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PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Persistent Nausea or Vomiting

The possible diagnoses for a patient presenting with persistent nausea and/or vomiting are many and varied, but in the main may be considered under five main headings:

  • Pregnancy
  • Visceral disease
  • Metabolic/toxic
  • Central nervous system disease
  • Psychiatric illness
Assessment of the patient

Assessment of the patient with persistent nausea and vomiting should fall into two categories:-

  1. Assessment of the physical state of the patient, which has occurred as a consequence of the nausea/vomiting. Look for evidence of:
    • Poor nutritional state
    • Dehydration
    • Electrolyte imbalance
  2. Assessment of the patient with regard to the potential underlying cause.1
    Pregnancy
    80% of pregnant women experience some form of nausea and/or vomiting related to pregnancy.2Visceral disease Metabolic/toxic Central nervous system disease Psychiatric disease
Investigations

Full history with particular attention to duration, severity, aggravating and relieving factors, associated features, drug and occupational history, social history, last menstrual period, previous medical history, recent trauma.
Full examination- in particular assess hydration, nutritional state, examine abdomen, sclera and optic discs, check for nystagmus.

  • Urine dipstick- for protein, blood, glucose, pH, bilirubin, urobilinogen
  • Serum Urea
  • Serum calcium
  • Liver function tests
  • Full blood count
  • Pregnancy test
  • Plain abdominal film
  • Abdominal ultrasound
  • Endoscopy
  • Abdominal CT/MRI scan
  • Cranial CT if suspicion of raised intracranial pressure
Management

Non-drug

  • Patients with persistent nausea and /or vomiting will require appropriate dietary advice and advice on fluid intake.
  • Patients with severe dehydration may require treatment for a time with intravenous fluids.
  • Psychiatric or psychology referral may be appropriate for those thought to have an underlying psychiatric/psychological cause.
  • Pregnant patients should be given emotional support, advice concerning diet, adequate nutritional intake, avoiding large volume meals and tight clothing and advised to avoid taking anti-emetic preparations available over the counter. Complimentary therapies such as ginger or acupressure may be useful.l3 Pregnant women who have severe vomiting may require hospitalization, where they can receive orally or intravenously administered corticosteroid therapy, and total parenteral nutrition.
  • There is some evidence for the use of acupuncture for the symptomatic relief of nausea and vomiting and this may be an option for some patients.4 It is particularly efficacious against nausea in post-operative patients, who had not received pre-medication.

Drugs

Once the caused of vomiting has been established, symptomatic relief may be given if appropriate, in the form of anti-emetic therapy.
Many classes of drugs exhibit anti-emetic properties such as antihistamines, phenothiazines such as prochlorperazine, anti-psychotic drugs such as haloperidol.5

  • Metoclopramide acts directly on the gastrointestinal tract and may be the drug of choice for visceral causes.
  • Medications including pyridoxine and doxylamine, have been shown to be safe and effective treatments in pregnancy.3, 6
  • Domperidone acts at the chemoreceptor trigger zone and is especially useful for nausea and vomiting associated with chemotherapy.
  • Dolasetron, granisetron, odansetron and tropisetron are specific 5HT3 antagonists and as such are particularly useful for post-operative nausea and vomiting and that associated with cytotoxic therapy.
  • Dexamethasone and nabilone, a synthetic cannabinoid, may be useful for patients on cytotoxic drugs with nausea that is resistant to other therapy.

Surgical

Surgery may be required to treat some underlying causes of nausea and vomiting e.g. raised intracranial pressure and some forms of obstruction.

Complications

Recurrent vomiting may result in dehydration, electrolyte disturbance, oesophagitis/gastritis and Mallory-Weiss syndrome.


Document references
  1. Quigley EM, Hasler WL, Parkman HP; AGA technical review on nausea and vomiting.; Gastroenterology. 2001 Jan;120(1):263-86.
  2. Koch KL, Frissora CL; Nausea and vomiting during pregnancy.; Gastroenterol Clin North Am. 2003 Mar;32(1):201-34, vi. [abstract]
  3. Quinla JD, Hill DA; Nausea and vomiting of pregnancy.; Am Fam Physician. 2003 Jul 1;68(1):121-8. [abstract]
  4. Lee A, Done ML; Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting.; Cochrane Database Syst Rev. 2004;(3):CD003281. [abstract]
  5. British National Formulary British Medical Association and Royal Pharmaceutical Society of Great Britain. London.
  6. Jewell D, Young G; Interventions for nausea and vomiting in early pregnancy.; Cochrane Database Syst Rev. 2003;(4):CD000145. [abstract]

Internet and further reading Acknowledgements EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 1368
Document Version: 21
DocRef: bgp2397
Last Updated: 4 Oct 2006
Review Date: 3 Oct 2008
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