Clinical Clinical Gastrointestinal Gastrointestinal cases.cases.

Dr. Ahmed Othman

Assistant lecturer of internal medicine

Case 1

MR is a 40-year-old malenwho complains of burning in his chest moving up towards his throat

• PMH – HTN • Treated with amlodipine/atorvastatin

combination product

Case 1

Wt: 70 kg • Social History: – Smokes 1-1.5 PPD x 20 yrs; • He has had occasional heartburn

in the past, especially following “over-eating.”

• He thinks that this seems different; he has been

eating healthy and exercising.

Gastroesophageal Reflux Disease

GERD - ACG “Clinical” Definition: • Chronic symptoms or mucosal

damage produced by the abnormal reflux of gastric contents into theesophagus

What is the most common presentation of GERD?

1- heart burn 2- Regurgitation 3-cough 4-post meal distension

Heartburn

• The most common symptom of GERD

• Retrosternal chest pain radiating upward toward the throat

What risk factors doesMR have for GERD?

1. Smoking 2. Obesity 3. Amlodipine/atorvastatin 4. 1 and 3 5. 1, 2, and 3

What risk factors doesMR have for GERD?

1. Smoking 2. Obesity 3. Amlodipine/atorvastatin 4. 1 and 3 5. 1, 2, and 3

Risk Factors for GERD

Physical Obesity

• Delayed gastric

emptying

• Pregnancy

• Systemic

sclerosis

• Hiatal hernia

• Recumbency

Behavioral Smoking

• Alcohol use

• Taking medications

such as calcium channel

blockers, nitrates, or

theophylline

• Consuming large meals

(especially before bedtime)

• Eating certain foods such as

chocolate, coffee, peppermint,

or fatty foods

Which of the following wouldbe appropriate approach to initialdiagnosis of MR’s pain?

1. Upper GI series 2. Endoscopy 3. Empiric trial of PPI 4. Gastric pH monitoring

Which of the following wouldbe appropriate approach to initialdiagnosis of MR’s pain?

1. Upper GI series 2. Endoscopy 3. Empiric trial of PPI 4. Gastric pH monitoring

Diagnosing GERD

No gold standard diagnostic test for uncomplicated GERD

• Initial diagnosis obtained via clinical symptoms and confirmed via empiric PPI treatment

• Endoscopy: – Reserved for patients with alarm symptoms or

disease complications – To screen for Barrett’s esophagus in patients with

long-standing GERD • pH Monitoring: patients not responsive to medical

or surgical treatment

Clinical Presentation of GERD

Esophageal/Typical

• Heartburn

• Acid regurgitation

Supraesophageal/Atypical

• Laryngitis

• Asthma

• Chronic cough

• Aspiration pneumonia

• Chest pain

• Dental erosions

Which of the following would be consideredalarm symptoms which warrant immediatereferral to a physician?

1. Regurgitation 2. Chronic cough 3. Laryngitis 4. Dysphagia

Which of the following would be consideredalarm symptoms which warrant immediatereferral to a physician?

1. Regurgitation 2. Chronic cough 3. Laryngitis 4. Dysphagia

Alarm Symptoms ofGastroesophageal Reflux Disease

Weight loss Choking

Dysphagia Chest pain

Bleeding

Therapeutic Goals in GERD

Relief of symptoms Healing of esophageal mucosa Prevent complications Maintainanace of symptoms relief

Life style changes Should be initiated and continued throughout course of

GERD therapy; however changes alone unlikely to control symptoms.

