Lecture 15: Nausea/Vomiting/Diarrhea Flashcards
Nausea
Inclination to vomit or as a feeling in the throat or epigastric region alerting an individual that vomiting is imminent
Retching
Involuntary, rhythmic diaphragmatic and abdominal contractions
Vomiting
Forceful ejection or expulsion of gastric contents through the mouth
Physiology
Central nervous system (CNS) and gastrointestinal tract (GIT)
- Medulla oblongata (vomiting center) gets input from:
- Cerebral cortex
• Sensory input – anticipation, memory, sight, smell - Chemoreceptor trigger zone
• Bloodstream or cerebrospinal fluid - Vestibular apparatus
• Motion and body position - Visceral GIT afferent nerves
• GIT mechanoreceptors and chemoreceptors
Pathophysiology – Primary Causes
* important ones that we can treat with self-care*
- Motion Sickness
- Food poisoning, Acute Viral gastroenteritis- an inflammation, swelling, and irritation of the inside lining of your gastrointestinal tract (stomach and small intestines)
- Generally self-limiting
- Caused by norovirus and rotavirus
- Pregnancy- 70-80% incidence (most commonly early pregnancy through week
22) - Overeating
Rotavirus
very contagious virus that causes severe, watery diarrhea and vomiting in infants and young children.
Norovirus
common virus that can cause gastroenteritis
- Norovirus is the most common cause of vomiting, diarrhea, and foodborne illness.
Complications
§ Aspiration § Dehydration § Diaphragmatic herniation § Electrolyte or acid-base abnormalities § Esophageal tears § Malnutrition
Clinical Presentation - Dehydration for Adults
§ Decreased skin turgor § Dizziness § Dry mouth § Excessive thirst § Fainting § Lightheadedness § Little or no urination § Reduced blood pressure
Clinical Presentation - Dehydration for Infants/Children
§ Absence of tears when crying § Body is “floppy” § Dark urine § Decreased skin turgor § Decreased urine output § Difficulty waking up § Dry mouth and tongue § Fast heartbeat § Lightheadedness § Sunken and/or dry eyes § Sunken fontanelle § Thirst § Unusual lethargy, sleepiness, decreased alertness, or irritability § Weight loss
Exclusions to Self-Care – Adults
§Too severe self-care cause
• Pregnancy with severe symptoms or breastfeeding
• Suspected food poisoning that does not clear in 24 hours
Associated symptoms
§ Blood in vomit
§ Fever and/or diarrhea
§ Head injury with N/V, blurry vision, or numbness and tingling
§ Severe abdominal pain, particularly right quadrants
§ Stiff neck with/without headache
Signs of complications
§ Urine ketones/high blood glucose (DKA/HHS) with signs of
dehydration in patients with diabetes
§ Yellow skin or eye discoloration and dark urine
Patient factors
§ Asthma; BPH; chronic bronchitis; emphysema; glaucoma
Other causes of Nasua, Vomting and Diarrhea
- Anorexia or bulimia; CNS, endocrine, GI, or serious metabolic disorders; gastroesophageal reflux disease (GERD); gastroparesis with DM
- Cancer treatment – chemotherapy or radiation
- Drug-induced – antibiotics, digoxin, estrogen, ethanol, lithium, NSAIDs, opioids, theophylline
Exclusions to Self-Care – Infants/Children
Caregiver unable/unwilling to manage at home
Associated symptoms
< 6 months old or weight < 8 kg, vomited clear fluids 3 times, watery diarrhea
§ Lack of urination in past 8-12 hours
§ Lethargic, unusually sleepy, listless, or crying
§ Refusal to drink liquids
§ Suspected poisoning
§ Stiff neck
§ Vomiting/Vomitus
• Contains red, black, or green fluid
§ Following head or abdominal injury
§ Plus diarrhea, distended abdomen, fever, or severe headache
§ Repeatedly projectile and/or continues > 8 hours
§ With each feeding
§ With recurrent, severe, acute abdominal pain
Goals of Self-Treatment
- Provide symptomatic relief
- Identify and correct underlying cause
- Prevent and correct complications
- Prevent and manage unwanted effects of medications
- Prevent future occurrences
Cerebral cortex
Sensory input – anticipation, memory, sight, smell
Chemoreceptor trigger zone
Bloodstream or cerebrospinal fluid
Vestibular apparatus
Motion and body position
Visceral GIT afferent nerves
GIT mechanoreceptors and chemoreceptors
Non-pharmacologic therapy are used mostly to
correct dehydration and electrolyte imbalances
Pharmacologic non-prescription options are limited
Target to appropriate pathway § Antacids § Antihistamines § Bismuth subsalicylate § H2RAs § Phosphorated carbohydrate solution (PCS)
Antihistamines Agents
- Dimenhydrinate (Dramamine)
- Diphenhydramine (Benadryl)
- Meclizine (Bonine, Dramamine Less Drowsy)
