiting do not cause a serious problem.
Problems caused by persistent nausea
- Persistent nausea, which is that experienced in pregnancy, on a long sea voyage, when taking chemotherapy, or due to a chronic medical condition, can be very distressing. Severe nausea can be exhausting and depressing, and some people think it is worse than vomiting (which can feel like a relief to people with persistent nausea).
Problems caused by persistent vomiting
- Repeated vomiting can cause dehydration, particularly in babies and small children.
- Persistent vomiting leads to loss of water and salts from the body, including sodium, potassium and chloride. Altering the balance of the body's salts can lead to complications, including irregularities of the heart rhythm. It can be very difficult to replace lost fluids and salts whilst vomiting continues.
- Tooth enamel damage is common in people with bulimia nervosa who induce vomiting on a regular basis as part of their illness. The acid from the stomach erodes and damages teeth, and digestive enzymes damage gums, leading to dental complications.
- Tears of the oesophageal lining (Mallory-Weiss tears) can cause bleeding, and you may see blood in the vomit. Recurrent vomiting can also lead the stomach and gullet to become inflamed (gastritis and oesophagitis).
- Vomiting whilst unconscious (for instance, after excess alcohol) can be very dangerous, as it can lead to stomach contents getting into your windpipe, and therefore into your lungs, where it can obstruct breathing or lead to severe lung inflammation.
What tests will doctors do for persistent nausea and vomiting?
The tests the doctor will do will depend on your history and examination, as these will give clues as to the most likely possible causes.
If you have been vomiting a lot then your doctor will usually want to check a blood test to make sure that the balance of salts, sugar and other substances in your blood has not been disturbed, and that you are not anaemic.
Other tests that might be offered include:
- Urine dipstick test to look for signs of infection.
- Pregnancy test.
- Imaging studies: X-ray, ultrasound, endoscopy or computerised tomography (CT)/magnetic resonance imaging (MRI) scan.
What treatments are there for persistent nausea and vomiting?
Ideally, the best treatment is to remove the cause, but this is not always possible. See separate leaflet called Medicines for Nausea.
Things you can do for yourself
- Trying to take small volumes of fluid (oral rehydration salts (ORS) can be helpful). If you vomit, wait 10-20 minutes before trying again and try very small sips. Keeping the fluid that you are drinking cold may help you at first.
- Don't try to take solids until you are sure you can manage liquids without vomiting. Once you do, start with light, plain food like toast or crackers.
- Avoid large-volume meals.
- Ginger biscuits are sometimes found to be helpful.
- Avoid physical activity straight after eating.
- If you are pregnant, see also suggestions in the separate leaflet called Morning Sickness in Pregnancy.
- If you are travelling, see also suggestions in the separate leaflet called Motion (Travel) Sickness.
Medicines for nausea and vomiting
Your doctor may offer you medicine for your nausea and vomiting, although they will be less keen to do this if you are pregnant.
- Metoclopramide: is useful for nausea and/or vomiting that is postoperative, or due to radiotherapy, migraine, and late-onset chemotherapy nausea.
- Prochlorperazine: is useful for nausea and vomiting caused by conditions that affect the inner ear, such as labyrinthitis, and those due to some medicines and some forms of cancer.
- Over the counter medicines are available to treat travel sickness, but be aware that some of these can make you very sleepy, sometimes for several hours, which means that if you take them you should not drive.
- Domperidone: is especially useful for nausea and vomiting associated with chemotherapy, and for patients with gastroparesis.
- Granisetron and ondansetron are useful for postoperative sickness, for nausea caused by chemotherapy, and in children.
- Dexamethasone and nabilone: may be useful for patients on cytotoxic drugs.
- Chemotherapy: if your chemotherapy has a high risk of nausea, three medicines that work in different ways may be given - for example, ondansetron, dexamethasone and aprepitant.
- If it is decided that you need treatment for vomiting in pregnancy, promethazine, prochlorperazine or metoclopramide may be prescribed, as they are not thought to harm the unborn baby.
- Some patients with persistent nausea and vomiting find acupuncture helpful.
- In some conditions affecting the stomach and bowel, surgery may be an option.
- Most people who have persistent nausea and vomiting are able to manage to rehydrate themselves using small, frequent drinks and ORS. With persistence, most children can too. The secret is to begin with tiny sips at intervals.
- People who are very lacking in fluid in the body (dehydrated) and who still cannot keep fluids down require intravenous fluids to rehydrate them.
Should I go to work if I have persistent nausea and/or vomiting?
This depends on whether you feel well enough, and on what you and your doctor think is the reason for the vomiting. The 'tests' to ask yourself regarding whether you should work are generally:
- Will I be able to do my job properly?
- Will going to work make my condition worse?
- Will I put others at risk by going to work?
Some people with nausea and vomiting should not go to work, even if they feel well enough to go. This applies to you if your nausea and vomiting might be due to infection, and you could pass that infection on to others. This includes people working in the area of food and hospitality, people working with children and people working in the care of sick or vulnerable patients.
Can nausea and vomiting be prevented?
Nausea and vomiting cannot always be prevented; it is part of the response our bodies have evolved to protect us from harmful substances and dangerous situations.
If you are going into a situation that you know will make you nauseous, such as a journey (because you are travel sick), you may help prevent the symptoms by:
- Eating smaller meals throughout the day.
- Eating plain crackers.
- Trying to drink small amounts of a sugary liquid, such as a soda or fruit juice. Ginger ale can help settle your stomach. Avoid acidic juices, such as orange juice.
- Two approaches which can help travel sickness - these are to look straight out of a front window, or to keep your eye completely closed.
- If taking medicines to prevent nausea and vomiting, taking the medicine 20 minutes to an hour before you are expecting your symptoms to develop. In the case of chemotherapy, you may be advised to take the anti-sickness medicine the previous day.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Mary Lowth
Dr Laurence Knott