7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 1/30

Nausea and Vomiting in Adolescents and Adults

Rahul Kuver, M.D. , John V. Sheffield, M.D. , and George B. McDonald, M.D.

1.0 Introduction

Nausea means feeling "sick to the stomach", a sensation that is associated with the urge to vomit. Vomiting, the forceful discharge

of gastric contents, may be a protective physiologic mechanism that prevents entry of potentially harmful substances into the

gastrointestinal tract 1!. ersistent vomiting can lead to dehydration, severe alkalosis, bleeding and rarely esophageal perforation

## irrespective of the cause of vomiting.

Vomiting is to be differentiated from retching, regurgitation or rumination. Retching or dry heaves involves the same

physiological mechanisms as vomiting, but occurs against a closed glottis$ there is no e%pulsion of gastric contents. Regurgitation is the return of small amounts of food or secretions to the hypopharyn% in the conte%t of mechanical obstruction of

the esophagus, gastroesophageal reflu% disease or esophageal motility disorders. Rumination is similar to regurgitation, e%cept

small amounts of completely swallowed food are returned to the hypopharyn% from the stomach and is often re#swallowed &!.

'umination is not associated with nausea.

(his review of nausea and vomiting is based on a )*+IN* literature search encompassing 1--0#&000, using the )e/

headings Nausea and Vomiting with the subheadings omplications, +iagnosis, +rug (reatment, (reatment, *tiology, sychology

and 'adiography. ertain articles, including placebo#controlled trials of therapy, comprehensive reviews and other publications

deemed seminal, were reviewed and are referenced. ertain articles prior to 1--0 were also reviewed. (he emphasis is placed on

articles that provide evidence which can be incorporated into guidelines for diagnosis and management.

ertain patients typically present with nausea and vomiting, such as cancer chemotherapy patients, patients recovering fromgeneral anesthesia, pregnant women and patients whose symptoms are related to motion. )any of these patients are seen in the

primary care setting. In most cases, the history can point to the etiology without the need for sophisticated diagnostic testing or

referral. In a minority of patients, unusual causes of nausea and vomiting may reuire thorough diagnostic testing and referral to a

specialist 1!.

2ssessment of the duration of nausea and vomiting is an important initial point in the history. ymptoms present for less than a

week may be due to conditions which are separable from those causing symptoms over weeks, months or years.

or acute nausea and vomiting, the diagnostic algorithm is !ased on three "e# $uestions %&a!le '(3

&a!le ' )) Ke# $uestions in the evaluation of acute nausea and vomiting 

1. Is immediate therapy necessary regardless of the cause4

&. 2re empiric symptomatic treatment and reassurance sufficient4

2. Is the patient a woman of child#bearing age4

5. 2re there symptoms of motion sickness or vertigo4

. 2re symptoms consistent with a viral syndrome4

6. Is e%peditious workup reuired to establish the cause4

2. Is abdominal or chest pain present4

5. Is there a history of drug, to%in, or environmental e%posure4

. an a pregnancy#related condition e%plain symptoms4

+. 2re N symptoms present4

*. an an infection account for symptoms4

7. 2re nausea and vomiting symptoms of a systemic disease4

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 2/30

8. Is the patient immunosuppressed4

/. Is the patient recovering from general anesthesia4

I. Is there an unusual cause or effect of nausea and vomiting4

7or chronic nausea and vomiting, the diagnostic algorithm is based on history and physical e%am findings that point to the organ

system involved3 the gastrointestinal tract, the nervous system or the endocrine system. sychogenic causes are an important

additional category to consider in chronic nausea and vomiting. 2 subset of patients will have no cause identified despite

e%tensive diagnostic testing. (his group of patients may benefit from referral to speciali9ed centers. ertain presentations prompt

referral to a gastroenterologist %&a!le '*(.

&a!le '* )) +am-les of S#m-toms and Diagnoses that rom-t Referral to a Gastroenterologist

ymptom:+iagnosis 7eatures (iming of 'eferral

8I bleeding ;rthostatic hypotension,tachycardia. igns suggesting ongoing

 bleeding melena, bright red blood in vomitus!

<rgent

2lkaline caustic ingestion +ysphagia, odynophagia stridor, chest pain,

abd pain

<rgent

2cetaminophen overdose 'ising prothrombin time, mental status

changes

<rgent$ evaluation

for orthotopic liver

transplantation

uspected gastric outlet

obstruction

Vomiting old food, large volume of vomitus,

succusion splash

<rgent or elective

Immunocompromised pt +ysphagia, odynophagia, chest:abd pain <rgent or elective

Inflammatory bowel disease 5loody diarrhea, fever, abdominal pain,

abdominal distention

<rgent or elective

holangitis 7ever, leukocytosis, =aundice,

elevated transminases, bilirubin, alkaline

 phosphatase

<rgent

8* reflu% disease 'efractory to symptomatic treatment *lective

hronic intractable

nausea:vomiting with

unrevealing workup

  *lective

1.1 2ssociated ymptoms

ertain symptoms are typically associated with nausea and vomiting. 2ssociated upper 8I tract complaints such as bloating,

early satiety, dysphagia and odynophagia should be sought. +yspepsia can be associated with nausea. ightheadedness,abdominal or chest pain, cough or hematemesis are symptoms that should prompt an assessment for conditions that may

reuire immediate therapy regardless of the underlying cause of nausea and vomiting. 2 missed menstrual period, vertigo,

arthralgias, low grade fevers and nausea and vomiting associated with motion are clues that suggest a condition that may be

treated empirically . ymptoms that are severe, such as chest or abdominal pain, N symptoms, fever with chills, a history

of an underlying systemic disease or of immunosuppression should prompt a diagnostic workup.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 3/30

1.& hysiology of nausea and vomiting

(he vomiting refle% is triggered by stimulation of chemoreceptors in the upper 8I tract and mechanoreceptors in the wall of the

8I tract which are activated by both contraction and distension of the gut as well as by physical damage. 2 coordinating center in

the central nervous system controls the emetic response. (his center is located in the parvicellular reticular formation in the lateral

medullary region of the brain. 2fferent nerves to the vomiting center arise from abdominal splanchnic and vagal nerves, vestibulo#

abyrinthine receptors, the cerebral corte% and the chemorece-tor trigger /one (>!.(he (> lies ad=acent in the area postrema

and contains chemoreceptors that sample both blood and cerebrospinal fluid. +irect links e%ist between the emetic center and the

(>. (he (> is e%posed to emetic stimuli of endogenous origin such as hormones associated with pregnancy and to stimuli of

e%ogenous origin such as drugs 6!. (he efferent branches of cranial nerves V, VII, and I?, as well as the vagus nerve and

sympathetic trunk produce the comple% coordinated set of muscular contractions, cardiovascular responses and reverse peristalsis

that characteri9es vomiting @!.

(he area postrema is rich in dopamine receptors and is a target for the antagonists haloperidol, metoclopramide and the

phenothia9ines. /istamine#1 and muscarinic cholinergic receptors are present in the nucleus ambiguus and lateral vestibular

nucleus. A#hydro%ytryptamine A/(! receptors are present within the area postrema. A/( can activate dopamine release. (he new

A/(6 receptor antagonists have demonstrated efficacy against cytoto%ic chemotherapy#induced emesis A!. +rugs effective

against motion sickness##such as prometha9ine, diphenhydramine and scopolamine##have little effect against cytoto%ic drug#

nduced emesis.

&.0 2cute nausea and vomiting

ymptoms present for less than a 0ee" are defined as acute. (he causes of nausea and vomiting of short duration are often

separable from etiologies leading to more chronic symptoms. In the initial evaluation of a patient presenting with acute nausea and

vomiting, assessment regarding the need for immediate therapeutic intervention regardless of the underlying cause is important. If

mmediate therapeutic intervention to correct the conseuences of vomiting are not necessary, or has been performed, then the

mportant uestions are whether empiric treatment of nausea and vomiting and reassurance are sufficient, and whether e%peditious

diagnostic work#up to determine the underlying cause is necessary. (hese latter two uestions are linked, and key historical points

can help determine the most appropriate diagnostic testing and therapy. 'eferral for additional diagnostic tests and:or management

needs to be considered for a variety of situations.

&.1 Immediate therapeutic intervention is necessary regardless of the cause.

• Vomiting with intravascular volume depletion reuires immediate intervetion

ertain conseuences of vomiting reuire immediate treatment regardless of the cause. (he diagnosis and treatment of conditions

described in this section are outlined in %&a!le *(.

Table 2 -- Problems caused by vomiting: signs, symptoms and treatment 

Problem Signs & Symptoms Other Findings Treatment

ntravascularVolumeDepletion

Thirst, lightheadednessSyncope, orthostatic hypotensionDecreased skin turgor Oliguria, tachycardia !otemia, shock, coma 

Increased "#$%r 'atioFractional ()cretion $a*+Increased T

See (Table 2a)

ypokalemicypochloremiclkalosis

ypotensionypoventilation-uscle cramps, tetany

#rine $a./0 m(12+#rine +*+0 m(12+

See (Table 2b)

3I "leeding ematemesis, melenaypotension, tachycardia

'arely, dysphagia, chest2back pain4intramural hematoma5

Decreased T 6arge bore IVsentral line

"lood trans7usionPlatelets i7 lo8FFP i7 coagulopathic3I consult

"oerhaaveSyndrome

Fever, chest2abdominal painDyspnea, shock, crepitance bnormal contrast 9:rays

6eukocytosisypo)ia

Surgical consult, $PO$3 tube straddling per7oration siteIV antibiotics ::

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 4/30

cover anaerobes 4Pen3, or lindamycin5cover 3ram neg aerobes and Staphaureus i7 recent hospitali!ation

spiration Fever, coughDyspnea

Decreased o)ygensaturationIn7iltrates on chest 9:ray

ontrol air8ay ntibiotics as above"ronchoscopy i7 locali!ed 8hee!ing orparenchymal volume loss to remove7oreign body

ntra:abdominal

bleeding

 bdominal painypotension, tachycardia

Increasing abd girthDropping T

T abdomenSurgical consultation

Table 2a -- Treatment of volume depletion secondary to Nausea and Vomiting-ild -oderate : Severe

Oral li1uids ::/:; liters2day

Oral electrolyte solutions3atorade, Pedialyte5

IV isotonic 7luids 40<=> saline5 :: +:/ liters over + hr, then based on monitoring o7 vital signs,urine output< onsider central venous or pulmonary capillary 8edge pressure measurementsto guide therapy< -onitor serum electrolytes :: replace ?@ and -g@ as needed<

Table 2b -- Treatment of hypoalemic hypochloremic alalosis

!ondition Treatment

-ild hypokalemia+ m(126 ?@ decrease A /00:;00 m(1 total bodyde7icit

Severe hypokalemia?@*/<Bm(126 A ;00:C00 m(1 total body de7icit

(?3 changes, neuromuscular symptoms

') A ;0:0 m(1 ?I p<o< -onitor serum ?

IV ?6 +0 to ;0 m(12hr depending on severity4+0 m(12hr normally, ;0m(12hr i7 ?*/5

ontinuous (?3 monitoring, check serum ? 1;h

Severe lkalosis 4p.E<BB5 heck "3s and serum electrolytes 1;h<In renal 7ailure pts, hemodialysis can correct alkalosis cid therapy ::use 8ith cautionalculate @ de7icit 4m(15 A 0<B ) lean body 8t 4kg5 ) 4measuredOG5 : 4desired OG5H<'eplace hal7 the de7icit over +/hr, remainderover ne)t /;hr l solution A +B0ml l in + liter sterile /O<

If vomiting has been severe and protracted, intravascular volume depletion may have occurred, leading to orthostatic

h#-otension and renal insufficiency. 1#-o"alemic h#-ochloremic al"alosis results from loss of gastric hydrochloric acid,

ncreased /B loss due to renin#angiotensin#aldosterone and volume contraction. In these situations, intravascular access should be

established and fluid resuscitation instituted prior to diagnostic studies.

• Vomiting or retching can cause mucosal in=ury and bleeding

*ither vomiting or retching can lead to mucosal in=ury e.g. Mallor#)2eiss tear!, evident as hematemesis and:or melena$

e%cessive blood loss may contribute to intravascular volume depletion. In the case of 8I bleeding with a significant drop in

hematocrit or signs of intravascular volume depletion, consultation for upper endoscopy should be obtained. In certain situations,

depending on the findings on endoscopy and the effectiveness of endoscopic therapy, surgical consultation may be necessary.

