Nausea and Vomiting

Nausea and Vomiting
I don’t think anyone of normal intelligence and human experience needs a long dissertation on the experience of nausea and vomiting. Nausea is the anticipatory sensation that one is going to vomit. Vomiting itself is the reflex mechanism by which the stomach upwardly expels its contents. There are usually contents from the small intestine, including bile, which are moved back into the stomach immediately prior to vomiting. The clinician’s dilemma is to determine the cause, to treat the cause and the symptoms, and to prevent complications such as dehydration and even shock. There are times when vomiting can result in the summoning of the emergency transportation service (911). These would include if there was chest pain which might suggest a heart attack or a tear in the esophagus. The presence of fainting, cold, clammy, pale skin, or confusion might represent shock. The occurrence of severe abdominal pain and the vomiting of fecally scented or appearing material might certainly suggest an intestinal obstruction. Vomiting with the signs of high fever and a stiff neck might suggest meningitis; needing immediate attention.
Perhaps the most important aspect of diagnosing the cause of nausea and vomiting is the medical history. Exactly how long has the vomiting been happening? In an infant or child who is vomiting longer than twenty-four hours, should have a thorough evaluation. Is the patient of fertile age? Has she missed her menstrual period or had other signs of pregnancy? Did the patient attend a July picnic and eat potato salad that had been sitting out longer than two hours? Is the patient an elementary school student, and have several members of his/her class been out with the “stomach flu”? Does the patient have a history of migraine, and is he/she having a headache now along with the nausea? Did the patient suffer a blow to the head that afternoon at football practice? Has the patient had severe bouts of vertigo? Are there chronic underlying medical conditions such as diabetes, kidney failure, or cancer? What medicines has one taken, and is there a history of heavy alcohol consumption? The list goes on and on, and it is the task of the clinician to tease out the particular history which would narrow the field of possible causes.
Next in the process of evaluation would follow the physical examination. Are the pupils unequal; suggesting a brain process such as a stroke or a brain injury, and is the remainder of the neurological exam normal? Do the vital signs such as high pulse rate and low blood pressure suggest shock? Is the skin yellow as from hepatitis or a cancer of the liver or pancreas? Is the patient “beet red” as from carbon monoxide poisoning? Is there a strong odor of alcohol or circumstance suggesting drug overdose? Does the patient have abnormally low body weight suggesting anorexia or bulimia? Are the heart exam and the electrocardiogram normal? Is the stomach rigidly hard or soft? Are there normal bowel sounds? Is there an area of localized tenderness? This process would continue until a full physical exam was completed.
The next process in the evaluation may be laboratory testing. If the urine is concentrated and there are ketones present, this is evidence of dehydration. Is the white blood cell count elevated as with a bacterial infection, or does it show a preponderance of lymphocytes as with a viral infection? Is the blood sugar too high or too low? Are the salts such as sodium and potassium normal? Do other tests suggest liver abnormality such as hepatitis? Your doctor will know which tests to order and how to interpret them to best fit your needs.
If you are the caregiver of an infant or child and if the vomiting has been less than twenty-four hours there are some general guidelines for prevention of dehydration. If you are breastfeeding, continue to do so, but give smaller lengths of feeding at increased intervals. For older children, oral rehydrating fluids such as Pedialyte are available without prescription. One formula is to give 10 teaspoons (50milliliters) per kilogram in incremental doses. This can be supplemented with water, jello, and diluted fruit juices. Sports drinks are not recommended as they may cause electrolyte abnormalities. If solid food is given, avoid high sugar or high fat foods, and choose instead complex carbohydrates such as rice, potatoes, wheat and bread, along with lean meat, fruits and vegetables.
Over the counter anti nausea medicines are not recommended. Your physician can, if he deems it to be necessary and safe, prescribe certain medicines for the symptoms of nausea. These may be oral or suppositories depending on whether they can be retained. Often in the office or ER a shot of medicine may be given first. There are precautions with their use, and certain ones are contraindicated in infants and young children, so check with your provider first rather than giving any leftover medications from a family member who was previously ill.
This article is meant to be a primer on nausea and vomiting. The take home message is to give your provider a complete history of the illness as possible. You may make dietary limitations early in the course of the illness and keep the hydration state as normal as possible. If there is a history of head injury, high fever, altered mental status, or abdominal pain take the patient in for a complete evaluation. A lot of the stomach viruses are highly contagious, so the family should practice frequent hand washing and careful handling of the ill person’s utensils and any items with vomit on them. Most causes of nausea and vomiting are benign and over in a day or two.

John Drew Laurusonis M.D.
Doctors Medical Center