Nausea%20-and-%20vomiting Diagnosis
Diagnosis
- A detailed history and physical exam are crucial in evaluating patients with nausea and vomiting and in determining the underlying cause of nausea and vomiting
History
- Determine the duration, frequency and severity of nausea and vomiting
- Nausea and vomiting is considered chronic when it lasts >1 month
- Determine when vomiting occurs during the day (timing) and the characteristic of the vomiting process itself
- Eg projectile vomiting may suggest an increased intracranial pressure (ICP) resulting from an intracranial problem
- Elicit information about the onset of vomiting ie relation to meals
- Investigate the quantity and quality of the vomitus
- Ask if vomitus consists of undigested, partially digested or bilious material
- Ask about a possible fecaloid character of the vomitus or a putrid odor which is characteristic of intestinal obstruction
- Ask about associated symptoms as these may assist in localizing the underlying disease process:
- Fever, weight loss
- CNS symptoms: Headache, focal neurologic deficits, neck stiffness, vertigo
- Abdominal pain, diarrhea
- Presence of a similar illness in the patient’s family and/or friends
- Ask about concomitant illnesses
- Patient may be suffering from nausea and vomiting related to treatment ie chemotherapy-related nausea and vomiting
Physical Examination
- Search for signs of dehydration or weight loss
- Orthostatic hypotension
- Postural increase in pulse rate
- Search for findings that may suggest autonomic neuropathy
- Postural decrease in blood pressure (BP) without a concomitant increase in pulse rate
- Conduct a careful abdominal examination
- Ascertain if there is abdominal tenderness, together with its specific location
- Listen for decreased bowel sounds
- Palpate for abdominal masses
- Conduct a detailed neurologic and psychiatric exam
- Check for cranial nerve abnormalities, gait problems, funduscopic changes and other relevant information
- The rest of the systemic physical exam may also provide other helpful information with regard to the etiology of nausea and vomiting
- Findings suggestive of autonomic neuropathy may be found
- Exam may reveal signs of systemic diseases causing nausea and vomiting
- Evidence of self-induced vomiting may be apparent
Laboratory Tests
- Diagnostic tests are done to aid in determining the underlying cause of nausea and vomiting and to assess the effects of nausea and vomiting on a patient
- Basic tests include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), standard blood chemistry
- Other tests to be done would depend on the diseases being considered, eg:
- Serum drug levels for possible drug toxicities
- Pregnancy test
- Thyroid-stimulating hormone (TSH) levels for possible thyrotoxicosis or Addison’s disease
- Fecal occult blood
Tests of Gastric Motor Function
- Gastric emptying time
- Relatively accurate, easy and noninvasive
- May reveal presence of gastroparesis
- Electrogastrography (EGG)
- A decrease in or the absence of the expected postprandial increase in the EGG amplitude has been shown to correlate with prolonged gastric emptying time and antral hypomotility
- Antroduodenal manometry
- May be useful in identifying patients with primary or diffuse motor abnormalities
- A normal study may be useful in ruling out dysmotility and pointing the clinical investigation into another direction
Imaging
- Imaging tests are usually focused on the abdominal area and are done depending on the etiologies of nausea and vomiting being considered eg mechanical gut obstruction
- Abdominal x-rays, barium studies
- Small bowel enema, small bowel follow-through exam
- Endoscopic investigations
- Computed tomography (CT) scan of the abdomen
Disorders of Gut Motility
Gastroparesis
- Functional disorders of gut motility give rise to nausea because of inability to clear food and secretions
- Gastroparesis may be part of the following conditions:
- Postvagotomy and postgastric drainage surgery patients
- Pancreatic malignancy
- Systemic diseases eg diabetes mellitus (DM), systemic lupus erythematous (SLE) and other connective tissue diseases
