inpatient / gastroenterology
Nausea and Vomiting
# Nausea and Vomiting
Checklist
-- ABCs: Is the patient protecting their airway?
-- Chart Check: h/o N/V disorder, cancer, ESRD, diabetes, abdominal surgeries, medications
-- Admission Criteria: need for IV fluids or meds, metabolic abnormalities, intractable vomiting despite anti-emetic therapy
-- HPI Intake: timing, triggers, meds and other drug use, red flags (coffee-ground emesis, hematemesis, GI bleed, bloating, weight loss, focal deficits)
-- Can't Miss: pregnancy, SBO, ischemia (myocardial and mesenteric), pancreatitis, pyelonephritis, cholecystitis, DKA, increased ICP
-- Admission Orders: CBC, BMP, LFTs, beta-hCG, lipase, UA, trop, EKG, KUB (check for SBO), consider CTAP if intractable or concerned for can't miss diagnoses
-- Initial Treatment to Consider: if EKG has normal QTc zofran, otherwise tigan, ativan, meclizine
Assessment:
-- History: *** timing, triggers, PO intake, meds, red flags, co-morbidities
-- Clinical: *** constipation, hematemesis, melena, abdominal pain, GERD, chest pain, SOB, diaphoresis
-- Exam: *** AMS, distended and tympanic abdomen, signs of peritonitis, focal deficits
-- Data: *** BMP, LFTs, lipase, UA, trop, KUB, can consider other imaging based on concern
-- Etiology/DDx: *** Most Common: gastroenteritis, food poisoning, meds/chemo, vertigo; Can't Miss: pregnancy/hyperemesis gravidarum, SBO, ischemia (myocardial and mesenteric), pancreatitis, pyelonephritis, cholecystitis, DKA, increased ICP; Other: GERD, IBS, migraine, uremia, bulemia/anorexia, functional (cyclic vomiting, cannabinoid)
-- Admission Orders: *** BMP, LFTs, lipase, UA, trop, EKG, KUB (check for SBO), consider CTAP if intractable or concerned for can't miss diagnoses; NPO
-- Initial Treatment to Consider: *** if EKG has normal QTc zofran, otherwise tigan, ativan, meclizine
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- Labs: BMP, LFTs, lipase, UA, trop
-- Imaging: KUB to ensure no SBO, consider CTAP if intractable or c/f above can’t miss diagnoses
-- EKG to assess QTc
Treatment
-- Normal QTc - ondansetron (Zofran) 4-8 mg PO/IV q8h, promethazine (Phenergan) 12.5-25mg PO/IV q4-6h, prochlorperazine (Compazine) 4-10mg PO/IV q6h, metoclopramide (Reglan) 10-20mg PO/IV q6-8h, haldol (Haloperidol) 0.5-4mg PO/IV q6h, olanzapine (Zyprexa) 5-10mg PO daily
-- Elongated QTc - trimethobenzamide (Tigan), lorezapam (Ativan) 0.5-2mg PO/IV q6h, dexamethason (Decadron) 4-8mg PO q4-6h, meclizine, scopolamine patch 0.3-0.6mg daily, aprepitant (Emend) 125mg day 1 then 80mg days 2-3, dronabinol (Marinol) 2.5-10mg q4-6h
-- Non-Pharm Tx: Inhaled isopropyl alcohol or other aromatherapy, meditation
-- NPO and NG tube decompression if c/f obstruction
Pharmacology of Nausea and Vomiting
If You Remember Nothing Else
Nausea and vomiting have many etiologies, some of which are life threatening. The most common causes of nausea/vomiting are gastroenteritis, food poisoning, meds/chemo, and vertigo. Don't miss red flags including coffee-ground emesis, hematemesis, GI bleed, bloating, weight loss, and focal deficits. In those with severe nausea and vomiting you need to rule out pregnancy, SBO, ischemia (myocardial and mesenteric), pancreatitis, pyelonephritis, cholecystitis, DKA, and increased ICP. There are many meds to treat nausea and vomiting and your choices are driven by the likely etiology, as well as whether the patient has a prolonged QTc. Patients can usually be discharged when life-threatening etiologies are ruled out, and their symptoms are managed with PO medicines, and they are tolerating adequate PO intake.
Clinical Pearls
- Though usually due to diseases of the GI system, nausea and vomiting has many other etiologies, including many that can be life threatening
- Patients who present with severe nausea/vomiting will likely be dehydrated, hypokalemic, and have a contraction metabolic alkalosis
- Mechanical complications of severe vomiting include Boerhaave syndrome and Mallory-Weiss syndrome from increased pressure of retching
- Those with nausea may only be able to tolerate smaller, more frequent, cold meals
- Many patients experience nausea after initiating opioid medications, and this usually wears off after 3+ days of use
- If you don't know the etiology of nausea and vomiting, it may help to trial a PPI or an H2 blocker to lower gastric secretions
Trials and Literature
- RCT of aromatherapy (isopropyl alchohol) with ondansetron vs aromatherapy alone vs oral ondansetron alone in adults in the ED - "aromatherapy with or without oral ondansetron provides greater nausea relief than oral ondansetron alone" (Ann Emerg Med, 2018)
- Revisiting the Physiology of Nausea and Vomiting - Challenging the Paradigm (Support Care Cancer, 2020)
Other Resources
- Curbsiders Podcast - #334 IBS, Functional Dyspepsia, and Cyclic Vomiting: Disorders of Gut Brain Interaction
- Clinical Problem Solvers - Nausea and Vomiting Thought Train
