STUDY - Technical - New Dacian's Medicine
Nausea
and Vomiting
Translation Draft
Nausea and vomiting can occur independently of each other, but are generally correlated and are assumed to be mediated by the same nerve pathways so that they can be discussed together. Nausea is the sensation of an imminent desire to spill, usually perceived in the throat or epigastrium. Vomiting (or emesis) means the explosive oral, forced removal of gastric contents. The effort to vomit denotes rhythmic contractions of the respiratory and abdominal muscles that often precede or accompany vomiting.
Nausea often precedes or accompanies vomiting. It is usually associated with diminished functional activity of the stomach (e.g. hypotonia, hypoperistaltic and hyposecretion) and altered motility of the small intestine (e.g. hypertonia and inverted peristaltics of the duodenum). Often, accompanying severe nausea, altered vegetative activity (especially parasympathetic) is highlighted, such as skin pallor, increased breathing, hypersalivation, defecation and sometimes hypotension and bradycardia (vasovagal syndrome), anorexia being usually present.
Nausea. the effort to shed and hypersalivation frequently precedes the spill, which is a highly integrated sequence of involuntary somatic and visceral processes. The stomach plays a relatively passive role in the spillage process, the main force of expulsion being provided by the abdominal musculature. With the relaxation of the gastric bottom and gastroesophageal sphincter, a sudden increase in intraabdominal pressure is achieved by strong contraction of the diaphragm and muscles of the abdominal wall. These together with concomitant ring contraction of the gastric pylorus lead to the expulsion of gastric contents into the esophagus. Increased intratoracic pressure leads to the subsequent movement of esophageal contents in the mouth.
Inversion of the normal direction of the esophageal peristalsis may play a role in this process. The reflex lifting of the soft palate during vomiting prevents the entry of the expelled material into the nasopharynx, while reflex closure of the bullet and inhibition of breathing helps prevent pulmonary aspiration. Repeated vomiting can have harmful effects in many ways. The process of vomiting, if strong, can lead to rupture of the esophagus through pressure exerted on it (Boerhaave syndrome) or linear mucous ruptures (Mallory-Weiss) in the region of the cardioesophageal junction, with consecutive hematemesis.
Prolonged vomiting can lead to dehydration, loss of gastric secretions (especially hydrochloric acid), causing metabolic alkalosis with hypokalemia, malnutrition with various deficient states and tooth decay. In states of depression of the central nervous system (e.g. coma), the gastric contents can be sucked into the lungs, with consecutive aspiration pneumonia.
Let's see now, what is the mechanism of vomiting! The act of spilling is under the control of two functionally distinct bulbar centers: the center of the vomit, in the dorsal portion of the lateral reticulated formation and the chemoreceptor trigger area, in the postrema area of the fourth ventricle floor. The center of the vomit controls and integrates the actual act of the emesis. It receives aferential stimuli from the gastrointestinal tract and other parts of the body, from the upper centers of the brain stem and cortical, especially from the labyrinthine apparatus and from the chemoreceptor trigger area.
Individuals vary considerably as the threshold of the vomit centers to different stimuli. Important efferent pathways in vomiting are frenic nerves (towards the diaphragm), spinal nerves (towards the intercostal and abdominal muscles) and visceral efferent fibers of the vagus nerve (towards the larynx, pharynx, esophagus and stomach). The vomit center is located next to other bulbar centers that regulate respiratory, vasomotor and vegetative function and may be involved in the act of vomiting.
The chemoreceptor trigger zone alone is not able to mediate the act of vomiting, rather, the activation of this area causing efferent pulses to the bulbar center of the vomit, which in turn initiates vomiting. The chemoreceptor trigger zone is an emetic chemoreceptor that can be activated by a variety of stimuli or drugs, including apomorphine and other opiates, levodopa (after dopamine decarboxylation), digital, bacterial toxins, radiation and metabolic abnormalities that occur in uremia and hypoxia.
It's the turn of the clinical manifestations... Nausea and vomiting are common manifestations in many organic and functional disorders. the precise mechanisms that trigger vomiting in different clinical conditions are not fully elucidated, making the classification of mechanisms difficult. Many acute abdominal emergencies leading to "acute surgical abdomen" are associated with nausea and vomiting. Vomiting can be found in the inflammation of a visceral, as in acute appendicitis or acute cholecystitis, intestinal occlusion or acute peritonitis.
