Nausea and VomitingNausea and Vomiting

Objectives

• To get a detailed history and associated symptoms

• To get the DD

• To recognize and treat typhoid

Case ReportCase Report

• A 29 year old woman G1/P0/Ab0 complains of severe, recurrent vomiting, worse in the morning but sometimes in the later part of the day, and failure to gain weight. She is in her 13th week of pregnancy. Her past medical history is negative except for obsessive-compulsive disorder.

• What is her diagnosis?

TerminologyTerminology

• Nausea: from the Latin naus ( a ship); a very unpleasant sensation that one may soon vomit

• Retching: muscular activity of the abdomen and thorax, often voluntary, leading to forced inspiration against a closed mouth and glottis without oral discharge of gastric contents (“dry heaves”)

• Vomiting: involuntary contractions of the abdominal, thoracic and GI (smooth) muscles leading to forceful expulsion of stomach contents from the mouth

Terminology, cont’dTerminology, cont’d

• Regurgitation: effortless return of esophageal or gastric contents into the mouth unassociated with nausea or involuntary muscle contractions.

• Rumination: food that is regurgitated in the postprandial period, re-chewed and then re-swallowed

VOMITINGVOMITINGPATHWAYSPATHWAYS

Ipecac syrup

Common etiologies of nausea Common etiologies of nausea and vomitingand vomiting

• GI tract disorders– toxins, infections,

obstruction, inflammation, motility disorders

• Non-GI infections – liver, CNS, renal,

pneumonia, others

• Pregnancy• Visceral inflammation

– pancreas, GB, peritoneum

• Myocardial ischemia or infarction

• Other CNS disorders– migraine, neoplasm, bleed

• Vestibular disorders• Metabolic/endocrine

– DKA, uremia, adrenal insufficiency, hyper- or hypothyroidism, hyper- or hypoparathyroidism

• Alcohol intoxication• Psychogenic • Radiation exposure• Medications

Clues to psychogenic vomitingClues to psychogenic vomiting

• Usually female and often young

• May deny or minimize nausea

• Rarely occurs in public or in front of others

• Co-existent eating disorder, laxative abuse, diuretic abuse common

• Psychological disturbances common

• Complications of vomiting may be present

Surreptitious vomiting: Surreptitious vomiting: when to suspect itwhen to suspect it

• Unexplained weight loss

• Co-existent eating disorder or other psychological condition

• Co-existent laxative and/or diuretic abuse

• Electrolyte and/or acid-base disturbances consistent with vomiting, including hypo-

kalemic nephropathy• Emetic complications (with denial of vomiting)

Medications that often cause Medications that often cause nausea and vomitingnausea and vomiting

• Cancer chemotherapy– e.g. cisplatin

• Analgesics– e.g. opiates, NSAIDs

• Anti-arrythmics– e.g., digoxin, quinidine

• Antibiotics– e.g., erythromycin

• Oral contraceptives

• Metformin• Anti-parkinsonians

– e.g., bromcryptine, L-DOPA

• Anti-convulsants– e.g., phenytoin, carbamazepine

• Anti-hypertensives • Theophylline• Anesthetic agents

Complications of VomitingComplications of Vomiting• Nutritional

– adults: weight loss; kids: failure to gain

• Cutaneous (petechia, purpura)

• Orophayngeal (dental, sore throat)

• Esophagitis/ esophageal hematoma• GE Junctional: M-W tears; rupture (Boorhaave’s)

• Metabolic: electrolyte, acid-base, water

• Renal: prerenal azotemia; ATN; hypokalemic nephropathy

Post-emetic purpura Post-emetic purpura (“mask phenomenom)(“mask phenomenom)

Cutis, 1986

Nausea and Vomiting: Nausea and Vomiting: Key Historical QuestionsKey Historical Questions

• How long?

• Relationship to meals?

• Contents of vomitus?

• Associated symptoms– pain in chest or abdomen, fever, myalgias, diarrhea,

vertigo, dizziness, headache, focal neurological symptoms, jaundice, weight loss

• Diabetes?

• When was last menstrual period?

