Nausea and Vomiting

Mark Feldman, MD
 Case Report
• A 29 year old woman G1/P0/Ab0 complains
of severe, recurrent vomiting, worse in the
morning but sometimes in the later part of
the day, and failure to gain weight. She is in
her 13th week of pregnancy. Her past
medical history is negative except for
obsessive-compulsive disorder.
• What is her diagnosis?
 Terminology
• Nausea: from the Latin naus ( a ship); a very
unpleasant sensation that one may soon vomit
• Retching: muscular activity of the abdomen and
thorax, often voluntary, leading to forced
inspiration against a closed mouth and glottis
without oral discharge of gastric contents
(“dry heaves”)
• Vomiting: involuntary contractions of the
abdominal, thoracic and GI (smooth) muscles
leading to forceful expulsion of stomach contents
from the mouth
 Terminology, cont’d
• Regurgitation: effortless return of
esophageal or gastric contents into the
mouth unassociated with nausea or
involuntary muscle contractions.
• Rumination: food that is regurgitated in the
postprandial period, re-chewed and then re-
swallowed
 VOMITING
PATHWAYS

Ipecac syrup
 Inter-subject variability in
emesis threshold in humans
• 18 healthy volunteers received the same dose of
the opiate/dopamine agonist, apomorphine
• Apo dose adjusted for weight (0.03 mg/kg s.q.)
• Responses among volunteers were heterogeneous:
– 16 reported nausea within 6±2 minutes after injection
– 14 developed vomiting 8±2 minutes after injection; the
other 2 who reported nausea did not vomit
– 2 neither reported nausea nor experienced vomiting

Cannon,Best,Batson,and Feldman. Behavior Research & Therapy 21:669-73,1983

 Common etiologies of nausea
and vomiting
• GI tract disorders
– toxins, infections,
obstruction, inflammation,
motility disorders
• Non-GI infections
– liver, CNS, renal,
pneumonia, others
• Pregnancy
• Visceral inflammation
– pancreas, GB, peritoneum
• Myocardial ischemia
or infarction
• Other CNS disorders
– migraine, neoplasm, bleed
• Vestibular disorders
• Metabolic/endocrine
– DKA, uremia, adrenal
insufficiency, hyper- or
hypothyroidism, hyper- or
hypoparathyroidism
• Alcohol intoxication
• Psychogenic
• Radiation exposure
• Medications
Nausea/vomiting as component of CC
on teaching service at PHD (75 cases)
GI DISEASES (n= 30 )

Gastroduodenal 6
PUD (2), FD, DG, GOO,food
poisoning
Intestinal diseases 8
SBO(2), LBO, pseudo-
obstruction, gastroenteritis(2),
diverticulitis (2)
Pancreatitis 6
Biliary disease 5
cholecystitis (3), cholangitis (2)
Hepatic disease 5
hepatitis (3), liver masses,
ischemia vs. hepatitis
Nausea/vomiting as component of CC
on teaching service at PHD (75 cases)
OTHERS (n=45)
Metabolic 11 CNS disease 13
DKA(6), hypergylcemia, hypo- CVA/TIA (4), meningitis (4),
glycemia, hypercalcemia, hypo- seizure (2), primary tumor,
natremia (3) brain metastases, toxo/HIV
Toxic 5 Renal causes 8
alcohol, CO, digoxin, lithium, uremia (4), UTI ± stones (2),
ethylene glycol acute renal failure, renal infarct
Miscellaneous 4 Cardiac 4
Malaria, pneumonia, bulimia,
diabetic foot ulcer with osteo cocaine-induced (2), USA, afib
 Clues to psychogenic vomiting
• Usually female and often young
• May deny or minimize nausea
• Rarely occurs in public or in front of others
• Co-existent eating disorder, laxative abuse,
diuretic abuse common
• Psychological disturbances common
• Complications of vomiting may be present
 Surreptitious vomiting:
when to suspect it
• Unexplained weight loss
• Co-existent eating disorder or other
psychological condition
• Co-existent laxative and/or diuretic abuse
• Electrolyte and/or acid-base disturbances
consistent with vomiting, including hypo-
kalemic nephropathy
• Emetic complications (with denial of vomiting)
 Medications that often cause
nausea and vomiting
• Cancer chemotherapy • Metformin
– e.g. cisplatin
• Anti-parkinsonians
• Analgesics – e.g., bromcryptine, L-DOPA
– e.g. opiates, NSAIDs
• Anti-convulsants
• Anti-arrythmics – e.g., phenytoin, carbamazepine
– e.g., digoxin, quinidine
• Anti-hypertensives
• Antibiotics
– e.g., erythromycin
• Theophylline
• Oral contraceptives • Anesthetic agents
 Less commonly recognized
causes of nausea and vomiting
• Rapid weight loss/
body casts (SMA syndrome)
• Infectious esophagitis
– esp. if immunocompromised

• Opiate withdrawal
• Herbal preparations
• Pregnancy
– nausea of early pregnancy
– hyperemesis gravidarum
– AFLP/ HELLP syndrome
 Complications of Vomiting
• Nutritional
– adults: weight loss; kids: failure to gain
• Cutaneous (petechia, purpura)
• Orophayngeal (dental, sore throat)
• Esophagitis/ esophageal hematoma
• GE Junctional: M-W tears; rupture (Boorhaave’s)
• Metabolic: electrolyte, acid-base, water
• Renal: prerenal azotemia; ATN;
hypokalemic nephropathy
 Post-emetic purpura
(“mask phenomenom)

Cutis, 1986
Mallory-Weiss tear with clot
 Two tears: one at 7 o’clock
opposite other tear at 1 o’clock
 Esophageal hematoma
secondary to forceful emesis

Lumen

mass

Digestive Diseases and Sciences 26: 1019, 1981

 Electrolyte and acid-base
disorders due to vomiting
Metabolic alkalosis
retention of HCO3- + volume- Typical SMA-6
contraction
Hypokalemia 130 78 28
renal K+ losses + GI K+ loss +  3 40 0.8
oral K+ intake
Hypochloremia
gastric chloride losses Pearl: Patients with uremia
Hyponatremia or Addison’s disease may
free water retention due to have normal or even high
volume contraction
serum K+ despite vomiting
 Nausea and Vomiting:
Key Historical Questions
• How long?
• Relationship to meals?
• Contents of vomitus?
• Associated symptoms
– pain in chest or abdomen, fever, myalgias,
diarrhea, vertigo, dizziness, headache, focal
neurological symptoms, jaundice, weight loss
• Diabetes?
• When was last menstrual period?
 Nausea and Vomiting:
Key Physical Findings
• Vital signs
• BP and pulse tilt test
• Cardiopulmonary exam
• Abdominal exam
• Rectal exam
• Neurological exam including funduscopic
exam (papilledema)
 Laboratory studies: guided by
history and physical
• Electrolytes, glucose, BUN/creatinine
• Calcium, albumin, total serum proteins
• CBC
• LFTs
• Pregnancy test
• Urinalysis
• Serum lipase  amylase
 Radiology studies: guided by
history and physical
• Plain abdominal films
• Abdominal sono or CT if pain is key feature
• Head CT or MRI if severe headache, papill-
edema, marked hypertension, altered mental
status, or focal neurological findings
• EGD or upper GI to separate GOO or high
duodenal obstruction from gastroparesis
• Radiopaque marker emptying studies or
radionuclide scintigraphy, esp. if diabetic
Chronic vomiting due to gastroparesis
associated with a gastric bezoar
Test meal: liquid, digestible
solid and indigestible solid
Radiopaque markers still in the
stomach 6 hours after meal in a
diabetic with nausea
 Markers in stomach 24 hours after
ingestion in patient with pseudo-
obstruction and small cell lung cancer
 ALGORITHMIC
APPROACH

or marker
 Treatment of nausea
and vomiting
1. Treat complications regardless of cause
e.g., replace salt, water, potassium losses
2. Identify and treat underlying cause,
whenever possible
3. Provide temporary symptomatic relief of
the symptoms
4. Use preventive measures when vomiting is
likely to occur (e.g., cancer chemotherapy,
parenteral opiate administration)
 Drugs with anti- emetic prop-
erties and known mechanisms
• Antihistamines, e.g., meclizine (AntivertR)
– esp. for vestibular disorders
• Anticholinergics, e.g., scopolamine (Transderm ScopR,
DonnatalR)
– esp. for vestibular and GI disorders
• Dopamine antagonists, e.g.,metoclopramide (ReglanR) or
prochlorperazine (CompazineR)
– esp. for GI disorders
• Selective serotonin-3 (5HT3) RAs, e.g., odansetron,
granisetron, dolasetron
– esp. to prevent chemotherapy-induced nausea/vomiting
 Drugs with anti-emetic
properties (continued)
Multiple mechanisms of action:
• Promethazine (PhenerganR)
– dopamine antagonist
– H1 antihistamine
– anticholinergic
– CNS sedative
– prevention of opiate-induced nausea and vomiting
• Hydroxyzine (AtaraxR, VistarilR)
– H1 antihistamine
– anticholinergic
– CNS sedation
– prevention of opiate-induced nausea and vomiting
 Drugs with anti-emetic
properties (continued)
Uncertain mechanism of action:
• Trimethobenzamide (TiganR)
– blocks apomorphine-induced emesis in dogs
– does not block emesis from p.o. CuSO4 in dogs
 probably acts in the chemoreceptor trigger
zone (CTZ) of the medulla oblongata
• Bismuth subsalicylate (Pepto-BismolR)
 Adjunctive antiemetic agents
• Dexamethasone (DecadronR)
– along with other anti-emetics for prevention of
cancer chemotherapy-induced emesis
• Dronabinol (MarinolR)
– for prevention of cancer chemotherapy-induced
emesis refractory to other agents
– [ also for anorexia and weight loss in AIDS]
 Summary
• Nausea and vomiting are features of many GI and non-GI
diseases and disorders.
• Regardless of its cause, treatment of nausea and vomiting
should initially focus on replacing volume and electrolyte
deficits. Later on, nutritional deficits must be addressed.
• Regardless of its cause, nausea and vomiting can cause
several life-threatening GI and non-GI complications.
• Elucidation of the cause is often possible, and treatment of
the underlying cause will usually be successful.
• Effective symptomatic therapies for nausea and vomiting
are available when the cause is unclear or when the
treatment of the underlying cause takes time to work.
 Follow up on Case Report
• The patient was diagnosed with
hyperemesis gravidarum.
• Her TSH was undetectable, her free T4 and
serum T3 were markedly elevated.
• Her symptoms resolved in a few weeks,
without recurrence.
Goodwin et al. Transient hyperthyroidism and hyperemesis
gravidarum. Am J Obstet Gynecol 167: 648, 1992 and J.
Clin Endocrin Metab 75: 1333, 1992