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Evaluation and Treatment of Nausea and Vomiting

Evaluation and Treatment of Nausea and Vomiting. Deon Cox-Hayley, DO University of Chicago. Nausea. Unpleasant subjective feeling of need to vomit. Case. 46 y/o with treated neurocystocercosis Hospitalized with intractable vomitting Compazine Ondansetron Reglan. How to treat?.

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Evaluation and Treatment of Nausea and Vomiting

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  1. Evaluation and Treatment of Nausea and Vomiting Deon Cox-Hayley, DO University of Chicago

  2. Nausea • Unpleasant subjective feeling of need to vomit

  3. Case • 46 y/o with treated neurocystocercosis • Hospitalized with intractable vomitting • Compazine • Ondansetron • Reglan

  4. How to treat?

  5. Vomiting center in medulla • Controls many involuntary, life-sustaining processes including • Respiration • Circulation • Digestion

  6. Vomiting center • Gastrointestinal tract • Respiratory center • breath holding • forceful contraction • Other brain stem centers • pallor • sweating • tachycardia

  7. Vomiting Center (VC) Diaphragm and abdominal muscles Upper GI tract

  8. Chemoreceptor trigger zone Vomiting Center (VC) Diaphragm and abdominal muscles Upper GI tract

  9. Chemoreceptor trigger zone Upper GI tract and pharynx Vomiting Center (VC) Diaphragm and abdominal muscles Upper GI tract

  10. Cortex Chemoreceptor trigger zone Upper GI tract and pharynx Vomiting Center (VC) Diaphragm and abdominal muscles Upper GI tract

  11. Cortex Chemoreceptor trigger zone Upper GI tract and pharynx Vestibular apparatus Vomiting Center (VC) Diaphragm and abdominal muscles Upper GI tract

  12. via Chemoreceptor Trigger Zone • Biochemical abnormalities • Sepsis • Drugs

  13. via Chemoreceptor Trigger Zone • Biochemical abnormalities • Hypercalcemia • Hyponatremia • Hepatic failure • Renal failure • Sepsis • Drugs • Chemotherapy • Opioids Digoxin Antibiotics Other

  14. via peripheral afferent • Irritation, obstruction of the GI tract (including pharynx and hepatobiliary system) 1. 2. 3. 4. 5. 6. 7.

  15. via peripheral afferent • Irritation, obstruction of the GI tract (including pharynx and hepatobiliary system) Cancer Chronic cough Esophagitis Gastritis Peptic ulceration Gastric distention Gastric compression Delayed gastric emptying Bowel obstruction Constipation Hepatitis Biliary obstruction Chemotherapy Radiotherapy

  16. via vestibular system Motion Malignant vestibular infiltration Drugs: aspirin, platinum

  17. via cortical centers • Psychological factors, • Anxiety • Sights • Smells • Tastes • Conditioned vomiting • Elevated intracranial pressure

  18. Treatment • Assess and treat underlying cause • Use of anti-emetics • Reassess

  19. Treatment • If mediated by the CTZ, • Antidopaminergic • Gastric stasis and compression • Pro-kinetic • Chemotherapy • 5-HT3 receptor antagonist • Cortical causes • Anxiolytic

  20. Phenothiazines • Examples • Compazine, Thorazine, Phenergan, Tigan • Action • Antidopaminergic • Side effects • Extra-pyramidal effects • Sedation • Hypotension

  21. Orthopromides • Example • Reglan • Action • anti-dopaminergic • direct gastrokinetic effect • Side effects • Sedation • Extra-pyramidal effects • Caution if obstruction

  22. Anti-cholinergics • Example • Scopolamine • Action • Anti-cholinergic near or at the VC • Decreases GI secretions and motility • Side Effects • dry mouth • delirium • constipation

  23. Antihistamine • Examples • Diphenhydramine, hydroxyzine, meclizine • Action • Uncertain action at the VC • Side Effects • Sedation • Dry mouth

  24. Cannabinoid • Example • Marinol • Action • Cortical • Sympathomimetic • Side effects • Drowsiness • Dysphoria • Delusions

  25. Corticosteroids • Examples • Prednisone, dexamethasone, hydrocortisone • Action • Undefined • Side effects • Stimulant • Improved appetite

  26. Benzodiazepines • Examples • Lorazepam, oxazepam, diazepam • Action • Cortical • Useful as an adjunct • Side effects • Sedation • Falls

  27. Serotonin receptor antagonists • Examples • Ondansitron, granisetron, dolasetron, and tropisetron, • Palonosetron (second generation) • Action • Prevent vagal stimulation in the GI tract • May have central action • Use--chemotherapy, radiation therapy • Side effects • constipation • headache

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