– Weight loss

– Avoidance of recumbency for 3 hours postprandially

– Diet modification (smaller, more frequent meals)

– Avoidance of certain foods (chocolate, peppermint, coffee, and perhaps onions and garlic)

– Cessation of smoking

– Discontinuance of drugs that decrease LES pressure (e.g.,

calcium channel blockers, anticholinergic agents, theophylline)

– Elevation of the head of the bed

The most appropriate therapeutic option for MR at this point would be…

1. Antacids prn 2. Low dose H2RA 3. Famotidine/antacid

combination product 4. PPI

The most appropriate therapeutic option for MR at this point would be…

1. Antacids prn 2. Low dose H2RA 3. Famotidine/antacid combination

product 4. PPI

If MR presents with continued burningin his chest in 4 weeks, despite beinggiven a PPI, you would… 1. Ask when/how he is taking his PPI

2. Refer him to a gastroenterologist

3. Tell him to double his PPI dose

4. Tell him to keep taking it for 6 more weeks to see if it works

If MR presents with continued burningin his chest in 4 weeks, despite beinggiven a PPI, you would… 1. Ask when/how he is taking his PPI 2. Refer him to a gastroenterologist 3. Tell him to double his PPI dose 4. Tell him to keep taking it for 6

more weeks to see if it works

Things to Consider for “PPI Failures”

• Are they taking it? • When are they taking it? • How are they taking it? – with food? • Pharmacokinetic/dynamic principles

The Approach to Maintenance inGastroesophageal Reflux Disease GERD is a chronic condition • Many patients with moderate or severe

GERD will require maintenance therapy • H2RAs may be effective in some patients,

although most will require long-term PPIs • The regimen needed to initially manage

symptoms is often the regimen needed to maintain remission of symptoms • Short courses (at least 2 to 4 weeks) of intermittent therapy may be an option forsome patients

Indications for Surgery

• Reasonable alternative for patients withmoderate to severe GERD

• Patient responds to medical therapy but suffers frequent and bothersome recurrence or is unwilling to live with the limitations imposed by medical therapy

• Young patient who needs medical therapy indefinitely

• Patient refractory to medical therapy • Cost (lifelong PPI therapy vs. surgery)?

Case 2

Case 2 It is 3 a.m. and an ambulance arrives at accident

and emergency (A&E) carrying Mr Ali salem, a 42-yearold man.

He has blood down his chin and over his shirt, but is alert and orientated. The emergency services were called out by the staff of a local night shelter. As he argued with the staff , he began to vomit. The staff saw he was vomiting blood and called for an ambulance. The paramedics state that en route to the hospital he retched and brought up a few spoonfuls of blood plus clots. Mr Ali is immediately placed in the resuscitation room.

How will you manage this patient?

Call for help

A (air way) ensure that it patent B ( tachypnea, stridor,…..) C( the patient is shocked?) D ( disability GCS)

Mr Ali starts to tell you about his days in the army

as the team take his vital observations, suggesting his airway is clear and he is breathing. He has a heart

rate (HR) of 130 bpm, respiratory rate of 30/min and blood pressure (BP) of 86/52 mmHg (supine). His

oxygen saturations are 97% on air. His GCS is 15/15.

What is your next step?

Mr Ali is in shock, i.e. he has an inadequate circulating volume, often defined as a BP <90/60 mmHg. He needs fluid resuscitation:

Get intravenous (IV) access: insert a large bore (14G–16G) cannula into each antecubital fossa.

• Take bloods for:

− Full blood count (?how anaemic is this patient –when bleeding).

− Clotting − Urea and creatinine (?

hypovolaemia/acute renal failure – also an elevated urea would indicate a signifi cant gastrointestinal (GI) bleed (effectively a large protein meal) that had gone on long enough to be digested and broken down into urea).

− Electrolytes (?electrolyte disturbance from vomiting). K+ may be elevated due to destruction of ingested red blood cells.

− Liver enzymes (?liver disease, a major cause of oesophageal varices and therefore of haematemesis).

− Cross-match four to six units of blood

• Volume resuscitation:

Give up to 2 L of normal saline (i.e. allowed to go in as rapidly as possible under monitoring HR and BP for response).

− Consider giving 1 or 2 units of blood† if there is fresh blood on digital rectal examination (suggesting ongoing bleeding) or signs of shock despite giving the normal saline, such as a postural drop in BP of >15 mmHg, or a systolic BP <100 mmHg. Use O, Rh-negative blood if type-specifi blood has not yet arrived.

Monitoring

insert a urinary catheter (to monitor renal function).