Other eating tract disorders, including those associated with chronic indigestion, are frequently accompanied by nausea and vomiting. In peptic ulcers, vomiting can be spontaneous or self-inflicted and can lead to relief of symptoms, especially if antral or pyloric edema causes obstruction of gastric discharge.
Nausea and vomiting are also important in patients with gastrointestinal motility disorders, including post-vagotomy, diabetic or idiopathic gastroparesis, other gastric "disrhythms", resulting from abnormal myoelectric activity and intestinal pseudoocclusion due to abnormal myogenous or neurogenic intestinal function. Gastroparesis can be demonstrated by gastric scanning after a radiolabelled lunch or by X-ray after ingestion of non-digestible radioopaque solid markers.
Experimentally it has been shown in some patients with nausea and vomiting, otherwise unexplained, to have accelerated ("tahigastria") or irregular gastric electrical activity ("gastric tachyarrhythmia"), measured by electrodes surgically implanted in the stomach serum or placed on the surface of the abdomen ("electrogastrogram"). Typically, intestinal obstruction of any cause (e.g. adhesions, malignancy, hernia, volvulus) can cause vomiting, as in the case of diseases of the liver, pancreas and bile ducts. nausea and vomiting may accompany distension and pain occurring in aerophagic syndromes.
Infections of the intestinal tract (viral, bacterial and parasitic) are characteristically associated with severe nausea and vomiting, often with diarrhea. Acute systemic infections with fever, especially in young children, are also frequently accompanied by vomiting and often severe diarrhea. the mechanism by which infection away from the gastrointestinal tract produces these manifestations may be related to stimulation of the triggering chemoreceptor area by abnormal toxins or metabolites.
Central nervous system disorders leading to increased intracranial pressure (e.g. neoplasms, encephalitis, hydrocephalus) may be accompanied by vomiting, which are often in the jet (very strong). Vertigo due to disorders of the labyrinthine apparatus, such as acute labyrinthitis and Meniere syndrome, may be accompanied by vomiting with nausea and vomiting effort. Similarly, motion sickness is characteristically associated with anorexia, nausea and vomiting, as well as apathy, increased salivation, cold sweats and headache.
In addition, migraine headache, tabetic seizures, acute meningitis and the reactive phase of synchon hypotension may be associated with nausea and vomiting. Nausea and vomiting may be present in acute myocardial infarction, especially when located posteriorly or transmurally and in congestive heart failure, may be related to liver congestion. The possibility that these symptoms are due to medicines (e.g. opiates or digital medicines) should always be considered in patients with heart disease.
Nausea and vomiting are common in cancer patients, especially those in the terminal stage. Nausea and vomiting usually accompany several metabolic and endocrine disorders, including uremia, diabetic ketoacidosis, hypo and hyperthyroidism, hyperthyroid crisis and adrenal insufficiency, especially adrenal crisis. Morning sickness in pregnancy is another example of nausea and vomiting likely related to hormonal changes (the term "hyperemesis gravidarium" applies when hydroelectrolytic disorders or nutritional deficiency result).
Side effects of many medicines and chemicals include nausea and vomiting. In some cases, drugs have central emetic effects, such as digitalics, morphine, histamine, phenytoin and some chemotherapy agents. In some cases, drug-induced gastric irritation causes stimulation of the bulbar center of the vomit, such as salicylates, aminophilin, some antibiotics and ipeca. Ingestion of a toxin (e.g. food poisoning) can also cause acute vomiting. Psychogenic vomiting refers to chronic or recurrent vomiting that may result from an emotional or psychological disorder.
Often patients with chronic emotional disorders and vomiting retain a relatively normal state of nutrition, since only a relatively small amount of ingested food is spilled. In some cases, regurgitation predominates over vomiting and the degree of weight loss may be disproportionate to the patient's description of the frequency and severity of vomiting. Anorexia nervosa and bulimia are emotional disorders that can be associated with vomiting and weight loss. Here it would be good to remember about the vomiting and nausea that occur in otherwise healthy people in case of mental shocks (referring to some visual perceptions such as corpses, etc., olfactory such as characteristic "ugly" odors, etc.).
