Articles

Nausea and Vomiting

Introduction

What Should I Know About Nausea and Vomiting?

Nausea and vomiting are common complaints seen in a variety of settings. The cause may be associated with something as simple as spinning too fast on an amusement park ride. It could also be the result of a medication or the symptom of something much more serious. Nausea and vomiting may occur independently, but generally they come hand in hand and are thought to be controlled by the same neural pathway which makes it easier to discuss them together. Nausea, of course, means the imminent desire to vomit, a general feeling of queasiness. Vomiting (or emesis) refers to the forceful oral expulsion of gastric, or stomach, contents. Retching denotes the labored rhythmic contraction of the chest and abdominal muscles that usually comes before or accompanies vomiting. (1)

Nausea usually precedes vomiting and is associated with a halt in the work that the stomach would normally be doing at that time related to the digestive processes. The activity of the small intestine is also altered. As if that were not bad enough, nausea can be accompanied by other distressing occurrences with the lower intestines as well. The act of vomiting requires the coordinated efforts of several muscles all at the same time. (2) The stomach itself plays a relatively passive role in vomiting, with the major force being provided by the abdominal muscles. There are two very different medullary centers that are actually responsible for the act of vomiting. Those centers are the chemoreceptor trigger zone, and the vomiting center. The vomiting center is located close to other medullary centers, which regulate respiration, vasomotor, and other functions that may play a role in vomiting. It is the vomiting center that actually controls the act of vomiting. It receives messages from the gastrointestinal tract and other parts of the body. (3) When excited, impulses are integrated by the vomiting center, resulting in messages to the salivation center, respiratory center, and the pharyngeal, GI, and abdominal muscles, leading to vomiting. (4)

The chemoreceptor trigger zone by itself cannot start the act of vomiting. The chemoreceptor trigger zone is usually associated with chemically induced vomiting, and can be activated by a number of different drugs, as well as other stimuli such as bacterial toxins and radiation. Similarly, the vomiting associated with pregnancy is probably initiated through the chemoreceptor trigger zone. Vomiting should be distinguished from regurgitation, which refers to the expulsion of food in the absence of nausea, and without the abdominal muscular contractions associated with vomiting.

Nausea and vomiting are associated with many organic and functional disorders. Many acute abdominal emergencies such as acute appendicitis, acute cholecystitis, intestinal obstruction, or peritonitis may be associated with nausea and vomiting, as well as other disorders of the alimentary tract. Viral, bacterial, and parasitic infections of the GI tract are typically associated with severe nausea and vomiting.

One of the most common causes of vomiting in children is viral gastroenteritis caused by rotavirus. Vomiting in infants may be associated with something as simple as overfeeding, too rapid feeding, inadequate burping, or lying down too soon after feeding. Vomiting in a newborn on the first day of life may suggest upper digestive tract obstruction or increase in intracranial pressure.

Another type of nausea called anticipatory nausea and vomiting may be caused either by specific stimuli associated with the administration of noxious agents or by the anxiety associated with the related treatments. Many patients demonstrate both types. The most often accepted theory for this pattern of conditioning is that by repeated pairing of chemotherapy and it’s after effects, certain odors, sounds, and settings associated with the treatment acquire the ability to elicit nausea and vomiting. (5) , (6)

Clearly it is impossible to detail all the clinical situations in which nausea and vomiting may be a pertinent finding. It should become evident, however, that because of the variable causes, management may vary from simple to quite complex.

Statistic

World Federation of Societies of Anaesthesiologists, 2003.

  • Postoperative nausea and vomiting (PONV) are the most common adverse events following surgery which is about 60-70% if older anaesthetic agents are used in comparison to 30% with use of newer agents.
  • Nausea and vomiting in pregnancy is extremely high (nausea affects between 75 - 85% of women, and vomiting about 50%).

Support Care Cancer; 6(3):244-7. 1998.

    Anticipatory nausea (AN) appears to occur in approximately 29% of patients receiving chemotherapy, or about 1:3, while anticipatory vomiting (AV) appears to occur in 11% of patients, or about 1:10.

Signs and Symptoms

[span class=alert]The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.[/span]

Not available

Three stages of emesis or vomiting

  1. Nausea, the feeling of the need to vomit, may include sweating, pale skin appearance, and increased saliva production
  2. Retching, which is the strong, powerful movement of stomach and chest muscles
  3. Vomiting, the forceful throwing up of stomach contents

Treatment Options

Conventional

The overall goal of therapy is to prevent or eliminate nausea and vomiting; however, treatment approaches vary greatly depending on the associated medical condition. For simple nausea and vomiting, one may choose to do nothing or to select from available over-the-counter medications.

