The symptoms of an episode of diabetic ketoacidosis usually evolve over a period of about 24 hours. Predominant symptoms are nausea and vomiting, pronounced thirst, excessive urine production and abdominal pain that may be severe. In severe DKA, breathing becomes rapid and of a deep, gasping character, called "Kussmaul breathing". The abdomen may be tender to the point that a serious abdominal condition may be suspected, such as acute pancreatitis, appendicitis or gastrointestinal perforation. Vomiting altered blood that resembles coffee grounds occurs in a minority of people and tends to originate from erosion of the esophagus. In severe DKA, there may be confusion or a marked decrease in alertness, including coma.