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Speciality Spotlight
Nausea
and vomiting are mediated by the same neural
pathways.
Nausea
A
feeling of an immense desire to vomit, referred to
throat or epigastrium. Associated with decreased tone
and movement of stomach and autonomic [parasympathetic]
activity e.g. salivation, perspiration, bradycardia.
Vomiting
Forceful
oral expulsion of gastric contents.
Retching
Labored
rhythmic contractions of respiratory and abdominal
muscles that precede or accompany vomiting.
Approach
to the patient –
Underlying cause should be identified.
Evaluation
begins with history [including drug history], physical
examination and if necessary routine laboratory tests.
e.g.- Complete blood count, ESR, electrolyte and glucose levels. Liver function tests.
In
50% of the patients with chronic nausea and vomiting,
the above mentioned tests do not reveal the cause. In
these cases, further specialized tests are needed.
e.g.
esophageal motility and PH gastric emptying studies.
Small intestinal mobility. Psychiatric consultation [In
selected patients].
1.
ACUTE ABDOMINAL EMERGENCY
Acute
appendicitis
Acute cholecystitis
Intestinal obstruction
Acute pancreatitis
2. DISORDERS OF G.I.T.
Indigestion
Peptic ulcers
Acute gastroenteritis
3. CARDIAC-
Acute myocardial infarction
Congestive heat failure
4. INCREASED INTRACRANIAL PRESSURE
Neoplasm
3..
LABYRINTHINE DISEASE
Minieres
disease
6.
DRUG INDUCED
Opiates,
phenytoin, digitalis
,Salicylates, aminophylline
,chemotherapy
7.
PSYCHOGENIC
ACUTE
ABDOMINAL EMERGENCY-
Clinical features-
Pains
in right lower quadrant of abdomen, aggravated by
motion, coughing. Fever 99o F 100 o
F. Loss of appetite, nausea and vomiting. Urge to pass
flatus or stools, which does not relieve distress.
Diagnosis-
1.
Elicitation of tenderness in any location
corresponding to position of appendix .
2.
Nausea and vomiting develop after the onset of
pain [extremely rare to occur before pain].
3.
Anorexia [Presence of
hunger] will arouse doubt about appendicitis.
Laboratory tests
1.
Diagnosis based on history and clinical features.
2.
Urine analysis [to exclude genitourinary
conditions that mimic appendicitis]
3.
Ultrasound [to exclude ovarian cyst and ectopic
pregnancy]
Treatment
Appendectomy
Acute intestinal obstruction
Cramp like mid abdominal pain which comes in
paroxysms. Patient is relatively comfortable during
intervals between the pains.
Distention
of abdomen
Vomiting
Diagnosis
1.
Abdominal distention
2.
Minimal tenderness and rigidity
3.
Temperature rarely above 100 0F
4.
Auscultation
Loud, high pitched, borborygmi coincide with colicky
pain
5 X-ray
abdomen
Treatment
Surgical
removal of obstruction
Acute
Cholecystitis
Clinical features-
Pain in right upper abdomen rediating to
interscapular region and shoulder. Anorexia, nausea and
vomiting. Low grade fever.
Diagnosis
1.
H/o prior attacks that resolved spontaneously
2.
Sudden onset of tenderness in right upper abdomen
with rebound tenderness.
3.
Palpable, enlarged, tense gall bladder
4.
A light blow to right subcostal area elicits a
marked increase in pain
5.
C.B.C. leukocytosis
6.
Ultrasound
Treatment
Surgical
removal of gall bladder.
Acute pancreatitis
Clinical
features
Acute severe abdominal pain in epigastrium
and periumbilical region radiating to back and chest.
Pain aggravated by supine position and relieved by
sitting with trunk flexed and knees drawn up.
Nausea,
vomiting and abdominal distention.
Diagnosis
1.
A distressed, anxious patient
2.
Low grade fever, tachycardia and hypotension.
3.
Bowel sounds diminished or absent.
4.
Laboratory tests
a..
Increased levels of serum amylase and lipase.
b.
Hyperglycemia
c.
Leukocytosis
d.
Ultrasonography
Treatment
1.
Analgesics
2.
IV fluids
3.
Antibiotics
DISORDERS
OF G.I.T.
Chronic
Indigestion –
Clinical
features
Epigastric
and periumbilical pain with nausea and vomiting.