(CVP) line if:

− Elderly and shocked patient: >60 years old and systolic BP <100 mmHg or Rockall score ≥3.

− Severe cardiac, respiratory, or renal disease.

− Patient requires more than four units of blood.

Case cont…..

Two large-bore cannulae are inserted, bloods are taken, and 2 L of normal saline started.

Mr Ali is observed carefully for 15 minutes. His HR is now 110 bpm and his BP has risen to 100/61 mmHg.

Question 2

What is you next step now that the patient is stable?

You need to establish where the blood came from

What are the causes of haematemesis?

Hematemesis

Peptic ulcer disease Gastric ulcer

Duodenal ulcer

Mallory-Weiss tear

Portal hypertension Esophagogastric varices

Gastropathy

Esophagitis

Dieulafoy’s lesion

Vascular anomalies

Hemobilia

Hemorrhagic gastropathy

Aortoenteric fistula

Neoplasms Gastric cancer

Kaposi’s sarcoma

Presenting complaint and systemic enquiry • How much blood has the patient

vomited? • What exactly was the character of

the vomit? Fresh blood suggests an upper GI bleed. ‘Coff ee grounds’ suggests blood that has been partially digested by stomach acids but might be confused with faeculent vomiting may occur with small bowel obstruction.

• Melaena (tarry black stools) or frank blood in stool?

Haematochezia is fresh blood in the stools. It is usually due to lower GI haemorrhage but can be due to a upper GI haemorrhage if the bleeding is profuse or the GI transit time fast.

• Did forceful vomiting trigger the haematemesis? Suspect a Mallory–Weiss tear

• Recent weight loss? Suspect upper GI malignancy.

• Problems swallowing? Suspect oesophageal malignancy.

• Easy bruising, distended abdomen, puff y ankles, lethargy? Suspect liver failure.

• Epigastric pain? Gnawing epigastric pain suggests gastric carcinoma.

Past history

Previous upper GI haemorrhage? How was it managed?

• Heartburn or epigastric pain? Suspect a bleeding peptic ulcer or bleeding oesophagitis/gastritis/duodenitis.

Bleeding tendency? Suspect a clotting problem that needs correcting.

• Chronic liver disease? Suspect both a bleeding tendency and oesophageal varices.

Drug history

Anticoagulants (e.g. warfarin)? Suspect a clotting problem.

• Regular non-steroidal anti-inflammatory drugs (NSAIDs),aspirin, steroids, or bisphosphonates? Suspect peptic ulcer disease.

Mr Ali is unsure whether the vomiting triggered the haematemesis or whether it was haematemesis from the very beginning.

He tells you that he had taken 4 tab of analgesic due to headache. He frequently has heartburn but denies any reflux.

He smokes ‘as much as [he] can’ and admits to having taken illicit drugs in the past, saying ‘you name it, I’ve done it’. He has never had any surgery and there’s been no change in his stools or weight. He does not take any regular medications.

What will you look for on examination?

Inspection Tattoos? Needle track marks? Piercings? •

Signs of liver disease: jaundice, scratch marks (jaundice is itchy), bruising, spider naevi (more than four), palmar erythema, gynaecomastia, ascites, ankle oedema, caput medusae? Suspect liver cirrhosis.

• Purpura? Suspect thrombocytopaenia (e.g. immune thrombocytopenic purpura (ITP) chronic liver disease).

• Cachexia? Suspect malignancy.

ABD EX

Hepatomegaly? • Splenomegaly? Suspect portal

hypertension (usually, but not always, due to liver cirrhosis).

• Epigastric tenderness? Suspect peptic ulcer disease or gastritis/duodenitis.

• Epigastric mass? Supraclavicular lymphadenopathy (Virchow’s node)? Suspect malignancy.

P/R • Haemorrhoids?

Case cont….

Mr Ali is jaundiced, has, and several tattoos. He is thin, but not cachectic.

He has palmar erythema and at least 10 spider naevi over his chest and shoulders). A digital rectal examination is unremarkable.

Investigations.