Vomiting can lead to aspiration

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 5/30

Vomitus may be aspirated, leading to respiratory compromise which may be severe enough to reuire endotracheal intubation and

mechanical ventilation. 2 corollary to this is the development of aspiration pneumonitis or pneumonia. In the case of aspiration

and hypo%emia, ensuring a patent airway is of paramount importance. (he management of such patients reuires a

multidisciplinary approach, and may include the services of an intensivist, gastroenterologist and primary care physician.

• Vomiting or retching can lead to esophageal rupture

Vomiting or retching may cause rupture of the esophagus Boerhaave s#ndrome!, a surgical emergency. 5oerhaave syndrome

deserves special consideration because a high inde% of suspicion is reuired to make a timely diagnosis and surgical intervention

s necessary. pontaneous rupture of the esophagus is an intrathoracic disaster if left untreated. 2s noted in a recent review of all

published cases in the literature since 1-C0 and 1C additional cases D!, non#specific symptoms such as chest and abdominal pain

can lead to mistaken diagnoses such as pulmonary embolus, myocardial infarction, aortic dissection, spontaneous pneumothora%,

pancreatitis or perforated peptic ulcer. 7orty percent of patients had a history of alcoholism, and @1E had peptic ulcer disease.

ain C6E! and vomiting F-E!, often associated with dyspnea 6-E! and shock 6&E!, were the ma=or symptoms. hysical e%am

may detect crepitus due to air in the soft tissues of the neck and thora%. hest and abdominal ?#rays may show subcutaneous

emphysema, pneumothora%, pneumomediastinum, pleural effusion and free mediastinal air. /owever, up to a third of patients

have normal routine ?#rays initially F!. *sophagograms with water#soluble contrast agents are diagnostic in most cases. (horacic

( scans may reveal mediastinal air or pleural fluid even when the esophagogram shows no leak and should be obtained when

there is a high degree of suspicion. In the series cited, the mortality rate was 61E, an improvement on the A0E mortality rate

noted prior to 1-C0.

• Intra#abdominal bleeding is a rare complication of vomiting

Intra#abdominal bleeding is a rare complication of vomiting. /emoperitoneum has been described following vomiting. plenic

aceration secondary to persistent emesis in a pregnant patient was diagnosed at laparotomy C!. /epatic laceration caused by

vomiting leading to massive intra#abdominal hemorrhage was described -!. In both cases, abdominal pain in the conte%t of

nausea and vomiting was the chief complaint. urgical intervention is necessary for diagnosis and treatment. 'ectus sheath

hematoma, diagnosed by ultrasound or (, may lead to abdominal pain, and needs to be considered in the patient who is anti#

coagulated 10!. 2nticoagulation or low platelet counts may lead to intramural hematomas of the esophagus after vomiting. (he

presentation is one of severe substernal or intrascapular pain, hematemesis and dysphagia.

&.&. *mpiric treatment and reassurance are sufficient

If the patient does not have complications of vomiting that reuire immediate attention, and if the underlying cause of the nausea

and vomiting as suggested by the history does not reuire e%peditious work#up and therapy, then the patient can be reassured and

treated empirically with anti#emetic agents %&a!le ''(. 

Table "" -- #rug treatment of nausea and vomiting 

Drug lass 3eneric $ame4Trade $ame5

#ses 'ecommendedDoses

Side (77ects

Phenothia$ines  hlorproma!ine4Thora!ine5

#ncommonlyused 7or $auseaand Vomiting

+0 : /B mg 1 ; : po/Bmg 1 Gh IV slo8/B:B0 mg 1 ;h I-

+00 mg 1 :Ch pr 

ypotension

Prochlorpera!ine4ompa!ine5 

$ausea andvomiting

B:+0 mg tid po/<B :+0 mg IV slo8 in7usionB:+0 mg 1 ;h I-/B mg bid pr 

ypotension

Proinetics -etoclopramide4'eglan5

isapride

4Propulsid5

Trimethoben!amide4Tigan5

(rythromycin

3astroparesis

3('D

$ausea andvomiting

3astroparesis

+0:/0 mg 1id po+0:/0 mg IV

+0:/0 mg 1id po

/B0 mg tid21id po/00 mg tid21id I-/00 mg tid21id pr 

/B0 mg 1id IV or po

()trapyramidalsymptoms

 bd pain, diarrheaDro8siness

Diarrhea, abd pain

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 6/30

"ethanechol 3astroparesis +0:/B mg 1id po  bd pain

 bd pain

%ntihistamines Dymenhydrinate4Dramamine5

-ecli!ine

4ntivert5

ycli!ine4-are!ine5

Prometha!ine4Phernagen5

Dyphenhydramine4"enadryl5

-otion sickness

-otion sickness

-enieres disease

-otion Sickness

-otion Sickness

B0 mg 1 ;h po

B0 mg 1 /;h po

B0 mg 1 ;h poB0 mg 1 ;h IV

/B mg 1 +/h po/B mg 1 +/h IV+/<B:B0 mg 1 +/h I-+/<B:B0 mg 1 +/h pr 

/B:B0 mg 1 h po

Dro8siness

Dro8siness

Dro8siness

Dro8siness

Dro8siness

"utyrophenones Droperidol Post:op /<B:B mg IV ypotensionSedation()trapyramidalsymptoms 

aloperidol 'arely used 0<B:/ mg po ypotensionSedation()trapyramidalsymptoms 

%nticholinergics Scopolomine4Transderm patch5

-otion Sickness +<B mg patch 1 G daysdelivers 0<Bg2day

Dro8siness

&-'T eceptor%ntagonists 

Ondansetron4Jo7ran5

3ranisetron4?ytril5

Post:ophemotherapy

hemotherapy

; : C mg IVG/ mg one time dose

+ mg bid po+0 mcg2kg IV

(levated 6FTs

eadache

$on:

pharmacological

 cupressure K -otion

Sickness

K Pregnancy

 

5efore such a decision is made, however, symptoms and signs that favor a self#limited illness should be reviewed and compared

with findings that favor serious underlying disease. uch a comparison is provided in %&a!le 3(.

Table -- Triage of the patient *ith the acute onset of nausea and vomitingFindings 7avoring sel7:limited

symptoms 

Findings that support serious

disease

Lounger age

Family members 8ith similar illness

-yalgias, arthralgias c28 viral

Older age

 bdominal or chest pain

+ate pregnancy

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 7/30

syndrome

$onbloody diarrhea

Vertigomotion sicness

Typical migraine symptoms

ssociated 8ith 7ood ingestion

ssociated 8ith medication

'ecent e)cess alcohol ingestion

arly pregnancy

"loody diarrhea

 nticoagulated state

Severe headache

Fever 

?no8n #nderlying Diseaseoronary artery disease

Prior 3I tract surgeryI"D

#iabetes mellitus,3allstones

 lcoholism

Gey uestions can help identify conditions that can be treated empirically. ertain presentations and etiologies are sufficientlycharacteristic as to be identifiable as self#limited. In these situations, no specific treatment is necessary, or, if specific therapy is

available, the benign nature of the condition precludes the need for an e%tensive diagnostic evaluation. 2 ma=ority of patients seen

n the ambulatory care setting falls into this category.

&.&.1 +arl# -regnanc#

If the patient is a woman of child#bearing age, a pregnancy test should be done. regnanc#)related nausea and vomiting is

common, reported in F0#-0E of pregnancies 11!1&6!. 'ising estrogen and progesterone levels during pregnancy have beenmplicated, as has maternal serum prostaglandin *& levels 1&@!. (he onset is usually shortly after the first missed menstrual

period, and symptoms may begin before the woman recogni9es that pregnancy has occurred. ymptoms typically begin by four to

si% weeks of gestation, peaking in severity by eight to twelve weeks, and resolving spontaneously by the &0th week 11!. Nausea,

sometimes accompanied by vomiting, is noted especially in the morning. In one prospective study of 1D0 pregnant women,

however, "morning sickness" occurred in only 1.CE, whereas C0E reported nausea lasting all day 1&A!. ymptoms usually

disappear by the fourth month of pregnancy, although they may persist into the third trimester. 5abies born to a mother with

nausea and vomiting of pregnancy have birth weights similar to babies born to mothers without these symptoms. (hus, the

prognosis for mother and baby is generally e%cellent. /owever, in one study a higher than normal incidence of antepartum

hemorrhage was noted 1&!. Vomiting during pregnancy is not teratogenic 16!.

If pregnancy#related nausea and vomiting are not characteristic of morning sickness for e%ample, has its onset in the second or

third trimester and is severe!, then other potentially more serious conditions such as hyperemesis gravidarum, acute fatty liver of

pregnancy, and /* syndrome need to be considered.

In general, referral to an obstetrician for management of nausea and vomiting of pregnancy is indicated for these more serious

conditions.

&reatment of regnanc#)related nausea and vomiting

7or typical pregnancy#related nausea and vomiting, reassurance is often all that is needed, although an anti#emetic may be

necessary. (raditionally, dietary advice such as dry toast in the morning and avoiding fatty foods was offered. 2ntacids for reflu%

symptoms associated with nausea and vomiting may be used. If an anti#emetic is necessary, then antihistamines may be used andare considered safe for use during pregnancy. (he efficacy or safety of phenothia9ines or metoclopramide have not been

established for nausea and vomiting of pregnancy in controlled trials despite their widespread use 11!.

linical trials assessing the efficacy of anti#emetic therapy are of varialbe uality. 2n analysis of such trials showed that anit#

histamines, pyrido%ine, and D acupressure appeared to reduce the freuency of nausea in early pregnancy 1&D!. 2 risk#benefit

assessment of drug therapy for nausea and vomiting of pregnancy show that controlled trials demonstrated the safety and efficacy

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 8/30

of dicyclomine, anti#histamine /1 receptor antagonists, and phenothia9ines 1&F!. (he pooled data, however, were not

homogenous.

2 prospective trial comparing pregnancy outcomes in women given metoclopramide in the first trimester for the treatment of

nausea and vomiting in pregnancy compared to women who received nonteratogenic drugs, showed no increased risk of fetal

malformations, spontaneous abortions, or decreased birth weight of the infants in the metoclopramide group 16A!.

(he effectiveness of pyrido%ine vitamin 5D! for nausea and vomiting of pregnancy has been studied in a randomi9ed, double#

blind placebo#controlled trial. atients in the treatment group received 60 mg:day of pyrido%ine hydrochloride for A days. 2

significant decrease in post#therapy nausea in the treatment group was noted 1@!. imilar results were noted for vomiting in

another study over a 6#day duration 1A!. Acu-ressure at the D point located on the wrist has also been studied in a randomi9ed,

double#blind placebo#controlled study and found to reduce nausea, but not vomiting, in pregnant patients 1D!. i%ty women were

assigned to two treatment groups3 one to a group receiving D acupressure, and a control group receiving pressure at another

anatomic location. ymptom scores after A#F days of treatment were used to =udge efficacy. Nausea scores improved over time in

both groups, achieving statistical significance in the acupressure group. In another study, 1D1 pregnant symptomatic women were

assigned to three groups3 D acupressure treatment, placebo acupressure band placed in an inappropriate location! or control.

Improvement in nausea and vomiting or retching was noted in all three groups, with no statistically significant differences noted

n the acupressure group 1F!.

&.&.& Vertigo

Nausea or vomiting associated with vertigo suggests another set of causes. Vertigo is a sensation of the environment spinning

around, often described as di99iness by the patient. *valuation of the di99y patient begins with a thorough history, which can

dentify the cause in many patients. If a characteristic change in head position brings on vertigo, benign positional vertigo is

usually the cause, which does not usually lead to nausea and vomiting. 2ssociated aural symptoms such as hearing loss, fullness in

the ears and tinnitus should be ascertained. Neurologic symptoms such as headache, visual changes or loss of sensation are

mportant to determine. oss of consciousness associated with vertigo should be determined.

eripheral causes of vertigo, such as !enign -ositional vertigo, vesti!ular neuronitis, Meniere4s disease and acoustic neuroma

need to be distinguished from central causes of vertigo, such as multiple sclerosis, brainstem ischemia and central nervous systemtumor. (he physical e%amination is often helpful in determining whether a peripheral or central cause of vertigo is present. 2

complete head and neck e%am including e%amination of the tympanic membranes is advised. ranial nerves should be tested,

ncluding assessment of e%traocular muscle function. Nystagmus can aid in diagnosis. N#stagmus of peripheral origin is rotatory

or hori9ontal. Vertical nystagmus is pathognomonic for brain stem disease, as is nystagmus that is more pronounced in one eye.

