Acute Nausea and Vomiting: Treat or Refer?

Nausea and vomiting are common symptoms that can stymie even the most experienced practitioners.

Many experts propose—and those of us who have experienced it will no doubt concur—that nausea often causes more suffering than pain.^1,2

Like pain, nausea is a subjective experience. Usually, patients say they feel like vomiting is imminent, or they think they'd feel better if they could just vomit. Sometimes, nausea leads to vomiting, but other times, it's a stand-alone symptom that simply causes misery. For practitioners, measuring the degree of the patient's nausea is very difficult, and research has shown that health care providers tend to underestimate the magnitude of patients' nausea.³

Patients who are nauseated or actively vomiting often arrive at the clinic dehydrated and malnourished from food avoidance. In the acute setting, the goal is to prevent further nausea and vomiting, and to alleviate patients’ distress.

This article describes what retail clinicians need to know about nausea and vomiting.

Assessment

The American Gastroenterological Association recommends a 3-step process when new cases of nausea and vomiting present⁴:

1. Recognize and correct symptoms, such as dehydration or electrolyte abnormalities
2. Look for the underlying cause and provide specific therapy
3. Use empiric therapy if the cause isn’t apparent

Nausea has been associated with several medical conditions, examinations, and treatments,^4,5and they may include the following:

· Gastrointestinal problems (eg, appendicitis, cholecystitis, pancreatitis, or obstruction or motility problems)

· Iatrogenic causes (eg, chemotherapy-induced nausea and vomiting, side effect to any drug, or illicit drug overdose)

· Infection (bacterial or viral) or toxin exposure (eg, food poisoning)

· Metabolic disruption (eg, dehydration or electrolyte abnormalities)

· Motion sickness

· Neurological and psychiatric diseases (eg, increased intracranial pressure, seizure, migraine, or emotional or physical stressors)

· Pregnancy

The vast majority of acute nausea and vomiting is of gastrointestinal origin subsequent to viral or bacterial infections.⁶Nevertheless, prevention and treatment of nausea is somewhat complicated because no single antiemetic blocks all nausea-triggering receptors.⁵

Although the general assessment approach for nausea and vomiting is the same as it is for most conditions, determining symptom duration is critical. Practitioners can usually assess and treat patients with acute nausea and vomiting immediately, sending them home to rest and recover. However, patients with chronic symptoms need a different approach and a far more elaborate work-up. The point to remember is that acute and chronic nausea and vomiting are usually entirely different entities and must be treated differently.^6,4

Retail clinicians should look for signs of dehydration, hypotension, or orthostatic changes. Evaluation of skin turgor and mucous membranes can indicate the problem’s magnitude, and abdominal and neurologic examinations are routine. In most cases, diagnostic tests are unnecessary, and the history and physical examination will suggest a cause. When reasonable clinical suspicion exists, appropriate lab tests can help pinpoint the problem.⁴

One frequently overlooked cause of nausea isdrug-induced side effects. Many medications cause or contribute to nausea, which can progress to vomiting (Table 1⁷). Therefore, it’s wise to ask patients what medications they take, and if any are new. Practitioners should note that the causative medication doesn’t necessarily need to be new, as some patients develop nausea from medications they’ve taken without problem for years.

Table 1: Drugs Most Often Associated with Nausea⁷

· Antibiotics

· Antidepressants

· Antivirals

· Aspirin, ibuprofen, and naproxen

· Ethanol abuse

· Chemotherapy

· Opioid analgesics

· Vitamins and mineral supplements, especially iron

Clinical red flags warrant referral for more comprehensive work-up or emergency care. If the patient has abdominal pain, the pain’s location, severity, and timing may suggest a specific cause. Patients with chest pain, severe abdominal pain, central nervous system symptoms, and high fever are candidates for immediate referral. Those who are immunocompromised or have hypotension or severe dehydration may also need emergency care, including intravenous fluid replacement. Geriatric patients are at high risk for complications and should be referred if dehydration, confusion, or pain are present.⁴

Treatment

Patients will want relief, and often-simple steps will help. Fluid and electrolyte replacement often helps patients feel better, and most patients—if they can eat—do best if they start with low-fat/low-fiber or liquid diets. Other prudent steps include avoiding fatty or spicy meals; staying well hydrated; drinking ginger ale or ginger tea; and eating small, frequent meals as tolerated.⁴

Research results have found that specific causes usually respond to targeted therapy. In 5 situations where retail clinicians will usually consult with the primary care provider or refer the patient for specialized care, trial results have proven that the nausea and vomiting is the result of unique mechanisms of action and will respond to specific drugs (Table 2^4,8).

