nNausea is the subjective disagreeable sensation of the need to vomit that may or may not result in vomiting.
nVomiting (emesis) is the forcible expulsion of the gastrointestinal contents through the mouth.
nThis is different from regurgitation, which is the passive passage of the gastric contents into the mouth.
nVomiting is controlled by the vomiting center in the medulla
nIt is triggered by
nafferent neural pathways from the gastrointestinal (GI) tract
ncerebral cortex
nvestibular apparatus
nchemoreceptor trigger zone within the medulla provides input to the vomiting center in response to bloodborne stimuli (such as drugs, toxins, and metabolic disorders)
Differential Diagnosis
nThere are a myriad of causes of nausea and vomiting, which can be included in the differential diagnosis
nThey range from mild, quickly resolving illnesses to serious, life-threatening conditions
nThe causes can be classified according to conditions within the GI tract and conditions outside the GI tract
Conditions within the GI tract
nObstructive
nPyloric obstruction
nSmall bowel obstruction
nColonic obstruction
nEnteric infections
nHepatitis
nViral gastroenteritis
nBacterial gastroenteritis
nInflammatory diseases
nPancreatitis
nAppendicitis
nCholecystitis
nMalignancy
nMetastatic disease
nRadiation therapy
nPancreatic cancer
nMucosal injury
nGastritis
nEsophagitis
n Peptic ulcer disease
nImpaired motility
nIntestinal pseudo-obstruction
nFunctional dyspepsia
nGastroesophageal reflux
nIrritable bowel syndrome
Conditions outside the GI tract
nPregnancy
nHyperemesis gravidarum
nCardiopulmonary disease
nMyocardial infarction
nLabyrinthine diesease
nMotion sickness
nViral Labyrinthitis
nMalignancy
nIntracerebral disorders (increased intracranial pressure)
nBrain tumor
nHemorrhage
nAbscess
nPseudotumor cerebri
nMigraine
nCNS infections
nMeningitis
nEncephalitis
nCyclic vomiting syndrome
nPsychiatric illness
nAnorexia and bulimia
nDepression
nAnxiety
nPsychogenic
Medications
nCancer chemotherapy
nAntibiotics
nDigoxin
nOral hypoglycemics
nOral contraceptives
nNonsteroid anti-inflammatory drugs
nBeta blockers
nOpioids
nTheophylline
nIron supplements
Endocrine/metabolic disease
nUremia
nLiver failure
nKetoacidosis
nThyroid and parathyroid disease
nAdrenal insufficiency
nNephrolithiasis (renal colic)
nPostoperative vomiting
APPROACH
nThe history and physical examination provide clinic clues that will narrow the large differential diagnosis
nThe history should reveal information on symptom characteristics such as
nduration of symptoms,
nseverity,
nfrequency,
nprovocative features such as relationship to meals and medications, and
nthe quality and quantity of vomits.
History
nAcute onset of nausea and vomiting in the setting of severe abdominal pain –
ngastrointestinal cause
nobstruction or
nperitoneal irritation from one of the inflammatory conditions (appendicitis, cholecystitis, and pancreatitis).
nAcute symptoms without abdominal pain -gastroenteritis, medications, central nervous system (CNS) conditions like hemorrhage and infection, and myocardial infarction
nChronic nausea and vomiting:
nGI conditions associated with impaired motor function (dysmotility),
nCNS diseases, and
nsystemic illnesses ranging from malignancy to endocrinopathies.
nIntermittent and recurrent symptoms:
ncyclic vomiting syndrome, a rare disorder of unknown etiology but strongly related to migraine headaches.