Nausea and Vomiting: Nausea and Vomiting: Key Physical FindingsKey Physical Findings

• Vital signs

• BP and pulse tilt test

• Cardiopulmonary exam

• Abdominal exam

• Rectal exam

• Neurological exam including funduscopic exam (papilledema)

Laboratory studies: guided by Laboratory studies: guided by history and physicalhistory and physical

• Electrolytes, glucose, BUN/creatinine

• Calcium, albumin, total serum proteins

• Complete blood count (CBC)

• Liver Function Tests

• Pregnancy test

• Urinalysis

• Serum lipase amylase

Radiology studies: guided by Radiology studies: guided by history and physicalhistory and physical

• Plain abdominal films

• Abdominal sono or CT if pain is key feature

• Head CT or MRI if severe headache, papill-edema, marked hypertension, altered mental status, or focal neurological findings

• EGD or upper GI to separate GOO or high duodenal obstruction from gastroparesis

• Radiopaque marker emptying studies or radionuclide scintigraphy, esp. if diabetic

Radio-opaque markers still in the stomach 6 hours after meal in a

diabetic with nausea

ALGORITHMICAPPROACH

or marker

Treatment of nausea Treatment of nausea and vomitingand vomiting

1. Treat complications regardless of causee.g., replace salt, water, potassium losses

2. Identify and treat underlying cause, whenever possible

3. Provide temporary symptomatic relief of the symptoms

4. Use preventive measures when vomiting is likely to occur (e.g., cancer chemotherapy, parenteral opiate administration)

Drugs with anti- emetic prop-Drugs with anti- emetic prop-erties and known mechanismserties and known mechanisms

• Antihistamines, e.g., meclizine (AntivertR)

– esp. for vestibular disorders

• Anticholinergics, e.g., scopolamine (Transderm ScopR, DonnatalR)

– esp. for vestibular and GI disorders

• Dopamine antagonists, e.g.,metoclopramide (ReglanR) or prochlorperazine (CompazineR)

– esp. for GI disorders

• Selective serotonin-3 (5HT3) RAs, e.g., odansetron, granisetron, dolasetron

– esp. to prevent chemotherapy-induced nausea/vomiting

Drugs with anti-emetic Drugs with anti-emetic properties (continued)properties (continued)Multiple mechanisms of action:Multiple mechanisms of action:

• Promethazine (PhenerganPromethazine (PhenerganRR))– dopamine antagonist

– H1 antihistamine

– anticholinergic

– CNS sedative

– prevention of opiate-induced nausea and vomiting

• Hydroxyzine (AtaraxHydroxyzine (AtaraxRR, Vistaril, VistarilRR))– H1 antihistamine

– anticholinergic

– CNS sedation

– prevention of opiate-induced nausea and vomiting

Drugs with anti-emetic Drugs with anti-emetic properties (continued)properties (continued)Uncertain mechanism of action:Uncertain mechanism of action:

• Trimethobenzamide (TiganTrimethobenzamide (TiganRR))– blocks apomorphine-induced emesis in dogs

– does not block emesis from p.o. CuSO4 in dogs

probably acts in the chemoreceptor trigger zone (CTZ) of the medulla oblongata

• Bismuth subsalicylate (Pepto-BismolBismuth subsalicylate (Pepto-BismolRR))

Adjunctive antiemetic agentsAdjunctive antiemetic agents

• Dexamethasone (DecadronDexamethasone (DecadronRR))– along with other anti-emetics for prevention of

cancer chemotherapy-induced emesis

• Dronabinol (MarinolDronabinol (MarinolRR))– for prevention of cancer chemotherapy-induced

emesis refractory to other agents– [ also for anorexia and weight loss in AIDS]

SummarySummary• Nausea and vomiting are features of many GI and non-GI

diseases and disorders.

• Regardless of its cause, treatment of nausea and vomiting should initially focus on replacing volume and electrolyte deficits. Later on, nutritional deficits must be addressed.

• Regardless of its cause, nausea and vomiting can cause several life-threatening GI and non-GI complications.

• Elucidation of the cause is often possible, and treatment of the underlying cause will usually be successful.

• Effective symptomatic therapies for nausea and vomiting are available when the cause is unclear or when the treatment of the underlying cause takes time to work.

Follow up on Case ReportFollow up on Case Report

• The patient was diagnosed with hyperemesis gravidarum.

• Her TSH was undetectable, her free T4 and serum T3 were markedly elevated.

• Her symptoms resolved in a few weeks, without recurrence.

Goodwin et al. Transient hyperthyroidism and hyperemesisgravidarum. Am J Obstet Gynecol 167: 648, 1992 and J.Clin Endocrin Metab 75: 1333, 1992