tbl 1 clinical approach to nausea and vomiting Flashcards
What is the definition of nausea?
unpleasant sensation of impending vomiting in epigastrium or throat
Definition of retching: spasmodic, abortive respiratory movements against a _______.
- When retching is part of the emetic sequence, it is usually associated with intense nausea and culminates in vomiting
closed glottis
Definition of vomiting:
- forceful oral expulsion of gastrointestinal contents, associated with abdominal musculature contraction
o Requires ________
central neurologic coordination
Definition of regurgitation: _____ reflux of gastric contents into the oesophagus that sometimes reaches the mouth
o Does not require the activity of abdominal or diaphragmatic muscles
effortless
Evaluation of nausea and vomiting – history, physical examination and investigations
- History should be taken by ascertaining if the patient truly has active vomiting or if passive regurgitation is present instead
o Regurgitation expulsion usually results from oesophageal disorders, a cardinal symptom of _______
- Duration of symptoms – acute vomiting is defined by a duration of 7 days or less, while chronic vomiting usually implies a duration of 1-month or longer
o Acute vomiting – ascertain if emergency action is required (such as for patients in shock or with hollow viscus perforation) and if a female patient is pregnant - The patient’s vomiting episodes should also be characterised, with details gathered on the symptom onset, frequency and severity, quality and quantity of vomitus as well as associated symptoms
gastroesophageal reflux disease (GERD)
(Patterns of vomiting- nature of vomitus suggests the location of gut pathology)
- Vomiting of partially digested food within a few hours post-meal – gastric cause such as gastric outlet obstruction and _____
- ______ – suggests small bowel obstruction
- Feculent or putrid odour to vomitus – present in intestinal obstruction due to bacterial degradation of stagnant intestinal contents
gastroparesis; Bilious vomitus
(Patterns of vomiting- timing and description of vomiting)
- Early morning vomiting before breakfast – classically present with increased ________, but can also result from uraemia, alcohol intake and pregnancy
- Projectile vomiting without nausea – raised intracranial pressure
- Nausea and vomiting within an hour post-meal – _______ or gastroparesis
- Vomiting during or soon after a meal – underlying eating disorder such as anorexia nervosa or bulimia
- Stereotypical discrete episodes of severe unrelenting vomiting – typical of ______ and cannabinoid hyperemesis
intracranial pressure; gastric outlet obstruction; cyclic vomiting syndrome
(Patterns of vomiting- associated symptoms)
- Early satiety, post-prandial fullness/bloating – ______
- Abdominal pain – biliary, pancreatic disorder
- Prominent, severe, colicky pain (may improve after vomiting) – _______
- Weight loss – malignancy, gastric outlet obstruction, gastroparesis. Malignancy must be ruled out
- CNS symptoms (e.g. headache, vertigo, focal neurological deficits) – central cause (for brainstem tumours, it is rare to have vomiting as the only cause)
gastroparesis; small bowel obstruction
General physical examination
- Signs of dehydration – if severe, patient must be hospitalised and fluid resuscitation initiated promptly
- Constitutional signs e.g. ______ and low body mass index suggest chronicity of disease
- Drop in the postural blood pressure with corresponding tachycardia – significant intravascular
depletion - Drop in postural blood pressure without corresponding tachycardia – may suggest ___________
- Examination of the peripheries – erosion of dental enamel due to of recurrent vomiting (such as in bulimia or GERD), fingernails with signs of self-induced vomiting (such as in anorexics)
- Changes of ______ e.g. Raynaud’s phenomenon, telangiectasia and
peripheral neuropathy
cachexia; autonomic neuropathy; scleroderma
Organ systems examination
- Abdominal examination – jaundice, abdominal masses or tenderness and lymphadenopathy
- Auscultation may demonstrate hyperactive bowel sounds in obstruction or absent bowel sounds in ileus
- ________ – detected by listening over the epigastrium while shifting the abdomen from side to side
o Suggests gastric outlet obstruction or gastroparesis - Targeted neurological examination – assessing cranial nerves, checking for
______ (an important sign of raised intracranial pressure) and observing the patient’s gait - Cranial nerve abnormalities and/or long tract signs suggest a central nervous system cause
- Check for systemic features of endocrine disorders e.g. thyrotoxicosis and Addison’s disease
Succussion splash; papilledema
Investigations- lab tests
- Full blood count, electrolytes, thyroid panel, and in diabetics, glycosylated haemoglobin
- Severe vomiting may lead to dehydration and _________ , partly due to loss of gastric hydrochloric acid in vomitus
- Pregnancy test is imperative in women to assess whether pregnancy and prior to performing radiologic studies
- Serum drug levels – may indicate toxicity among patients taking _______ or recreational drugs
hypokalemic metabolic alkalosis; digoxin,
theophylline, salicylates
[Tests for obstruction and mucosal abnormalities (OGD, radiology)]
(OGD)
OGD – most sensitive modality for oesophageal, gastric, duodenal mucosa
Assessment for oesophageal pathology e.g. Hiatus hernia, GERD
Assessment for gastroduodenal pathology
- Gastritis/duodenitis, ulcers
- Gastric outlet obstruction and gastroparesis – retained food in stomach after prolonged fasting is a sign
Ability to take mucosal biopsies for histology/microbiology e.g. biopsy of gastric ulcers, testing for Helicobacter pylori, duodenal biopsies for celiac disease
(Radiology)
- Supine and upright abdominal radiographs if - obstruction is suspected – may reveal dilated gastric or bowel loops and air-fluid levels
- However, AXRs can be normal or non-specific in up to 22% of patients with ________
- Abdominal CT – more comprehensive assessment of the intra-abdominal viscera, may elucidate presence of and cause for obstruction if present
- Abdominal ultrasound is more sensitive than CT if _______ such as cholelithiasis is suspected
Contrast follow-through studies such as CT or MR enterography or enteroclysis – if small bowel pathology is suspected as a cause for vomiting
- Can detect high-grade obstruction, strictures and diverticula
partial small-bowel obstruction; gallbladder pathology
Tests for gut motor function
- If neither obstruction or mucosal disease is evident, an underlying motility disorder should be considered
- Tests of oesophageal motor function e.g. _______ may reveal achalasia
- Tests of gastric motor function e.g. Gastric emptying scintigraphy may help to diagnose gastroparesis, but is not widely used in Singapore
High resolution oesophageal manometry
Imaging of central nervous test
- e.g. CT or MRI brain – important in ruling out pathology such as _________
- Autonomic function testing e.g. ________ is useful in evaluating for autonomic neuropathy, such as in poorly-controlled diabetics
intracranial bleeds and space-occupying lesions; tilt-table test
Complications of nausea and vomiting – can lead to a number of potentially serious consequences, particularly when protracted and recurring
Emetic injury
- Oesophagitis – can be due to chronic protracted vomiting, of which endoscopic severity can range from mild erythema to ___________
- Longitudinal mucosal or transmural lacerations at GEJ – can be induced by _________or vomiting
- Mallory-Weiss syndrome – longitudinal mucosal or transmural lacerations associated with acute bleeding and haematemesis
- _________ – spontaneous rupture of the oesophageal wall with free perforation and secondary mediastinitis with high mortality
Glottic spasm
- Glottic spasm and _________ may develop during vomiting due to pharyngeal irritation by acid or bilious material
- Aspiration pneumonia – if vomiting occurs in patients with a depressed cough reflex or reduced consciousness, gastric contents may enter the bronchi
Fluid, electrolyte and mineral deficiencies
Nutritional deficiencies
erosions and ulcerations; abrupt severe retching; Boerhaave’s syndrome