N#stagmus may be tested by having the patient look ahead, then 60 degrees to the left and to the right. ausing at each position

allows evaluation of nystagmus. Induced nystagmus is done by rapidly changing the position of the head. (he /allpike#+i% or

Nylen#5arany! maneuver is performed by making the patient undergo a rapid change from the erect sitting position to a supine

position with the head hanging to the left, right or center. 2 positive test is present when paro%ysmal nystagmus is induced after a

brief delay. 2 positive test is diagnostic for either benign positional vertigo, which is seldom associated with nausea and vomiting$

or a central nervous system disorder. In order to distinguish the two, the following characteristics of nystagmus are noted. 7or

benign positional vertigo, a 6#&0 second latency, rotatory nystagmus and adaptation i.e. less response to repeat testing! is seen.

7or a central nervous system cause, no latency is seen, the nystagmus can be vertical or hori9ontal and can last longer than D0

seconds and there is no adaptation.

5alance testing such as the 'omberg test and assessment of the gait should also be performed. Vertigo can also be an early

symptom in multiple sclerosis. esions in the lower midbrain and pons produce internuclear ophthalmoplegia. (his is checked for

by having the patient follow the finger of the e%aminer from side to side hori9ontally. In this type of nystagmus the eye on the side

to which the ga9e is directed participates strongly with a hori9ontal nystagmus, whereas the opposite eye will show less

nystagmus and weakness of internal rotation. 2 careful cardiac e%amination is also necessary, as arrhythmias can produce

symptoms which are confused with vertigo 1C!.

S-ontaneous and 5nduced N#stagmus and their 6auses

S-ontaneous N#stagmus

ymptom:ign eripheral entral

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 9/30

+irection <sually hori9ontal#rotatory

 Never purely vertical

2ny direction

)ay be purely vertical

+irection of fast component 2way from side with disease (oward side with disease

or direction changing!

*ffect of visual fi%ation uppressed Not suppressed

<sual anatomical location of 

 problem

abyrinth or vestibular nerve 5rainstem or cerebellum

5nduced N#stagmus 

7eature eripheral 5V! entral

(ime to onset after 

uick position change

latency!

6#&0 seconds Immediate

+uration ess than 1 minute ersists longer than 1 minute

7atigability )arked None

Vertigo may be a symptom of a more serious underlying disorder , such as vertebro#basilar vascular insufficiency or a

cerebellopontine#angle tumor. In order to determine which vertiginous patient needs further diagnostic testing and possible

referral, several items in the history are helpful. 2re there associated neurologic symptoms such as headache, visual changes or

oss of sensation and strength, suggesting cortical or brain stem disorders4 Is there a history of sei9ures4 /as the patient lost

consciousness with the episode of vertigo4 Is there antecedent cranial or cervical trauma4 If the answer is affirmative to any of

these uestions, then empiric therapy is not advised.

'eferral to a neurologist and possibly a neurosurgeon may be necessary in patients with N symptoms suggestive of a brain

stem lesion, vertebro#basilar insufficiency or cortical lesions. 2dditionally, in patients with vertigo associated with sei9ures,referral to a neurologist is appropriate. If vertigo is associated with syncope, a thorough cardiac evaluation by a cardiologist may

be indicated to rule out arrhythmias or other cardiac causes.

&.&.&.1 Vesti!ular neuronitis

(he sudden onset of vertigo with nausea and vomiting, increasing in severity over several hours with resolution over a similarspan of time, is characteristic of vestibular neuronitis. atients may awaken from sleep with vertigo. (here is often a history of a

recent or concurrent upper respiratory tract infection, and clusters of cases may be seen. (he etiology is probably viral, and the

condition is often diagnosed in adolescents and young adults. 7ollowing the acute episode, prolonged di99iness similar to motion

sickness may be noted, lasting weeks to months. No new associated auditory deficits, fullness in the ear, or tinnitus are noted.

ersistent nystagmus toward the affected side may be noted. linical and histopathologic studies implicate an isolated lesion of

the vestibular nerve 1-!.

In cases where there is doubt about the diagnosis based on the signs and symptoms, additional diagnostic tests to consider include

audiologic assessment, electronystagmography with caloric testing and head (. 'eferral to an otolaryngologist should be

considered for refractory or atypical cases.

&reatment

(reatment for nausea and vomiting is symptomatic, similar to that for motion sickness %&a!le ''(.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 10/30

&.&.&.& Acute la!#rinthitis

2cute labyrinthitis symptomatically is similar to vestibular neuronitis, e%cept hearing loss on the involved side is also noted. (he

cause may be viral, bacterial or due to a to%in 1C!. 2 history of recent or concurrent upper respiratory tract infection is often

given. )ost patients improve over 1#& weeks, although recurrent episodes have been described. )ost report an upper respiratory

tract illness 1#& weeks prior to the onset of vertigo. everal members of the patientHs family may be affected, and it is seen more

often in spring and early summer. In most cases a viral etiology is likely.

2 subgroup of patients may have herpes 9oster oticus 'amsay#/unt syndrome!, with vertigo and periauricular vesicles or facial

paralysis. Vesicles may be seen on the pinna and on the face in the distribution of the sensory branch of the seventh cranial nerve.

Vertigo may last days to weeks.

&reatment

No specific therapy is recommended. ymptomatic treatment with anti#vertigo medications as for motion sickness may be used if

symptoms are severe %&a!le ''(. If there is suspicion of a bacterial etiology, with fever, chills and a purulent middle ear, then

medical therapy with antibiotics and possibly surgical therapy is indicated to prevent meningitis. In this case, referral to an

otolaryngologist should be considered. 7or the 'amsay#/unt syndrome, acyclovir is effective in the treatment of facial paralysis,

but is ineffective for vertigo 1C!.

&.&.&.6 Meniere4s disease

evere nausea and vomiting may be a manifestation of endolymphatic hydrops, or )eniereHs disease. ymptoms characteristicallynclude episodic aural fullness, tinnitus, hearing loss and vertigo. If vertigo is associated with hearing loss or tinnitus, an

audiogram is needed to diagnose )eniereHs disease or acoustic neuroma. (he onset is abrupt, and usually no precipitating factors

are identified. 2ttacks of vertigo can last a few hours to &@ hours, and subside gradually. /ori9ontal or hori9onto#rotatory

n#stagmus may be observed.

&reatment

(reatment is with restriction of salt intake and anti#vertigo drugs. ymptomatic relief of vertigo can be obtained with

anticholinergic agents e.g. scopolamine orally or by transdermal patch!, or antihistamines e.g. diphenhydramine, mecli9ine or

cycli9ine!. +ia9epam &#A mg orally D#Ch is effective in suppressing the vestibular system %&a!le ''(. In severe cases, referral to

an otolaryngologist is appropriate.

&.&.6 Motion sic"ness

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 11/30

)otion sickness is a form of physiologic vertigo. erspiration, increased salivation, yawning and malaise are described by

patients with motion sickness. /yperventilation can lead to hypocapnia, and venous pooling can predispose to hypotension and

syncope. (he sight and smell of food can e%acerbate nausea. )otion sickness is readily diagnosed by history. (his is a common

syndrome that can occur in an automobile, airplane or at sea. *%aggerated self#generated movement, in fact, can cause motion

sickness by forcing rapid and inappropriate changes of vestibular function &0!.

&reatment

(he treatment of vertigo associated with motion sickness is empirical &1!. (ransdermal scopolamine can prevent motion sickness.

(he patch must be placed several hours prior to the anticipated onset of motion sickness. Anti)histamines such asdymenhydrinate, mecli9ine, cycli9ine, prometha9ine and diphenhydramine can be used

%&a!le ''( (he main side effect of this drug class is drowsiness.

Acu-ressure on the D point located on the wrist, which has been used in traditional hinese medicine to treat nausea and

vomiting of pregnancy, has been evaluated in a randomi/ed, -lace!o)controlled dou!le)!lind stud#. i%ty#four sub=ects were

randomly divided into @ groups D acupressure, dummy#point acupressure, sham D acupressure, and control! and sub=ected to

optokinetic drum rotation which elicits motion sickness in normal volunteers. ub=ects in the D acupressure group reported

significantly less nausea and the incidence of gastric tachyarrhythmia was reduced in this group &&!. In another blinded placebo#

controlled study on 6D patients, however, acupressure provided no protection &6!.

&.&.@ Viral s#ndrome

2cute infections with viruses such as Norwalk agent or other enteric viruses can be accompanied by headache, fever, arthralgias

and non#bloody diarrhea as well as nausea and vomiting. (hese symptoms, suggestive of a viral etiology, are an indication that no

specific diagnostic testing is necessary.

&reatment

*mpiric therapy with liberal fluid intake, anti#emetics and antipyretics may suffice. *mpiric therapy should only be instituted inmmunocompetent patients with symptoms that are mild and typical for a viral syndrome. igns such as protracted fever with

chills, bloody diarrhea and clinically evident fluid depletion should be handled with proper diagnostic studies and appropriate

specific therapy.

2 randomi9ed, double#blind comparison of treatment of uncomplicated nausea and vomiting due to viral gastroenteritis with

prochorpera9ine ompa9ine! or prometha9ine hernergan! was published. (he results showed that prochoropera9ine was

significantly better in terms of symptom relief compared to prometha9ine 11-!.

&.&.A ost)o-erative

ost#operative nausea and vomiting is common, but is unlikely to be encountered in the primary care setting. In a prospective

evaluation of 101 patients admitted for abdominal surgery, the overall incidence of nausea and vomiting was @&E &@!. (hese

symptoms are generally attributed to the general anesthetic agents or analgesics used. In the immediate post#operative setting,

these patients are often treated empirically. /owever, the possibility of other causes of nausea and vomiting must be kept in mind.

Vomiting in the post#operative period following laparoscopy may lead to pneumomediastinum and bilateral pneumothoraces &A!.

ongestion of the eye secondary to phakomorphic glaucoma can lead to intractable nausea and vomiting in the post#operative

state &D!.

&reatment

hile post#operative nausea and vomiting is unlikely to be encountered in the primary care setting, treatment regimens have been

studied in this patient population. (herefore, it is useful to be aware of this literature. 7or e%ample, the efficacy, safety and cost#

effectiveness of ondansetron @ mg intravenously! was compared to dro-eridol 0.D&A mg or 1.&A mg intravenously! in a

randomi9ed, double#blind placebo#controlled trial for the prevention of postoperative nausea and vomiting after outpatient

gynecologic surgery in 1D1 women. +roperidol 0.D&A mg iv provided antiemetic prophyla%is comparable to that of ondansetron @

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 12/30

mg iv without an increased incidence of side effects and in the most cost#effective manner &F!. In another randomi9ed, double#

blind, placebo#controlled trial conducted on patients undergoing laparoscopic cholecystectomy, prophylactic anti#emetic therapy

with ondansetron, tropisetron, granisetron or metoclopramide was studied. ;ndansetron prophyla%is resulted in a lower incidence

of post#operative nausea and vomiting compared to metoclopramide or placebo. (here were no statistically significant differences

among the three 7)1&3 rece-tor antagonists&C!. 2 review of published controlled trials comparing A#/(6 receptor antagonists

to traditional anti#emetic agents including metoclopramide, perphena9ine, prochlorpera9ine, cycli9ine and droperidol! for

prophyla%is of postoperative nausea and vomiting showed the A#/(6 receptor antagonists to be superior 1&C!.

&.6 Diagnostic 0or"u- re$uired

*%perienced physicians triage patients based on the patients history and presentation as well as on clinical instincts that factor in

severity of illness and familiarity with the patient %&a!le 3(. )ost causes of acute vomiting are self#limited illnesses, but nausea

and vomiting can be symptoms of conditions that reuire e%peditious diagnostic workup and treatment %&a!le 8(. 8uidelines for

referral are included in each section.

&.6.1 2bdominal or chest pain

2 history of pain may indicate that nausea and vomiting is a conseuence of a pathophysiologic process in the thoracic cavity or

abdomen. 2bdominal pain preceding nausea and vomiting indicates an organic lesion. ain following vomiting may be due to

tenderness of the abdominal musculature, an abdominal wall or esophageal hematoma, especially in patients who are anti#

coagulated! or esophageal perforation.

