Vomiting resident survival guide

Vomiting Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Dos
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

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Overview

Vomiting or Emesis means forcible emptying of the contents of stomach in which the stomach has to overcome the pressures that are normally in place to keep food and secretions within the stomach.Nausea and vomiting are most common causes for patients to seek primary care treatment, so it is very important to identify and properly manage the underlying problems causing vomiting.Though the mechanisms causing of nausea and vomiting are not completely understood, it is thought that the activation of a medullary vomiting centre by either afferent input from the gastrointestinal tract due to presence of local irritants or stimulation of the central chemoreceptor trigger zone by circulating emetogenic substances may cause vomiting.Dopamine and serotonin are the main transmitters both in central nervous system and gastrointestinal tract related vomiting. The most common causes of vomiting are Gastroenteritis, Migraine, Gastro peresis,Post operative, radiation and chemotherapy related vomiting, tumor, increased intracranial pressure,Hepatitis, Cholecystitis,Labyrithitis, Alcohol abuse, pregnancy induced vomiting. The management of most cases of nausea and vomiting depends on a good history and a detailed complete physical examination. Most episodes of vomiting that lasts for less than 48 hours have an existing triggering factor such as infection, viral illness, or food poisoning and can be managed by removing the triggering factor and by supportive therapy. Chronic and unexplained nausea and vomiting can be a difficult to treat as the cause is often obscure and requires special investigation.

Causes

Life Threatening Causes

Life-threatening causes of vomiting include:

• Head injury
• Bowel obstruction
• Appendicitis
• Meningitis
• Myocardial Infarction
• Brain tumor
• Pancreatitis

Common Causes

Common causes include:

• Gastric outlet obstruction
• Small bowel obstruction
• Irritable bowel syndrome
• Pancreatic adenocarcinoma
• Hepatitis
• Cholecystitis
• Pancreatitis
• Crohn’s disease
• Gastroparesis
• Chronic intestinal pseudo-obstruction
• Post-operative nausea and vomiting
• CNS causes
  • Migraine
  • Increased intracranial pressure
    • Malignancy
    • Hemorrhage
    • Infarction
    • Abscess
    • Meningitis
  • Congenital malformation
  • Hydrocephalus
  • Pseudotumor cerebri
  • Seizure disorders
  • Demyelinating disorders
• Infectious causes
  • Gastroenteritis
  • Otitis media
  • Pseudotumor cerebri
  • Acute intermittent porphyria
• Labyrinthine disorders
  • Motion sickness
  • Labyrinthitis
  • Tumors
  • Meniere’s disease
  • Iatrogenic
• Endocrinological and metabolic causes
  • Pregnancy
  • Uremia
  • Diabetic ketoacidosis
  • Hyperparathyroidism
  • Hypoparathyroidism
  • Hyperthyroidism
  • Addison’s disease
• Miscellaneous causes
  • Cardiac disease
    • Myocardial infarction
    • Congestive heart failure
  • Radiofrequency ablation
  • Starvation
• Cancer chemotherapy
• Radiation therapy
• Cardiovascular medications
  • Digoxin
  • Antiarrhythmics  
  • Antihypertensives
  • β-Blockers
  • Calcium-channel antagonists
• Antibiotics/Antivirals
• Ethanol Abuse
• Renal infection and renal stone

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Vomiting

Patient comes with vomiting

Take complete history

Ask the following questions about vomiting ❑ How long have you had nausea and vomiting? ❑ How much have you vomited? ❑ What is the colour of the vomitus? ❑ Have you had previous episodes like this or this is the first time? ❑ Is there any foul smell of the vomitus? ❑ Is there only food particle or any other mucous/substance present with the vomitus? ❑ Have you notice any blood streaks mixed with vomitus?

Ask the related questions ❑ Did your nausea and vomiting occur right after eating? ❑ Do you have a fever? ❑ Do you take any other medication? ❑ Have you recently eaten out? ❑ Have you eaten any canned product? ❑ Have you suffered from headache or photophobia along with this vomiting? ❑ Did you have any abdominal pain?

Record the vitals: ❑ Blood pressure ❑ Weight ❑ Body Mass Index ❑ Temperature ❑ Heart rate ❑ Respiratory rate

Do general physical examination: ❑Look for signs of dehydration *Look for sunken eyes *Dry mouth/tongue, thirst *Dry skin *Dizziness and a lack of focus *Orthostatic blood pressure drop,tachycardia *Light-headedness *Dark urine or decreased urine output *Increased capillary refill time *Poor skin turgor *Tiredness *Appetite ❑ Perform abdominal examination *Look for any abdominal tenderness *Presence of bowel sound

Do the following invetigations ❑ Complete blood count ❑ Electrolytes ❑ Liver function test ❑ Pancreatic enzymes ❑ USG of the abdomen if complains of abdominal pain. ❑ Pregnancy test if applicable. ❑ Abdominal X-ray and abdominal CT scan if any symptoms of mechanical obstruction ❑ Esophagogastroduodenoscopy if mucosal diseases such as ulcer or mass are suspected. ❑ Scintigraphic measures of solid phase gastric emptying (such as 99mTc-sulfur colloid in egg) are commonly used to evaluate gastric motion function in suspected gastroparesis.