Hb 12.7 g/dL RBC 3.2 × 1012 cells/L WCC 5 × 109 cells/L Platelets 105 × 109

cells/L MCV 112 fL Albumin 20 g/L Bilirubin 62 μM ALT 105 U/L AST 94 U/L ALP 52 U/L

GGT 230 U/L Serum amylase 56 U/L Urea 9.1 mM Creatinine 102 μM Na 136 mM K 4.1 mM PT 21.5 seconds APTT 52 seconds

What do these blood results suggest?

Are there any further investigations you will request in light of his history, examination, and initial blood results?

?

Low albumin, platelet count Elevatd bilirubin, liver enzymes,

urea Coagulopathy

You should order:

Viral markers.??Urine analysis?

It is difficult to accurately identify the aetiology of haematemesis until endoscopy is performed.

How would you manage any haematemesis patient whilst they await endoscopy? Is there anything you would do differently or in addition in the case of Mr Tucker, and why?

All patients awaiting endoscopy for haematemesis should be managed as follow

• Regular observation. Hourly to begin with. Every 30 minutes if BP or HR.↓ ↑

• Nil by mouth. The patient must remain nil by mouth until the endoscopy is performed. Stomach contents will obstruct the view at endoscopy and carry a significant risk of aspiration into the lungs during the procedure.

• Fluids. All patients will need ongoing IV fluids as they are nil by mouth and potentially still bleeding.

• Correct coagulopathy. If your clotting screen has identified a clotting abnormality,

Our patient should additionally be managed for his suspected chronic liver diseaseand oesophageal varices

Reduce portal hypertension. Glypressin is an ADH agonist that reduces mesenteric blood flow and thus reduces portal pressure. An IV infusion is effective in about 80% of patients.

• Antibiotic cover. should also receive fairly broad-spectrum antibiotics (e.g. ciprofloxacin) prior to endoscopy, as up to 50% of patients with liver disease and upper GI bleeding develop sepsis

Rx

Glypressin 2m1 amp Claforan 1 9m ,cefotax, tavanic 500

or alfacef 500 bottle Hemakion amp IM or slowly IV. Controloc 40 mo vial

Endoscopic report

Large sized esophageal varices(F3), bluish in color (Cb), located at the middle third(Lm), with multiple red color signs(RC+++), band ligation was done with good hemostasis.

Severe PHG.

If endoscopy fail to control bleeding:

Ballon tamponade.

TIPS

Surgery.

Medical TTT of bleeding peptic ulcer. PPI 80 mg IV bolus then 40 mg/5 hr IV Infusion( 48-

72 hr).

PPI vials

Nexium 40

Controloc 40

Pantazole 40

Zurcal 40

Risek 40

Case 3

Mr fouad is 50 year old male patient complaining from diffuse abdominal pain , not known to be diabetic or hypertensive , and examination revealed hepatomegaly.

his physician asked abdoninal u/s for him which done and revealed enlarged fatty liver, other wise is normal

Next step?

1- Lipogram 2-hepatitis marker 3-Fasting blood glucose 4-liver enzymes 5-All of the above

Next step?

1- Lipogram2-hepatitis marker3-Fasting blood glucose4-liver enzymes5-All of the above

Lipogram ---normal Fasting blood glucose ---normal HCV Ab +ve HBs Age –ve AlT---90 AST—110

Next step?

1-Liver biopsy 2- HCV RNA by PCR 3-Start treatment of CHC

immediately 4-all of the above

Next step?

1-Liver biopsy 2- HCV RNA by PCR 3-Start treatment of CHC

immediately 4-all of the above

HCV RNA IS:

1.298.312

You diagnose MR Fouad to be chronic hepatitis C infection , what would you do next?

Sofosbuvir 400 mg

Sovaldi Sofolanork Gratisovir Hopefor hep Nucleobuvir Tigaglor

Daclatasivir 60 mg

Daclanork Clatasev Daklenza dactavira

When you order PCR?

1- every month 2-after end of treatment 3- 3 months after end of TTT 4-all of the above

When you order PCR?

1- every month 2-after end of treatment 3- 3 months after end of TTT 4-all of the above

Investigations you order monthly?