&.6.1.1 oronary artery disease

2cute and chronic myocardial ischemia, as well as myocardial infarction, may present with nausea and vomiting. (hese symptoms

may be accompanied by abdominal bloating or fullness. ;ften, concomitant substernal chest pain is present, or the patient may

give a history of angina pectoris. *ven in the absence of classic signs and symptoms of myocardial ischemia, the physician must

keep an open mind to the possibility of a cardiac source of symptoms. 2t a minimum, an electrocardiogram should be obtained in

such patients. 7urther diagnostic evaluation and therapy depend on the clinical impression. ardiac en9ymes to rule out

myocardial infarction and electrocardiographic monitoring may be necessary. )anagement in consultation with a cardiologist

should be considered.

&.6.1.& Intra#abdominal inflammation

2 variety of inflammatory conditions within the abdomen may present with nausea and vomiting including cholecystitis,

appendicitis, pancreatitis, inflammatory bowel disease, cholangitis and peritonitis. (he duration, location, uality, radiation and

pattern of abdominal pain, and factors that e%acerbate or ameliorate the pain, may help distinguish between these possibilities. 2

history of biliary colic or gallstones suggests cholecystitis or gallstone pancreatitis. ain in the periumbilical area which moves to

the right lower uadrant over time classically suggests appendicitis. ;n physical e%am, certain findings are suggestive of aparticular diagnosis. )urphyHs sign tenderness and inspiratory arrest with palpation in the right upper uadrant of the abdomen!

may be elicited in acute cholecystitis. 'ebound tenderness on abdominal e%am suggests peritonitis, and in the conte%t of free air

on ?#ray, warrants laparotomy. In acute pancreatitis, diffuse tenderness to palpation of the abdomen may be elicited, making this

diagnosis a difficult one to make on physical findings alone &-!. Nausea and vomiting in the conte%t of intra#abdominal

nflammation are symptoms that should respond to treatment of the underlying inflammatory process.

'eferral to a gastroenterologist should be considered in severe cases of pancreatitis, in those whom choledocholithiasis is

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 13/30

suspected as a cause of pancreatitis or cholangitis, and in cases where the diagnosis is uncertain. 7or patients with inflammatory

bowel disease I5+! presenting with nausea and vomiting, symptoms may be due to a flare of I5+ or the presence of bowel

obstruction see below!. )anagement of I5+ with the aid of a gastroenterologist should be considered. 'eferral to a general

surgeon is warranted in cases of acute cholecystitis, appendicitis or peritonitis.

&.6.1.6 G5 tract o!struction

;bstruction of the stomach or intestine can present with nausea, vomiting and abdominal pain. hen abdominal pain precedes

nausea and vomiting, obstruction of the 8I tract should be strongly considered. Gastric outlet o!struction may be due to peptic

ulcer disease in the pyloric channel or duodenal bulb, or benign or malignant gastric tumor. atients may complain of early satiety

and bloating. 2bdominal pain is generally postprandial. ymptoms may be worse after a solid meal compared to a liuid one.

(hese symptoms may be resolved with vomiting as the stomach is decompressed. (he volume of gastric contents e%pelled may be

arge. (he vomitus may be foul#smelling, containing food ingested more than 1& hours previously. /eartburn due to reflu% of

acidic gastric contents may be a complaint. hysical e%am findings include a distended abdomen with tympany and, in some

cases, epigastric tenderness. 2 succussion splash heard with the stethoscope after gently rocking the patient from side to side

mplicates retention of liuid contents in the stomach.

+iagnostic tests include upright abdominal ?#rays showing an enlarged gas#filled stomach, contrast radiographs and endoscopy.

ater soluble contrast ?#rays are helpful when a gastric !e/oar is suspected, or when a tight stenosis is present. *ndoscopy is inmany cases the procedure of choice, as histologic diagnosis and in some cases therapy can be provided. 'eferral to a

gastroenterologist is appropriate in cases of acute nausea and vomiting suspected to be due to gastric outlet obstruction.

In the small bowel, a history of prior abdominal surgery may predispose to small !o0el o!struction caused by adhesions. *ightypercent of small bowel obstructions are due to post#operative adhesions. ;ther etiologies include primary or metastatic carcinoma,

benign tumor, internal and e%ternal hernias and rohns disease. ess commonly, prior abdominal radiation, intussusception,

endometriosis, volvulus and congenital abnormalities can lead to small bowel obstruction. (he patient can present with intestinal

colic, which may be intermittent initially, progressing to sustained abdominal pain centered in the midline of the abdomen at or

cephalad to the umbilicus. Vomiting is a cardinal feature, with complete obstruction leading to vomiting of liuid material which

may be feculent if the obstruction is in the distal small intestine. hysical findings include a distended abdomen$ dilated, palpable

oops of bowel$ and high#pitched, intermittent bowel sounds.

2n important aspect of the diagnostic evaluation is the differentiation of incomplete from complete small !o0el o!struction.

omplete obstruction should be considered if the patient is not able to pass flatus. 2bdominal radiographs supine and upright

views! should be obtained. omplete obstruction is suggested by dilated loops of small bowel with air#fluid levels without gas in

the large bowel. In partial obstruction, gas is noted in the colon and rectum, although air#fluid levels and dilated loops of small

bowel are present. If the differentiation between partial and complete obstruction is still uncertain, contrast radiography may help

differentiate these conditions and rule out a paralytic ileus.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 14/30

If the diagnostic evaluation suggests partial obstruction, nasogastric suction and IV fluids should be instituted. ack of clinical

mprovement in @C hours warrants operative treatment. omplete small !o0el o!struction is an indication for laparotomy.

'esuscitation pre#operatively includes correction of hypo%emia, replacement of intravascular volume and correction of serum

electrolyte abnormalities.

rimary small bowel malignant tumors presented with abdominal pain C6E!, nausea and:or vomiting A@E! and weight loss

A6E! in a retrospective review of D- patients 60!. ymphoma was the most common tumor @&E!, followed by adenocarcinoma

6CE!, carcinoid 10E! and leiyomyosarcoma 10E!. In @1E, the tumor was located in the =e=unum, in the ileum in 66E, in the

duodenum in &&E and in multiple sites in @E. ;f the DA symptomatic patients, @6E presented as surgical emergencies.

)etastases to the 8I tract can present with abdominal pain and nausea and vomiting. )elanoma and breast cancer can metastasi9e

to the small bowel. In a review of DC patients with metastatic melanoma, sites commonly involved were the small bowel FAE!,

arge intestine &AE! and stomach 1DE! 61!.

&.6.& Drug, toin or environmental e-osure

&.6.&.1 Drugs as a 6ause of Nausea and Vomiting

&.6.&.1.1 +rugs associated with nausea and vomiting at prescribed dosages

)any drugs routinely used in clinical practice can cause nausea and vomiting when taken at the prescribed dose. (herefore a

careful drug history, including the use of over#the#counter medications and herbal and non#traditional medications, is mandatory.

*stablishing a temporal relationship between the institution of a medication and symptoms of nausea and vomiting is highly

suggestive. 2lternatively, changes in dosing or the addition of a drug to an already lengthy list of medications suggests a drug#

related effect. 2 large number of drugs have nausea and vomiting listed as a potential side effect$ indeed, almost any drug can

potentially cause these symptoms. /owever, there are certain drugs for which nausea and vomiting is seen in a significant

minority of patients. (hese agents are listed in %&a!le 7( and are described below.

Narcotic analgesics such as morphine, which dramatically decrease gut motility, can lead to constipation and 8I tract obstruction.

(he incidence of narcotic#induced emesis was as high as @0E in one study 6&!. rescription and over the counter non#steroidal

anti#inflammatory drugs N2I+s! have nausea and less commonly vomiting! as a side effect. Nausea is also seen in up to @0E

of patients taking the non#narcotic analgesic tramadol. (heophylline and digo%in can cause nausea and vomiting, especially when

plasma drug levels are elevated. Nausea and occasionally vomiting has been noted with the selective serotonin reuptake inhibitors.

hlorouine causes nausea and vomiting as a side effect both at prescribed doses and in overdose situations.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 15/30

2ntibiotics and anti#parasitic agents can cause nausea and vomiting. (he most common adverse effect of metronida9ole is nausea,

seen in 1&E of patients. (rimethoprim#sulfametho%a9ole is associated with nausea and vomiting. *rythromycin can cause nausea

and vomiting$ the mechanism may be related to its role as an agonist for the pro#motility hormone motilin. 2nti#helminthics such

as albenda9ole and thiabenda9ole have been associated with nausea and vomiting. (he amebicide iodouinol has nausea and

vomiting as a side effect.

;ther drugs which commonly cause nausea and vomiting include estrogens, levodopa, bromocriptine and potassium and iron

salts. 7or the latter two types of agents, gastric irritation may be the mechanism. (imolol eye drops can cause severe nausea and

vomiting 11A!.

&.6.&.1.& +rugs associated with nausea and vomiting in overdose situations

ome drugs may cause nausea and vomiting when e%cessive doses are ingested, or when serum levels increase due to renal or

hepatic insufficiency. everal prescription drug overdoses presenting with nausea and vomiting have been reported, including

sonia9id 66!, misoprostol 6@!, colchicine 6A! and metronida9ole. inchonism secondary to uinine to%icity classically presents

with nausea, vomiting, and tinnitus. rolongation of the J#( interval is often noted 6D!. pecific overdose situations which are

known to present with nausea and:or vomiting are listed in %&a!le 9( 6F!. (his list is not comprehensive$ communication with a

'egional oison ontrol enter for up#to#date management recommendations should be considered.

&.6.&.& 6hemothera-eutic agents

(hese drugs are notorious for their emetogenic properties. In the conte%t of chemotherapy regimens, anti#emetic therapy is often

prescribed. hile this situation is unlikely to be encountered in the primary care setting, it is important to keep this possibility in

mind. In particular, anticipatory nausea and vomiting may develop in a patient who has undergone prior chemotherapy. In a study

of 1D adult cancer patients with chemotherapy#induced anticipatory nausea and vomiting, hypnosis was shown to be highly

effective 160!. In all patients studied, anticipatory nausea and vomiting disappeared.

(he severity of chemotherapy#induced emesis depends on the particular drug used cisplatin is associated with the highest

ncidence!, the dose of the drug and the method of administration 6C!. Vomiting may be delayed & to A days after cisplatin

administration and may be difficult to control. Nausea and vomiting may also be encountered in the setting of fractionated

radiotherapy for malignancy 6-!. 2n overview of the treatment of patients with chemotherapy#induced nausea and vomiting is

found in the section on drug therapy.

&.6.&.6 Alcohol *thanol!

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 16/30

*%cessive alcohol intake may cause severe nausea and vomiting. Mallor#)2eiss tears are directly caused by vomiting or retching

and can be encountered in the patient who has been drinking alcohol. 2cute pancreatitis may be present and leads to nausea,

vomiting and abdominal pain. Intracranial hemorrhage secondary to head trauma from a fall in an inebriated patient can cloud the

clinical presentation, as increased intracranial pressure can itself be a cause of nausea and vomiting. 2lcoholic hepatitis can also

present with nausea and vomiting. Nausea and vomiting in the patient with a history of alcohol use therefore reuires vigilance for 

these associated conditions. 2 history obtained from family members or witnesses, a careful abdominal e%am,

head:eyes:ears:nose:throat e%am and neurological e%am, measurement of blood alcohol levels, hematocrit, coagulation profile,

transaminases 2(:2(! and serum amylase and lipase should be obtained in a patient suspected of heavy alcohol use who

presents with severe nausea and vomiting. 2ncillary diagnostic tests such as chest and abdominal ?#rays and a head ( scan may

be necessary to rule out the wide variety of associated conditions that can lead to nausea and vomiting in the patient who presents

after heavy alcohol consumption %&a!le :(.

&.6.&.@ *nvironmental toins and e%posures 

*%posure to certain environmental to%ins can lead to nausea and vomiting as prominent symptoms. 6ar!on monoidentoication presents in a non#specific manner. /eadache, di99iness, fatigue and nausea and vomiting are common @0!. In

addition, disturbed =udgment and diminished visual acuity may be seen. 5lood carbo%yhemoglobin levels of @0#D0E are

associated with tachypnea, tachycardia, ata%ia, syncope and sei9ures. (he *G8 may show ( segment changes, conduction

blocks and atrial or ventricular arrhythmias. herry#red coloration of the lips or skin is rare.

(reatment consists of supportive care and 100E o%ygen. arbo%yhemoglobin levels should be measured every two to four hours,

and o%ygen continued until blood levels are less than 10E. /yperbaric o%ygen 6 atm! is recommended for patients who present

with neurologic signs or symptoms, *G8 changes consistent with ischemia, shock, severe metabolic acidosis and pulmonary

edema.