If patient gives history of

History of ❑ Abdominal pain ❑ Eating out or eating reheated canned food. ❑ Abdominal bloating ❑ Passage of loose stool

History of ❑Headache

History of ❑ Acidosis ❑ Dehydration

History of ❑ Abdominal pain

Gastroenteritis

❑ Photophobia ❑ Triggered by smell, light or loud sound ❑ Unilateral headache usually, maybe bilateral which stays for 2-3 days. ❑ May have history of taking wine, chocolate.

❑ Dizziness ❑ Altered behaviour ❑ Vision changes ❑ Weakness of any part of body/ paralysis

Migraine

Tumor

Metabolic disorder

Weight loss, loss of appetite

Pain related to food, radiates to the back

presence of jaundice, hepatomegaly

Gastric carcinoma

Pancreatitis

Hepatitis

Treatment

Shown below is the treatment of Vomiting.

Medications used to treat Nausea and Vomiting

Mechanism	Name	Dose	Side effects
5-HT3 antagonists	Ondansetron Granisetron Palonosetron	4–8 mg q4–8 hours 1–2 mg q24 hours 0.075–0.25 mg q24 hours	Headache Fatigue Malaise Constipation
Benzamides	Metoclopramide Domperidone	10–20 mg q6–8 hours 10 mg q8–24 hours	Sedation Anxiety Mood disturbances Sleep disruption Dystonic reactions Tardive dyskinesia Galactorrhea Sexual dysfunction
Phenothiazines	Prochlorperazine Promethazine Chlorpromazine Perphenazine	5–10 mg q6–8 hours 12.5 –25 mg q4–6 hours 10–25 mg q4–6 hours 4–8 mg q8–12 hours	Extrapyramidal side effects Tardive dyskinesia Neuroleptic malignant syndrome Hyperprolactinemia QT prolongation
Cannabinoids	Dronabinol Nabilone	2.5–10 mg q6–8 hours 1–2 mg q8–12 hours	Palpitations Tachycardia Vasodilation/facial flushing Euphoria, abnormal thinking Dizziness Paranoia,, Depersonalization,Hallucinations Visual changes
Anticholinergics	Scopolamine	0.3–0.6 mg q24 hours	Tachycardia Confusion Dry mouth constipation Urinary retention
Antihistamines	Meclizine Diphenhydramine Cyclizine Hydroxyzine	25–50 mg q24 hours 25–50 mg q6–8 hours 25–75 mg q8 hours 25–100 mg q6–8 hours	Drowsiness Blurred vision Dry mouth constipation Urinary retention
Benzodiazepines	Lorazepam Alprazolam	0.5–2 mg 0.25–1 mg	Ataxia Cognitive dysfunction Depression Dizziness Drowsiness Dysarthria Fatigue Irritability Memory impairment Sedation
Corticosteroids	Dexamethasone	4–8 mg q4–6 hours	Emotional instability Acne Bruising Hyperglycemia Adrenal suppression Cushing’s syndrome
Butyrophenones	Droperidol	0.625–1.25 mg q24hours	QTc prolongation Orthostatic hypotension Extrapyramidal symptoms CNS effects
NK-1 Receptor Antagonists	Aprepitant	80–125 mg q24 hours	Fatigue Constipation Hiccup

Below is the algorithm showing the treatment of vomiting :

Patient comes with vomiting

Motion sickness with labirynthitis

Migraine

Post-operative or chemotherapy related vomiting

Gatroenteritis

Gastroperesis

Pregnancy induced vomiting

Antihistamines

Phenothiazines

Phenothiazines,Cannabinoids,Corticosteroids,Aprepitant

Antibiotics

Prokinetic medications

❑ Doxylamine succinate/pyridoxine hydrochloride ❑ Complementary and alternative therapies, such as ginger, acupressure, and vitamin B6

Prokinetic Medications ❑ Metoclopramide ❑ Domperidone ❑ Erythromycin

Dos

• Encourage patient to keep taking small sips of water frequently so that they don't become dehydrated.
• Recommend patients to take sweet drink such as fruit juice for replacing lost sugar, although they should avoid sweet drinks if those make them feel sick.
• Recommend to have salty snacks, such as crisps, can help replace lost salt.

Don'ts

• Patient who is vomiting continuously and also has past medical history of Diabetes corrected with Insulin should consult with their physicians before taking insulin as vomiting alters blood sugar levels.
• Renal consultation should be acquired especially with severe hyponatremia

References

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