Nausea and vomiting

Nausea, an unpleasant feeling of vomiting is an afferent vegetative impulse (including an increase in the parasympathetic tone) of the medullary emetic center. Vomiting - forced removal of gastric contents due to unintentional contraction of the muscles of the abdominal wall when the stomach bottom is lowered and the esophageal sphincter relaxes. Vomiting should be distinguished from regurgitation, regurgitation of gastric contents, not associated with nausea or forced contraction of abdominal muscles.

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Causes and pathophysiology of nausea and vomiting

Nausea and vomiting occur in response to irritations of the emetic center and come from the gastrointestinal tract (eg, obstruction of the stomach or intestines, acute gastroenteritis, peptic ulcer, gastrostasis, cholecystitis, choledocholithiasis, internal organ perforation or acute abdomen of other etiology, toxic substances intake); some causes are localized in other parts of the body (eg, pregnancy, systemic infection, exposure to radiation, drug toxicity, diabetic ketoacidosis, cancer) or CNS (eg, increased intracranial pressure, vestibular center stimulation, pain, meningitis, head trauma, brain tumor ).

Psychogenic vomiting can be spontaneous or develop unintentionally in stressful or unusual situations. Psychological factors that cause vomiting can be singled out separately (eg, the repulsive nature of food). Vomiting can be an expression of disapproval, for example if vomiting appears in a child as a reaction to hardening, or be a symptom of a conversion disorder.

Cyclic emetic syndrome is an unexplored disorder characterized by severe, discrete episodes of vomiting or sometimes only nausea that develop at different time intervals with the preservation of relative health between episodes of vomiting. This is normal in childhood (age from 5 years) and tends to persist in adults. Causes may be associated with migraine headaches, possibly a variant of migraine.

Acute, severe vomiting can lead to general dehydration and electrolyte imbalance. Chronic vomiting can lead to eating disorders, weight loss and metabolic disorders.

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Assessment of nausea and vomiting

Anamnesis and physical examination

Diarrhea and fever suggest infectious gastroenteritis. Vomiting of undigested food suggests achalasia or divergent of Zenker. Vomiting of partially digested food a few hours after admission presupposes pyloroduodenal stenosis or gastrostasis. Headache, changes in mental status, or edema of the optic disc suggest a pathology of the central nervous system. Ringing in the ears or dizziness - defeat of the labyrinth. Stool retention and bloating - intestinal obstruction.

Vomiting that occurs when thinking about food or temporarily unrelated to food has a psychogenic cause, which gives reason to assume an individual or family illness with the functional nature of nausea and vomiting. Patients need to clarify the possible relationship between vomiting and stressful situations, as patients may not take into account this relationship or even not to note the feelings of distress at that time.

Examination

All women of childbearing age should undergo urine testing for pregnancy. In patients with severe vomiting, vomiting more than 1 day, or signs of dehydration, other laboratory tests should be performed (eg, electrolytes, blood urea nitrogen, creatinine, glucose, urinalysis and sometimes functional liver tests). Patients with symptoms or signs of obturation or perforation should perform radiographs of the abdominal cavity in the horizontal and vertical position of the body. Diagnosis of chronic vomiting usually includes endoscopy of the upper digestive tract, X-ray examination of the small intestine, examination of the passage of the stomach and antral-duodenal motility.

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Treatment of nausea and vomiting

Certain conditions including dehydration require treatment. Even without significant dehydration, intravenous infusion therapy (0.9% physiological saline 1 l or 20 ml / kg in children) often leads to relief of symptoms. In adults, antiemetics (eg, prochlorperazine 5-10 mg IV or 25 mg in the rectum) are effective for the most severe vomiting. In addition, prescribe drugs metoclopramide (5-20 mg orally or iv from 3 to 4 times a day) and sometimes scopolamine (1 mg after 72 hours). Medication should not normally be given to children due to side effects. Antihistamines (eg dimenhydrinate 50 mg orally every 4-6 hours and meklysin 25 mg orally every 8 hours) are effective in case of vomiting associated with lesion of the labyrinth. Secondary vomiting to chemotherapeutic drugs may require the use of 5HT ₃ antagonists (eg, ondansetron, granisetron); When using chemotherapy drugs that cause severe vomiting, a new preparation of pre-drug substance-P neurokinin inhibitor 1 can be added to treatment.

When vomiting psychogenic, a soothing conversation creates the patient's understanding of the cause of discomfort and the desire to cooperate to minimize symptoms, regardless of the cause. You should avoid making comments like "everything does not fit" or "a problem in emotions". You can try short-term symptomatic therapy with antiemetics. If long-term follow-up is required, friendly, regular visits to the doctor can help solve the underlying problem.