Heartburn,
belching after a large meal or citrous fruits, alcohol
or aspirin.
Diagnosis-
1.
X-ray and imaging studies of esophagus, stomach,
small intestine and biliary tract.
2.
Search for extra intestinal causes.
e.g.
Tuberculosis, congestive heart failure, neoplasm.
Treatment
Antacids
Ranitidine
Elimination of certain foods
e.g. milk, legumes
Avoidance
of aspirin, NSAIDS
Peptic
ulcer
Clinical
features
Epigastric
pain 2-3 hours after eating and awakens the patient at
night. The pain is relieved by food or antacids.
Fullness after eating, nausea, bloating
Diagnosis
Barium
swallow
X-ray
Endoscopy
of upper G.I.T.
with mucosol biopsy for detection of H. pylori.
Treatment
Antacids
Ranitidine
Eradication of H-pylori with tripple therapy
Acute gastroentecitis –
Abrupt
onset of cramps in abdomen,nausea, vomiting with
diarrhea and
fever. Headache and myalgia.
Diagnosis
Stool test to
search, the cause
Anthelmintic
Cardiac
Acute
myocardial infarction
Clinical
features
Acute
severe pain in the central portion of chest and / or
epigastrium. The pain is precipitated by vigorous
exercise emotional stress, and not relieved by rest.
Presence of sweating, nausea and vomiting.
Diagnosis –
1.
Frequent location of pain beneath the xiphoid
process and denial of the patient having a heart attack
gives a mistaken impression of indigestion.
2.
E.C.G.
3.
Serum creatimine phosphokinase levels
4.
2-.D. echocardiography
Treatment
1.
Admission of ICCU
2.
Treatment of complications
e.g. Arrhythmias, heat failure
3.
Control of pain
Sublingual nitroglycerine
I.V. morphine
I.V. betablocker
Congestive
heart failure
Clinical
features
Breathlessness
during activity with fatigue, weakness, anorexia, nausea
and pain in abdomen.
Diagnosis
1.
X-ray chest
2.
2-D echocardiography
Treatment
1.
Digitalis
2.
ACE – inhibitors
Moderate
restriction of activity and salt
intake
INCREASED
INTRACRANIAL PRESSURE
–
Neoplasm
Clinical
features –
1.
These are due to increased intracranial pressure
due to metastases of cancer of lungs, breast and
melanoma.
2.
Headache, nausea, vomiting, behavioral changes,
seizures
Diagnosis
MRI
Treatment
1.
Control of various symptoms with I.V.
dexamethasone
2.
Intubation and hyperventilation
3.
Brain -radiation therapy
LABYRINTHINE
DISEASES –
Menieres disease
Clinical features
Recurrent vertigo with nausea, vomiting, tinnitus
and progresive deafness
Diagnosis
1.
Caloric testing
2.
Electro rystagmography [ENG]
Treatment
1.
Bed rest
2.
Low-salt intake
3.
Cyclizine or meclizine
Surgical destruction of the labyrinth
Drug
induced
e.g.-
.Opiates, phenytoin, digitalis,
salicylates,
aminophylline,
chemotherapy
Psychogenic
–
Clinical
features –
Chronic or recurrent vomiting due to an emotional
or psychological disturbances.
e.g.
– Bulimia
nervosa –
Massive
binge eating followed by vomiting and
excessive use
of laxatives.
Episodic compulsive eating of large amounts of
food
coupled with
fear that eating can not be stopped voluntarily.
Diagnosis
1.
Morbid fear of becoming fat.
2.
Secracy about eating and vomiting episodes.
Treatment
1.
Psychotherapy
2.
Antidepressant
Drug
induced
e.g.-
.Opiates, phenytoin, digitalis,
salicylates,
aminophylline,
chemotherapy
Psychogenic
–
Clinical
features –
Chronic or recurrent vomiting due to an emotional or
psychological disturbances.
e..g.
– Bulimia
nervosa –
Massive
binge eating followed by vomiting and
excessive use
of laxatives.
Episodic compulsive
eating of large amounts of
food
coupled with
fear that eating can not be stopped voluntarily.
Diagnosis
–
1.
Morbid fear of becoming fat.
2.
Secracy about eating and vomiting episodes.
Treatment
–
1.
Psychotherapy
2.
Antidepressant
