Nausea and vomiting in general practice
Overview
History will focus on timing of symptoms, their relation to meals, characteristics of vomitus, and associated complaints. Check for early morning onset (metabolic disturbances, alcoholic binge, early pregnancy), precipitation by meals (psychogenic, pyloric channel ulcer, gastritis), onset several hrs after eating (obstruction, gastric atony), emesis of food ingested > 12 hrs earlier (gastric stasis), vomiting of large volumes (> 1500 mL/day).
Inquire about blood or “coffee ground” material, bilious vomitus (pyloric channel open), pure gastric juice (peptic ulcer disease, Zollinger-Ellison syndrome), lack of acid (atrophic gastritis, gastric cancer), feculent material (distal small-bowel obstruction and blind-loop syndrome). Check history for abdominal pain, fever, jaundice, weight loss, abdominal surgery, external hernias, family history of emesis, symptoms of DM, prior renal disease, ischemic heart disease, drug use (e.g., digitalis, narcotics), visual disturbances, headache, ataxia, vertigo, and last menstrual period. Ask about concurrent emotional and social stresses; if you suspect bulimia, gently inquire into self-image, binge eating, and self-induced emesis. Note any acute hepatitis risk factors (sick contacts; IV drug abuse; exposure to raw shellfish, pastries, poultry; travel to area with poor sanitation or cholera).
Physical examination
Check for postural hypotension, elevated BP, irregularities of rate and rhythm, Kussmaul's respiration, pallor, hyperpigmentation, jaundice, papilledema, retinopathy, nystagmus, stiff neck, abdominal distention, visible peristalsis, abnormal bowel sounds, succussion splash, peritoneal signs, focal tenderness, organomegaly, masses, flank tenderness, muscle weakness, ataxia of gait, and asterixis. If history of vertigo with nausea, perform Barany’s maneuver. In patients with suspected bowel motility disorder, check for signs of autonomic insufficiency (postural hypotension without increase in heart rate, lack of sweat, blunted pulse and BP responses to Valsalva's maneuver).
Management
Therapeutic trials
If you suspect gastroesophageal motility disorder, consider short course of prokinetic agent such as metoclopramide (Primpran) or cisapride (Motiprid) 10 mg, 30 mins before meal supplemented by a proton pump inhibitor (e.g., 20 mg/day omeprazole). Patients with suspected underlying effective disorder sometimes respond to 4 to 8-wk trial of antidepressant; select agent with minimal anticholinergic activity (e.g., trazodone, desipramine, or fluoxetine).
| Table (1). Medications for nausea and vomiting | |
|---|---|
| Pharmacotherapy | Comment |
| Phenothiazines | For initial symptomatic treatment of vomiting caused by drugs, metabolic disorders, and gastroenteritis; use with caution in emesis due to hepatitis and cholestasis because drug is hepatically metabolized. Consider prochlorperazine (Emedrotec, 5–10 mg q6h prn) or promethazine (12.5–25 mg q6–8h, or rectally 25 mg TID prn). |
| Antihistamines | Consider meclizine (Navoproxin, 12.5–25 mg TID prn) for symptomatic relief of emesis due to vestibular disturbances. For more rapid onset of action, consider dimenhydrinate (Dramenex 50 mg) just before or with onset of symptoms; for more prolonged effect, consider transdermal scopolamine (single transdermal patch applied behind ear several hrs before travel and left on for ≤ 3 days). Avoid use before driving or using machinery. |
| Prokinetic agents | For patients with emesis resulting from gastroparesis. Consider metoclopramide (10 mg after food and every night at bedtime) or cisapride (Motiprid, 10 mg after food and every night at bedtime); cisapride causes fewer CNS effects but can prolong QT interval. |
| Drugs for morning sickness | Recommend small morning feedings and try to avoid or minimize antiemetic use. For more prolonged, severe forms (hyperemesis gravidarum), first consider supportive psychotherapy and trial of hypnosis, but drug Rx is sometimes necessary. Consider trial of vitamin B6 (25 mg/day). Alternatively, try short course of metoclopramide (see above). |
Symptomatic relief
Whenever possible, treat etiologically. Consider symptomatic measures only when you have identified cause, but Rx of underlying condition does not adequately control symptoms; do not use symptomatic therapy in lieu of diagnosis.
Psychogenic vomiting
Focus attention on underlying conflicts and stresses troubling patient. Avoid antiemetics.
Referral criteria
For patients suspected of having a refractory motility disorder, referral for specialized motility studies is recommended. In cases of suspected psychogenic vomiting, psychiatric consultation is necessary due to the potential for serious psychological disturbances and suicidal tendencies; referral to a skilled mental health professional is advised. Hospitalization is required for parenteral fluid and electrolyte replacement and further evaluation if postural hypotension is present, particularly in elderly patients. Similar treatment protocols should be followed if there is evidence of bowel obstruction, increased intracranial pressure (ICP), or any other gastrointestinal, neurological, or metabolic emergency. Consider hospitalizing patients for observation if they remain undiagnosed after extensive evaluation and are unresponsive to therapeutic trials.
References
- F Longstreth. Approach to The Adult With Nausea And Vomiting. [online] UpToDate 2020. Available at: https://www.uptodate.com/contents/approach-to-the-adult-with-nausea-and-vomiting.
- Metz 2007. Nausea and Vomiting in Adults: A Diagnostic Approach. [online] Available at: https://www.racgp.org.au/afpbackissues/2007/200709/200709metz.pdf.
