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Nausea and vomiting

Nausea and vomiting are complex processes involving the cerebral cortex, vestibular nuclei, and the chemoreceptor trigger zone (CTZ). Various factors such as gastric atony, retroperistalsis, and muscle contractions contribute to these symptoms. Management requires identifying reversible causes, like gastrointestinal irritants or hypercalcemia, and selecting appropriate antiemetics. Treatments may include prokinetic agents like Metoclopramide or antispasmodics such as Buscopan. Non-drug therapies and dose adjustments based on patient needs are essential for effective symptom control.

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Nausea and vomiting

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  1. Nausea and vomiting

  2. Cerebral cortex Vestibularnuclei CTZ GABA 5HT ACh H1 5HT3 D2 Gut wall Vagal/splanchnic afferents • Gastric atony • Retroperistalsis • Thoracic and abdominal muscle contractions Vomiting centre 5HT3 ACh H1 5HT2

  3. Movement/vertigo Vestibularnuclei CTZ • Gastric atony • Retroperistalsis • Thoracic and abdominal muscle contractions Vomiting centre

  4. Hyponatraemia Fear/anxiety Raised ICP Vestibularnuclei CTZ • Gastric atony • Retroperistalsis • Thoracic and abdominal muscle contractions Vomiting centre

  5. HypercalcaemiaUraemia Morphine Cytotoxic chemotherapy Vestibularnuclei CTZ • Gastric atony • Retroperistalsis • Thoracic and abdominal muscle contractions Vomiting centre

  6. Vestibularnuclei CTZ IntestinalDistension Cytotoxic chemotherapy Vomiting centre • Gastric atony • Retroperistalsis • Thoracic and abdominal muscle contractions Abdominal RXT Gastric irritants

  7. Case studies • Pick the most appropriate antiemetic in each case

  8. Management • Treat reversible causes • Remember unrelated causes e.g gastroenteritis • Choose the most appropriate antiemetic for the cause • Prescribe the same antiemetic regularly and prn • If oral absorption in doubt, use sc route • Remember non-drug treatments • Consider dexamethasone • REVIEW

  9. Common anti-emetics • Prokinetic for gastricstasis, functional bowel obstruction Metoclopramide 10mg tds or 30-60mg/24hr CSCI • Acting on CTZ trigger zone for chemical causes of vomiting eg morphine, renal failure Haloperidol 1.5-3mg stat/nocte or 2.5-5mg sc stat and 2.5-10mg/24hr CSCI

  10. Common anti-emetics • Antispasmodic and antisecretory if bowel colic and/or need to reduce GI secretions Buscopan 20mg stat 60 – 120mg/24hr CSCI • Acting in the Vomiting Centre for raised ICP, motion sickness or mechanical bowel obstruction Cyclizine 50mg tds 150mg/24hr CSCI • Broad-spectrum for mechanical obstruction, or if others fail Levomepromazine 6-12.5mg nocte

  11. Nausea and Vomiting • Bentley A, Boyd K. Palliative Medicine 2001;15:247-53.

  12. Summary • Try to establish the cause and choose an appropriate antiemetic, rather than picking your favourite • Avoid combinations that may antagonise each other • Choose an appropriate route

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