1. Evaluation and Treatment of Nausea and Vomiting
Deon Cox-Hayley, DO
University of Chicago

2. Nausea
Unpleasant subjective feeling of need to vomit

3. Case 46 y/o with treated neurocystocercosis
Hospitalized with intractable vomitting
Compazine
Ondansetron
Reglan

4. How to treat?

5. Vomiting center in medulla
Controls many involuntary, life-sustaining processes including
Respiration
Circulation
Digestion

6. Vomiting center Gastrointestinal tract Respiratory center
breath holding
forceful contraction
Other brain stem centers
pallor
sweating
tachycardia

7. Vomiting Center
(VC)
Diaphragm and
abdominal muscles
Upper GI tract

8. Chemoreceptor trigger zone
Vomiting Center
(VC)
Diaphragm and
abdominal muscles
Upper GI tract

9. Chemoreceptor trigger zone
Upper GI tract
and pharynx
Vomiting Center
(VC)
Diaphragm and
abdominal muscles
Upper GI tract

10. Chemoreceptor trigger zone
Cortex
Chemoreceptor trigger zone
Upper GI tract
and pharynx
Vomiting Center
(VC)
Diaphragm and
abdominal muscles
Upper GI tract

11. Chemoreceptor trigger zone
Cortex
Chemoreceptor trigger zone
Upper GI tract
and pharynx
Vestibular
apparatus
Vomiting Center
(VC)
Diaphragm and
abdominal muscles
Upper GI tract

14. Biochemical abnormalities
via Chemoreceptor Trigger Zone
Biochemical abnormalities
Sepsis
Drugs

15. Biochemical abnormalities
via Chemoreceptor Trigger Zone
Biochemical abnormalities
Hypercalcemia
Hyponatremia
Hepatic failure
Renal failure
Sepsis
Drugs
Chemotherapy
Opioids
Digoxin
Antibiotics
Other

16. via peripheral afferent
Irritation, obstruction of the GI tract
(including pharynx and hepatobiliary system) 1. 2. 3. 4. 5. 6. 7.

17. via peripheral afferent
Irritation, obstruction of the GI tract
(including pharynx and hepatobiliary system)
Cancer
Chronic cough
Esophagitis
Gastritis
Peptic ulceration
Gastric distention
Gastric compression
Delayed gastric emptying
Bowel obstruction
Constipation
Hepatitis
Biliary obstruction
Chemotherapy
Radiotherapy

18. via vestibular system
Motion
Malignant vestibular infiltration
Drugs: aspirin, platinum

19. via cortical centers Psychological factors, Anxiety Sights Smells
Tastes
Conditioned vomiting
Elevated intracranial pressure

20. Treatment Assess and treat underlying cause Use of anti-emetics
Reassess

21. Treatment If mediated by the CTZ, Gastric stasis and compression
Antidopaminergic
Gastric stasis and compression
Pro-kinetic
Chemotherapy
5-HT3 receptor antagonist
Cortical causes
Anxiolytic

22. Phenothiazines Examples Action Side effects
Compazine, Thorazine, Phenergan, Tigan
Action
Antidopaminergic
Side effects
Extra-pyramidal effects
Sedation
Hypotension

23. Orthopromides Example Action Side effects Reglan anti-dopaminergic
direct gastrokinetic effect
Side effects
Sedation
Extra-pyramidal effects
Caution if obstruction

24. Anti-cholinergics Example Action Side Effects Scopolamine
Anti-cholinergic near or at the VC
Decreases GI secretions and motility
Side Effects
dry mouth
delirium
constipation

25. Antihistamine Examples Action Side Effects
Diphenhydramine, hydroxyzine, meclizine
Action
Uncertain action at the VC
Side Effects
Sedation
Dry mouth

26. Cannabinoid Example Action Side effects Marinol Cortical
Sympathomimetic
Side effects
Drowsiness
Dysphoria
Delusions

27. Corticosteroids Examples Action Side effects
Prednisone, dexamethasone, hydrocortisone
Action
Undefined
Side effects
Stimulant
Improved appetite

28. Benzodiazepines Examples Action Useful as an adjunct Side effects
Lorazepam, oxazepam, diazepam
Action
Cortical
Useful as an adjunct
Side effects
Sedation
Falls

29. Serotonin receptor antagonists
Examples
Ondansitron, granisetron, dolasetron, and tropisetron,
Palonosetron (second generation)
Action
Prevent vagal stimulation in the GI tract
May have central action
Use--chemotherapy, radiation therapy
Side effects
constipation
headache