2cute arsenic -oisoning can present with nausea and vomiting @1!. 2cute fluoride -oisoning from a public water system

produced a clinical syndrome characteri9ed by nausea, vomiting, diarrhea, abdominal pain and paresthesias @&!. esticidee%posure can present with an%iety, vertigo, nausea, vomiting, tearing and weakness @6!. *lemental mercury vapor to%icity

presented with nausea, headache, lumbar pain and shortness of breath at rest @@!. In each of these e%amples, nausea and vomiting

were present in the ma=ority of cases but the presenting symptom comple%es were non#specific.

ood -oisoning due to pre#formed bacterially#derived to%ins can present with nausea and vomiting in association with abdominal

pain and diarrhea. taphylococcal food poisoning typically presents with nausea, vomiting, cramping abdominal pain and diarrhea

between two and four hours after ingestion of food contaminated by the enteroto%in produced by Staphylococcus aureus . ;ften, a

cluster of cases is identified. (reatment is symptomatic. (he illness is short, rarely lasting more than &@ hours.

Vibrio parahemolyticus poisoning is associated with the consumption of raw or improperly refrigerated seafood. (he incubation

period is between 1& and &@ hours, and patients present with e%plosive watery diarrhea, nausea, vomiting and abdominal cramps.

(reatment is supportive, although in protracted cases, antibiotic therapy with tetracycline or ampicillin may be used. ;ther

bacterial causes of food poisoning such as Clostridium perfringens type 2 and Bacillus cereus cause nausea and vomiting as

predominant symptoms in a minority of patients.

&oin e%posure can occur by consumption of seafood or e%posure to marine to%ins. combroid poisoning by the consumption of

spoiled fish of the dark meat varieties can present with skin rash, diarrhea, palpitations, headache, nausea, abdominal cramps,

paresthesias, an unusual taste sensation and breathing difficulties. atients respond to anti#histamines as the to%in is histamine @A,

@D!. igatuera poisoning, seen predominantly in tropical areas, presents with nausea, abdominal pain, vomiting and diarrhea.

eripheral neuropathic symptoms are also characteristic, including paresthesias, dental discomfort and confusion of peripheral hot

and cold sensation. (reatment is symptomatic.

2lthough not to%ins, certain foods can cause hypersensitivity reactions which present with nausea, vomiting, abdominal pain anddiarrhea @F!.

ertain envenomations can present as nausea and vomiting. S-ider !ites, particularly by the female black widow spider or brown

recluse spider, can present with nausea and vomiting. ikewise, scorpion stings and snake bites can present with nausea and

vomiting. In all of these cases, pain, erythema and swelling at the site of the bite is usually evident. <nusual e%amples of

envenomations which present with nausea and vomiting are those due to the bite of the 8ila monster @C! and the sting of the

ortuguese man#of#war @-!.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 17/30

ertain environmental e%posures can lead to nausea and vomiting. 1eat ehaustion occurs in an unacclimati9ed person who

e%ercises on a hot day. It results from loss of salt and water, with the patient complaining of headache, nausea, vomiting,

di99iness, weakness, irritability, cramps or diaphoresis. (herapy consists of rest in a cool environment, and volume repletion with

salt#containing solutions. If vomiting is present, IV normal saline may be necessary.

1igh altitude illness can occur in people unacclimati9ed to altitude who ascend to more than &000 meters in less than 1#& days.

2cute mountain sickness presents with headache, nausea, vomiting, anore%ia, dyspnea, lethargy, sleep disturbance, vertigo,

palpitations and difficulty concentrating. (reatment consists of liberal fluids, mild analgesics for headache, prochlorpera9ine for

nausea, and for severe symptoms, o%ygen at &#6 liters :minute and descent of 1000#1A00 meters.

&.6.6 ;ate -regnanc#

If the patient is pregnant, nausea and vomiting of pregnancy, especially early in gestation, is common and is a self#limited and

benign condition. In the third trimester of a normal pregnancy, the incidence of nausea and vomiting decreases A0!. If nausea and

vomiting in the pregnant woman does not fit this typical pattern, then the following conditions should be considered. If symptoms

are severe, or begin in the second or third trimester, then other more serious conditions need to be considered. 7or each of the

conditions described below, management along with an obstetrician should be considered %&a!le <(.

&.6.6.1 1#-eremesis gravidarum

If vomiting is protracted such that fluid and electrolyte disturbances or nutritional deficiency develops, then the condition is

termed hyperemesis gravidarum. ;nset of symptoms is often soon after the first missed menstrual period. lassically the vomiting

disappears during the third month, and rarely persists into the fourth month. atients with hyperemesis gravidarum do not have an

ncreased incidence of to%emia of pregnancy or spontaneous abortion, and their babies are not underweight or otherwise affected.

In one study, however, intrauterine growth retardation in patients with hyperemesis gravidarum was reported A1!. omen with

twins or with molar pregnancy hydatidiform mole! have an increased incidence of hyperemesis gravidarum. (hese women have

elevated concentrations of human chorionic gonadotropin /8!. 2bnormalities of thyroid function tests are also common. (he

metabolic conseuences of hyperemesis gravidarum can be severe due to dehydration and muscle wasting, with mortality

ncreased in untreated patients. 8astric emptying is not delayed in patients with hyperemesis gravidarum, suggesting that the

disorder is not due to an upper 8I tract motility disturbance 1&&!.

&reatment

(reatment is directed at fluid and electrolyte replacement and supportive psychotherapy 11!. arenteral nutritional therapy may

be necessary. tandard anti#emetics are generally not effective. uccessful management with intravenous hydrocortisone, followed

by oral prednisolone has been described in a series of seven patients A&!. (he combination of intravenous droperidol and

diphenhydramine was shown to improve symptoms A6!.

2 placebo#controlled, randomi9ed single#blind study of manual acupressure for the treatment of hypermesis gravidarum

performed in 66 women showed that nausea and vomiting was reduced in the acupressure group compared to the placebo group

1&1!.

&.6.6.& Acute fatt# liver of -regnanc#

(his is a serious condition of unknown etiology, occurring in 1316,000 deliveries. ymptoms of nausea, vomiting, headache and

malaise begin in the third trimester, usually around week 6A. 7eatures of pre#eclampsia hypertension, edema, proteinuria! may be

present. (he disease often progresses to hepatic failure complicated by disseminated intravascular coagulation. If nausea and

vomiting begin in the latter part of pregnancy, serum aminotransferase activity 2(:2(! should be measured. *levated

aminotransferases in the &00#A00 range is an indication for liver biopsy. (he characteristic finding on biopsy is microvesicular fat.

)aternal morbidity is high, and the condition should be suspected in patients with symptoms of pre#eclampsia with

hypoglycemia, low fibrinogen and prolonged prothrombin time A@!.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 18/30

&reatment

;nce this diagnosis is established, early delivery is indicated to prevent maternal and fetal death AA!. )anagement by an

obstetrician, and referral to a center speciali9ing in high#risk obstetrics should be considered.

&.6.6.6 1+;; S#ndrome

2 syndrome of hemolysis, elevated liver en9ymes and low platelet count can complicate pre#eclamptic:eclamptic patients. atients

typically present in the third trimester with epigastric or right upper uadrant pain and nausea and vomiting. (hey may present

with no signs of pre#eclampsia hypertension, proteinuria, or edema!, and therefore a non#obstetric diagnosis may be entertained

AD!.

&reatment

)anagement in con=unction with an obstetrician is recommended, and referral to a center speciali9ing in high#risk obstetrics

should be considered.

&.6.@ N symptoms

/eadache, pro=ectile vomiting often in the morning without antecedent nausea, a history of migraine, transient ischemic attacks,

vertigo, photophobia or neck stiffness are elements of the history which should direct the clinician to a N e%planation fornausea and vomiting.

/eadache may be due to migraine, increased intracranial pressure or cerebral vascular hemorrhage. (he clinical diagnosis of

migraine is based on headache characteristics and associated symptoms, particularly nausea and vomiting. (he treatment of

migraine has been recently reviewed AF!. (reatment strategies include A#hydro%ytryptamine agonists, ergotamine tartrate,

sumatriptan, dihydroergotamine, N2I+s and opiates. umatriptan, a selective serotonin receptor agonist, is particularly effective

and well#tolerated AC! A-!. (reatment with oral sumatriptan has been studied in a randomi/ed dou!le)!lind -lace!o)controlled

stud#, and found to be effective D0!.

/eadache in the presence of fever and neck stiffness suggests meningitis D1!. Nausea and vomiting may be a feature of

meningitis. erebral cysticercosis can present with positional headache and nausea and vomiting D&!11D!.

rimary intraventricular hemorrhage presented with nausea and vomiting in F1E of cases in a review of 1@ cases. /eadache and

mental status changes were noted in an eual number of cases D6!. 'eferral to a neurologist or neurosurgeon may be necessary.

Vertebrobasilar vascular insufficiency is a common cause of vertigo in the elderly. Vertigo is abrupt in onset, lasts several minutes

and is often associated with nausea and vomiting. 2ssociated symptoms due to ischemia in the territory of the posterior circulation

nclude visual hallucinations, drop attacks, diplopia, headache and visual field defects. ( scans are usually normal, as symptoms

are transient. 2ngiography may be helpful, but carries a risk of arterial spasm and stroke. 'eferral to a neurologist should be

considered.

Vertigo with nausea and vomiting may also accompany infarction of the lateral brain stem or cerebellum or both. Gey findings are

an acute onset of symptoms, clear cerebellar signs such as e%tremity and gait ata%ia and ga9e#evoked n#stagmus. (hese patients

must be carefully observed for the development of progressive brain stem dysfunction due to edema at the site of infarction.onsultation with a neurologist should be obtained.

erebellopontine#angle tumors, such as acoustic neuroma, meningioma and epidermal cysts grow slowly, so that acute vertigo 

with associated nausea and vomiting are rarely presenting symptoms. ;ccasionally, acute onset of vertigo may be present.

<nilateral, progressive hearing loss is present, identified by an abnormal brain#stem auditory evoked response. *valuation by

magnetic resonance imaging )'I! is the most sensitive study. *very patient with vertigo and a unilateral hearing loss or tinnitus

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 19/30

must be assumed to have a retrocochlear lesion until radiographically proven otherwise 1C!. (reatment is surgical removal, so

that referral to an otolaryngologist or neurosurgeon is indicated.

&.6.A 5nfections as a 6ause of Nausea and Vomiting

Infections may present with nausea and vomiting, especially if viral in origin. Nausea and vomiting accompanied by diarrhea and

fever suggests viral gastroenteritis. ;ften, this is self#limited, and patients recover with supportive care. ;ccasionally, volume

depletion is severe, and may reuire volume replacement. 5lood in the stool and fever warrants further investigation and may

ndicate inflammatory bowel disease or bacterial enteritis or colitis.

ertain other infections of the upper 8I tract of non#viral etiology, although rare, should be considered. *sophageal infections are

more commonly seen in immunocompromised patients, and can present with nausea and vomiting alone, although most patients

will develop esophageal symptoms such as dysphagia and odynophagia. 7or immunocompromised patients, the most common

pathogens are andida, )V and /V D@!.

8astric syphilis has become an uncommon disease, with only &@ cases reported in the literature in the past & decades. (he most

common symptoms in a review of F cases were abdominal pain, nausea, and vomiting, with signs of syphilis present in A patients.(he diagnosis was established by identification of spirochetes on mucosal biopsy in D patients. (he diagnosis should be

considered in patients at risk for se%ually transmitted disease who complain of nausea, vomiting and abdominal pain and in whom

unusual gastric lesions or ulcers are refractory to therapy DA!.

<nusual infections such as 'ocky )ountain potted 7ever can present with nausea and vomiting, along with fever, headache,

myalgia and anore%ia. (hese symptoms can be difficult to distinguish from self#limited viral infection. 2 rash may appear later in

the course, but is not pathognomonic DD!.

/epatic abscess presented with nausea and vomiting in @0E of cases in a review of 6A patients. (wenty#nine patients had bacterial

abscesses, and D had amebic abscesses. 7ever was present in -AE and right upper uadrant pain in D6E of patients DF!.

&.6.D S#stemic disease as a cause of nausea and vomiting

2cute nausea and vomiting may be the manifestation of a definable disease process. hile diseases such as diabetes mellitus,

endometriosis and renal insufficiency are chronic in nature, acute e%acerbations may lead to presentations that include nausea and

vomiting.

