Approach to the adult with nausea and vomiting
- George F Longstreth, MD
George F Longstreth, MD
- Voluntary Clinical Professor of Medicine
- University of California San Diego School of Medicine
Nausea, the unpleasant sensation of being about to vomit, can occur alone or can accompany vomiting (the forceful expulsion of gastric contents), dyspepsia, or other gastrointestinal symptoms. Retching differs from vomiting in the absence of expulsion of gastric content. In addition, patients may confuse vomiting with regurgitation, which is the return of esophageal contents to the hypopharynx with little effort . (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults".)
The recommendations made in this topic are generally consistent with the American Gastroenterological Association (AGA) guidelines for nausea and vomiting . The pathophysiology of nausea and vomiting and the overall approach to the patient with these symptoms will be reviewed here. The prevention and treatment of chemotherapy-induced nausea and vomiting and characteristics of antiemetic drugs are discussed separately. (See "Prevention and treatment of chemotherapy-induced nausea and vomiting in adults" and "Characteristics of antiemetic drugs".)
Normal function of the upper gastrointestinal tract involves an interaction between the gut and the central nervous system. The motor function of the gut is controlled at three main levels: the parasympathetic and sympathetic nervous systems; enteric brain neurons; and smooth muscle cells. A discussion of the anatomy and physiology of gastric motor function is discussed separately. (See "Pathogenesis of delayed gastric emptying".)
Nausea — Studies that produce motion sickness in humans indicate how some of the physiologic interactions can cause nausea [3,4]. In one report, for example, gastric myoelectrical activity and endogenous neuroendocrine responses were compared in subjects with and without motion sickness elicited by vection (induced by rotating a drum with black and white vertical stripes around seated stationary subjects) . Thirteen subjects developed tachygastria (an increase in gastric slow wave rhythm) and motion sickness during vection, while nine maintained normal gastric rhythms and remained symptom-free. Nausea followed within minutes of and was proportional to the degree of tachygastria. Anticipatory increases in plasma cortisol and beta endorphin occurred in subjects who developed nausea and gastric tachyarrhythmias; endogenous epinephrine and norepinephrine concentrations were also increased in these subjects.
Vomiting — Vomiting is a reflex that allows an animal or person to rid itself of ingested toxins or poisons. It can be activated by humoral or neuronal stimuli, or both . Multiple afferent and efferent pathways exist which induce vomiting; the following are the major components of these pathways:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Hasler WL, Chey WD. Nausea and vomiting. Gastroenterology 2003; 125:1860.
- American Gastroenterological Association. American Gastroenterological Association medical position statement: nausea and vomiting. Gastroenterology 2001; 120:261.
- Koch KL, Stern RM, Vasey MW, et al. Neuroendocrine and gastric myoelectrical responses to illusory self-motion in humans. Am J Physiol 1990; 258:E304.
- Xu LH, Koch KL, Summy-Long J, et al. Hypothalamic and gastric myoelectrical responses during vection-induced nausea in healthy Chinese subjects. Am J Physiol 1993; 265:E578.
- Carpenter DO. Neural mechanisms of emesis. Can J Physiol Pharmacol 1990; 68:230.
- Hornby PJ. Central neurocircuitry associated with emesis. Am J Med 2001; 111 Suppl 8A:106S.
- Bashashati M, McCallum RW. Neurochemical mechanisms and pharmacologic strategies in managing nausea and vomiting related to cyclic vomiting syndrome and other gastrointestinal disorders. Eur J Pharmacol 2014; 722:79.
- Lang IM, Sarna SK, Dodds WJ. Pharyngeal, esophageal, and proximal gastric responses associated with vomiting. Am J Physiol 1993; 265:G963.
- Metz A, Hebbard G. Nausea and vomiting in adults--a diagnostic approach. Aust Fam Physician 2007; 36:688.
- Scorza K, Williams A, Phillips JD, Shaw J. Evaluation of nausea and vomiting. Am Fam Physician 2007; 76:76.
- Brzana RJ, Koch KL. Gastroesophageal reflux disease presenting with intractable nausea. Ann Intern Med 1997; 126:704.
- Herrell HE. Nausea and vomiting of pregnancy. Am Fam Physician 2014; 89:965.