Table 2: Targeted Antiemetic Drugs for Specific Conditions^4,8

Condition

Drugs of Choice

Chemotherapy-induced nausea and vomiting

· Acute chemotherapy-induced nausea and vomiting

A 5-HT3 receptor antagonist + dexamethasone + an NK1 receptor antagonist +/- olanzapine

· Delayed chemotherapy-induced nausea and vomiting

Metoclopramide +dexamethasone +/- olanzapine

Cyclic vomiting syndrome for adults

Tricyclic antidepressants

Gastroparesis

Supportive treatment and possible gastric pacing

Postoperative nausea and vomiting

Droperidol/dexamethasone or ondansetron

Pregnancy

· Morning sickness

Meclizine, promethazine, electrolyte replacement, and thiamine supplementation

· Hyperemesis gravidarum

Prochlorperazine, chlorpromazine, metoclopramide, and methylprednisolone

Practitioners can prescribe empiric therapy when they suspect garden variety, self-limiting nausea and vomiting. Prochlorperazine is a reasonable first choice.⁴Other medications that can help include antihistamine (eg, dimenhydrinate, meclizine, cyclizine) prokinetic agents (eg, metoclopramide), and serotonin antagonists (eg, ondansetron).^4,9Ginger extract, ginger syrup and ginger capsules can also alleviate nausea, but they shouldn’t be used in patients taking anticoagulants.^10-12When motion sickness is the problem, patients often find the scopolamine transdermal patch convenient.

Conclusion

Health care practitioners should know that acute nausea is easier to control than chronic unexplained nausea,⁹but patients with either condition are usually miserable. Careful questioning can help identify the underlying cause, since “stomach flu” is often circulating. Patients need empathy and reassurance that with time, most of these conditions resolve quickly.

References

1. Easton R, Bendinelli C, Sisak K, Enninghorst N, Balogh Z. Prehospital nausea and vomiting after trauma: Prevalence, risk factors, and development of a predictive scoring system.J Trauma Acute Care Surg. 2012;72(5):1249-1254.

2. Lehmann HP, Fleisher LA, Lam J, Frink BA, Bass EB. Patient preferences for early discharge after laparoscopic cholecystectomy.Anesth Analg. 1999;88(6):1280-1285.

3. O'Mahony S, Coyle N, Payne R. Current management of opioid-related side effects.Oncology (Williston Park). 2001;15(1):61-82.

4. Quigley EM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting.Gastroenterology. 2001;120:263—286.

5. Garrett K, Tsuruta K, Walker S, Jackson S, Sweat M. Managing nausea and vomiting. Current strategies.Crit Care Nurse. 2003;23(1):31-50.

6. Hasler W, Chey W. Nausea and vomiting.Gastroenterology. 2003;125: 1860—1867.

7. Vazquez-Roque MI, Bouras EP. Chronic nausea. IN:Functional and Motility Disorders of the Gastrointestinal Tract. Lacy BE, Crowel MD, eds. New York, NY: Springer, 2015.

8. Hesketh PJ, Bohlke K, Lyman GH, et al. Antiemetics: American Society of Clinical Oncology focused guideline update.J Clin Oncol. 2016;34:381-386

9. Singh P, Yoon SS, Kuo B. Nausea: a review of pathophysiology and therapeutics.Therap Adv Gastroenterol. 2016;9(1):98-112.

10. Maitre S, Neher J, Safranek S. FPIN's clinical inquiries: ginger for the treatment of nausea and vomiting in pregnancy.Am Fam Physician. 2011;84:1-2.

11. Ding M, Leach M, Bradley H. The effectiveness and safety of ginger for pregnancy-induced nausea and vomiting: a systematic review.Women Birth. 2013;26:e26-e30.

12. Tiran D. Ginger to reduce nausea and vomiting during pregnancy: evidence of effectiveness is not the same as proof of safety.Complement Ther Clin Pract. 2012;18:22-25.