*ndocrine emergencies can present with nausea and vomiting. Dia!etic "etoacidosis can present with vomiting, along with

polyuria, polydypsia, abdominal pain and changes in mental status. Ninety percent of patients are known diabetics. (he smell of

acetone on the patientHs breath, and the deep#breathing pattern of GussmaulHs respiration aid in the diagnosis DC!. ikewise,

severe vomiting and abdominal pain are central clinical features of alcoholic "etoacidosis. 2s in diabetic ketoacidosis, severe

dehydration can lead to GussmaulHs respiration and mental status changes D-!.

Acute adrenal insufficienc# usually presents with nausea, vomiting, severe hypotension and dehydration F0!. Nausea and

vomiting are common in the uremic patient F1!.

Intestinal endometriosis can present with abdominal pain and nausea and vomiting. In a review of &D cases, abdominal pain was

the main presenting feature in &0, with associated nausea and vomiting in 1&. *stablishing the diagnosis preoperatively was

difficult in patients without a known history F&!.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 20/30

&.6.F 5mmunosu--ression

(he immunosuppressed patient can be considered in a separate category because such patients deserve a thorough diagnostic

workup even if signs and symptoms initially point to a benign self#limited condition as the cause.

(he classic situation is the patient with A5DS, although immunosuppression due to drugs and severe illness need to be considered.

hile the cause of nausea and vomiting may be similar to those seen in immunocompetent patients, several other etiologies need

to be considered. hiefly, opportunistic infections of the upper 8I tract, such as andida esophagitis, )V or /V infection F6!

may be present. hile nausea and vomiting are rarely the sole symptoms seen in these situations, other more typical symptoms

such as odynophagia or dysphagia, hematemesis and weight loss may be accompanied by nausea and vomiting. 7or these patients,

referral to a gastroenterologist for endoscopy to establish the diagnosis should be considered, especially if an empiric trial of

therapy e.g. flucona9ole for presumptive andida esophagitis! is unsuccessful.

&.6.C =nusual causes and conse$uences

(here can be unusual causes or conseuences of nausea and vomiting. (his uestion should be asked by the e%aminer if the

patient does not fit a typical profile in terms of symptoms, or if an unusual complaint arises as a conseuence of vomiting.

(here are several conseuences of nausea and vomiting which are rare but should be considered. Visual floaters may be due tovitreous hemorrhage and retinal vein rupture caused by emesis F@!. tress fracture of the hyoid bone caused by induced vomiting

has been described FA!. (ooth surface enamel loss may occur with repeated emesis FD!. 5enign retropneumoperitoneum can be

nduced by vomiting FF!.

ikewise, unusual causes of nausea and vomiting have been described. S#stemic mastoc#tosis can present with nausea due to

mast cell infiltration of the gastric mucosa FC!. Visually induced paro%ysmal nausea and vomiting can be the presenting

manifestation of multi-le sclerosis F-!. 2cuired or hereditary angioedema can present with gastrointestinal complaints

ncluding episodic nausea C0!. 8astric outlet obstruction may occur due to a giant duodenal gallstone. (his condition is called

Bouveret4s s#ndrome, and often indicates the presence of a cholecystoduodenal fistula C1!. *mesis of gallstones has been

described, indicative of a fistula between the gallbladder and the stomach or duodenum C&!.

6.0 6hronic nausea and vomiting

hronic nausea and vomiting is defined as the presence of symptoms for over a week. (he patient may describe intermittent

symptoms lasting months or years. 2 number of different conditions may be responsible for such symptoms, and a thorough

history and physical e%am are invaluable in pointing to the correct diagnosis.

6.1 (he cause is known from prior workup

In certain situations of chronic or recurrent nausea and vomiting, the cause has been established on previous diagnostic workup. In

these situations, treatment may be instituted without e%tensive diagnostic workup, although the physician must keep an open mind

regarding alternative etiologies. If the patient does not respond to specific therapy, further diagnostic studies should be initiated.

6.& (he cause is not known

If no prior diagnosis or underlying etiology is evident, the patient with chronic or recurrent nausea and vomiting reuires a

diagnostic work#up. onditions such as the post#gastrectomy state, diabetes mellitus leading to gastroparesis and prior abdominal

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 21/30

surgery can predispose to recurrent nausea and vomiting. Gnowledge of the underlying condition aids the physician in fashioning

a diagnostic and treatment plan. In this situation, a full diagnostic workup may not have been performed in the past despite the

chronicity of symptoms. If such is the case, the history, physical e%amination, screening laboratory tests and abdominal ?#rays

supine and upright! are the first steps in the diagnostic workup. +iagnostic tests useful in the evaluation of the patient with

chronic nausea and vomiting are outlined in %&a!le >(. ome of the causes of chronic nausea and vomiting are rare, and referral

for speciali9ed diagnostic testing may be necessary. ertain conditions prompt referral to a gastroenterologist

%&a!le '*(.

6.&.1 (he gastrointestinal tract is involved

hronic nausea, accompanied in a subset of patients by vomiting, can be due to a variety of gastrointestinal causes. 2chalasia,

esophageal masses, peptic ulcer disease, gastroparesis, occult gastrointestinal cancer, intestinal pseudo#obstruction and

gastroesophageal reflu% disease are e%amples of gastrointestinal diseases that can present with nausea with or without vomiting.

6.&.1.1 G5 tract o!struction

G5 tract o!struction needs to be ruled out early in the diagnostic workup, and this can be accomplished initially by supine and

upright abdominal ?#rays, followed by contrast studies if indicated. 8I tract obstruction can lead to acute nausea and vomiting. If

abdominal pain precedes nausea and vomiting, obstruction of the 8I tract should be strongly considered. Gastric outlet

o!struction can be caused by peptic ulcer disease, particularly in the pyloric channel or duodenal bulb. (umor and !e/oar

formation are less common reasons for gastric outlet obstruction. ;ther causes of 8I tract obstruction such as small bowel

obstruction and stricture formation e.g. with rohns disease! need to be considered.

2 history of prior gastric resection is associated with nausea and vomiting, often presenting many years following the surgery

date. Vomiting of bile may be noted. Vagotomy with partial gastrectomy with 5illroth I or II anatomy can predispose to

obstruction. 'ou%#en#K gastro=e=unostomies can lead to altered gastric emptying rates, manifesting as nausea and vomiting. (he

'ou% stasis syndrome, characteri9ed by abdominal discomfort, nausea, vomiting or !e/oar formation was noted in DE of &0

patients following 'ou%#en#K gastro=e=unostomy C6!. 2 prior fundoplication can lead to distal esophageal obstruction leading to

vomiting with associated dysphagia. Nausea has been described following laparoscopic fundoplication C@!. In each of these

situations, contrast studies help in defining the altered anatomy, and endoscopic e%amination allows mucosal lesions to be

dentified and appropriately treated. 'eferral to a gastroenterologist, and in some cases to a surgeon, is necessary in many of these

patients.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 22/30

;ther causes of nausea and vomiting involving the 8I tract include esophageal lesions such as achalasia or esophageal masses that

may cause obstruction to the passage of food. 'egurgitation of undigested food, rather than true vomiting, may be the presenting

complaint. +ysphagia, with or without odynophagia, is usually part of the patientHs complaints. 'eferral to a gastroenterologist for

endoscopy, biopsy and management is indicated for these disorders.

6.&.1.& ;ther 8I causes

ertain situations where 8I causes of nausea and vomiting are present without evidence of mechanical obstruction also need to be

considered.

hronic intractable nausea can be the primary symptom of gastroeso-hageal reflu disease. In a study of 10 outpatients with this

symptom, acid reflu% was the cause of intractable nausea in all patients. In this group of three men and seven women, the average

duration of nausea was & years, with a range of 6 months to D years. None had responded to empiric therapies for nausea. *ither

upper endoscopy or &@ hour esophageal p/ studies showed gastroesophageal acid reflu% in all patients. *sophagitis was

documented on upper endoscopy in A patients$ and in the D patients who had esophageal p/ testing, abnormally increased acid

reflu% was documented. (reatment included omepra9ole, ranitidine or cisapride$ one patient who did not respond to high dose /&blocker or proton pump inhibitor therapy underwent Nissen fundoplication. (reatment of gastroesophageal reflu% led to symptom

resolution in all patients CA!. ith a mean follow#up of D months, all patients reported no recurrence of nausea.

hronic peptic inflammation due to -e-tic ulcer, gastritis or ?ollinger)+llison s#ndrome can present with nausea and vomiting.

Helicobacter pylori infection leads to chronic gastritis and has been associated with gastric and duodenal ulcers. Nausea and

vomiting can be associated symptoms of ulcer disease. atients with recurrent vomiting and suspected peptic ulcer disease should

undergo endoscopy to evaluate this possibility. (he diagnosis of H pylori infection can be established via several methods.  H

pylori serology provides evidence of e%posure to the organism. 5reath testing and a stool antigen test are available to non#

nvasively determine whether active infection is present. *ndoscopy with biopsy of the antrum to demonstrate the organism is the

gold standard, and should be considered in cases where peptic ulcer disease is a diagnostic consideration. 2 rapid urease en9yme

test may be used concurrently with biopsy. ;nce the presence of the organism has been established, and the symptoms and clinical

picture are deemed suitable for treatment, several drug combinations are available.

+osino-hilic gastroenteritis is characteri9ed by peripheral eosinophilia, eosinophilic infiltration of the 8I tract and symptoms

referable to the 8I tract including abdominal pain, nausea, vomiting, diarrhea, anemia and protein#losing enteropathy. eripheral

eosinophilia is not an invariable finding. In a review of C patients, the diagnosis was established by endoscopic mucosal biopsy in

A and by laparotomy with full#thickness biopsy in the remainder. atients were treated with prednisone with response in all

patients CD, CF!.

Infiltrative lesions of the stomach linitis -lastica! can present with early satiety and nausea and vomiting. ancreatic cancer can

ead to gastroparesis and nausea and vomiting.

Nausea and vomiting may be caused by disorders of gastric motility without obstruction or evidence of inflammation.

Gastro-aresis is the most common of these motility disorders. In most cases, the diagnosis is made clinically, in the absence of

mechanical lesions causing obstruction of the 8I tract. cintigraphic gastric emptying studies are the gold standard CC, C-!. In

difficult to treat cases, the patient may be referred to a gastroenterologist at a tertiary care center. *soteric tests such as

antroduodenal motility tests and electrogastrography may be used to document slowed gastric muscular activity. (reatment of

gastroparesis includes dietary measures, such as maintaining adeuate hydration, eating small freuent meals, and avoiding fatty

foods and indigestible solids. harmacologic therapy includes antiemetics as well as prokinetic agents. ro"inetic agents such as

metoclopramide and cisapride have been used to treat this disorder -0!. +omperidone has also been shown to enhance gastric

emptying. *rythromycin in low, prokinetic doses &A0 mg ; (I+ 60 minutes before meals! may also be tried. <sually prokinetic

agents are given 1A to 60 minutes prior to meals to enhance the effect on gastric emptying at mealtime. 2 bedtime dose may help

n emptying the stomach of indigestible solids and thereby prevent be9oar formation.

6.&.& (he nervous system is involved

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 23/30

Nervous system causes of chronic nausea and vomiting include organic brain disease, often manifesting with focal neurologic

signs$ autonomic nervous system diseases$ and degenerative neuromuscular diseases of the gut.

6.&.&.1 7ocal neurologic signs are present

6entral nervous s#stem %6NS( causes of vomiting may be due to stimulation of the emetic center in the medulla oblongata. It

may be seen in patients with brain lesions, increased intracranial pressure, hydrocephalus, vestibular disorders and posterior

cranial fossa lesions. )etabolic#induced and drug#induced vomiting are partially mediated by the N through stimulation of the

chemoreceptor trigger 9one in the floor of the fourth ventricle area postrema!.

2 thorough neurologic e%am is critical to rule out N lesions, and includes testing of cranial nerves, vestibular function and

pupillary function. (he presence of peripheral neuropathy and e%trapyramidal signs should be ascertained. Imaging studies of the

head ( or )'I! are important diagnostic studies to rule out N lesions. 7or vertiginous symptoms, referral to an

otolaryngologist and consideration for electronystagmography is appropriate.

(reatment will depend on the diagnosis. onditions such as increased intracranial pressure, intracranial bleed and intracranial or

posterior fossa tumor indicate the need for referral to a neurologist or neurosurgeon.

