Vomiting is often associated with gastrointestinal (GI) disturbances such as food poisoning, gastritis, or intestinal infections. However, there exists a wide range of non-GI causes of vomiting—conditions that originate outside the digestive tract yet present with nausea and emesis as key symptoms.
To simplify and remember these non-GI causes, the mnemonic “ABCDEFGHI” serves as a reliable, clinically relevant tool. Each letter stands for a systemic condition that may trigger vomiting. This article will explore these in-depth, supporting each with pathophysiology, clinical presentations, diagnostic relevance, and management strategies.
A – Acute Renal Failure and Addison’s Disease
Acute Renal Failure
Acute renal failure (also known as acute kidney injury or AKI) leads to an accumulation of metabolic waste products in the bloodstream, particularly urea and creatinine. This state, known as uremia, disrupts the chemoreceptor trigger zone (CTZ) in the brain, provoking nausea and vomiting.
Addison’s Disease
Addison’s disease, or primary adrenal insufficiency, results in a lack of cortisol and aldosterone, leading to electrolyte imbalances such as hyponatremia and hyperkalemia. These imbalances are potent triggers for vomiting. Cortisol deficiency also lowers the body's stress threshold, exacerbating gastrointestinal symptoms.
Clinical Clues:
- Fatigue
- Hypotension
- Salt craving
- Hyperpigmentation
- Nausea and vomiting
B – Brain Pathology: Raised Intracranial Pressure (ICP)
The vomiting center in the medulla is highly sensitive to increased intracranial pressure (ICP). Conditions like traumatic brain injury, tumors, hydrocephalus, or meningitis can raise ICP and provoke sudden, often projectile vomiting, typically without preceding nausea.
Red flags for brain-induced vomiting:
- Morning vomiting
- Headache
- Papilledema
- Altered consciousness
- Seizures
This type of vomiting is a neurological emergency and mandates immediate neuroimaging (e.g., CT or MRI).
C – Cardiac Conditions: Myocardial Infarction
It may surprise some, but myocardial infarction (MI), especially the inferior wall MI, can cause vomiting as a primary symptom. The vagus nerve, which innervates the heart and stomach, gets stimulated during cardiac ischemia, triggering nausea and vomiting.
Who is at risk of silent or atypical MIs with vomiting as the main symptom?
- Diabetics
- Elderly individuals
- Women
Accompanying symptoms may include:
- Epigastric discomfort
- Shortness of breath
- Sweating (diaphoresis)
- Fatigue
- Chest tightness
D – Diabetic Ketoacidosis (DKA)
DKA is a medical emergency caused by insulin deficiency, typically in type 1 diabetes mellitus. The acid-base imbalance, along with the accumulation of ketone bodies and dehydration, triggers vomiting.
Clinical features:
- Polyuria and polydipsia
- Abdominal pain
- Deep, labored (Kussmaul) breathing
- Fruity breath odor
- Altered mental status
Lab Clues:
- High blood glucose
- Low bicarbonate
- High anion gap metabolic acidosis
- Positive urine/serum ketones
E – Ear Disorders: Labyrinthitis and Ménière’s Disease
The inner ear plays a critical role in balance. Infections (labyrinthitis) or conditions like Ménière’s disease can disturb the vestibular system, leading to vertigo that is often accompanied by nausea and vomiting.
Symptoms:
- Spinning sensation (vertigo)
- Nausea and vomiting
- Tinnitus (ringing in the ears)
- Hearing loss
- Nystagmus
These symptoms are due to overstimulation of the vestibular nuclei, which are closely linked to the vomiting center in the medulla.
F – Foreign Substances: Alcohol and Drugs
Toxins such as alcohol, recreational drugs, or medications (e.g., chemotherapeutic agents, digoxin, opioids) can directly irritate the stomach lining or activate the chemoreceptor trigger zone (CTZ) in the brainstem, leading to vomiting.