Let's move on to a few presentations on differential diagnosis. Vomiting should be differentiated from regurgitations, which refer to the expulsion of food in the absence of nausea and without diaphragmatic abdominal muscle contraction associated with vomiting. Regurgitation of esophageal contents may occur in the esophageal strictures or esophageal diverticulum. regurgitation of gastric contents generally found in disorders with gastroesophageal reflux due to the incompetence of the lower gastroesophageal sphincter, in spasm or pyloric obstruction due to peptic ulcer or in gastroparesis.
The hiccup is a distinctive sound caused by the contraction of the inspiring muscles, abruptly finished by closing the bullet. Short episodes of hiccups may be caused by gastric distension, sudden change in temperature, ingestion of alcohol, excessive smoking or emotion, while persistent hiccups may signify a serious underlying disease, such as a structural injury or central nervous system infection, diaphragmatic irritation by a tumor or inflammatory process, metabolic disorder vascular lesion, intraabdominal process or systemic infection.
In addition, a number of drugs, including barbiturates and sedatives, general anesthetics and psychogenic factors can lead to hiccups. Rumination is the effortless regurgitation of undigested food, starting a few minutes after eating, probably due to contraction of the abdominal muscles and simultaneous voluntary relaxation of the lower esophagus. It is rare in adults, but more common in patients with bulimia nervosa and in infants, children and people with mental impairments.
The temporal relationship between vomiting and feeding may be of diagnostic utility. Vomiting that occurs predominantly in the morning often occurs in the first months of pregnancy and in uremia. Alcoholic gastritis is also usually accompanied by early morning vomiting and vomiting, so-called dry vomiting. Vomiting that occurs during or shortly after eating suggests psychogenic vomiting or peptic ulcer with pilorospasm. Vomiting that occurs 4 to 6 hours or later after eating and involves the elimination of large amounts of undigested food often indicates gastric retention (e.g. pyloric obstruction, gastroparesis) or certain oesophageal disorders (achalasia, Zenker diverticulum).
Vomiting in the jet or without a history of nausea suggests the possibility of a lesion of the central nervous system. Associated symptoms may also provide diagnostic clues. For example, vertigo and tinnitus indicate the possibility of Meniere syndrome. A long history of vomiting with low or absent weight loss suggests psychogenic vomiting. Relief of abdominal pain with vomiting is characteristic for peptic ulcer. Early satiety is characteristic for gastroparesis. The nature of vomiting also provides clues for diagnosis. If the vomiting contains large amounts of free hydrochloric acid, obstruction of gastric discharge due to an ulcer or a hypersecretory condition as in Zollinger-Ellison syndrome should be considered.
The absence of free hydrochloric acid may indicate gastric malignancy. A fecaloid or putrid odor reflects the result of bacterial action on the intestinal contents and may occur in distal intestinal occlusion, peritonitis or gastrocolic fistula. The ball is usually present in the gastric contents pores whenever vomiting is prolonged (it has no significance outside the constant presence in large quantities, when it can mean an obstructive lesion under Vater's ampula). The presence of blood in the gastric contents usually denotes a bleed from the esophagus, stomach or duodenum.
In the patient approach, every effort should be made to identify the underlying cause of nausea and vomiting. The evaluation should begin with careful anamnesis, including a careful history of the drugs taken, following physical examination and, if necessary, routine laboratory tests, such as a complete haemoleukogram, hematoid sedimentation rate (VSH), electrolyte values, including blood urea and creatinineemia, glucose values and liver function tests.
Additional testing should be dictated by the patient's age and clinical condition, especially when nausea and vomiting are chronic. A pregnancy test should be performed in women of childbearing age. In selected cases, urine tests, cultures, a toxicological test and endocrine function tests (thyroid function tests, morning plasma cortisol) may be indicated. The possibility of an underlying gastrointestinal or hepatobiliary condition can be assessed by routine x-ray and barium, ultrasound, computed tomography (CT) and endoscopy.