Antihistamines MOA
Compete with histamine at central and peripheral H1-receptor sites to prevent histamine-receptor interaction and resulting mediator release
Antihistamines Contraindications
Breastfeeding
hypersensitivity
MAOI use
narrow angle glaucoma
Antihistamines Precautions/Warnings
Asthma
BPH
chronic bronchitis
emphysema
Antihistamines Adverse Effects
Blurred vision; constipation; dry eyes; dry mucous membranes;
incoordination; reflex tachycardia; sedation; urinary
hesitancy/retention
May cause paradoxical excitation: insomnia; irritability; nervousness
Antihistamines Drug Interactions
Alcohol
Anticholinergics
Sedatives
Dimenhydrinate Adult dosing
50-100 mg every 4-6 hours
MDD: 400mg
Dimenhydrinate 6-12 dosing
25-50 mg every 6- 8 hours
MDD: 150 mg
Dimenhydrinate 2-6 dosing
12.5-25 mg every 6-8 hours
MDD: 75 mg
Diphenhydramine adult dosing
25-50 mg every 6- 8 hours
MDD: 300 mg
Diphenhydramine 6-12 dosing
12.5-25 mg every 6-8 hours
MDD: 150 mg
Diphenhydramine 2-6 years old dosing
Not
recommended
Meclizine adult dosing
25-50 mg one hour prior to travel
MDD: 50 mg
Meclizine 2-12 years old
Not recommended
Antihistamines Patient Education
Take at least 30-60 minutes before travel, then take continuously for duration of travel
Phosphorated Carbohydrate Solution Products
Emetrol- Phosphoric acid/dextrose/fructose
Emetrol MOA
Direct local action on GIT wall to decrease smooth muscle contraction and delay gastric emptying time
Emetrol Contraindications
Hereditary fructose intolerance; hypersensitivity
Emetrol Precautions/Warnings
Diabetes
Emetrol Adverse Effects
Diarrhea; stomach pain
Emetrol Dosing adult
15-30 mL by mouth every 15
minutes until distress subsides
Max 5 doses/1 hour
Emetrol Pediatric 2-12 yrs old
5-10 mL by mouth every 15
minutes until distress subsides
Max 5 doses/1 hour
Complementary Medicine
- Ginger
- Pyridoxine (vitamin B6)
- Acupressure
Ginger
- Used in motion sickness, pregnancy, surgery
- Adverse Effects: mild GI – belching, discomfort, heartburn
Pyridoxine (vitamin B6)
First-line treatment for pregnancy N/V (nausea/vomiting) per American College of
Obstetricians and Gynecologists (ACOG)
- Adverse Effects: well tolerated
- High doses (> 200 mg/day) may lead to lethargy,
neuropathy, and weakness
Acupressure
- Used in motion sickness and pregnancy
- Direct pressure on pericardium-6 point on wrist
- BioBand, ReliefBand NST, Sea-Band
Treating Complications – Dehydration
Oral Rehydration Solutions (ORS)
Oral Rehydration Solutions (ORS)
- Rehydrate and correct electrolyte imbalances
- Preferred sugar to sodium ratio of 3:1
• Too much sugar can draw water into GIT and increase dehydration
• Cola, ginger ale, fruit juice, and sports drinks may have too much sugar
Examples: Enfalyte, Pedialyte
Treating Complications – Dehydration adults
Gauge need according to thirst
- Replace 30-50% fluid lost within 24 hours
Treating Complications – Dehydration Pediatrics
Minimal dehydration
- < 10 kg: 60-120 mL ORS after each vomiting episode
- ≥ 10 kg: 120-240 mL ORS per episode
Mild-moderate dehydration
• 50-100 mL/kg ORS over 3-4 hours
For severe dehydration->
Refer for emergency department in IV rehydration
Treatment for Food Poisoning/Viral Gastroenteritis
Non-pharmacologic methods
- Eliminate contaminated food
- Bland diet (BRAT diet)
- Explain signs/symptoms of dehydration
- May initiate ORS
- For excessive vomiting and at patient’s request, refer for
prescription antiemetic - Reassess in 24 hours
BRAT method
Banana
Rice
Apple juice
Toast
Treatment – Motion Sickness
- Acupressure
- Avoid excess food or alcohol before and during extended flights
- Avoid reading during travel
- Avoid strong odors
- Drive the vehicle, if possible
- Focus the line of vision straight ahead
- Stay where motion is least expected
Motion Sickness Pharmacologic options
Antihistamines
Treatment – Overeating
Non-pharmacologic options
Limit disagreeable options – alcohol, caffeine, dairy, smoking
- Remote offending food items
Treatment – Overeating
Pharmacologic options
Antacids
§ Bismuth subsalicylate
§ H2RAs
§ PCS
Treatment – Pregnancy
Non-Pharmacologic Methods
- Before getting out of bed and eating breakfast, eat several dry
crackers or toast - Do not overeat and avoid greasy/fatty foods
- Eat 4-5 small meals per day instead of 3 large meals
- Relax in bed for 10-15 minutes upon waking and get out of bed
slowly - Sleep in an area with a fresh air source
- Try small sips of carbonated beverages or fruit juice
Treatment Pregnancy- Pharmacologic Options
- Doxylamine – antihistamine used off-label