6.&.&.& (he autonomic nervous system is involved

+isorders of autonomic supply may alter gut motility and result in vomiting. 2utonomic system degenerations such as idiopathic

orthostatic hypotension, as well as diseases causing autonomic neuropathy such as diabetes mellitus, may produce motility

disturbances in the gut. igns of autonomic neuropathy such as orthostatic hypotension, absence of sweating and absence of pulse

and blood pressure responses to Valsalva maneuver should be sought. hronic nausea and vomiting is encountered in the diabetic

patient.

6.&.&.6 +egenerative neuromuscular diseases of the gut

)otility disturbances in the 8I tract can lead to acute presentations mimicking that of 8I tract obstruction. )ost of the

neuromuscular disorders are uncommon. Neuromuscular diseases of the 8I tract such as intestinal pseudo#obstruction and hollow

visceral neuropathy or myopathy may alter the muscle of the intestinal wall or the nerves of the myenteric ple%us or both.

atients can present with chronic une%plained abdominal pain, abdominal distention and bloating, early satiety, nausea, vomiting

and alterations in bowel habits -1! -&!. 5oth purely myogenic familial visceral myopathy, somatovisceral myopathy,

scleroderma! and purely neurogenic motility disorders von 'ecklinghausens disease or hagas disease! e%ist. )i%ed conditions

also e%ist. 7or e%ample, in amyloidosis the lesion may be an infiltration of muscle and nerve. Nausea and vomiting are freuent

but not invariable features of gut motility disorders. (he area of the gut involved is important in determining the predominant

clinical presentation3 whereas gastroduodenal motility disorders often cause nausea and vomiting, the predominantly intestinal

motility disorders chronic intestinal pseudo#obstruction syndrome! may present as abdominal distension, pain and disturbances of 

bowel movement often without recurrent vomiting. Intestinal pseudo#obstruction caused by paraneoplastic syndromes can also

present with nausea and vomiting.

7or the diagnosis of neuromuscular causes of nausea and vomiting, referral for speciali9ed testing may be necessary, especially in

those patients with longstanding symptoms who remain undiagnosed and who do not respond to therapeutic trials. )echanical

causes of 8I tract obstruction should be ruled out with contrast studies or endoscopy. hile radionuclide studies may document

delayed gastric emptying, the precise etiology for such an abnormality in the non#diabetic patient will not be known. *sophageal,

antro#duodenal or anorectal manometry may be useful to document altered 8I tract motility$ however, the precise etiology behind

such abnormalities will not be known. In these situations, referral for speciali9ed studies is appropriate. (ests such as small bowel

manometry and electrogastrography may prove useful. In a small number of cases, laparotomy with full thickness small bowel

biopsy may be necessary in order to arrive at a diagnosis.

6.&.6 *ndocrine or metabolic cause

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 24/30

*ndocrine and metabolic causes can lead to chronic nausea and vomiting. (he classic situations are the patient with diabetes

mellitus, the patient with adrenal insufficiency and the patient with hypercalcemia.

6.&.6.1 Dia!etes mellitus

Nausea and vomiting, often accompanied by weight loss and early satiety, are common gastrointestinal symptoms in patients with

diabetes. *pisodes of nausea and vomiting may last days to months or occur in cycles C-!. 2bout half of patients with insulin or

non#insulin#dependent diabetes have delayed gastric emptying diabetic gastro-aresis!. ome complain of epigastric pain,

nausea, vomiting or postprandial fullness. Be/oars may form in the stomach, leading to gastric outlet obstruction e%acerbating the

underlying gastroparesis. +iabetic gastroparesis may contribute to inadeuate glycemic control and impaired absorption of orally

administered drugs. 2lthough less common, gastric emptying rates may be accelerated in diabetics as well -6!.

6.&.6.& Adrenal insufficienc#

2drenal insufficiency presents with nonspecific symptoms such as weakness, fatigue, nausea, vomiting, anore%ia and weight loss.

It should be suspected if the patient has hyperpigmentation, hyponatremia and:or hyperkalemia$ a history of autoimmune disease

such as hypothyroidism or diabetes$ or recent use of corticosteroids F0!. 8astric stasis has been demonstrated in a patient with

primary adrenal insufficiency -@!, and therefore this diagnosis should be considered in patients presenting with chronic nausea

and vomiting. (he short cosyntropin ortrosyn! stimulation test &A0 ug IV or I), with measurement of plasma cortisol 60

minutes later! is diagnostic, with a normal response being stimulated plasma cortisol greater than &0 ug:dl. ith the diagnosis of

adrenal failure, therapy with hydrocortisone 100 mg IV Ch should be given, along with normal saline with AE de%trose until

hypotension is treated. )aintenance therapy with prednisone is reuired.

6.&.6.6 1#-ercalcemia

/ypercalcemic states can alter gut motility and present with nausea and vomiting. 8I symptoms of severe hypercalcemia serum

calcium L 1& mg:dl! includes nausea and vomiting, as well as anore%ia, constipation and abdominal pain. Neurologic symptoms

nclude such as weakness, fatigue, confusion, stupor and coma$ renal effects such as polyuria and nephrolithiasis may be seen.

+ehydration resulting from nausea and vomiting and anore%ia can lead to even more severe hypercalcemia -A!. erum ioni9ed

calcium is a better indicator of true hypercalcemia, as total serum calcium levels are linked to serum albumin levels. rimary

hyperparathyroidism and malignancy are the two most common causes of hypercalcemia. (reatment of the underlying cause, as

well as treatment of the hypercalcemia with e%tracellular volume restoration, saline diuresis and treatment with bisphosphonates

should be instituted when appropriate.

6.&.@ s#chogenic causes

'epetitive vomiting may be a conscious and voluntary act as in patients with !ulimia who vomit in part to control their weight. In

rumination, the patient increases intraabdominal pressure, regurgitates food into the mouth and swallows it again. 2t a more

subconscious level, vomiting may occur in otherwise healthy persons as part of a strong emotional reaction, and in patients as an

e%pression of an underlying psychopathologic condition or as a conversion reaction.

In the diagnostic workup of psychogenic vomiting, a thorough history including a family and social history are important. Volume

depletion and signs of nutritional deficiencies should be sought on physical e%amination. 2 complete neurologic e%am should beperformed. +epression, weight loss and altered perception of body image suggest anoreia nervosa. *%cessive concern with

body weight, loss of dental enamel, parotid hypertrophy, electrolyte disturbances and chronic diarrhea indicate !ulimia -D!.

2lmost A0E of bulimics report nausea and other gastrointestinal symptoms -F!. 7ormal psychiatric testing including inpatient

evaluation and assessments such as the )innesota )ultiphasic ersonality Inventory should be considered. (hese types of tests

may be helpful if an abnormality in the hypochondriasis, depression or hysteria scales is found. 'eferral to a psychiatrist should

be considered.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 25/30

;ften, psychogenic causes of nausea and vomiting are diagnoses of e%clusion. 'ecently, however, hypomotility in the gastric

antrum, abnormal gastric electrical activity and delayed gastric emptying have been reported in patients thought to have

psychogenic nausea and vomiting. sychologic stress may in fact lead to vomiting in otherwise normal people -C!. In patients

with functional nausea and vomiting, tricyclic antidepressants at low doses may be of benefit. In a retrospective analysis of 6F

such patients treated with amitriptyline, desipramine, nortriptyline do%epin or imipramine, symptomatic response was documented

n C@E of the patients. +ose at response averaged A0 mg:day, and the outcome was not related to the tricyclic antidepressant used

11F!.

anic disorder has been associated with nausea --!. atients with borderline personality disorder can present with episodic

vomiting 100!. ocial phobia may manifest as nausea and fear of eating in public 101!.

(he c#clic vomiting s#ndrome is characteri9ed by recurrent, self#limited episodes of nausea and vomiting separated by symptom#

free intervals. In a report of F1 cases, the length and symptomatology of episodes were stereotyped and characteristic for each

patient 10&!. (here was a coincident relationship with migraine and irritable bowel syndrome. atients could identify conditions

that precipitated episodes, commonly heightened emotional states and infections 106!. hile all patients in the series were

children, a case in a DA#year old diabetic woman with a 10 year history of recurrent nausea and vomiting was reported 10@!.

*pisodes of vomiting were always characteri9ed by elevations in serum 2(/, serum cortisol and urinary cortisol. /owever,

suppression of these elevations with de%amethasone did not alleviate the clinical symptoms. Intramuscular ketorolac produced

prompt and sustained relief.

2 review of 1F adult patients with cyclic vomiting syndrome who had been treated with tricyclic antidepressants was published

11C!. ymptoms began at age 6A range 1@#F6 years!. (he average duration of each episode was D days range 1#&1 days!. (hesymptom#free interval averaged 6.1 months range 0.A to D months!. 7ewer than a third of the patients reported a prodrome or

triggering events. (ricyclic antidepressant therapy led to complete remission of symptoms in 1F.DE of patients, and partial

response in AC.AE of patients.

6.&.A No cause found despite thorough investigation

7inally, there may be patients in whom no etiology can be determined despite e%tensive diagnostic testing. In this group of

patients, a gastric emptying study should be performed 10A!. If the emptying study is abnormal, a trial of a -ro"inetic agent such

as metoclopramide may be useful. In cases of intractable gastroparesis, placement of gastrostomy tubes and =e=unostomy tubes for

decompression and feeding respectively may be effective 10D!. rior to the institution of these measures, the patient should beconsidered for referral to a tertiary care center for further testing, including electrogastrography and small bowel motility studies.

If the gastric emptying study is normal, then consideration can be given to laparotomy with full thickness biopsy of the small

ntestine to rule out a neuropathic or myopathic disorder. uch an invasive approach should be considered in the rare patient in

whom vomiting is severe and has led to nutritional compromise or to severe disruption of uality of life.

@.0 Drug (herapy for Nausea and Vomiting

@.1 lasses of +rugs

(he following is a brief summary of the drugs used to treat nausea and vomiting, including indications, contraindications and

potential adverse reactions. 7or most of these agents, safety for use in pregnancy has not been established. henever possible, the

potential benefits must be weighed against potential adverse effects. (his is not a comprehensive list of potential uses and adverse

effects. 7or detailed information regarding these drugs, the package insert should be consulted prior to prescribing. 2 summary of

anti#emetic agents is provided in %&a!le ''(.

@.1.1 henothia/ines

rochlorpera9ine and chlorproma9ine are the phenothia9ines used most freuently for nausea and vomiting of various causes.

(hey act at the (> to block dopamine receptors. rochlorpera9ine has good absorption after parenteral and oral administration,

with a serum half#life of F hours. ide effects include hypotension, autonomic responses, hypersensitivity reactions e.g.

cholestatic =aundice! and hormonal dysfunction. 2ntidopaminergic effects include dystonia, dyskinesia and tardive dyskinesia.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 26/30

@.1.1.1 rochlorpera9ine ompa9ineM!

Indications are moderate to severe nausea and vomiting. ontraindications include concomitant use of N depressants including

alcohol. *%trapyramidal side effects including tardive dyskinesia are related to duration and total cumulative dose of neuroleptics.

Neuroleptic malignant syndrome hyperpyre%ia, muscle rigidity, altered mental status, autonomic instability including

tachycardia, labile blood pressure and cardiac arrhythmias! can occur. afety for use in pregnancy has not been uneuivocally

established, although based on limited information, the drug appears relatively safe.

2 randomi9ed, double#blind comparison of treatment of uncomplicated nausea and vomiting due to viral gastroenteritis with

prochlorpera9ine ompa9ine! or prometha9ine hernergan! was published. (he results showed that prochlorpera9ine was

significantly better in terms of symptom relief compared to prometha9ine 11-!. (ime to complete symptom relief was

significantly shorter with prochlorpera9ine than with prometha9ine. rochlorpera9ine also caused significantly fewer complaints

of drowsiness.

@.1.1.& rometha9ine henerganM!

(his is a phenothia9ine derivative which also has anti#/1 histamine receptor effects. Indications are the prevention and control of

nausea and vomiting associated with anesthesia and surgery, and active and prophylactic treatment of motion sickness. ide

effects include drowsiness, and sei9ure threshold may be lowered. <se with alcohol and other N depressants effects should be

avoided.

@.1.1.6. hlorproma9ine (hora9ineM!

Indications are nausea and vomiting. 2s for other phenothia9ines, side effects include e%trapyramidal reactions and the neuroleptic

malignant syndrome. afety is not established in pregnancy.

@.1.1.@. (hiethylpera9ine maleate (orecanM!

Indications are nausea and vomiting. ontraindications are N depression and comatose states. IV administration is

contraindicated due to hypotension. *%trapyramidal side effects can be seen.

