Vomiting

From Anvita Health Wiki

Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Pathology 5 Laboratory 6 Radiology 7 Complications 8 Management 9 More General Terms 10 Additional Terms 11 References

More Specific Terms

• cyclic vomiting syndrome (CVS)
• morning sickness (nausea & vomiting of pregnancy)
• post-operative nausea & vomiting

Introduction

• Vomiting is the forceful expulsion of gastric contents through the mouth.

Etiology

• infectious diseases

• bacterial, viral, parasitic
• gastroenteritis, hepatitis, otitis, meningitis

• enterotoxins
• acute abdomen

• appendicitis
• intestinal obstruction
• cholecystitis
• visceral inflammation
• pancreatitis
• intestinal perforation
• peritonitis
• mesenteric ischemia

• pharmaceutical agents

• antineoplastic agents: cisplatin, doxorubicin ...
• digitalis, digoxin
• levodopa
• potassium chloride
• estrogens
• opiates
• theophylline
• ferrous sulfate
• antibiotics: tetracyclines, erythromycin
• NSAIDs
• azathiaprine

• alcohol
• increased intracranial pressure
• pregnancy, generally confined to 1st trimester
• gastric retention

• gastroparesis, pyloric obstruction

• peptic ulcer disease
• upper GI bleeding:

• blood in the stomach may stimulate vomiting

• aerophagia
• metabolic & endocrine disorders

• diabetic ketoacidosis, adrenal insufficiency, thyrotoxicosis, uremia, hypercalcemia, hyponatremia

• labyrinthine diseases

• acute labyrinthitis, Meniere's disease

• cardiac disease

• congestive heart failure ( CHF), myocardial infarction ( MI)

• pain
• autonomic dysfunction (common with advanced cancer)
• psychogenic

• anorexia nervosa, bulemia, emotional upset
• cyclic vomiting syndrome

Pathology

• triggered by receptors in the stomach & CNS
• vomiting receptors in the CNS are found in the lateral reticular formation & the chemoreceptor trigger zone ( CTZ) of the area postrema in the floor of the 4th ventricle
• the vestibulocochlear nerve associated with movement
• cerebral cortex associated with anxiety

Laboratory

• pregnancy test
• electrolytes
• liver function tests, amylase, lipase Special Laboratory:

• esophagogastroduodenoscopy ( EGD)

Radiology

• plain abdominal radiograph: intestinal obstruction
• upper GI series - motility & mucosa of the proximal GI tract
• gastric emptying scan - gastroparesis
• computed tomography or magnetic resonance imaging of brain

Complications

• dehydration
• hypokalemia
• metabolic alkalosis
• aspiration pneumonitis
• malnutrition
• dental caries
• ruptured esophagus ( Boerhaave's syndrome)
• Mallory-Weiss tear

Management

• hydration is probably the most effective antiemetic [5]
• pharmaceutical agents ( anti-emetics)

• dopamine receptor antagonists

• phenothiazines

• prochlorperazine ( Compazine) 5-20 mg PO/ IV/ IM every 6-8h (NO better than placebo) [5]
• chlorpromazine ( Thorazine)

• butyrophenones

• haloperidol ( Haldol)
• droperidol ( Inapsine) better than placebo [5]

• metoclopramide ( Reglan) 10 mg IV every 2-3 hours, 10-30 mg PO QID (NO better than placebo) [5]

• 5-hydroxytrypamine-3 5HT-3 antagonists

• preventative agents ( premedication) for chemotherapy- induced nausea & vomiting
• ondansetron ( Zofran)

• improves hydration in children [3,5]

• granisetron ( Kytril)

• corticosteroids

• dexamethasone
• methylprednisolone

• antihistamines - useful for inner ear dysfunction

• dimenhydrinate
• promethazine
• cyclizine

• anticholinergics: useful for motion sickness

• scopolamine ( Transderm Scop, Hyoscine)
• dimenhydrinate ( Dramamine)
• glycopyrrolate
• hyocyamine ( Levsin)

• octreotide ( Sandostatin) decreases gastrointestinal secretion & motility
• ginger may be of benefit

• combination therapy ( palliative care)

• suppository anti-emetic combination (BRD)
• intravenous anti-emetic combination

• avoid all foods for several hours

• irritable stomachs respond to food with vomiting
• begin refeeding with small quantities of clear liquid

• specific therapy for underlying etiology

• see management of nausea/vomiting by etiology

More General Terms

• sign/symptom

Additional Terms

• emesis
• management of nausea/vomiting by etiology

References

1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
2. Bruera & Neumann Canadian Medical Assoc. J (CAMJ):158:1717, 1998
3. Freedman SB et al, Oral ondansetron for gastroenteritis in a pediatric emergency department N Engl J Med 2006; 354:1698 PMID: [1]
4. Braude D, Soliz T, Crandall C, Hendey G, Andrews J, Weichenthal L. Antiemetics in the ED: a randomized controlled trial comparing 3 common agents. Am J Emerg Med. 2006 Mar;24(2):177-82. PMID: [2]
5. Prescriber's Letter 14(8): 2007 Ondansetron (Zofran) in Children with Viral Gastroenteritis Detail-Document#: [3] (subscription needed) [4]
6. Nausea and Vomiting: NIH Institute and Center Resources [5]
7. National Guideline Clearinghouse
   - Vomiting in infants up to 3 months of age. (American College of Radiology) ngc-guideline: [6]
   - Nausea and vomiting. Editorial Board Palliative Care: Practice Guidelines. Association of Comprehensive Cancer Centres ngc-guideline: [7]

vomiting