- Complementary medicine – ginger, pyridoxine
For pregnancy, you must refer
If no relief after 1 week, refer
Diarrhea
- Abnormal increase in stool frequency, liquidity, and/or
weight
-Frequency changes with the patient - > 3 bowel movements per day considered abnormal
Acute diarrhea
Acute: < 14 days
§ May be caused by intolerance of certain foods, medications, poisoning,
various non-GI acute or chronic illnesses
§ Managed with fluid/electrolyte replacement, dietary interventions, and
non-prescription therapy
Persistent diarrhea
14 days to 4 weeks
Chronic diarrhea
> 4 weeks
Pathophysiology
Infectious Diarrhea/Gastroenteritis
Bacterial, protozoal, viral
§ Norovirus most common cause in adults
§ Rotavirus most common cause in infants/young children
§ Increased risk
§ Acquired immunodeficiency syndrome (AIDS), diverticulitis
§ Consumption of unsafe foods (raw or undercooked eggs, meat, shellfish)
§ Living/working environment: caregivers, congregate living conditions
(multifamily dwellings, nursing homes, prisons), daycare centers, food
handlers
Traveler’s Diarrhea
Acquired through ingestion of contaminated food or water
- Fruits, hot sauces, ice, raw meats, seafood, vegetables, water
- 3-8 watery stools per day associated with at least one additional GI symptom – abdominal pain, nausea, vomiting
- Symptoms usually subside over 3-7 days
Food-Induced
Food intolerances
- Allergy
- Ingestion of excessive fat, fiber, seeds, spice
- Lactose intolerance
Clinical Presentation of Diarrhea
> 3 bowel movements per day
-Stool characteristics provide information about
pathophysiology
§ Black, tarry: upper GI bleeding
§ Red
§ Ingestion of red foods (beets) or drugs (rifampin)
§ Lower bowel or hemorrhoidal bleeding
Undigested food particles: disease of small intestine
§ Yellow: bilirubin or potentially serious liver pathology
§ White: fat malabsorption disease
Black tarry stool means
upper GI bleeding
Red stool means
Ingestion of red foods (beets) or drugs (rifampin)
§ Lower bowel or hemorrhoidal bleeding
Undigested food particles means
disease of small intestine
Yellow stool
bilirubin or potentially serious liver pathology
White
fat malabsorption disease
Exclusions to Self-Care Associated symptoms
High output, including frequent and substantial volumes of diarrhea - Persistent fever - Persistent vomiting - Visible blood, pus, or mucus in stool
Exclusions to Self-Care: Signs of complications (severe dehydration)
Children showing behavioral/mental changes (apathy, irritability,
lethargy, unconscious)
- Children who have no tears when crying
- Children who have not urinated in 8 hours
- Orthostatic hypotension
Orthostatic hypotension
decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position
Exclusions to Self-Care: Patient Factors
- Pregnancy
- Risk for significant complications including chronic medical conditions or concurrent illness
- Diabetes
- Immunocompromised patients: AIDS, cancer, chemotherapy, frail patients
≥ 65 years, organ transplant recipients) - Renal disease
- Severe cardiovascular disease
- Young age (age < 6 months or weight < 8 kg)
Exclusions to Self-Care: Too severe or long-lasting
Chronic or persistent diarrhea
§ Suboptimal response to already administered ORS
Goals of Self-Treatment
- Prevent or correct fluid/electrolyte loss and acid-base
disturbance - Control symptoms
- Identify and treat the cause
- Prevent acute morbidity and mortality
- Prevent and manage unwanted effects of medications
Non-Pharmacologic Therapy
Fluid and electrolyte management
- Rehydration and maintenance
- Preferred: ORS
- Household items (juices, soups, sports drinks) may have high carbohydrate and/or low sodium
Non-Pharmacologic Therapy: Diarrhea
Dietary management
Withhold food no longer than 24 hours
- Reintroduce normal, age-appropriate diet once rehydrated
- BRAT diet NOT recommended
- Avoid caffeine, fatty foods, simple sugars (gelatin, juices, soft drinks), spicy foods
Pharmacologic Therapy: Diarrhea
- Evidence lacking to show agents other than loperamide or bismuth subsalicylate reduce stool frequency or duration of disease in adults
- No antidiarrheals shown to significantly improve clinical outcomes < 5 years of age
- Consider digestive enzymes (alpha-galactosidase or lactase)
for food-induced diarrhea
Loperamide Brand Name
Imodium (2 mg caplets; 1 mg/7.5 mL oral liquid)
Loperamide MOA
Stimulates peripheral micro-opioid receptors on the intestinal circular muscles to slow intestinal motility and allow absorption of
electrolytes and water.
