Nausea and Vomiting (PowerPoint download) by ewghwehws


									Nausea and Vomiting
• To get a detailed history and
  associated symptoms
• To get the DD
• To recognize and treat
             Case 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
• What is her diagnosis?
• 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’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-

Ipecac syrup
  Common etiologies of nausea
       and vomiting
• GI tract disorders              • Other CNS disorders
   – toxins, infections,              – migraine, neoplasm, bleed
     obstruction, inflammation,
     motility disorders           • Vestibular disorders
• Non-GI infections               • Metabolic/endocrine
                                      – DKA, uremia, adrenal
   – liver, CNS, renal,                 insufficiency, hyper- or
     pneumonia, others
                                        hypothyroidism, hyper- or
• Pregnancy                             hypoparathyroidism

• Visceral inflammation           •   Alcohol intoxication
   – pancreas, GB, peritoneum     •   Psychogenic
• Myocardial ischemia             •   Radiation exposure
  or infarction                   •   Medications
    Clues 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:
        when 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
     nausea and vomiting
• Cancer chemotherapy           • Metformin
   – e.g. cisplatin
                                • Anti-parkinsonians
• Analgesics                      – e.g., bromcryptine, L-DOPA
   – e.g. opiates, NSAIDs
                                • Anti-convulsants
• Anti-arrythmics                 – e.g., phenytoin, carbamazepine
   – e.g., digoxin, quinidine
                                • Anti-hypertensives
• Antibiotics
   – e.g., erythromycin
                                • Theophylline
• Oral contraceptives           • Anesthetic agents
     Complications 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
(“mask phenomenom)

                  Cutis, 1986
       Nausea and Vomiting:
      Key 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:
        Key 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
        history 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
     history 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

or marker
        Treatment of nausea
           and vomiting
1. Treat complications regardless of cause
  e.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-
 erties and known mechanisms
• Antihistamines, e.g., meclizine (AntivertR)
   – esp. for vestibular disorders
• Anticholinergics, e.g., scopolamine (Transderm ScopR,
   – 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
          properties (continued)
          Multiple mechanisms of action:
• Promethazine (PhenerganR)
   –   dopamine antagonist
   –   H1 antihistamine
   –   anticholinergic
   –   CNS sedative
   –   prevention of opiate-induced nausea and vomiting
• Hydroxyzine (AtaraxR, VistarilR)
   –   H1 antihistamine
   –   anticholinergic
   –   CNS sedation
   –   prevention of opiate-induced nausea and vomiting
      Drugs with anti-emetic
      properties (continued)
     Uncertain mechanism of action:
• Trimethobenzamide (TiganR)
  – 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-BismolR)
 Adjunctive antiemetic agents
• Dexamethasone (DecadronR)
  – along with other anti-emetics for prevention of
    cancer chemotherapy-induced emesis
• Dronabinol (MarinolR)
  – for prevention of cancer chemotherapy-induced
    emesis refractory to other agents
  – [ also for anorexia and weight loss in AIDS]
• 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 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 hyperemesis
   gravidarum. Am J Obstet Gynecol 167: 648, 1992 and J.
   Clin Endocrin Metab 75: 1333, 1992

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