What is the cause of white emesis (vomitus)?

From the Guidelines

White emesis in infants is most commonly caused by gastroesophageal reflux (GER) and is usually benign, but it can also be a sign of underlying pathology, such as intestinal obstruction, which requires prompt medical evaluation. According to the American College of Radiology 1, vomiting in infants can be categorized as nonbilious or bilious, with the latter suggesting a more serious underlying condition. The clinical differentiation between vomiting and regurgitation can be challenging, but a thorough clinical evaluation, including history and physical examination, can lead to the diagnosis in most instances.

Some key points to consider when evaluating an infant with white emesis include:

• The presence of bilious emesis or repeated forceful vomiting, which should be evaluated for underlying obstruction 1
• The age of the infant, as congenital GI tract abnormalities are a primary consideration in the first week of life 1
• The presence of other symptoms, such as abdominal pain, fever, or blood in the vomit, which can indicate a more serious underlying condition
• The infant's weight gain and overall health, as infants with normal weight gain and no other symptoms tend not to have obstruction as the cause of their vomiting 1

In terms of management, parents should seek medical evaluation if their infant experiences white emesis, especially if it's accompanied by other concerning symptoms. While waiting for medical care, infants should be kept hydrated with small sips of clear fluids, and solid foods, alcohol, caffeine, and NSAIDs should be avoided. In some cases, over-the-counter antacids or H2 blockers may be recommended for temporary symptom relief, but this should only be done under the guidance of a healthcare professional.

From the Research

Definition and Causes of White Emesis

• White emesis, also known as nausea and vomiting, can be caused by various factors, including gastrointestinal diseases, metabolic and endocrine conditions, neurologic causes, and psychogenic disorders 2, 3.
• The pathophysiology of nausea and vomiting involves neuronal pathways and neurotransmitters, and treatment should be directed based on knowledge of these pathways 2.

Evaluation and Treatment of Nausea and Vomiting

• A practical 5-step approach to the clinical evaluation and treatment of nausea and vomiting includes defining the patient's symptoms, determining whether symptoms are acute or chronic, considering medication or toxin adverse effects, formulating a differential diagnosis, and directing treatment based on the underlying cause 2.
• Management of acute nausea and vomiting may involve an empirical trial of antiemetics without extensive testing, while chronic or moderate-severe symptoms require testing for an underlying cause and consideration of medication adverse effects, neurologic causes, gastrointestinal diseases, metabolic or endocrine conditions, and psychogenic disorders 2, 3.
• Nonpharmacologic management options include fluid and electrolyte replacement, small, frequent meals, and avoidance of trigger foods, while antiemetic drugs can effectively reduce symptoms of acute nausea and vomiting 3.

Specific Treatments for Nausea and Vomiting

• A long-acting bimodal release oral ondansetron tablet has been shown to be an effective antiemetic among adolescents and adults with moderate to severe vomiting from acute gastroenteritis, decreasing the need for intravenous access and emergency department care 4.
• Treatment of chronic nausea and vomiting should be based on a thoughtful discussion of benefits, side effects, and costs, and may involve pharmacotherapy, bioelectrical neuromodulation, behavioral and surgical therapies, and complementary medicine 5, 6.

Challenges and Future Directions

• Chronic nausea and vomiting can be difficult to control, leading to a significant decline in the patient's quality of life and increased cost of medical care from repeated hospitalizations 6.
• Emerging understandings of the pathophysiology of nausea and vomiting are leading to improved therapies, including newer immunotherapies, bioelectrical neuromodulation, and complementary medicine 6.