Clinical Notes : Gastroenterology

14. Nausea and Vomiting in Adults

Presentation

Findings from the history and physical examination should guide diagnostic testing in patients with nausea and vomiting.

The duration of nausea and vomiting, associated symptoms, and alleviating and exacerbating factors can help determine the likely cause

Ask about :

  • exposure to toxins

  • suspect food

  • sick contacts

  • recent radiation therapy, surgery, or chemotherapy

The absence of significant abdominal pain, headaches, and other alarm signs or symptoms can narrow the differential diagnosis.

 

Presentations of N+V that suggest specific diagnoses

Evaluation

Diagnostic testing may be warranted in patients with :

  • signs of significant dehydration (e.g., decreased urine output, skin tenting, dry mucous membranes)

  • signs of acidosis caused by diabetic ketoacidosis or another underlying disorder (e.g., markedly increased respiratory rate, fruity odor to breath, altered mental status) 

  • severe abdominal pain or distension

  • hematochezia

  • jaundice

  • melena

  • severe headache

  • urinary tract infection symptoms

  • abdominal pain relieved by vomiting

  • hematemesis

  • feculent vomiting

 

Evaluation of N+V

Management

 

Diagnostic testing may be warranted in patients with :

  • signs of significant dehydration (e.g., decreased urine output, skin tenting, dry mucous membranes)

  • signs of acidosis caused by diabetic ketoacidosis or another underlying disorder (e.g., markedly increased respiratory rate, fruity odor to breath, altered mental status) 

  • severe abdominal pain or distension

  • hematochezia

  • jaundice

  • melena

  • severe headache

  • urinary tract infection symptoms

  • abdominal pain relieved by vomiting

  • hematemesis

  • feculent vomiting

 

Treatment of N+V in adults

Prochlorperazine (Stemetil)

First line now because of limitations of Domperidone and Metoclopramide

  • Avoid use

    • together with Tramadol and Codeine (excess sedation)

    • impaired liver function

    • dementia (cardiac failure, arrhythmia and pneumonia)

    • Parkinsonism (extrapyramidal effects)

  •       Dosage

    • 10 mg tds or QID PO

    • 12,5 mgdaily followed by oral dose

 

Cyclizine (Valoid)

  • Avoid use

    • Lactation (limited data)

  • Dosage

    • 50 mg tds PO / IM / IV

 

Domperidone (Motilium, Domerid)

  •   Indications

    • Benefits outweigh risks if using domperidone to treat nausea and vomiting only

    • No longer indicated for bloating or fullness

  • Avoid use

    • Liver disease

    • Existing heart rhythm abnormalities (Eg prolonged QT, heart block etc)

  • Dosage

    • 10mg tds x 1/52PO

    • 20mg bd suppositories

    • Lowest possible dose for shortest duration possible.

    • Maximum duration 1 week

 

Metoclopromide (Maxolon)

  •     Indications

    • N&V associated with migraine only (also increases absorption of analgesia)

    • Post op N&V prevention (as a second line in children 1-18yrs)

    • Radiotherapy and chemotherapy induced nausea (second line in children)

    • Not indicated for gastroparesis, bloating, GORD etc.

  • Avoid use

    • Elderly and cardiac disease

    • Parkinsonism (Extrapyramidal side effects/ neurological side effects are well known (higher risk in children)

  • Dosage

    • Adults 10mg tds maximum

    • Children >1 year 0.1-0.15mg/kg tds (max 0.5mg/kg body weight/ 24 hours)

    • Maximum length of treatment is 5 days

 

Advice

for patients with nausea who are well enough to be managed at home.

  • In most cases N&V resolves in 12-48 hours regardless of treatment

  • Ensure adequate rest, fluids and simple painkillers if required.

  • It is uncertain how much benefit you will get from anti sickness drugs

  • If you would like to try anti sickness drugs, they are safe but can have unpleasant side effects in 1 out of 6 people such as

    • Restlessness

    • Agitataion

    • Muscle stiffness and limb jerking

    • Tongue thrusting or facial grimacing

    • If these occur you should stop taking the drug and see a doctor as soon as you can

  • You will need to contact your doctor again if

    • you are worried you are not keeping enough fluid down

    • you develop new symptoms or worse symptoms

     eg blood in vomit/ diarrhoea or severe abdominal pain

 
 
journals.png

Anderson WD, Straye SM

Evaluation of Nausea and Vomiting in Adults: A Case-Based Approach

Am Fam Physician. 2013 Sep 15;88(6):371-379.

Access

Parkman HP, Hasler WL, Fisher RS

American Gastroenterological Association. American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis.

Gastroenterology. 2004;127(5):1592–1622.

Access

Scorza K, Williams A, Phillips JD, Shaw J.

Evaluation of nausea and vomiting.

Am Fam Physician. 2007;76(1):76–84.

Access

Assessment of nausea and vomiting, adults

BMJ Best Practice

June 2018

Access

 

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