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?

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

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

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

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

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

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

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

Biochemical abnormalities via Chemoreceptor Trigger Zone Biochemical abnormalities Sepsis Drugs

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

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

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

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

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

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

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

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

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

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

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

Cannabinoid Example Action Side effects Marinol Cortical Sympathomimetic Side effects Drowsiness Dysphoria Delusions

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

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

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