This reduced fecal volume, increased viscosity,
reduced fluid/electrolyte loss
Loperamide Contraindications
- Abdominal pain without diarrhea; acute ulcerative colitis
- Bacterial enterocolitis
- Children < 2years
- Hypersensitivity
- Pseudomembranous colitis associated with antibiotic use
Loperamide Adverse Effects
Constipation
Dizziness
Loperamide Dosing Adults
Adults ≥ 12 years
- 4 mg by mouth initially followed by 2 mg by mouth after each loose stool
MDD 8 mg
Loperamide Dosing Children
2 mg by mouth initially followed by 1 mg by mouth after each loose stool
§ 9-11 years (60-95 lb): MDD 6 mg
§ 6-8 years (48-59 lb): MDD 4 mg
Loperamide Special Pops
Breastfeeding: likely compatible
Pregnancy: exclusion to self-care
Loperamide Concerns
Increasing number of individuals are taking extremely high doses to self-manage opioid withdrawal or achieve a euphoric high
Loperamide Toxicity symptoms
- Anxiety
- Cardiac arrest
- Decreased consciousness
- Dyspnea
- Generalized weakness
- Nausea and vomiting
- New-onset or recurrent syncope
- Palpitations
- Presyncope
- Seizure-like activity
Solid forms of Loperamide
Unit-dose packaging only
Maximum of 24-count (48 mg)
Liquid products of Loperamide
4 ounce and 8 ounce sizes only
Maximum of 32 mg in 8 fluid ounces
Bismuth Subsalicylate Brand Name
Kaopectate
Pepto-Bismol
262 mg caplets/tablets
262 mg/15 mL,
525 mg/15 mL oral liquids
Bismuth Subsalicylate MOA
Salicylate provides antisecretory effect; bismuth exhibits antimicrobial effects directly against bacterial and viral gastrointestinal pathogens
Bismuth Subsalicylate Contraindications
Hypersensitivity
Pregnancy
Bismuth Subsalicylate Precautions/Warnings
Bleeding disorders
children
pregnancy
renal failure
Bismuth Subsalicylate Adverse Effects
Fecal discoloration (gray-black) tongue discoloration (darkening)
Bismuth Subsalicylate Dosing Adults
262-525 mg by mouth every 30 mins- 1 hour as needed
MDD 8 doses (262 mg) 4 doses (525 mg
Bismuth Subsalicylate Pediatrics
Not recommended: Risk of Ryes syndrome
Bismuth Subsalicylate Special Pops
- Breastfeeding: avoid
- Pediatrics: do not use < 12 years (Reye’s syndrome)
- Pregnancy: contraindicated
Patient Education: What you say when your advising a patient on a specific medication
Most acute diarrheal episodes end within 48 hours
§Non-pharmacologic measures: Prevent and correct dehydration
Pharmacological options - Medication name and indication - Administration and dosing § Potential side effects and how to manage § Warnings § Follow-up
Evaluation of Patient Outcomes
§Most acute diarrheal episodes end within 48 hours
§ Dietary supplementation
§ Increased appetite, return to normal diet
§ Oral rehydration
§ Body weight, mental alertness, vital signs
§ Pharmacologic agents
§ Improved stool consistency, reduced stool frequency
Refer if:
- Bloody or mucoid stools
- diarrhea continuing > 48 hours
- high fever
- worsening illness