- Idiopathic gastroparesis
- The dysfunction is documented by tests of gastric motor function
- Clinicians should be careful not to quickly assume that confirmed gastroparesis is the primary cause in itself of a patient’s symptoms
Other Conditions Associated with Disorders of Gut Motility
- Other conditions that may result in gut dysmotility are chronic intestinal pseudo-obstruction, Roux-en-Y syndrome, functional dyspepsia
Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum
Nausea and Vomiting of Pregnancy
- A common condition that affects about ¾ of pregnant women
- 25% of women may have nausea only
- May occur at all times of the day (not just in the morning)
- Symptoms usually begin 4-7 weeks after the last menstrual period and cease by 12 weeks in most women
- Symptoms that begin after the 9th week of gestation are not typical of nausea and vomiting of pregnancy
- Increased incidence is noted in the following situations:
- Previous pregnancy with nausea and vomiting
- Nulliparity
- Younger age of the mother
- Obesity
- Family history of hyperemesis gravidarum
- Increased placental mass (eg molar or multiple pregnancies)
- History of motion sickness or migraine
- Nausea and vomiting of pregnancy is self-limiting in most patients and it usually resolves without complications as pregnancy proceeds
Hyperemesis Gravidarum
- Represents the most severe form of nausea and vomiting of pregnancy
- Most common reason for hospital admission during the 1st part of pregnancy
- A diagnosis of exclusion based on typical signs and symptoms and the absence of other causes that may explain the clinical presentation
- Criteria for diagnosis are as follows:
- Persistent vomiting not related to other causes
- Evidence of weight loss, usually ≥5% of prepregnancy weight
- Evidence of starvation ie ketonuria
- Abnormalities of electrolyte levels, thyroid and liver may also be present
- Hyperemesis gravidarum may lead to significant complications, eg the following:
- Rupture of the esophagus
- Wernicke’s encephalopathy secondary to Thiamine deficiency
- Hyperthyroxinemia with low thyroid-stimulating (TSH) levels
- Depression
Differential Diagnoses for Nausea and Vomiting of Pregnancy
- Nausea and vomiting that begins after the 9th week of gestation is not characteristic of nausea and vomiting of pregnancy and should be investigated further
- Headache, fever, abdominal pain or tenderness are not typical in nausea and vomiting of pregnancy
- Diseases that may present as nausea and vomiting in pregnant patients include the following:
- Pregnancy-related conditions: Preeclampsia, acute fatty liver of pregnancy
- GI diseases: Gastroenteritis, biliary tract disease, hepatitis, peptic ulcer disease, appendicitis, etc
- Neurologic diseases: Migraines, CNS tumors
- Genitourinary tract diseases: Pyelonephritis, kidney stones, uremia
- Other conditions: Hydatidiform mole, diabetic ketoacidosis, drug-related toxicity, eating disorders, labyrinthitis, motion sickness
Postoperative Nausea and Vomiting (PONV)
Risk Factors for PONV
The presence of certain risk factors is predictive of a patient’s likelihood of experiencing post operative nausea and vomiting (PONV)
Very High Risk
The presence of certain risk factors is predictive of a patient’s likelihood of experiencing post operative nausea and vomiting (PONV)
- Patient Factors
- Female gender
- Nonsmoker
- Postoperative opioid use
- Previous episode of PONV
- History of motion sickness
- Surgical Factors
- Craniotomy
- Laparoscopy
- Laparotomy
- Major breast surgery
- Otolaryngological procedures
- Plastic surgery
- Strabismus surgery
Very High Risk
- >4 factors present
- Emesis potential >80%
- 3-4 risk factors present
- Emesis potential 40-80%
- 1-2 risk factors present
- Emesis potential 20-40%
- PONV is seen more often in patients who have undergone general
anesthesia compared to those who have received regional anesthesia
- Propofol use decreases the risk of PONV
- Dehydration, pain and anxiety can increase the incidence of PONV
Chemotherapy- and Radiation-Related Nausea and Vomiting