Clinical clues to Possible cause of nausea and vomiting:
nQuality of vomiting
nBilious - Small bowel obstruction
nFeculent- Small bowel obstruction or rarely colonic
nProjectile - Pyloric obstruction or intracerebral condition
nHematemesis-Peptic ulcer disease, esophageal varices, esophagitis (GERD), Mallory-Weiss tear
nPartially digested food - Gastroparesis or pyloric obstruction
nQuantity
nLarge volumes- Small bowel obstruction
nFrequency
nOnly in the morning -Pregnancy, intracerebral condition, uremia, and alcohol use
nRecurrent and intermittent - Cyclic vomiting syndrome
nProvocative features
nImmediately after eating Eating disorder (bulimia)
n>1 hour after eating -Gastroparesis or pyloric obstruction
nWhile a passenger in car- Motion sickness
nRecumbent posture - Intracranial involving the posterior fossa
nAfter taking medications - Medications
nAssociated symptoms
nCrampy, colicky pain- Obstructive conditions
nAbdominal pain relieved with vomiting- Pyloric obstruction
nEpigastric pain radiating to back -Pancreatitis
nRight upper quadrant abdominal pain - Cholecystitis
nRight lower quadrant abdominal pain- Appendicitis
nAbdominal pain radiating to groin- Nephrolithiasis (renal colic)
nJaundice, dark urine, light stools- Hepatitis or choledocholithiasis
nConstipation - Colonic obstruction
nDiarrhea, myalgia, headache -Viral gastroenteritis
nChest pain and diaphoresis - Myocardial infarction
nHeadache- Migraine, meningitis, gastroenteritis, or intracerebral process
nNeck stiffness, photophobia, altered mental status- Meningitis
nVertigo and ataxia –Labyrinthitis
nMissed menstrual period- Early pregnancy
nAssociated comorbid conditions
nDiabetes-Ketoacidosis or gastroparesis
nHistory of abdominal surgery -Small bowel obstruction
nHeart disease- Myocardial infarction
nKidney disease- Uremia
nPeptic ulcer disease- Pyloric obstruction
nPregnancy- Hyperemesis gravidarum, acute fatty liver, HELLP syndrome
nMigraine headaches- Cyclic vomiting syndrome
Physical exam findings
nFever- Infection or inflammatory conditions
nHigh-pitched bowel sounds- Mechanical obstruction
nSuccussion splash- Pyloric obstruction
nRebound and guarding - inflammatory disorders
nPapilledema- Intracerebral disorders
nNystagmus - Labrynthine disorder
nKernig and Brudzinski signs- Meningitis
Treatment-General Measures
nMost causes of acute vomiting are mild, self-limited, and require no specific treatment.
nPatients should ingest clear liquids and small quantities of dry foods
nFor more severe acute vomiting, hospitalization may be required.
nPatients unable to eat and losing gastric fluids may become dehydrated, resulting in hypokalemia with metabolic alkalosis.
n Intravenous saline solution with 20 mEq/L of potassium chloride is given in most cases to maintain hydration.
nA nasogastric suction tube for gastric decompression improves patient comfort and permits monitoring of fluid loss.
nSerotonin 5-HT3-receptor antagonists- Ondansetron, granisetron
nDopamine antagonists- The phenothiazines, butyrophenones, and substituted benzamides have antiemetic properties that are due to dopaminergic blockade as well as to their sedative effects.
nDopamine D2 antagonists treat emesis evoked by area postrema stimuli and are useful for medication, toxic, and metabolic etiologies.
nCorticosteroids- Corticosteroids (eg, dexamethasone) have antiemetic properties, but the basis for these effects is unknown
nFor the prevention of postoperative nausea and vomiting, corticosteroids, serotonin antagonists, and droperidol have efficacy; however, combinations of these agents have additive benefit.
nAntihistamines and anticholinergics- eg, meclizine, dimenhydrinate, transdermal scopolamine
nvaluable in the prevention of vomiting arising from stimulation of the labyrinth, ie, motion sickness, vertigo, and migraines
nSedatives- Benzodiazepines are used in psychogenic and anticipatory vomiting
nProkinetic agents- Metoclopramide, Erythromycin , Domperidone and Tegaserod.
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