Nausea and Vomiting

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Nausea and Vomiting

• Mark Feldman, MD

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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
  disorder.
• What is her diagnosis?

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Terminology

• 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

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Terminology, contd

• 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

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VOMITING PATHWAYS
Ipecac syrup
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Inter-subject variability in emesis threshold in
humans

• 18 healthy volunteers received the same dose of
  the opiate/dopamine agonist, apomorphine
• Apo dose adjusted for weight (0.03 mg/kg s.q.)
• Responses among volunteers were heterogeneous
• 16 reported nausea within 62 minutes after
  injection
• 14 developed vomiting 82 minutes after
  injection the other 2 who reported nausea did
  not vomit
• 2 neither reported nausea nor experienced vomiting

Cannon,Best,Batson,and Feldman. Behavior Research
Therapy 21669-73,1983
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Common etiologies of nausea and 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

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Nausea/vomiting as component of CC on teaching
service at PHD (75 cases)

• Gastroduodenal 6
• PUD (2), FD, DG, GOO,food poisoning
• Intestinal diseases 8
• SBO(2), LBO, pseudo-obstruction,
  gastroenteritis(2), diverticulitis (2)

• Pancreatitis 6
• Biliary disease 5
• cholecystitis (3), cholangitis (2)
• Hepatic disease 5
• hepatitis (3), liver masses, ischemia vs.
  hepatitis

GI DISEASES (n 30 )
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Nausea/vomiting as component of CC on teaching
service at PHD (75 cases)
OTHERS (n45)

• Metabolic 11
• DKA(6), hypergylcemia, hypo-
• glycemia, hypercalcemia, hypo-natremia (3)
• Toxic 5
• alcohol, CO, digoxin, lithium, ethylene glycol
• Miscellaneous 4
• Malaria, pneumonia, bulimia, diabetic foot ulcer
  with osteo

• CNS disease 13
• CVA/TIA (4), meningitis (4), seizure (2),
  primary tumor, brain metastases, toxo/HIV
• Renal causes 8
• uremia (4), UTI stones (2), acute renal
  failure, renal infarct
• Cardiac 4
• cocaine-induced (2), USA, afib

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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

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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)

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Medications that often cause nausea 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

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Less commonly recognized causes of nausea and
vomiting

• Rapid weight loss/ body casts (SMA syndrome)
• Infectious esophagitis
• esp. if immunocompromised
• Opiate withdrawal
• Herbal preparations
• Pregnancy
• nausea of early pregnancy
• hyperemesis gravidarum
• AFLP/ HELLP syndrome

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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 (Boorhaaves)
• Metabolic electrolyte, acid-base, water
• Renal prerenal azotemia ATN hypokalemic
  nephropathy

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Post-emetic purpura (mask phenomenom)
Cutis, 1986
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Mallory-Weiss tear with clot
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Two tears one at 7 oclock opposite other tear
at 1 oclock
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Esophageal hematoma secondary to forceful emesis
Lumen
?mass
Digestive Diseases and Sciences 26 1019, 1981
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Electrolyte and acid-base disorders due to
vomiting

• Metabolic alkalosis
• retention of HCO3- volume-contraction
• Hypokalemia
• renal K losses GI K loss ? oral K intake
• Hypochloremia
• gastric chloride losses
• Hyponatremia
• free water retention due to volume contraction

Typical SMA-6
Pearl Patients with uremia or Addisons disease
may have normal or even high serum K despite
vomiting
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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?

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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)

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Laboratory studies guided by history and physical

• Electrolytes, glucose, BUN/creatinine
• Calcium, albumin, total serum proteins
• CBC
• LFTs
• Pregnancy test
• Urinalysis
• Serum lipase ? amylase

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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

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Chronic vomiting due to gastroparesis associated
with a gastric bezoar
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Test meal liquid, digestible solid and
indigestible solid
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Radiopaque markers still in the stomach 6 hours
after meal in a diabetic with nausea
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Markers in stomach 24 hours after ingestion in
patient with pseudo-obstruction and small cell
lung cancer
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(No Transcript)
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ALGORITHMIC APPROACH
or marker
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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)

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Drugs with anti- emetic prop-erties 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

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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

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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)

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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

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Summary

• 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.

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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