The diagnosis of nausea and vomiting is obvious. Both symptoms are often present together, but there nausea without vomiting without nausea and vomiting. The difficulty is the etiologic diagnosis.
The characteristics of vomiting is to be specified by the examination or inspection; they can order food, watery, bilious, fécaloïde or hemorrhagic. Vomiting may cause significant fluid and electrolyte disorders. The risk is that of gastrointestinal bleeding that can induce (Mallory-Weiss syndrome). There is not always a relationship between the apparent abundance vomiting and their impact. We must check the status of patient’s clinical hydration, serum electrolytes, creatinine and hematocrit.
Before a hypochloremic alkalosis, with or without hypokalemia, think liability vomiting possibly underestimated.
If nausea and vomiting occur in very different situations, a nauseous state can have the same meaning as etiological profuse vomiting. Nausea and vomiting can be acute or chronic, dominate the clinical picture, or be a symptom expected of a pathology or treatment.
The orientation is different depending on whether the symptom is acute or chronic.
NAUSEA AND VOMITING ACUTE:
The causes are numerous, and sometimes difficult to diagnose. The treatment may be urgent.
The indigestion is easily recognized before the chronology of events and the relief brought by vomiting.
Acute vomiting may occur in the context of abdominal pain within the biliary pathology biliary colic, acute cholecystitis, acute pancreatitis.
We must also think about viral hepatitis, particularly in préictérique phase.
Occlusions (cessation of materials and gas, abdominal pain, fluid levels) are the leading cause of digestive surgical acute vomiting.
The surgical hospital care is needed urgently. The electrolyte rebalancing is essential. The mesenteric infarction and acute peritonitis are also surgical emergencies.
We must first think of acute meningitis and subarachnoid hemorrhage. Vomiting is so easy, “jet”, accompanied of other signs of meningeal irritation. Nausea is inconstant.
The hospitalization, lumbar puncture and treatment are urgent.
The cerebral hemorrhage can also cause vomiting.
True vertigo and motion sickness is usually accompanied by nausea and vomiting.
Migraine can be accompanied by nausea and vomiting.
Among endocrine causes include diabetic ketoacidosis (interest dextro and dipstick), acute adrenal insufficiency and significant hypercalcemia (interest of the chemistry panel and serum calcium).
Other causes are multiple, note, however, among them:
– Renal colic;
– Myocardial infarction (in particular lower);
– Acute glaucoma (see Chapters eye pain and visual acuity Decrease).
Acute inaugural psychogenic vomiting are rare.
NAUSEA AND VOMITING CHRONIC:
The symptoms persist for more than 48 hours. They can be regular or even daily. The problem is not so urgent that the etiologic diagnosis, the causes can be organic or psychogenic.
More than the hiatus hernia and gastroesophageal reflux, should be mentioned here hyposthenic dyspepsia,also called motor type dyspepsia. The postprandial abdominal discomfort results in bloating, belching, nausea, but rarely by vomiting.
The endoluminal gastrointestinal tumors can be accompanied by nausea, and secondarily, in the event of stenosis or occlusion, vomiting. These include gastric cancer, gastric lymphoma and colon tumors (faecal vomiting).
The extraluminal tumors are also responsible for the symptoms. This is often a large tumor clinically detectable.
Finally, include chronic pancreatitis, especially in case of false cysts, slimes and morning of the alcoholic.
Neurological causes, general diseases:
The intracranial pressure (usually through brain tumors) typically causes sudden vomiting, easy, “jet”.
Autonomic nervous system can cause nausea and vomiting in the context of the autonomous gastroparesis Diabetes: long silent, symptoms occur at the stage of gastroplégie. Also include Shy Drager syndrome and amyloidosis.
The digestive involvement of scleroderma (stomach and proximal small) sometimes causes vomiting.
Finally some rare diseases (neuropathies and myopathies family visceral visceral) can cause nausea and vomiting.
Endocrine and obstetric causes:
Endocrine causes are rarely involved in the chronic nausea and vomiting.
These include chronic hypercalcemia and hyperthyroidism.
It has been implicated in vomit the first trimester of pregnancy.
Formerly classified as psychogenic vomiting appear to be associated with a subclinical hyperthyroidism. The biochemical relationship between gonadotropin (hCG) and thyroid stimulating hormone (TSH) is in question, with an inverse relationship between hCG and hCG between HRT and direct and vomiting. Other factors play, but vomiting disappear with the physiological decline in hCG.
Acute fatty liver of the 3rd trimester of pregnancy may be accompanied by nausea and vomiting with abdominal pain are the telltale clinical signs.
The same symptoms are observed during the HELLP syndrome, which requires a very active obstetric attitude.
In emotional subjects, even minimal stress causes vomiting. Volunteers and Hidden vomiting are observed in bulimia and anorexia nervosa with vomiting.
NAUSEA AND VOMITING ASSOCIATED WITH THERAPEUTIC:
Expected Side effects:
Chemotherapies are an obvious cause.
