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Nausea and vomiting

Nausea and vomiting. Cerebral cortex. Vestibular nuclei. CTZ. GABA 5HT. ACh H1. 5HT 3 D 2. Gut wall. Vagal/splanchnic afferents. Gastric atony Retroperistalsis Thoracic and abdominal muscle contractions. Vomiting centre. 5HT 3. ACh H1 5HT 2. Movement/vertigo. Vestibular nuclei.

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Nausea and vomiting

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  1. Nausea and vomiting

  2. Cerebral cortex Vestibularnuclei CTZ GABA 5HT ACh H1 5HT3 D2 Gut wall Vagal/splanchnic afferents • Gastric atony • Retroperistalsis • Thoracic and abdominal muscle contractions Vomiting centre 5HT3 ACh H1 5HT2

  3. Movement/vertigo Vestibularnuclei CTZ • Gastric atony • Retroperistalsis • Thoracic and abdominal muscle contractions Vomiting centre

  4. Hyponatraemia Fear/anxiety Raised ICP Vestibularnuclei CTZ • Gastric atony • Retroperistalsis • Thoracic and abdominal muscle contractions Vomiting centre

  5. HypercalcaemiaUraemia Morphine Cytotoxic chemotherapy Vestibularnuclei CTZ • Gastric atony • Retroperistalsis • Thoracic and abdominal muscle contractions Vomiting centre

  6. Vestibularnuclei CTZ IntestinalDistension Cytotoxic chemotherapy Vomiting centre • Gastric atony • Retroperistalsis • Thoracic and abdominal muscle contractions Abdominal RXT Gastric irritants

  7. Case studies • Pick the most appropriate antiemetic in each case

  8. Management • Treat reversible causes • Remember unrelated causes e.g gastroenteritis • Choose the most appropriate antiemetic for the cause • Prescribe the same antiemetic regularly and prn • If oral absorption in doubt, use sc route • Remember non-drug treatments • Consider dexamethasone • REVIEW

  9. Common anti-emetics • Prokinetic for gastricstasis, functional bowel obstruction Metoclopramide 10mg tds or 30-60mg/24hr CSCI • Acting on CTZ trigger zone for chemical causes of vomiting eg morphine, renal failure Haloperidol 1.5-3mg stat/nocte or 2.5-5mg sc stat and 2.5-10mg/24hr CSCI

  10. Common anti-emetics • Antispasmodic and antisecretory if bowel colic and/or need to reduce GI secretions Buscopan 20mg stat 60 – 120mg/24hr CSCI • Acting in the Vomiting Centre for raised ICP, motion sickness or mechanical bowel obstruction Cyclizine 50mg tds 150mg/24hr CSCI • Broad-spectrum for mechanical obstruction, or if others fail Levomepromazine 6-12.5mg nocte

  11. Nausea and Vomiting • Bentley A, Boyd K. Palliative Medicine 2001;15:247-53.

  12. Summary • Try to establish the cause and choose an appropriate antiemetic, rather than picking your favourite • Avoid combinations that may antagonise each other • Choose an appropriate route

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