@.1.1.A erphena9ine (rilafonM!

Indications are severe nausea and vomiting. ontraindications are obtunded patients, those receiving large doses of N

depressants, and when blood dyscrasias, bone marrow suppression or liver damage is present. (ardive dyskinesia and neuroleptic

malignant syndrome may occur.

@.1.& Antihistamines

(hese agents work predominantly at the level of the vestibular afferents and within the brain stem. (heir use in antiemesis is

imited mainly to motion sickness and postoperative emesis. (he drugs most commonly used are cycli9ine, diphenhydramine and

prometha9ine.

@.1.&.1 )ecli9ine 2ntivert M! 5onine M!.

Indications are nausea, vomiting and di99iness associated with motion sickness. It may also be used to treat vertigo associated

with diseases affecting the vestibular system. (he ma=or side effect is drowsiness. <se with alcohol is to be avoided. +ue to its

potential anticholinergic actions, it should be used with caution in asthma, glaucoma and prostate gland enlargement. )ecli9ine

appears to be relatively safe for use in pregnancy.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 27/30

@.1.&.& +iphenhydramine 5enadryl M!.

Indication is primarily for treatment of motion sickness. ide effects include sedation. It should be used with caution with narrow#

angle glaucoma, stenosing peptic ulcer, pyloroduodenal obstruction and symptomatic prostatic hypertrophy. 2dditive effects with

alcohol and other N depressants occurs.

@.1.6 ro"inetic agents

(hese agents influence 8I motility through one or more of the following pathways3 1. +irectly or indirectly promoting cholinergic

tone$ &. 2ntagoni9ing inhibitory neurotransmitters e.g. serotonin, dopamine!$ or 6. )imicking noncholinergic nonadrenergic

compounds that increase motility e.g. motilin!. rokinetic agents have been used in the treatment of gastroparesis.

)etoclopramide, domperidone and cisapride are effective both in eliminating the symptoms of gastroparesis and in enhancing the

rate of gastric emptying 10F!.

@.1.6.1 holinergic agents

+irect cholinergic agents include bethanechol, which is the most commonly prescribed agonist, and acts by enhancing the

amplitude of contractions throughout the 8I tract, including the lower esophageal sphincter. (hese agents also stimulate the

secretion of saliva and gastric acid. ide effects develop due to enhanced parasympathetic tone, including abdominal cramps,

diarrhea, salivation, flushing, bradycardia and blurred vision.

@.1.6.& ubstituted 5en9amides

(his class of drugs promotes 8I tract motility and increases antroduodenal coordination by indirectly stimulating cholinergic

nerves. (hey cause the release of acetylcholine from enteric neurons. ide effects include a usually transient increase in stool

freuency. +rugs that belong to this class include metoclopramide, cisapride and trimethoben9amide. 2s metoclopramide e%hibitssignificant anti#dopaminergic effects, it is discussed in the following section.

isapride ropulsidM! was used as a prokinetic for conditions in which delayed gastric emptying may be etiologic. 2ntro#

duodenal motility is enhanced by this agent. In contrast to metoclopramide, cisapride e%hibits no anti#dopaminergic activity. It is

also used for gastroesophageal reflu% disease. ardiac arrhythmias such as ventricular tachycardia, ventricular fibrillation, torsade

de pointes and J( prolongation may occur when cisapride is used concurrently with ketocona9ole, itracona9ole, micona9ole,

flucona9ole, erythromycin, troleandomycin and clarithromycin. +ue to these adverse effects, cisapride was withdrawn from the

market, and is only available from the manufacturer under a compassionate use protocol.

(rimethoben9amide (iganM! is used to treat nausea and vomiting. Its side effects include drowsiness. afety in pregnancy is not

established, although based on limited information, the drug appears to be relatively safe.

@.1.6.6 +opamine receptor antagonists

)etoclopramide is the prototype drug of this class, and has both peripheral and central dopamine receptor antagonist effects.

eripherally, it enhances release of acetylcholine from intrinsic cholinergic neurons. It is an effective antiemetic in patients

receiving chemotherapy. ide effects limit the use of metoclopramide, with an incidence between 10#&0E. (he most common are

due to N effects, ranging from mild an%iety, restlessness, depression, nervousness and insomnia, to marked an%iety, confusion,

disorientation and hallucinations. 7atigue and e%trapyramidal side effects such as tremor, akathisia, tardive dyskinesia and

dystonic reactions that mimic arkinsonHs disease are due to its central antidopaminergic properties. 8ynecomastia due to

enhanced prolactin release has been described 10F!. 5ased on limited information, metoclopramide appears to be relatively safe

for use in pregnancy.

+omperidone )otiliumM! is a ben9imida9ole derivative with anti#dopamine effects in the upper 8I tract. 2 distinguishing feature

compared to other substituted ben9imida9ole agents is the lack of cholinergic activity. 2ntro#duodenal motility and coordination is

enhanced specifically by its peripheral anti#dopaminergic effects. 5ecause domperidone does not cross the blood#brain barrier, no

significant central nervous system anti#dopaminergic effects are seen. entral nervous system side effects as seen with

metoclopramide are rare. 7emale patients may develop galactorrhea due to increased prolactin levels.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 28/30

+omperidone was effective in improving delayed gastric emptying in 1F patients with documented gastroparesis. 7urthermore,

uality of life was enhanced in more than C0E of these patients. ymptoms such as nausea and vomiting, abdominal pain and

bloating were improved significantly in this group of patients 10-!.

2 direct comparison of metoclopramide and domperidone in a randomi9ed, double#blind study has been reported. Ninety#five

patients with nausea and vomiting due to a variety of gastrointestinal causes were given either metoclopramide 1A mg bid! or

domperidone 10 mg or &0 mg tid!. hile both metoclopramide and low and high dose domperidone reduced nausea and vomiting

compared to baseline, there were no significant differences noted between the three treatment groups 110!.

@.1.6.@ )otilin agonists

*rythromycin acts as a prokinetic agent by binding to receptors for the hormone motilin, which regulates the gastric migrating

motor comple%. 2s such, it can be used for delayed gastric emptying. (achyphyla%is can be a problem, making long#term use of

this drug difficult.

@.1.@ Anticholinergics

(he most commonly used agent is hyoscine hydrobromide scopolamine hydrobromide!. It is one of the best agents for motion

sickness, and is useful in postoperative nausea and vomiting. In the palliative care setting, it is used for the management of

ntractable retching and for the control of nausea, emesis and pain produced by intestinal obstruction.

@.1.@.1 copolamine (ransderm copM!

Indications are nausea and vomiting associated with motion sickness. (he patch should be applied to the skin behind the ear.

rogrammed delivery of 0.A mg of scopolamine over 6 days is provided. It should be used with caution in elderly patients, and in

patients with pyloric obstruction or urinary bladder neck obstruction, or those with intestinal obstruction. It can be used in

pregnancy if the anticipated benefit =ustifies the potential risk to the fetus. 2dverse reactions include dry mouth, drowsiness,

blurred vision and transient dilation of pupils.

@.1.A 7)1&3 rece-tor antagonists

A#/(6 receptors are located both centrally and peripherally, with high concentrations in the 8I tract. 2ntagonists for this receptor

have been evaluated and found to be effective for a variety of conditions, including cancer chemotherapy#induced emesis, emesis

due to total body irradiation 111!, 8I motility disturbances, carcinoid syndrome and nausea and vomiting related to migraine and

an%iety 6!.

@.1.A.1 ;ndansetron

;ndansetron is the prototype drug of this class. It is effective in the control of chemotherapy#induced emesis. (he principal site of

action is in the area postrema, with some gastric prokinetic activity. ;ndansetron is not effective against motion sickness. 8iven

orally, ondansetron can be dosed C#1& hours. ;ndansetron is superior to high#dose metoclopramide in chemotherapy#induced

emesis. ide effects are few, and include constipation, headache and a transient rise in transaminases.

@.1.A.& ;ther  7)1&3 rece-tor antagonists

2dditional A#/(6 receptor antagonists which have been tested clinically are granisetron and tropisetron. omparative studieshave shown similar efficacy for these two agents 11&!. +irect costs of the drugs in this class did vary widely 1&-!. *fficacy is

more pronounced for cisplatin#containing regimens than for less emetogenic regimens. *ffectiveness is greater for acute emesis

than for delayed emesis. Nausea is more difficult to control than emesis by these agents. 8ranisetron Gytril M! is indicated for the

prevention of nausea and vomiting associated with initial and repeat courses of emetogenic cancer therapy, including high#dose

cisplatin.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 29/30

@.1.D )iscellaneous agents

@.1.D.1 orticosteroids

(hese agents can assist in relief of cytoto%ic drug#induced emesis, especially when combined with other antiemetics.

+e%amethasone alone or in combination with ondansetron were shown to be eually efficacious in preventing delayed

chemotherapy#induced nausea and vomiting in patients at low risk for this 161!. 2 meta#analysis of the available randomi9edevidence of the effectiveness of de%amethasone in the treatment of chemotherapy#induced nausea and vomiting was published.

(hirty#two studies met the inclusion critieria. +e%amethasone was superior to placebo or no treatment for complete protection of

acute emesis odds ratio &.&&$ -AE confidence interval lO, 1.C- to &.D0!. 2lso, de%amethasone was superior to placebo or no

treatment for complete protection from delayed emesis odds ratio &.0@$ -AE l$ 1.D6#&.AD! 16&!. In adrenal insufficiency,

treatment of the underlying cortisol deficiency with corticosteroids will ameliorate the symptoms of this disorder, including

nausea and vomiting.

@.1.D.& )egestrol 2cetate

(his is a progesterone used in the treatment of advanced breast cancer, which has appetite#stimulating properties and can improve

the symptoms of nausea from a variety of causes in cancer patients.

@.1.D.6 (etrahydrocannabinol dronabinol! and Nabilone

(he role of delta#-#tetrahydrocannabinol, the active component of mari=uana, and nabilone, a synthetic cannabinoid, is mainly in

cytoto%ic drug#induced emesis 116!. ide effects tend to limit their usefulness. 2lterations in mood, motor coordination,

cognitive function and memory are common. Nabilone has been used successfully for the management of intractable nausea and

vomiting in terminally staged 2I+ patients 11@!.

+ronabinol )arinolM! is an orally active cannabinoid. It is used for prophyla%is of chemotherapy#induced emesis. ombination

treatment with prochlorpera9ine may result in synergistic or additive antiemetic effects and attenuate the to%icities. 2 potential for

abuse e%ists.

@.1.D.@ 5en9odia9epines

(he an%iolytic and amnesic properties of some ben9odia9epines can be beneficial for patients whose nausea and vomiting have a

psychological component. (his is particularly so for the conditioned emesis of cytoto%ic chemotherapy.

@.1.D.A 5ismuth subsalicylate epto#5ismolM!

2lthough usually used for the symptomatic control of diarrhea, associated upper 8I complaints such as nausea may be relieved.

@.1.D.D (ricyclic 2ntidepressants

(he tricyclic antidepressant class of drugs amitriptyline, nortriptyline, do%epin, desipramine, and imipramine! have been used at

ow doses average does A0 mg:day for the treatment of fuctional nausea and vomiting 11F! and cyclic vomiting syndrome 11C!,

with some efficacy.

@.1.D.F 8inger >ingiber officinale!

8inger has been advocated as a treatment for nausea and vomiting. 2 systematic review, however, of the evidence from si%

randomi9ed clinical trials did not show a significant difference from placebo. /owever, individual non#controlled studies have

favored ginger over placebo for the treatment of nausea and vomiting caused by seasickness, early pregnancy and chemotherapy

1&0!.

7/21/2019 Nausea and Vomiting in Adolescents and Adults

http://slidepdf.com/reader/full/nausea-and-vomiting-in-adolescents-and-adults 30/30

@.1.D.C Neurkinin#1 antagonists

(he tachykinin substance is locali9ed within both the gastrointestinal vagal afferent nerve fibers and in the neural pathways

nvolved in the emetic response in the brainstem. (herefore, substance is thought to be a key mediator of nausea and vomiting,

and antagonists to its receptor, nuerokinin#1 NG#1!, are now being tested for their anti#emetic properties. reliminary studies in

humans show that NG1 receptor antagonists are effective in controlling both chemotherapy#induced and postoperative nausea and

vomiting 166!. In a randomi9ed, double#blind comparison with ondansetron in the prevention of postoperative nausea and

vomiting, the NG1 receptor antagonist #1&&,F&1 &00 decreased emetic episodes more effectively than ondansetron 16@!.