If a neurological disease is suspected a TC in the head is indicated. In more than 50% of patients with chronic nausea and vomiting, the basic assessment described above may be irrelevant and, in selected cases, additional specialized testing may be useful, especially if gastrointestinal motility is suspected. A testing device may be considered, including 24-hour esophageal motility and pH testing, studies on the discharge and motility of the small intestine. In patients, a formal psychiatric examination may prove to be revealing.
Effective treatment of nausea and vomiting usually depends on correcting the underlying cause. Antiemetic agents vary in utility, depending on the cause of symptoms, patient responsiveness and the occurrence of side effects. Antihistamines such as dimenhydrate, meclizine and promethazine hydrochloride are effective in controlling nausea and vomiting due to motion sickness and other inner ear disorders may be effective in pregnancy, uremia and postoperative vomiting. They do not act on the trigger chemoreceptor area and are of little value in other causes of vomiting.
Anticholinergics like scopolamine block central muscarinic receptors in the related pathways of the vomit reflex and are also effective in motion sickness. Phenothiazide derivatives such as prochlorperazine and haloperidol, structurally related to butyrofenone, inhibit central dopaminergic receptors and act mainly on the chemoreceptor trigger ing. They are also ineffective in severe nausea and vomiting, can cause sedation, hypotension and Parkinson's effects. Metoclopramide is the prototype of selective dopaminergic antagonists called substituted benzamides and is useful in all types of vomiting except motion sickness and inner ear dysfunction.
In contrast to phenothiasides that have anticholinergic effects, metoclopramide has strong peripheral cholinergic effects that potentiate gastric discharge and may be superior to phenothiazides in the treatment of severe nausea and vomiting and is especially useful in the treatment of gastroparesis. Unfortunately, neurological side effects are common, including drowsiness, dystonic reactions, anxiety, insomnia, depression, parkinsonism, confusion and increased prolactin levels. And the examples of drugs could continue with newer alternative agents but I'm not going to discuss in this blog, in its entirety, the medications...
We'll hear from each other on June 14th when I'm going to deal with indigestion.
Nausea and vomiting can occur independently of each other, but are generally correlated and are assumed to be mediated by the same nerve pathways so that they can be discussed together. Nausea is the sensation of an imminent desire to spill, usually perceived in the throat or epigastrium. Vomiting (or emesis) means the explosive oral, forced removal of gastric contents. The effort to vomit denotes rhythmic contractions of the respiratory and abdominal muscles that often precede or accompany vomiting.
Nausea often precedes or accompanies vomiting. It is usually associated with diminished functional activity of the stomach (e.g. hypotonia, hypoperistaltic and hyposecretion) and altered motility of the small intestine (e.g. hypertonia and inverted peristaltics of the duodenum). Often, accompanying severe nausea, altered vegetative activity (especially parasympathetic) is highlighted, such as skin pallor, increased breathing, hypersalivation, defecation and sometimes hypotension and bradycardia (vasovagal syndrome), anorexia being usually present.
Nausea. the effort to shed and hypersalivation frequently precedes the spill, which is a highly integrated sequence of involuntary somatic and visceral processes. The stomach plays a relatively passive role in the spillage process, the main force of expulsion being provided by the abdominal musculature. With the relaxation of the gastric bottom and gastroesophageal sphincter, a sudden increase in intraabdominal pressure is achieved by strong contraction of the diaphragm and muscles of the abdominal wall. These together with concomitant ring contraction of the gastric pylorus lead to the expulsion of gastric contents into the esophagus. Increased intratoracic pressure leads to the subsequent movement of esophageal contents in the mouth.
Inversion of the normal direction of the esophageal peristalsis may play a role in this process. The reflex lifting of the soft palate during vomiting prevents the entry of the expelled material into the nasopharynx, while reflex closure of the bullet and inhibition of breathing helps prevent pulmonary aspiration. Repeated vomiting can have harmful effects in many ways. The process of vomiting, if strong, can lead to rupture of the esophagus through pressure exerted on it (Boerhaave syndrome) or linear mucous ruptures (Mallory-Weiss) in the region of the cardioesophageal junction, with consecutive hematemesis.