Because the symptoms of nausea and vomiting may represent any number of conditions, it is necessary to determine the cause of these symptoms before deciding on which product is appropriate. This should be done with a qualified health care professional. Products available for self-medication include antacids; histamine 2 antagonists such as cimetidine, famotidine, and ranitidine; antihistimine-anticholinergic agents such as meclizine, cyclizine, dimenhydrinate, and diphenhydramine; and phosphorylated carbohydrate solutions. Drugs requiring a prescription are some of the antihistamine-anticholinergic drugs and the phenothiazines. Both nonprescription and prescription drugs are usually effective in small, infrequently administered doses.

For more complicated cases of nausea and vomiting, a combination of drug therapies may be recommended. Your healthcare professional may recommend small doses of several medications to help with these symptoms.

Antiemetic regimens for patients receiving cancer chemotherapy should include medication prior to chemotherapy, and one or more doses during and/or after chemotherapy. Drugs commonly used in this setting include prochlorperazine alone or in combination with lorazepam; granisetron, ondancetron, or dolasetron alone or one of the three in combination with dexamethasone or methylprednisolone.

Nutritional Suplementation


Vitamin B6

and pregnancy: Several studies have reported that pyridoxine can reduce nausea and vomiting associated with morning sickness in the early stages of pregnancy. In one study, 31 women took 25 mg of vitamin B6 orally every 8 hours for 72 hours, while an additional 28 pregnant women received a placebo. In women with severe nausea, those taking vitamin B6 experienced significantly better improvement in nausea scores compared to the women taking the placebo. However, there were no significant differences between treatment and placebo groups in cases of mild to moderate nausea. Women taking vitamin B6 also had a much greater improvement in vomiting after 3 days of therapy. (7)

In another trial, which was double-blind, pregnant women took 30 mg of vitamin B6/day orally for 5 days or a placebo. The results revealed that women taking vitamin B6 had a significant decrease in their nausea scores compared to the placebo women and they also had a greater reduction in the mean number of vomiting episodes. Although these outcomes did not reach statistical significance, these results suggest that vitamin B6 can help to reduce the severity of nausea in the first few months of pregnancy. (8)


Vitamin K

One study reports that extended nausea and vomiting during pregnancy, also known as hyperemesis gravidarum, can result in malnutrition. One manifestation of this malnutrition could be a deficiency of vitamin K, which affects the body’s blood clotting mechanisms. This study provides the case history of a women at 15 weeks' gestation whose prolonged nausea and vomiting was complicated by an episode of severe nose bleeding. Investigation revealed a blood clotting defect caused by a vitamin K deficiency. This problem was completely resolved after vitamin K supplementation. Vitamin K status should be evaluated in those rare cases when a pregnant woman with prolonged nausea and vomiting presents with a bleeding problem. It is suggested that prophylactic vitamin K supplementation should be considered in women with severe and prolonged vomiting. (9)


Multivitamin

/mineral supplement: For an occasional incident of nausea and vomiting due to the flu, over indulgence in alcohol, or food poisoning, no nutritional recommendation is necessary. However, if an individual is experiencing chronic nausea and vomiting for extended periods of time, nutrient depletions might occur due to vomiting and loss of appetite. Examples of conditions that might cause this type of problem include morning sickness, or nausea and vomiting due to chemotherapy for cancer treatment. In these cases, taking a multivitamin/mineral nutritional supplement might be helpful, if tolerated. Cancer patients may benefit greatly by getting intravenous nutritional support during the time they are undergoing chemotherapy.

A portion of one published study was designed to evaluate pregnant women who reported vomiting and seek a relationship between vitamin supplementation episodes of vomiting. The results revealed that women who did not take nutritional supplementation before 6 weeks’ gestation experienced significantly more episodes of vomiting. (10) These results indicate that vitamin and mineral nutritional supplementation before and during the early stages of pregnancy can help to reduce the incidence of vomiting.

Herbal Suplementation


Ginger

Ginger has been used throughout history as both a culinary herb and a medicinal agent. Ginger has gained attention in the United States because of its effect on motion sickness, nausea, and to aid in digestion. Several studies have been published which support ginger’s antiemetic activity compared to drug or placebo therapy. (11) , (12) , (13) , (14) Ginger may be warranted instead of antihistamines for motion sickness because it does not cause drowsiness. (15) Ginger may also be of value in the treatment of hyperemesis gravidarum, a condition in morning sickness where severe dehydration and electrolyte disturbances may occur through excessive vomiting. (16) A double-blind, controlled clinical study reported that the use of ginger for treatment of nausea in pregnancy was found to decrease the number of events as well as lessening the severity of nausea. (17) Studies have found that women using ginger in early pregnancy can reduce their symptoms. (18) , (19) The effectiveness of ginger root pre-surgically as an antiemetic agent was comparable with metoclopramide in a double-blind, placebo controlled study. (20) