Evaluation and Treatment of Evaluation and Treatment of Nausea and VomitingNausea and Vomiting

Deon Cox-Hayley, DODeon Cox-Hayley, DO

University of ChicagoUniversity of Chicago

NauseaNausea

• Unpleasant subjective feeling of need Unpleasant subjective feeling of need to vomitto vomit

CaseCase

• 46 y/o with treated 46 y/o with treated neurocystocercosisneurocystocercosis

• Hospitalized with intractable Hospitalized with intractable vomittingvomitting– CompazineCompazine– OndansetronOndansetron– ReglanReglan

How to treat?How to treat?

Vomiting center in medullaVomiting center in medulla

• Controls many Controls many involuntary, life-involuntary, life-sustaining sustaining processes processes including including – Respiration Respiration – Circulation Circulation – DigestionDigestion

Vomiting centerVomiting center

– Gastrointestinal tractGastrointestinal tract– Respiratory centerRespiratory center

•breath holdingbreath holding•forceful contraction forceful contraction

– Other brain stem centersOther brain stem centers •pallorpallor•sweatingsweating•tachycardiatachycardia

Vomiting Center(VC)

Upper GI tractDiaphragm and

abdominal muscles

Vomiting Center(VC)

Chemoreceptor trigger zone

Upper GI tractDiaphragm and

abdominal muscles

Vomiting Center(VC)

Chemoreceptor trigger zone

Upper GI tract and pharynx

Upper GI tractDiaphragm and

abdominal muscles

Vomiting Center(VC)

Chemoreceptor trigger zone

Upper GI tract and pharynx

Cortex

Upper GI tractDiaphragm and

abdominal muscles

Vomiting Center(VC)

Chemoreceptor trigger zone

Upper GI tract and pharynx

Cortex

Vestibular apparatus

Upper GI tractDiaphragm and

abdominal muscles

•

via Chemoreceptor via Chemoreceptor Trigger ZoneTrigger Zone

• Biochemical Biochemical abnormalitiesabnormalities– – – –

• SepsisSepsis• DrugsDrugs

– –

via Chemoreceptor Trigger via Chemoreceptor Trigger ZoneZone

• Biochemical Biochemical abnormalitiesabnormalities– HypercalcemiaHypercalcemia– HyponatremiaHyponatremia– Hepatic failureHepatic failure– Renal failureRenal failure

• SepsisSepsis• DrugsDrugs

– ChemotherapyChemotherapy– OpioidsOpioids

Digoxin

Antibiotics

Other

•

via peripheral afferentvia peripheral afferent

• Irritation, obstruction of the GI tractIrritation, obstruction of the GI tract

(including pharynx and hepatobiliary (including pharynx and hepatobiliary system)system)

1.1.

2.2.

3.3.

4.4.

5.5.

6.6.

7.7.

via peripheral afferentvia peripheral afferent

• Irritation, obstruction of the GI tractIrritation, obstruction of the GI tract

(including pharynx and hepatobiliary (including pharynx and hepatobiliary system)system)

CancerCancer

Chronic coughChronic cough

EsophagitisEsophagitis

GastritisGastritis

Peptic ulcerationPeptic ulceration

Gastric distentionGastric distention

Gastric compression

Delayed gastric emptying

Bowel obstruction

Constipation

Hepatitis

Biliary obstruction

Chemotherapy

Radiotherapy

via vestibular systemvia vestibular system

MotionMotion

Malignant vestibular Malignant vestibular infiltrationinfiltration

Drugs: aspirin, platinumDrugs: aspirin, platinum

via cortical centersvia cortical centers

• Psychological factors, Psychological factors, • AnxietyAnxiety• SightsSights• SmellsSmells• TastesTastes• Conditioned vomitingConditioned vomiting• Elevated intracranial Elevated intracranial

pressurepressure

TreatmentTreatment

• Assess and treat Assess and treat underlying causeunderlying cause

• Use of anti-emeticsUse of anti-emetics• ReassessReassess

TreatmentTreatment

• If mediated by the CTZ,If mediated by the CTZ,– Antidopaminergic Antidopaminergic

• Gastric stasis and Gastric stasis and compressioncompression– Pro-kinetic Pro-kinetic

• ChemotherapyChemotherapy– 5-HT3 receptor antagonist5-HT3 receptor antagonist

• Cortical causesCortical causes– AnxiolyticAnxiolytic

PhenothiazinesPhenothiazines

• ExamplesExamples– Compazine, Thorazine, Phenergan, Compazine, Thorazine, Phenergan,

TiganTigan

• ActionAction– AntidopaminergicAntidopaminergic

• Side effectsSide effects– Extra-pyramidal effectsExtra-pyramidal effects– SedationSedation– HypotensionHypotension

OrthopromidesOrthopromides

• ExampleExample– ReglanReglan

• ActionAction– anti-dopaminergicanti-dopaminergic– direct gastrokinetic effectdirect gastrokinetic effect

• Side effectsSide effects– SedationSedation– Extra-pyramidal effectsExtra-pyramidal effects– Caution if obstructionCaution if obstruction

Anti-cholinergicsAnti-cholinergics

• ExampleExample– ScopolamineScopolamine

• ActionAction– Anti-cholinergic near or at the VCAnti-cholinergic near or at the VC– Decreases GI secretions and Decreases GI secretions and

motilitymotility

• Side EffectsSide Effects– dry mouthdry mouth– deliriumdelirium– constipationconstipation

AntihistamineAntihistamine

• ExamplesExamples– Diphenhydramine, hydroxyzine, Diphenhydramine, hydroxyzine,

meclizinemeclizine

• ActionAction– Uncertain action at the VCUncertain action at the VC

• Side EffectsSide Effects– SedationSedation– Dry mouthDry mouth

CannabinoidCannabinoid

• ExampleExample– MarinolMarinol

• ActionAction– CorticalCortical– SympathomimeticSympathomimetic

• Side effectsSide effects– DrowsinessDrowsiness– DysphoriaDysphoria– DelusionsDelusions

CorticosteroidsCorticosteroids

• ExamplesExamples– Prednisone, dexamethasone, Prednisone, dexamethasone,

hydrocortisonehydrocortisone

• ActionAction– UndefinedUndefined

• Side effectsSide effects– StimulantStimulant– Improved appetiteImproved appetite

BenzodiazepinesBenzodiazepines

• ExamplesExamples– Lorazepam, oxazepam, Lorazepam, oxazepam,

diazepamdiazepam

• ActionAction– CorticalCortical

• Useful as an adjunctUseful as an adjunct• Side effectsSide effects

– SedationSedation– FallsFalls

Serotonin receptor Serotonin receptor antagonistsantagonists

• ExamplesExamples– Ondansitron, granisetron, Ondansitron, granisetron,

dolasetron, and tropisetron,dolasetron, and tropisetron,– Palonosetron (second Palonosetron (second

generation)generation)• ActionAction

– Prevent vagal stimulation in the Prevent vagal stimulation in the GI tractGI tract

– May have central actionMay have central action• Use--chemotherapy, radiation Use--chemotherapy, radiation

therapytherapy• Side effectsSide effects

– constipationconstipation– headacheheadache