Prolonged vomiting can lead to dehydration, loss of gastric secretions (especially hydrochloric acid), causing metabolic alkalosis with hypokalemia, malnutrition with various deficient states and tooth decay. In states of depression of the central nervous system (e.g. coma), the gastric contents can be sucked into the lungs, with consecutive aspiration pneumonia.
Let's see now, what is the mechanism of vomiting! The act of spilling is under the control of two functionally distinct bulbar centers: the center of the vomit, in the dorsal portion of the lateral reticulated formation and the chemoreceptor trigger area, in the postrema area of the fourth ventricle floor. The center of the vomit controls and integrates the actual act of the emesis. It receives aferential stimuli from the gastrointestinal tract and other parts of the body, from the upper centers of the brain stem and cortical, especially from the labyrinthine apparatus and from the chemoreceptor trigger area.
Individuals vary considerably as the threshold of the vomit centers to different stimuli. Important efferent pathways in vomiting are frenic nerves (towards the diaphragm), spinal nerves (towards the intercostal and abdominal muscles) and visceral efferent fibers of the vagus nerve (towards the larynx, pharynx, esophagus and stomach). The vomit center is located next to other bulbar centers that regulate respiratory, vasomotor and vegetative function and may be involved in the act of vomiting.
The chemoreceptor trigger zone alone is not able to mediate the act of vomiting, rather, the activation of this area causing efferent pulses to the bulbar center of the vomit, which in turn initiates vomiting. The chemoreceptor trigger zone is an emetic chemoreceptor that can be activated by a variety of stimuli or drugs, including apomorphine and other opiates, levodopa (after dopamine decarboxylation), digital, bacterial toxins, radiation and metabolic abnormalities that occur in uremia and hypoxia.
It's the turn of the clinical manifestations... Nausea and vomiting are common manifestations in many organic and functional disorders. the precise mechanisms that trigger vomiting in different clinical conditions are not fully elucidated, making the classification of mechanisms difficult. Many acute abdominal emergencies leading to "acute surgical abdomen" are associated with nausea and vomiting. Vomiting can be found in the inflammation of a visceral, as in acute appendicitis or acute cholecystitis, intestinal occlusion or acute peritonitis.
Other eating tract disorders, including those associated with chronic indigestion, are frequently accompanied by nausea and vomiting. In peptic ulcers, vomiting can be spontaneous or self-inflicted and can lead to relief of symptoms, especially if antral or pyloric edema causes obstruction of gastric discharge.
Nausea and vomiting are also important in patients with gastrointestinal motility disorders, including post-vagotomy, diabetic or idiopathic gastroparesis, other gastric "disrhythms", resulting from abnormal myoelectric activity and intestinal pseudoocclusion due to abnormal myogenous or neurogenic intestinal function. Gastroparesis can be demonstrated by gastric scanning after a radiolabelled lunch or by X-ray after ingestion of non-digestible radioopaque solid markers.
Experimentally it has been shown in some patients with nausea and vomiting, otherwise unexplained, to have accelerated ("tahigastria") or irregular gastric electrical activity ("gastric tachyarrhythmia"), measured by electrodes surgically implanted in the stomach serum or placed on the surface of the abdomen ("electrogastrogram"). Typically, intestinal obstruction of any cause (e.g. adhesions, malignancy, hernia, volvulus) can cause vomiting, as in the case of diseases of the liver, pancreas and bile ducts. nausea and vomiting may accompany distension and pain occurring in aerophagic syndromes.
Infections of the intestinal tract (viral, bacterial and parasitic) are characteristically associated with severe nausea and vomiting, often with diarrhea. Acute systemic infections with fever, especially in young children, are also frequently accompanied by vomiting and often severe diarrhea. the mechanism by which infection away from the gastrointestinal tract produces these manifestations may be related to stimulation of the triggering chemoreceptor area by abnormal toxins or metabolites.
Central nervous system disorders leading to increased intracranial pressure (e.g. neoplasms, encephalitis, hydrocephalus) may be accompanied by vomiting, which are often in the jet (very strong). Vertigo due to disorders of the labyrinthine apparatus, such as acute labyrinthitis and Meniere syndrome, may be accompanied by vomiting with nausea and vomiting effort. Similarly, motion sickness is characteristically associated with anorexia, nausea and vomiting, as well as apathy, increased salivation, cold sweats and headache.