The most formidable anticancer classes are:
– Intercalating agents and especially anthracyclines adriamycin, idarubicin and camptothecin;
– Alkylating agent: salts of platinum, nitrogen mustards, especially cyclophosphamide, carbazines;
– Antimetabolites: gemcitabine, fluorouracil;
– Taxanes: paclitaxel above;
– Anti-cancer monoclonal antibody (alentuzumab) or imatanib.
In all these cases, dose adjustment, and now the treatment setrons have significantly improved tolerance.
Conventional side effects:
Radiation therapy, whether abdominal, chest or neck, may cause nausea and vomiting.
For the record, postoperative vomiting associated with surgery and anesthetic drugs (analgesics and hypnotics).
Nausea and vomiting are common after taking antibiotics. Among the beta-lactams include oxacillin, amoxicillin, amoxicillin-clavulanic acid, the 3rd generation cephalosporins. Are also responsible macrolides, fusidic acid, teicoplanin, norfloxacin, metronidazole and cyclins.
TB except pyrazinamide, are rarely responsible for nausea or vomiting.
This list is not exhaustive.
The HIV treatments often result in digestive disorders, poor adherence source. These include zidovudine, nevirapine, enfuvirtide, efavirenz, or zalcitabine DDC, lamivudine, didanosine, tenofovir, and all protease inhibitors (stavudine and ritonavir, especially when it is used at full dose, no partner lopinavir).
Less classical emetic drugs:
Antiviral drugs are not targeting HIV have proven cause of nausea and vomiting.
The interferon a and ribavirin especially used in hepatitis C have been implicated.
It is the same for neuraminidase inhibitors used in influenza (oseltamivir).
Among antimalarials include especially chloroquine (nausea) and mefloquine (vomiting).
More rarely, was incriminated the amiodaquine-derivatives wormwood association.
In antiplatelet agents, it should think about the vomiting warning for lactic acidosis if excessive intake of aspirin (especially in children) and when taking ticlopidine (risk of thrombotic thrombocytopenic purpura).
The anti-infl ammatory nonsteroidal (classical or coxibs) cause according to a 2003 study just over 10% of nausea and vomiting.
Bisphosphonates (zoledronic acid, etidronic, especially alendronic and risedronic) can cause nausea, diarrhea and vomiting.
Inhibitors of angiotensin converting enzyme can give vomiting and diarrhea, up to 20% of cases in some series.These symptoms majorem much the risk of kidney failure.
Psychotropic drugs are a major cause of nausea and vomiting.
Among the antiepileptic include oxcarbazepine and carbamazepine.
Among antiparkinsonians, we think of pergolide, derivatives of ergot and treatment by transdermal nicotine test.
The drugs used in Alzheimer’s disease donepezil, rivastigmine or galantine
– Can all give anorexia, vomiting and weight loss. This effect is noted even in 90% of cases, at least in its minor or moderate events.
Nausea and vomiting are the most common side effect reported when taking inhibitors of serotonin reuptake(especially fluvoxamine).
Metformin often causes abdominal discomfort and diarrhea or vomiting, especially early in treatment.
Thyroid hormones self-administered sometimes give willingly febrile vomiting. The méfipristone causes nausea or vomiting in 10% of cases.
Antimitotic and immunosuppressive drugs used in the treatment of autoimmune diseases in low doses can cause nausea and vomiting: especially mycophenolate mofetil, azathioprine, and cyclosporine fluorouracil.
Calcium intake per os, an excessive content of water in copper drink (more than 5 mg / L, rarely reaches threshold) and the zinc salts used in dermatology are due to nausea or vomiting.
Treatment should be of etiologic First, the cause is medical or surgical. Stopping a well tolerated treatment does often enough: the list of responsible drugs is immense and sometimes conceals unexpected and unknown perpetrators.
Conventional symptomatic treatments act on the central causes symptoms u effector organs (stomach and digestive motility).
Table I shows the major molecules used and their dosage.
The domperidone (Motilium®) family butyrophenones has a neighbor effect.
The metopimazine (Vogalène®), phenothiazine derivative, has more neuroleptic and anticholinergic action low.
Cisapride (Prepulsid®) must not be used (risk of heart rhythm disturbances).
Metoclopramide, metopimazine and alizapride be used orally and parenterally. They are the most prescribed medications.
If resistance can be used chlorpromazine (Largactil®) drops at a dose of V to XV drops. It acts on the central component with an excellent result.
Postoperative vomiting are treated with drugs listed above but also by setrons.
The setrons are particularly useful in vomiting associated with chemotherapy: ondansetron (Zophren®), granisetron (Kytril®), dolasetron (Anzemet®), tropisetron (Navoban®).
Corticosteroid therapy is also used when it is not an integral part of the chemotherapy regimen.
The aprepitant (EMEND®) is an antagonist of NK1 receptors of substance P used in oncology in postchimiothérapie vomiting.
Motion sickness is typically treated with antihistamines (diphenhydramine (Nautamine®) or dimenhydrinate (Mercalm®) with significant risk of side effects (sleepiness, atropine effects). The transdermal scopolamine(Scopoderm TTS®) is a good alternative, especially in pregnant women.
Finally, psychogenic vomiting are treated by a reinsurance psychotherapy, even small doses of chlorpromazine.