- Carney CP, Andersen AE. Eating disorders. Guide to medical evaluation and complications. Psychiatr Clin North Am 1996; 19:657.
- Harrington BC, Jimerson M, Haxton C, Jimerson DC. Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. Am Fam Physician 2015; 91:46.
- Tack J, Talley NJ, Camilleri M, et al. Functional gastrointestinal disorders. In: Rome III, The Functional Gastrointestinal Disorders, 3rd ed, Drossman DA, et al (Eds), Degnon Associates, McLean, VA 2006.
- Moffet HL. Common infections in ambulatory patients. Ann Intern Med 1978; 89:743.
- Carmeli Y, Samore M, Shoshany O, et al. Utility of clinical symptoms versus laboratory tests for evaluation of acute gastroenteritis. Dig Dis Sci 1996; 41:1749.
- Skolnik A, Gan TJ. Update on the management of postoperative nausea and vomiting. Curr Opin Anaesthesiol 2014; 27:605.
- Sullivan S. Cannabinoid hyperemesis. Can J Gastroenterol 2010; 24:284.
- Soriano-Co M, Batke M, Cappell MS. The cannabis hyperemesis syndrome characterized by persistent nausea and vomiting, abdominal pain, and compulsive bathing associated with chronic marijuana use: a report of eight cases in the United States. Dig Dis Sci 2010; 55:3113.
- Choung RS, Locke GR 3rd, Lee RM, et al. Cyclic vomiting syndrome and functional vomiting in adults: association with cannabinoid use in males. Neurogastroenterol Motil 2012; 24:20.
- Stanghellini V, Chan FK, Hasler WL, et al. Gastroduodenal Disorders. Gastroenterology 2016; 150:1380.
- Parkman HP, Hasler WL, Barnett JL, et al. Electrogastrography: a document prepared by the gastric section of the American Motility Society Clinical GI Motility Testing Task Force. Neurogastroenterol Motil 2003; 15:89.
- Cherian PT, Cherian S, Singh P. Long-term follow-up of patients with gastric outlet obstruction related to peptic ulcer disease treated with endoscopic balloon dilatation and drug therapy. Gastrointest Endosc 2007; 66:491.
- Hejazi RA, McCallum RW. Review article: cyclic vomiting syndrome in adults--rediscovering and redefining an old entity. Aliment Pharmacol Ther 2011; 34:263.
- Egerton-Warburton D, Meek R, Mee MJ, Braitberg G. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo. Ann Emerg Med 2014; 64:526.
- Furyk JS, Meek R, McKenzie S. Drug treatment of adults with nausea and vomiting in primary care. BMJ 2014; 349:g4714.
- Tura P, Erdur B, Aydin B, et al. Slow infusion metoclopramide does not affect the improvement rate of nausea while reducing akathisia and sedation incidence. Emerg Med J 2012; 29:108.
- Maganti K, Onyemere K, Jones MP. Oral erythromycin and symptomatic relief of gastroparesis: a systematic review. Am J Gastroenterol 2003; 98:259.
- Olden KW, Chepyala P. Functional nausea and vomiting. Nat Clin Pract Gastroenterol Hepatol 2008; 5:202.
- Jones MP, Maganti K. A systematic review of surgical therapy for gastroparesis. Am J Gastroenterol 2003; 98:2122.
- APPROACH TO MANAGEMENT
- History and physical examination
- DIFFERENTIAL DIAGNOSIS
- SPECIFIC DISORDERS
- Acute disorders
- - Acute gastroenteritis
- - Postoperative nausea and vomiting
- - Vestibular neuritis
- - Patients receiving chemotherapy
- - Drugs
- Chronic disorders
- - Nausea and vomiting of pregnancy
- - Chronic nausea vomiting syndrome
- - Gastroparesis
- - Gastroesophageal reflux
- - Gastric outlet obstruction
- - Eosinophilic gastroenteritis
- - Cyclic vomiting syndrome
- - Chronic idiopathic intestinal pseudo-obstruction
- - Rumination syndrome
- Drug therapy
- - Antiemetics and prokinetics
- - Antidepressants
- Gastric electrical stimulation
- Surgical therapy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS