| ID | 13 |
|---|---|
| Name | NAUSEA & VOMITING |
| Cause | 1. Infections: Gastroenteritis, food poisoning, hepatitis A or B, acute systemic infections, urinary tract infections etc. 2. Gastrointestinal diseases: Gastric outlet obstruction- peptic ulcer disease, malignancy. Small intestinal obstruction- adhesions, hernias, volvulus, crohn’s disease, carcinomatosis. Gastroparesis- diabetic, medications, postviral, posrvago-tomy. 3. Acute abdominal conditions: Peritonitis- due to perforation of gas containing hollow viscus, appendicitis, spontaneous bacterial peritonitis. Cholecystitis, pancreatitis. 4. Hepatobiliary or pancreatic disorders: Acute pancreatitis, cholecystitis or choledocho-lithiasis. 5. Drugs & irritants: Alcohol, NSAIDs, oral antibiotics, opioids, anticonvulsants, antiparkinsonism drugs, p-blockers, antiarrhythmics, digoxin, nicotine, oral contraceptives, oral anti-diabetics, cytotoxic drugs etc. 6. Cardiac diseases: Acute myocardial infarction, congestive cardiac failure. 7. Urological disease: Stones, uremia. 8. CNS disorders: Headache, migraine, vertigo, labyrinthitis, meniere’s syndrome, motion sickness, increased intracraneal pressure due to CNS tumours, subdural or subarachnoid hemorrhage, meningitis, encephalitis, psychogenic causes. 9. Endocrine: Diabetic ketoacidosis, adrenocortical crisis, hypothyroidism, parathyroid disease. 10. Radiation therapy: Radiation therapy in malignancy. 11.Pregnancy: Specially in the early months. |
| Signs Symptoms | Symptoms that occur with nausea and vomiting include: Abdominal pain. Diarrhea. Fever. Light-headedness. Vertigo. Rapid pulse. Excessive sweating. Dry mouth. |
| Diagnosis | 1. Pyloric stenosis- effortless projectile vomiting; frothy copious, recognizable old food with sour smell & no bile. 2. Peritonitis- small in amount & persistent vomiting. 3. Gastroenteritis- persistent vomiting with diarrhoea. 4. Peptic ulcer- ‘cofry ground’ coloured vomiting, after meal relieves pain. 5. Oesophageal varieces- copius amount fresh blood. 6. Nasopharynx, oropharynx- bright red blood. 7. Advanced intestinal obstruction- feculent vomit. 8. Psychogenic- vomiting but no weight loss. 9. Acute appendicitis, acute cholecystitis, acute intestinal obstruction- sudden onset of vomiting; bile may be present. lO.Intracranial disease- vomiting without preceeding nausea, headaches, stiff neck, vertigo, focal paresis or weakness. 11. Severe pain & vomiting suggest, peritoneal irritation, acute intestinal obstruction, pancreatobilliary disease. 12. Acute symptoms without or with mild abdominal pain caused by food poisoning, infectious gastroenteritis, drugs. 13. Vomiting immediately after meal suggests bulimia or psychogenic causes. 14. Chronic vomiting- gastroparesis, psychogenic causes. 15,On examination aspiration of 200ml of gastric residual material of fasting patient suggests gastric outlet obstruction (GOO). Ausculto-purcussion & succution splash is also done in gastric outlet obstruction. |
| Investigations | Nil investigations may be appropriate. Basic biochemistry may include (as appropriate): • electrolytes and renal function • full blood count • pancreatic and liver enzymes • glucose. If small bowel obstruction is suspected, erect and supine abdominal radiographs should be considered. |
| Management | Eat bland foods, such as dry toast and crackers. Eat food cold or at room temperature to decrease its smell and taste. Avoid fatty, fried, spicy, or very sweet foods. Try small amounts of foods high in calories that are easy to eat (such as pudding, ice cream, sherbets, yogurt, and milkshakes) several times a day |
| Introduction | Nausea: Nausea is an intensely disagreeable sensation of sickness or queasiness, with a feeling of wanting to vomit1. It is often associated with autonomic effects including hyper salivation, pallor & sweating, & usually proceeding emesis. Vomiting: Expulsion of gastric contents through the mouth due to a forcful contraction of abdominal muscles and diaphragm. Regurgitation: Appearence of previously swallowed food in the mouth without vomiting i.e an effortless reflux of liquid or food contents of stomach1. It usually has an acid or bitter taste because of the presence of gastric juice or bile. This is due to contraction of the stomach muscles against closed pylorus. The pathophysiology of vomiting is due to stimulation of medullary vomiting centre by four different sources of afferent input: i. afferent vagal fibres & splanchnic fibres from the gastrointestinal viscera, ii. fibres of the vestibular system, iii. higher central nervous system centres (viz. certain sights, smells, or emotional experiences may induce vomiting), iv. the chemoreceptor trigger zone, located outside the blood-brain barrier (which may be stimulated by drugs and chemotherapeutic agents, toxins, hypoxia, uremia, acidosis, and radiation therapy |
| History | |
| Etiology | See under cause |
| Clinical Features | See under sign and symptoms |
| Preventions | Eat bland foods, such as dry toast and crackers. Eat food cold or at room temperature to decrease its smell and taste. Avoid fatty, fried, spicy, or very sweet foods. Try small amounts of foods high in calories that are easy to eat (such as pudding, ice cream, sherbets, yogurt, and milkshakes) several times a day |
| Treatment | A. General management: 1. Nothing should be given by mouth until the vomiting stops. 2. When vomiting stops dry food in small amount to be given frequently. Better to give cold food. 3. Simple acute vomiting due to morning sickness, dietary or alcoholic indiscretion may require little or no treatment. Avoiding known aggravating factors and taking simple corrective dietary measures may suffice. 4. If vomiting is severe and prolonged- attempt should be taken to determine the cause and specific medication. 5. General measures- adequate hydration and correction of electrolyte imbalance by oral saline or 5-10% dextrose in saline may be given intravenously. B. Medical treatment: • Antihistamines & anticholinergics (e.g meclizine, dimenhydrinate): Meclizine 25-50mg daily orally in nausea and vomiting. In motion sickness, an initial dose of 25-50mg 1 hour prior to travel, may be repeated every 24 hours for the duration of the journey. In vertigo, 25-100mg daily in divided doses. Dimenhydrinate 25-50mg orally or by i.m every 4-6 hourly may be useful for patients with vestibular disorders, such as, motion sickness, vertigo, migraines. • Dopamine antagonists (e.g metoclopramide, prochlorperazine, promethazine, trimetho-benzamide): Metoclopramide 10-20mg every 6-8 hours orally or i.v may be useful in nausea & vomiting of gastrointestinal disorders & cancer chemotherapy. Prochlorperazine 5-10mg orally or by deep i.m or i.v every 4-6 hours or 25mg suppository every 6 hours may be used for vomiting caused by drugs, radiation sickness or surgery. Promethazine 25-75mg daily orally or i.m or i.v. For severe nausea & vomiting in pregnancy, 25mg at bedtime, increased if mecessary to a maximum of l00mg daily. Children, 5-10 years, 12.5-37.5mg daily, High doses of dopamine antagonists are associated with antidopaminergic side effects, including extrapyramidal reactions and deprssion. • Sedatives- Benzodiazepines (e.g diazepam, lorazepam), alone or with anticholinergics, may be helpful in patients with psychogenic and anticipatory vomiting. Diazepam 2-5mg may be given every 4-6 hours orally or i.v. Or, Lorazepam l-2mg every 4-6 hours orally or i.v. • Serotonin 5-HT3-receptor antagonists (viz. ondansetron, granisetorn, dolasetron and palonosetron) are effective in preventing chemotherapy and radiation-induced nausea and vomiting when administered before initiation of treatment. Ondansetron 8mg twice daily orally; or, 8mg once or twice daily to 24-32mg once daily by i.v. Granisetron Img or 0.0lmg/kg once daily i.v; or 2mg once daily orally. Dolasetron 100mg or 1.8mg/kg once daily i.v; or 100mg once daily orally. • Corticosteroids (e.g dexamethasone, methylprednisolone) are found to play role as antiemetic in chemotherapy induced vomiting, but the basis of this effect is unknown. These products also enhance the efficacy of serotonin receptor antagonists. Dexamethasone 8-20mg i.v once daily; or, 4-20mg once or twice daily orally may be helpful in chemotherapy induced vomiting. Methylprednisolone 40-100mg once daily i.v. C. Psychotherapy: After determining the possible psychic basis. D. Treatment of complications: Such as pulmonary aspiration of vomitus, malnutrition, hypokalemia, alkalosi |
| Complications | If a patient is unconscious or only partly conscious, the vomitus may be inhaled (aspirated). The acid in the vomitus can severely irritate the lungs, causing aspiration pneumonia. Chronic vomiting can result in undernutrition, weight loss, and metabolic abnormalitie |
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