Worshipping at the Porcelain Altar: Nausea and Vomiting

Transcription

1 Worshipping at the Porcelain Altar: Nausea and Vomiting EDUARDO GODOY, MD FAMILY MEDICINE, SOUTH BAY MEDICAL CENTER TORRANCE MOB Financial Disclosures: I have no financial ties other than those owed: to my bank as I continue to pay back my Medical School loans to Amazon in support of my wife s substance use disorder which requires regular nonprescription use of purses, shoes and various other accessories. Generic medication names are used, however, if brand names are mentioned it is not to state preference for the brand but due to common use and familiarity of the brand name in daily practice. Outline Term Definition Anatomy Physiology Etiology Differential Diagnoses Sequelae of Vomiting Medications Cases 1

2 Definitions NAUSEA: the unpleasant sensation of being about to vomit, can occur alone or can accompany vomiting VOMITING: the forceful expulsion of gastric contents REMEMBER, vomiting is an adaptive response to eliminate gastric contents that may be toxic. RETCHING: Muscular abdominal contraction in the absence of expulsion of gastric content. REGURGITATION: the return of esophageal contents to the hypopharynx with little effort Vomiting Efferent signaling Muscular contractions involved in emesis 2

3 Nausea/Vomiting Triggers Nausea/Vomiting Triggers Pain, Repulsive sights, smells, anxiety triggers from higher centers stimulate Vomiting Center directly Motion inner ear vestibular nucleus stimulate Vomiting Center directly Toxins in gut lumen: stimulate Enterochromaffin Cells 5HT3 (Serotonin) Gut Mucosal Cell 5HT3 receptors stimulate Vagus stimulate CTZ (Chemoreceptor Trigger Zone) trigger Vomiting Center Systemic Toxins stimulate CTZ directly (outside blood brain barrier) CTZ: reacts to Dopamine, histamine, toxins, Serotonin, Substance P, Acetylcholine Pharyngeal Stimulation, Duodenal/Gastric distension/irritation NTS (Nucleus Tractus Solitarius) and CTZ stimulate Vomiting Center Evaluation of Vomiting History: Duration, frequency Fevers Pain location, periodicity Association with food Recent ingestions medication, illicit substances, EtOH, supplements LMP Physical Exam: Vitals: BP, HR, Temp, prior and current weight Oral Mucosa, tenting of skin Abdominal exam: Tenderness, Distension Labs: Electrolytes, Creatinine CBC, UA, Urine tox, Ur hcg, bedside glucose testing 3

4 What is happening with your patient? Acute (hours to days) vs Chronic (more than a week) If acute rule out life threatening conditions: bowel obstruction mesenteric ischemia acute pancreatitis myocardial infarction Evaluate for consequences or complications of nausea and vomiting - Hypovolemia - Hypokalemia - Metabolic alkalosis Consider therapy based on above for definitive treatment as well as relief of symptoms Alarm Signs Age >55 Abdominal Pain Unintended Weight loss Progressive Dysphagia Persistent Vomiting Evidence of GI bleeding Family Hx Gastrointestinal Ca Altered Mental status Feculent Vomiting Melena Hematochezia Focal Neurological Deficit GI causes Differential Diagnoses Common Uncommon More Uncommon Appendicitis Adhesions Mesenteric Ischemia Cholecystitis Gastritis GERD Gastroparesis IBS Peptic Ulcer Disease Esophageal Motility Disorders Incarcerated Hernia Intestinal Obstruction Pancreatitis Peritonitis 4

5 Metabolic Differential Diagnoses Common Uncommon DKA Pregnancy (usually <9W) Uremia Adrenal Disorders Parathyroid Disorders Thyroid Disorders Other Causes Psychiatric Disorders Miscellaneous Cyclic Vomiting Syndrome Acute Glaucoma Functional Emesis Acute MI Anxiety Nephrolithiasis Eating Disorder Pain Rumination Syndrome Sequelae of Vomiting Dehydration Dry mucosa, elevated HR, drop in BP, elevated Urine SG Urine SG low consider DKA Acid Base disturbances look to urine dip for clues With metabolic alkalosis - Ur ph >6.5 initially, then after 3-4 days, Ur ph <5.5 as more Na and HC03 is resorbed With metabolic acidosis Ur ph <5.5 Alkalosis and acidosis often leads to cyclic nausea/vomiting Glycosuria and Urine Ketones consider DKA, confirm with Random glucose testing Hypokalemia and Ketoacidosis: Hypokalemia as K is excreted in exchange for resorbed Na Serum CO2 reduced and anion gap elevates. Hematemesis: Mallory Weiss Tear Gastric bleed from PUD, Gastric ulcer 5

6 Antiserotonergic Antiemetics Serotonin (5-HT 3 ) receptor blockers: block mucosal receptors, Vagal receptors, CTZ and NTS receptors Ondansentron (Zofran) crosses the blood brain barrier slowly, acts mostly peripherally; pregnancy category B, no effect on motion sickness (not on BEERS list at all) Mirtazapine (Remeron) - also a strong Histamine receptor antagonist; good for anxiety, insomnia (on BEERS list to be used with caution), pregnancy category C Ginger - peripherally acting, in dose of up to 6 grams/day with no daily doses up to 6 g ginger seems to be a drug with few side effects; safe in pregnancy Antidopaminergic Antiemetics D2 (Dopamine) receptor blockers in CTZ and NTS; often triggered by neoplastic disease, radiation sickness, opioids, cytotoxic drugs Droperidol (Inapsine), Haloperidol (Haldol), Trimethobenzamide (Tigan), Chlorpromazine (Thorazine), Prochlorperazine (Compazine), all are pregnancy category C except for Metoclopramide***(Reglan) ALL on BEERS list as medications to be avoided; Dopamine antagonist use is limited due to sedative and extra pyramidal side effects; all cross BBB ***Metoclopramide (Reglan) is also a 5HT3 receptor antagonist and also has pro-kinetic effects; useful for gastroparesis; pregnancy category B Antihistamine Antiemetics H1 (Histamine) blockers: cause of nausea/emesis from triggering receptors in CTZ and NTS, also helps with nausea from higher centers (motion sickness), opioid nausea: Diphenhydramine (Benadryl), Mirtazapine (Remeron), Meclizine (Antivert), Promethazine (Phenergan), Hydroxyzine (Vistaril) All on BEERS list to avoid in the elderly except Mirtazapine which is generally considered safe but is a potentially inappropriate medication to be used with caution in older adults; may cause SIADH and hyponatremia. All Pregnancy Category C except Meclizine Category B Doxylamine (Unisom)*** 25 mg QHS safe in pregnancy, not on BEERS list. Pyridoxine (vitamin B6)*** not an antihistamine; 25 mg TID safe in pregnancy *** only medications specifically labelled by US FDA for treatment of nausea and vomiting of pregnancy Category A 6

7 Antiemetics Ach (Acetylcholine) blockers (Anticholinergics): direct action on the VC or CTZ useful for motion sickness; Scopolamine, easily crosses the blood brain barrier - can cause dry mouth, balance, sedation, urticaria, constipation, hallucination, urinary retention, confusion; on BEERS list - avoid in the elderly; Pregnancy Category C Watch for antihcholinergic effects such as constipation, dry mouth, dyshydrosis (inability to sweat), sedation Antiemetics Chamomile, Peppermint teas, mechanism unknown, avoid Peppermint in patients with GERD or gastritis Emetrol Glucose/Fructose/Phosphoric acid mechanism unknown; contraindicated in diabetics Cannabinoids used in pts unresponsive to other agents: may cause changes in perception, dizziness, anxiety and loss of coordination; can result in Cannabinoid Hyperemesis Syndrome: condition is associated with compulsive bathing behavior, chronic cannabis use, seen with other psychiatric co-morbidities such as anxiety/depression Case #1 Urgent Care no labs available 45 y.o. male with T2 diabetes - crampy abdominal pain, emesis since dinner last night. Emesis is hourly, not keeping anything down BP: 100/70, HR120, T: 98.6 RBS: 300 U dip: SG 1.007, Nit -, LE -, Ket ++ What to do now? IV NS 1 L bolus, Insulin 10 units Ondansetron SL Labs? BMP, CBC, Mg++, Cr, LFT; What will results likely be? To ER for likely DKA 7

8 Case #2 Same Day Clinic 18 y.o. female with emesis for the past week. BP: 120/80, HR 80, T: 98.6 No abdominal pain Emesis after movement, when has to go to school or when has to talk to parents/teachers Labs:? UA: SG: 1.013, Nit neg, LE neg, Hgb neg, U HCG -, Utox DDx:? - Bulemia, CVS, Anxiety, substance abuse, pregnancy, BPPV Case #3 Same Day clinic 31 year-old woman with T1 DM on insulin pump since the age 2, hypothyroidism, diabetic peripheral neuropathy with intractable nausea and vomiting for 2 weeks Skin and oral mucosa dry, Minimal generalized abdominal tenderness, craving salt. Vitals: BP 90/50, HR 120 T: 98.6 Hgb: 18.1 WBC: 7.7 /liver function test/tsh WNL RBS: 220 UA: SG: 1.013, LE neg, Nit neg, Ket neg, Lactic Acid 2.2 BNP: Na 129, K:5.2 What one lab would be most useful? AM Cortisol will give you the answer: <0.01 Addison s Disease autoimmune disease causing Adrenal insufficiency Case #4 Urgent Care Obese 25 y.o. G2P1, 15 weeks G.A. Nausea and vomiting daily x 2 weeks, can tolerate food in small sips Epigastric Pain after eating, emesis worse after meals HR: 110, BP: 130/85, T: 98.6 UA: SG: 1.015, Nit -, LE-, Bili + RUQ TTP Labs: Alk P, ALT, AST, T Bili all elevated, CBC WNL, Diff Dx:? Hyperemesis Gravidarum, Cholecystitis, Tx: Ondansetron, fluids, ultz, 8

9 Case #5 Same Day Clinic 25 y.o. male with daily emesis x 1 month, hx anxiety, depression, in ER 3 x this month for same complaint, found to have normal Cr, low K, all other labs normal. Today with dry oral mucosa, mild headache, vomiting in exam room HR: 120, BP:110/80, T: 98.6 Labs: CBC, LFT WNL, Na 135 K: 3.3 RBS: 160 Ur: SG: 1.025, Nit neg, LE neg What next? U TOX: Admits to drinking heavily, smoking MJ daily x 6 mo since dad died Cannabis Hyperemesis Syndrome Mini Cases 1: What is best antiemetic for Elderly with Insomnia and anxiety-related nausea? Remeron What is best antiemetic for 35 y.o. who will be taking an Ocean Trip? What should they watch out for with this medication Scopolamine; Constipation, avoiding heat and excessive alcohol, What is best antiemetic for a 22 y.o. at 9 weeks G.A. with mild morning sickness? Vit B6, Doxylamine, Ginger, Emetrol Mini Cases 2: What would you use for a chemo patient in whom Nausea is no longer controlled with Ondansetron (Cisplatin 1 week ago)? Metoclopramide (Reglan) Centrally acting, prokinetic, Dopamine antagonist What would be the best option for managing vertigo and nausea in elderly? Doxylamine (Unisom) 9

10 Thank You!!! 10