1-CBC,ALT,AST,Bilrubin 2-Albumin,PT,Creatinine 3-PCR 4-HCV Ab 5-1,3

Investigations you order monthly?

1-CBC,ALT,AST,Bilrubin 2-Albumin,PT,Creatinine 3-PCR 4-HCV Ab 5-1,3

NB

Any cirrhotic patient and chronic HBV patientss( with or without L.C), should be screened for HFL by abdominal u/s and AFP every 6 months.

Case 4

Miss Nadia is 35 year old pregnant 32 week presented with a 3 days history of nausea and vomiting , her vomit look like a digested food,

she has been un able to keep anything down other than a bit of water and some soup, she has had a high temperature;

She is multiparous with four previous children and says she never had any morning sickness (or any other problems) during those pregnancies. Two of her children have also been unwell with vomiting and diarrhea over the past week.

On examination, her pulse is 88 bpm, blood pressure 110/66 mmHg, temperature 37.7°C, respiratory rate 12/min, and oxygen saturations of 98% on room air. Her abdomen is soft and non-tender, and the fetal heart rate is present and normal.

Blood test results include:

Na 136 mM,

K 3.8 mM,

urea 8.1 mM, creatinine 148 μM.

Urinalysis is unremarkable.

What is the most likely diagnosis?

1- hyperemesis gravidarum 2-gastroenteritis 3- morning sickness 4- Food poisoning

What is the most likely diagnosis?

1- hyperemesis gravidarum 2-gastroenteritis 3- morning sickness 4- Food poisoning

Classifications- Primary Vs. Secondary :

A- Primary : Usually due to a GI illness ( Obstruction Or Gastroenteritis )

B- Secondary : Due to either :

1- Sever visceral pain .2- Sever Systemic illnesses ( MI , Sepsis , Shock ) .3- Specific conditions like : pregnancy “ Hormonal “ , Raised ICP “ CNS Mechanism “ , Toxins “ Homeostatic Reflex “ . Motion Sickness “ Neuroendocrine “ Or Chemo “ CTZ “ .

Classifications- Acute Vomiting : Occurs ( < or = 1 Week ) , Usually associated with : obstruction , ischemic , toxic , metabolic , infectious , neurological and post-operative reasons .

- Chronic : Occurring for more than 1 Month , Usually due to partial obstruction , motility disorder , neurological chronic condition , pregnancy or functional reasons .

- Cyclic : Which has an onset of repetitive but interrupted cycles of high frequency vomiting , followed by an asymptomatic phase usually due to Viral Causes .

- Recurrent .

Most Common Cause Of Nausea And Vomiting

1- Acute Gastroenteritis

2- Systemic Febrile Illnesses .

3- Medications

All of following can complicate vomiting except?

1- Hypovolemia 2-Aspiration 3-Hypokalemia 4-metabolic acidosis

All of following can complicate vomiting except?

1- Hypovolemia 2-Aspiration 3-Hypokalemia 4-metabolic acidosis

Sequelae Of Vomiting-Aspiration :-Mallory Weiss tear -Dehydration-Electrolyte imbalance-Metabolic acidosis

All of the following are warning manifestations in N/V except?

1-High grade fever 2-Crushing chest pain 3-Diarrhea 4-Reduced consciousness

All of the following are warning manifestations in N/V except?

1-High grade fever 2-Crushing chest pain 3-Diarrhea 4-Reduced consciousness

Warning manifestation of N/V

1- high grade fever

2-Reduced cosciousness

3-Rigid abdomen

4-Meningeal signs

5-Morning vomiting,headache,projectile

6-Chest pain

7- Faeculant, Bilious vomiting

8-Hematemesis

An Approach of patient with vomiting

History 1- Duration : to define the type of vomiting and to give you a close picture of what kind of sequelae might have this patient developed .

2- Time + Onset / Offset : to define the type or the etiology causing it :

A- Acute Onset : Gastroenteritis , Pancreatitis , Cholycystitis , Appendicitis , Anaphylaxis , Medication Effect Or Toxicity .