Incidence of Chemotherapy-Related Nausea and Vomiting
Acute-onset Nausea and Vomiting
- About 70-80% of cancer patients receiving chemotherapy experience nausea and vomiting
- The incidence and severity of nausea and vomiting following chemotherapy are influenced by the following factors:
- Chemotherapeutic agents used
- Dosage of chemotherapeutic agents
- Schedule and route of administration
- Radiation therapy target
- Individual patient propensities eg gender, age, previous chemotherapy, history of alcohol use
- Poor compliance or withdrawal from chemotherapy
- Malnutrition, anorexia, metabolic imbalances
- Decreased level of functioning
- Esophageal tears
Acute-onset Nausea and Vomiting
- Occurs within a few minutes to several hours after chemotherapy administration
- Usually peaks after 5-6 hours and resolves within 24 hours
- Arises >24 hours after chemotherapy administration
- A conditioned response which occurs before patients receive their next chemotherapy treatment
- Anticipatory nausea and vomiting usually occurs when patients have had a previous unpleasant experience with chemotherapy
- Younger patients are more prone to anticipatory nausea and vomiting because they have poorer emesis control and they usually receive more aggressive chemotherapy regimens
- Nausea and Vomiting that arises in spite of preventive treatment
- Symptoms that occur during subsequent chemotherapy sessions when antiemetic prophylaxis has failed during previous treatment sessions
- The type of antiemetic treatment regimen that a patient needs depends on
the emetogenic potential of the chemotherapeutic agents that a patient
is receiving
- The risk of nausea and vomiting for chemotherapeutic agents with high emetic risk lasts for about 3 days and with moderate emetic risk 2 days after the final dose of chemotherapy
- IV agents: Anthracycline/cyclophosphamide combination, Carmustine (>0.25 g/m2), Cisplatin, Cyclophosphamide (>1.5 g/m2), Dacarbazine, Doxorubicin (≥0.06 g/m2), Epirubicin (>0.09 g/m2), Ifosfamide (≥2 g/m2 per dose), Mechlorethamine, Streptozocin
- IV agents: Azacitadine, Bendamustine, Busulfan, Carboplatin, Carmustine (≤0.25 g/m2), Clofarabine, Cyclophosphamide (≤1.5 g/m2), Cytarabine (>0.2 g/m2), Daunorubicin, Doxorubicin (<0.06 g/m2), Epirubicin (<0.09 g/m2), Idarubicin, Ifosfamide (<2 g/m2 per dose), Irinotecan, Melphalan, Methotrexate (≥0.25 g/m2), Oxaliplatin, Temozolomide, Trabectedin
- Busulfan (≥0.004 g/day), Cyclophosphamide (≥0.1 g/m2/day), Etoposide, Niraparib, Olaparib, Procarbazine, Rucaparib, Temozolomide (>0.075 g/m2/day)
- IV agents: Cytarabine (0.1-0.2 g/m2), Docetaxel, Etoposide, Fluorouracil, Gemcitabine, Liposomal Doxorubicin, Methotrexate (<0.25-0.05 g/m2), Mitomycin, Mitoxantrone, Paclitaxel, Pemetrexed, Topotecan
- IV agents: Bevacizumab, Bleomycin, Cladribine, Cytarabine (<0.1 g/m2), Fludarabine, Ipilimumab, Methotrexate (≤0.05 g/m2), Peginterferon, Pertuzumab, Pembrolizumab, Rituximab, Trastuzumab, Vincristine, Vinblastine, Vinorelbine
- Abemaciclib, Capecitabine, Chlorambucil, Erlotinib, Everolimus, Fludarabine, Hydroxyurea, Imatinib, Melphalan, Methotrexate, Neratinib, Regorafenib, Ribociclib, Sunitinib, Thalidomide, Topotecan, Vemurafenib
1List of chemotherapeutic agents shown above is not exhaustive. Please refer to available guidelines from health authorities for the complete list.
Radiation-Induced Nausea and Vomiting- Patients receiving whole body or upper abdominal radiation therapy have
the greatest chance of developing nausea and vomiting after the
procedure
- The rapidly dividing cells of the intestinal tract are especially sensitive to radiation
- The potential for postradiation nausea and vomiting is increased by a higher total and daily fractional dose of radiation and a larger amount of irradiated tissue
Classification of Radiotherapy Emetogenic Potential According to Irradiated Site
High (Emetic Risk >90%)
- Total body irradiation
Moderate (Emetic Risk Between 30-90%)
- Craniospinal irradiation, upper abdomen
Low (Emetic Risk Between 10-30%)
- Cranium, head and neck, thorax, pelvis
Minimal (Emetic Risk <10%)
- Breast, extremities