Nausea NauseaTreatment Nausea and related symptoms Some definitions are helpful. Nausea is the feeling that vomiting might occur! Vomiting is the forceful expulsion of gastric contents. This is a complex and "automated" reflex action. Retching is different from vomiting. Gastric contents oscillate between the stomach and oesophagus. Regurgitation is a symptom often confused with vomiting. Food is brought back into the mouth without "effect". Easy or “free” regurgitation worse on lying down or bending suggests severe gastro-oesophageal reflux rather than vomiting. Regurgitation of undigested foods suggests partial oesophageal obstruction.This can be due to a stricture (see heartburn) or tumour or from failure of relaxation of the lower oesophageal sphincter, as occurs in achalasia. Anorexia is a loss of desire to eat. This has a wide range of causes including some gastro-intestinal diseases but also cancer, depression or metabolic disorders. "The fear of eating" because of expected abdominal discomfort (perhaps after a delay of 30-60 minutes) is a specific symptom which suggests small bowel obstruction. A feeling of being full after eating a small quantity of food is different again. Usually there is a normal appetite prior to starting a meal. These symptoms are difficult to explain but are rarely due to any underlying problem. Refer to section on indigestion and normal gastroscopy. Chronic belching is a symptom mainly due to excessive swallowing of air which usually occurs during eating or drinking. Excessive air swallowing may occur because of oral irritation or acid reflux. Most commonly excessive air swallowing is due to anxiety or has become a habit. Gastroparesis has bcome a more frequently used diagnosis. This means delayed emptying of the stomach. This may cause nausea, bad breath, abdominal bloating, upper abdominal discomfort or pain. This diagnosis is difficult to prove Tests are unreliable There is no clear reason for this problem The treatments are diasppointing Sudden onset of nausea and vomiting Vomiting of acute onset usually has associated symptoms that help make the diagnosis. Acute vomiting associated with diarrhoea is likely to be due to gastroenteritis or food poisoning. Symptoms of fever, muscle aches and headache may suggest viral gastroenteritis, particularly if other members of the family are affected. Acute abdominal pain is often associated with nausea and vomiting. In this situation it is the nature of the pain rather than the presence of vomiting that is going to be most helpful in making a diagnosis. Some conditions such as gallstone pain (biliary colic) are particularly associated with nausea and vomiting. Nausea and vomiting associated with pain in the right upper abdomen suggests acute hepatitis. Vomiting that has the smell of faeces and abdominal distension would suggest bowel obstruction. Inner ear problems have the associated specific symptom of vertigo. For all of these situations – urgent medical attention is required for diagnosis then appropriate treatment. Chronic Symptoms - lasting several weeks Medications Many different drugs cause nausea - some examples are: Digoxin and theophylline are commonly associated with nausea in the elderly. These drugs may cause symptoms even if the drug levels are within the accepted range. Many antibiotics cause nausea. Erythromycin in particular may cause nausea and vomiting, together with pain in the right upper abdomen. Flagyl and Tiberal are particularly likely to cause nausea and may also result in acute nausea and vomiting when taken with alcohol. Anti-inflammatory drugs frequently cause nausea. They may be causing an ulcer but can cause symptoms even when the stomach looks normal on examination by gastroscopy. Non- "gut" Causes There are a number of non- "gut" causes of nausea and vomiting, but they are usually easily recognised. Pregnancy results in morning nausea and vomiting. Usually 8-14 weeks after the last menstrual period but may continue throughout pregnancy. Migraine is often distinguished from tension headache because of the associated nausea and vomiting. Eating disorders such as bulimia. This is characterised by frequent binge eating and vomiting. There may also be inappropriate and excessive use of laxatives and diuretics. "Gut" Causes There are many causes of vomiting that relate to diseases of the oesophagus and stomach. Vomiting that occurs immediately on awakening may suggest hazardous alcohol intake. Vomiting non-digested food soon after meals suggests oesophageal disease such as achalasia or stricture. Vomiting that occurs 3-4 hours after a meal, particularly associated with partially digested food, suggests blockage to the outlet of the stomach. Anorexia, fullness in the upper abdomen and nausea usually has no underlying cause. Rarely it may be a symptom of serious disease such as gastric ulcer or gastric carcinoma. Examination by gastroscopy is recommended. Sudden forceful vomiting may result in traumatic tearing of the lining of the oesophagus. This results in vomiting of blood. This is the most common in the young person after excessive alcohol intake or during a gastroenteritis illness. Gastroscopy is the most helpful examination but will often be normal. Treatment of nausea General treatment Dehydration needs to be avoided using gastrolyte (best option) or sports fluids (Gatorade). Drinking extra water is not adequate. Drugs to stop vomiting may be given before a clear diagnosis is made. Medication for nausea and vomiting. Many different medications are available for treatment. The choice is usually related to ease of use, the possible side-effects, and also whether one medication has some helpful additional effects. Prochlorperazine (Stemetil) acts directly on the vomiting centre in the brain. The main side-effects are unwanted sedation and rarely muscle spasms. This drug is used widely for treatment of nausea and vomiting from many different causes. Stemetil is available as a tablet and suppository (rectal) and a buccal preparation called Buccastem - placed between the lips and the gums (available directly from the chemist). Metoclopramide (Maxalon) and domperidone (Motilium) act by stimulating gut motility and accelerating gastric emptying. Metoclopramide should be avoided in children and the elderly. Metoclopramide has some particular use in the treatment of migraine, as delayed emptying of the stomach is part of the spectrum of this illness. Motilium (domperidone) is useful if fullness and bloating after meals are a major part of the symptoms. The anti-cholinergic drugs, e.g., atropine hyoscine, or cyclizine (Marzine) are used mainly for the prevention of motion sickness. Drying of the mouth and blurred vision are common side-effects which reduces their acceptability. Scopolamine (Scopaderm), a transdermal preparation, appears to be more acceptable. Cyclizine is useful for motion sickness and also for other causes of nausea. Chemotherapy sometimes causes severe nausea. Zofran (ondansetron) is very effective particularly if given early. It is sometimes used for post-operative nausea.