In addition, migraine headache, tabetic seizures, acute meningitis and the reactive phase of synchon hypotension may be associated with nausea and vomiting. Nausea and vomiting may be present in acute myocardial infarction, especially when located posteriorly or transmurally and in congestive heart failure, may be related to liver congestion. The possibility that these symptoms are due to medicines (e.g. opiates or digital medicines) should always be considered in patients with heart disease.
Nausea and vomiting are common in cancer patients, especially those in the terminal stage. Nausea and vomiting usually accompany several metabolic and endocrine disorders, including uremia, diabetic ketoacidosis, hypo and hyperthyroidism, hyperthyroid crisis and adrenal insufficiency, especially adrenal crisis. Morning sickness in pregnancy is another example of nausea and vomiting likely related to hormonal changes (the term "hyperemesis gravidarium" applies when hydroelectrolytic disorders or nutritional deficiency result).
Side effects of many medicines and chemicals include nausea and vomiting. In some cases, drugs have central emetic effects, such as digitalics, morphine, histamine, phenytoin and some chemotherapy agents. In some cases, drug-induced gastric irritation causes stimulation of the bulbar center of the vomit, such as salicylates, aminophilin, some antibiotics and ipeca. Ingestion of a toxin (e.g. food poisoning) can also cause acute vomiting. Psychogenic vomiting refers to chronic or recurrent vomiting that may result from an emotional or psychological disorder.
Often patients with chronic emotional disorders and vomiting retain a relatively normal state of nutrition, since only a relatively small amount of ingested food is spilled. In some cases, regurgitation predominates over vomiting and the degree of weight loss may be disproportionate to the patient's description of the frequency and severity of vomiting. Anorexia nervosa and bulimia are emotional disorders that can be associated with vomiting and weight loss. Here it would be good to remember about the vomiting and nausea that occur in otherwise healthy people in case of mental shocks (referring to some visual perceptions such as corpses, etc., olfactory such as characteristic "ugly" odors, etc.).
Let's move on to a few presentations on differential diagnosis. Vomiting should be differentiated from regurgitations, which refer to the expulsion of food in the absence of nausea and without diaphragmatic abdominal muscle contraction associated with vomiting. Regurgitation of esophageal contents may occur in the esophageal strictures or esophageal diverticulum. regurgitation of gastric contents generally found in disorders with gastroesophageal reflux due to the incompetence of the lower gastroesophageal sphincter, in spasm or pyloric obstruction due to peptic ulcer or in gastroparesis.
The hiccup is a distinctive sound caused by the contraction of the inspiring muscles, abruptly finished by closing the bullet. Short episodes of hiccups may be caused by gastric distension, sudden change in temperature, ingestion of alcohol, excessive smoking or emotion, while persistent hiccups may signify a serious underlying disease, such as a structural injury or central nervous system infection, diaphragmatic irritation by a tumor or inflammatory process, metabolic disorder vascular lesion, intraabdominal process or systemic infection.
In addition, a number of drugs, including barbiturates and sedatives, general anesthetics and psychogenic factors can lead to hiccups. Rumination is the effortless regurgitation of undigested food, starting a few minutes after eating, probably due to contraction of the abdominal muscles and simultaneous voluntary relaxation of the lower esophagus. It is rare in adults, but more common in patients with bulimia nervosa and in infants, children and people with mental impairments.
The temporal relationship between vomiting and feeding may be of diagnostic utility. Vomiting that occurs predominantly in the morning often occurs in the first months of pregnancy and in uremia. Alcoholic gastritis is also usually accompanied by early morning vomiting and vomiting, so-called dry vomiting. Vomiting that occurs during or shortly after eating suggests psychogenic vomiting or peptic ulcer with pilorospasm. Vomiting that occurs 4 to 6 hours or later after eating and involves the elimination of large amounts of undigested food often indicates gastric retention (e.g. pyloric obstruction, gastroparesis) or certain oesophageal disorders (achalasia, Zenker diverticulum).