Common offenders:
- Chemotherapy drugs (cisplatin, doxorubicin)
- Digitalis toxicity
- Excessive alcohol
- Opiates
- Antibiotics (erythromycin, tetracyclines)
Mechanisms:
- Gastric irritation
- Vestibular disturbance
- Central (CNS) activation
G – Gravidarum (Hyperemesis Gravidarum)
Nausea and vomiting are common in pregnancy, particularly during the first trimester. However, in hyperemesis gravidarum, these symptoms become severe and prolonged, leading to weight loss, electrolyte imbalances, and ketosis.
Risk Factors:
- Multiple gestation
- Molar pregnancy
- History of motion sickness
- Female fetus
Consequences if untreated:
- Dehydration
- Nutritional deficiencies
- Wernicke’s encephalopathy
H – Hypercalcemia
Elevated serum calcium levels disrupt gastrointestinal motility and CNS function, leading to:
- Anorexia
- Nausea
- Vomiting
- Constipation
- Confusion
Common causes:
- Hyperparathyroidism
- Malignancy (PTHrP-related)
- Vitamin D toxicity
- Thiazide diuretics
- Prolonged immobilization
Classic mnemonic:
"Stones, Bones, Groans, Thrones, and Psychiatric Overtones"
I – Infections (UTI, Meningitis)
Certain infections outside the GI tract can trigger vomiting through systemic inflammation, fever, or central nervous system involvement.
Urinary Tract Infection (UTI)
Severe UTIs, especially pyelonephritis, can present with vomiting due to fever, renal involvement, and toxin release.
Meningitis
Meningitis causes increased intracranial pressure, triggering vomiting, particularly in children. Other signs include:
- Neck stiffness
- Photophobia
- Seizures
- Confusion
- Fever
Tabular Summary of the ABCDEFGHI Mnemonic
| Mnemonic | Condition | Mechanism of Vomiting | Diagnostic Clues |
|---|---|---|---|
| A | Acute Renal Failure, Addison’s | Uremia, electrolyte imbalance | ↑ Creatinine, hyponatremia, hyperkalemia |
| B | Brain (↑ ICP) | Pressure on vomiting center | Headache, papilledema, seizures |
| C | Cardiac (MI) | Vagal stimulation | Chest pain, epigastric discomfort |
| D | Diabetic Ketoacidosis | Acidosis, ketonemia | Fruity breath, Kussmaul respiration |
| E | Ear diseases | Vestibular dysfunction | Vertigo, tinnitus, nystagmus |
| F | Foreign substances (drugs, ETOH) | CTZ stimulation, gastric irritation | History of exposure |
| G | Gravidarum (pregnancy) | hCG stimulation of vomiting center | Positive pregnancy test, ketonuria |
| H | Hypercalcemia | GI motility disruption, CNS effects | Serum calcium >10.5 mg/dL |
| I | Infection (UTI, meningitis) | Systemic inflammation or ↑ ICP | Fever, altered mental state |
Frequently Asked Questions (FAQ)
Can vomiting occur without a stomach or digestive issue?
Yes. Vomiting is a reflex controlled by the brain, specifically the vomiting center in the medulla. It can be activated by toxins, pressure, hormonal changes, or vestibular dysfunction, all of which can occur independently of the GI tract.
What are red flags that vomiting is non-GI in origin?
- Vomiting without nausea
- Associated neurological symptoms (headache, vision changes, seizures)
- No relief after vomiting
- Recent head trauma
- Severe dehydration without diarrhea
- Signs of systemic illness (e.g., altered mental status, fever, hypotension)
Is vomiting a symptom of heart attack?
Yes, especially in inferior wall myocardial infarction, where vagal stimulation can cause nausea and vomiting. This presentation is particularly common in elderly, diabetic, and female patients.
Why does high calcium cause vomiting?
Hypercalcemia disrupts the neurological and GI systems, leading to decreased gastric motility and central symptoms like confusion and nausea.
How does pregnancy cause vomiting?
Elevated levels of human chorionic gonadotropin (hCG) stimulate the vomiting center, especially in the first trimester. In hyperemesis gravidarum, this effect becomes severe and pathological.