B- Morning : Raised ICP , Primary Tension or Migraine Headaches , Pregnancy , Uremia , Alcoholism .

C – 1 Hour After Eating : Gastric Outlet Obstruction Or Gastroparisis .

D- 12 Hours After Eating : Gastric Or Intestinal Obstruction .

History 3- Content Of The Vomit :

- If Bilious >>> then Gastric outlet obstruction is out of the question , cause the area between the stomach and duodenum is intact .

- If Undigested Food >>> Achalasia Or Stricture

- If Digested Food >>>> Might be due to toxins or anaphylaxis .

- If Hematemisis >>> Suspect Upper GI Bleed with its causes .

- If Fecal Mater Or Smells So >>>> Distal Bowel Obstruction , Fistula , Bacteria Overgrowth due to long standing outlet obstruction .

History 4- Associated Symptoms : Hyper-salivation, defecation, tachycardia, bradycardia, atrial fibrillation, and termination of ventricular tachyarrhythmias are associated phenomena with nausea and vomiting. Chronic headaches with nausea and vomiting should raise the index of suspicion for an intracranial lesion. Also, vomiting without preceding nausea is typical of central nervous system pathology

5- Past Medical & Surgical Hx : The past medical history will reveal the presence of any GI disease or previous surgeries

6- Social & Traveling Hx : The social history should include inquiries about alcohol or other substance abuse.

7- Medications & Dietary Habits : Nutritional history is valuable in the consideration of failure to thrive in infancy thorough medication list, including over-the-counter drugs, should be included.

Physical Examination

Tests- CBC : If Hb and HCT are High >>> Dehydration due to loss of dilutional effect .

- Electrolytes : Hypochloremia , Hypokalemia .

- BUN / Creatinine Ratio : If 20:1 >> Sever Dehydration .

- Lipase : Pancreatitis >>> Dehydration

- Urineanalysis : For UTI , Pregnancy Test , DKA , Hematouria , Stones , Sterile Pyoria in Appendicitis .

- Culture , Sensitivity & Titers : To Rule In Or Out Infection ( B , V , F , P ) .

- LFTs + Ammonia : Cholysystitis , Ascending Cholingitis , Liver Failure .

- Chest & Abdominal X-Rays : Focus , Perforation , Obstruction .

- CT & Angio : Ischemia & Infarction .

- ECG : MI - TFT : Thyroid Disease - Drug Levels

DDx In General Population

Assessment & Management

- Make sure you cover your : A-B-C-D-E

- Try to limit and stop lethal & Critical causes like Boerhaave's , GI Bleed , Mesenteric Ischemia , Intracranial Bleed , Meningitis , DKA , MI & Sepsis .

- Direct your therapy to the cause of nausea and vomiting while treating the effects of that process .

Assessment & Management

1- Rehydration & Electrolyte Imbalance: If the patient can take orally and tolerate it , Give ORS or Any rehydration fluids like Getorade , If cant take P.O >>>> I.V Aiming To Replenish Fluid Volume And Electrolytes Loss .

2- Nasogastric Tube : If the patient is persistently vomiting due to a GI bleed , Gastroparisis , Pancreatitis , Or Bowel Obstruction .

Assessment & Management3- Pharmacological Treatment (( Very Important )) :

A- Phenothiazine : (( Prochlorperazine , Droperidol, Promethazine ))

- Have Dopamine Antagonistic Effect In CTZ .

- Side Effects may include : Restlessness and Dystonia , Which can be treated with Diphenhydramine + Benztropine.

B- Serotonin Antagonists : (( Ondansetron“ Zofran, Danset “ ))

- Works Well In Area Posterma & The GI Tracts .

- Best For Chemotherapy & Theophylline Or Acetaminophen Toxicity Adjunct Therapy .

- Side Effects may include : Headaches & Constipation .

Assessment & Management

C- Prokinetic Agents : (( Metoclopramide (primperan-plasil, Cisapride))

- Works as An Antagonist to Dopamine + Cholinergic + Serotonin Receptors .