Vomiting in the jet or without a history of nausea suggests the possibility of a lesion of the central nervous system. Associated symptoms may also provide diagnostic clues. For example, vertigo and tinnitus indicate the possibility of Meniere syndrome. A long history of vomiting with low or absent weight loss suggests psychogenic vomiting. Relief of abdominal pain with vomiting is characteristic for peptic ulcer. Early satiety is characteristic for gastroparesis. The nature of vomiting also provides clues for diagnosis. If the vomiting contains large amounts of free hydrochloric acid, obstruction of gastric discharge due to an ulcer or a hypersecretory condition as in Zollinger-Ellison syndrome should be considered.
The absence of free hydrochloric acid may indicate gastric malignancy. A fecaloid or putrid odor reflects the result of bacterial action on the intestinal contents and may occur in distal intestinal occlusion, peritonitis or gastrocolic fistula. The ball is usually present in the gastric contents pores whenever vomiting is prolonged (it has no significance outside the constant presence in large quantities, when it can mean an obstructive lesion under Vater's ampula). The presence of blood in the gastric contents usually denotes a bleed from the esophagus, stomach or duodenum.
In the patient approach, every effort should be made to identify the underlying cause of nausea and vomiting. The evaluation should begin with careful anamnesis, including a careful history of the drugs taken, following physical examination and, if necessary, routine laboratory tests, such as a complete haemoleukogram, hematoid sedimentation rate (VSH), electrolyte values, including blood urea and creatinineemia, glucose values and liver function tests.
Additional testing should be dictated by the patient's age and clinical condition, especially when nausea and vomiting are chronic. A pregnancy test should be performed in women of childbearing age. In selected cases, urine tests, cultures, a toxicological test and endocrine function tests (thyroid function tests, morning plasma cortisol) may be indicated. The possibility of an underlying gastrointestinal or hepatobiliary condition can be assessed by routine x-ray and barium, ultrasound, computed tomography (CT) and endoscopy.
If a neurological disease is suspected a TC in the head is indicated. In more than 50% of patients with chronic nausea and vomiting, the basic assessment described above may be irrelevant and, in selected cases, additional specialized testing may be useful, especially if gastrointestinal motility is suspected. A testing device may be considered, including 24-hour esophageal motility and pH testing, studies on the discharge and motility of the small intestine. In patients, a formal psychiatric examination may prove to be revealing.
Effective treatment of nausea and vomiting usually depends on correcting the underlying cause. Antiemetic agents vary in utility, depending on the cause of symptoms, patient responsiveness and the occurrence of side effects. Antihistamines such as dimenhydrate, meclizine and promethazine hydrochloride are effective in controlling nausea and vomiting due to motion sickness and other inner ear disorders may be effective in pregnancy, uremia and postoperative vomiting. They do not act on the trigger chemoreceptor area and are of little value in other causes of vomiting.
Anticholinergics like scopolamine block central muscarinic receptors in the related pathways of the vomit reflex and are also effective in motion sickness. Phenothiazide derivatives such as prochlorperazine and haloperidol, structurally related to butyrofenone, inhibit central dopaminergic receptors and act mainly on the chemoreceptor trigger ing. They are also ineffective in severe nausea and vomiting, can cause sedation, hypotension and Parkinson's effects. Metoclopramide is the prototype of selective dopaminergic antagonists called substituted benzamides and is useful in all types of vomiting except motion sickness and inner ear dysfunction.
In contrast to phenothiasides that have anticholinergic effects, metoclopramide has strong peripheral cholinergic effects that potentiate gastric discharge and may be superior to phenothiazides in the treatment of severe nausea and vomiting and is especially useful in the treatment of gastroparesis. Unfortunately, neurological side effects are common, including drowsiness, dystonic reactions, anxiety, insomnia, depression, parkinsonism, confusion and increased prolactin levels. And the examples of drugs could continue with newer alternative agents but I'm not going to discuss in this blog, in its entirety, the medications...
We'll hear from each other on June 14th when I'm going to deal with indigestion.
Let us hear only good and
live in understanding for love and gratitude!
Dorin, Merticaru