- Cisapride Works On The GI Receptors Only Unlike Metoclopramide .

- They Both Increase Gastric Motility & Emptying .

- Side Effects may include : Restlessness , Lightheadedness & Dystonia .

D – Antihistamines : (( Dimenhydrinate , Meclizine (navoproxine,ezadoxine )cyclizine as emetrex)

- Best used to prevent Motion Sickness & N&V Due To Vestibular Problems .

- Side Effects may Include : Drowsiness , Dry Mouth , & Hypertension .

Assessment & Management

E – Anticholinergics: (( Scopolamine & Hyoscine“ Bascopan “ ))

- Which may be given as a supportive treatment to colicky pain in Uncomplicated acute gastroenteritis & and is also effective in prophylaxis of Motion Sickness

F- Benzodiazepines :

- Which are effective in Nausea and vomiting due to anxiety disorder .

G- Substance P Neurokinin 1 Antagonists : (( Aprepitant ))

- Used an adjunct therapy to prophylaxis against post Chemotherapy N&V as well as Post-Operative .

Etiology Directed Treatment

- Pregnancy Related N&V :

* For Mild To Moderate >>> Rehydration P.O or I.V + Pyridoxine + Antihistamines + Prokinetic Agents + Ondansetron + Prochlorperazine.

* For Severe >>> Admission , Fluids + Electrolytes , Corticosteroids .

- Post Operative Related N&V : Due To Nitroxide & Propofol

* Ondansetron , Metoclopramide, Droperidol.

- Post Chemotherapy Related N&V : Acute ( 24 Hours ) Chronic ( > 1 Day )

* Ondansetron + Aprepitant + Dexamethasone.

Dosage

Nausea & Vomiting Dietary Steps

- We cant expect all patients who had nausea and vomiting to resume their normal diet once vomiting stops , it should be in the following sequence to grantee a relaxed gradual coming back to normal diet :

Step 1 : Start With Water , Clear Fluids & Electrolyte Replenishing Drinks , Keep In Mind That Citrus & Sweet Flavored Can Irritate GI .

Step 2 : After Pt Has Tolerated Clear Fluids , Next Step Is Semi Liquids Like Soups , Bare In Mind Though That They Should Be Low Fat High Carbs .

Step 3 : Tolerating The Above , Start On A Moderate Diet Of High Protein And Low Fat

Step 4 : Patient Can Resume Normal Diet , If Above Are Tolerated .

DO NOT DISCHARGE IF1- There Is A Significant Underlying Disease .

2- If The Diagnosis Or Cause Of Nausea & Vomiting Isn’t Clear .

3- Poor , Relapse Or No Response To Treatment .

4- Nausea & Vomiting Continues Or Becomes Even More Frequent .

5- If The Patient Is Of The Extremes Of Age .

6- If The Patient Is Un-Able To Follow Up In The Clinic .

7- If The Patient Is Dependant Or Unable To Follow Instructions .

8- If The Patient Still Cant Take Per Oral .

DISCHARGE IF1- There Is No Significant Underlying Disease .

2- If The Cause Is Clear & Appears To Be No Serious .

3- Good Or Full Response To Treatment .

4- Nausea & Vomiting Becomes Less Or Stops .

5- If The Patient Can Actually Take Clear Fluids Per Oral .

6- If The Patient Has A Close Follow-Up In 24-48 Hours .

7- If The Patient Understands The Instructions & Is Able To Abide To Them And Is Self Dependant .

Take Home Message1- Understanding Pathophysiology Of N&V Is Important In Defining & Treating Lethal And Critical Causes .

2- Not Every Etiology Responds To Just Antiemetic Therapy , Your Goal Is To Know How And Why And From Where Its Happening In Order To Hit The Right Receptor With Your Medication .

3- Although Nausea & Vomiting Might Sound Easy And Less Serious Than A lot Of Signs & Symptoms , Its Sequelae Can Sometimes Be Catastrophic .

4- Abide To The ( A , B , C , D , E ) Protocol In Management .

5- Treat The Causes As You Are Treating The Sequelae Of N & V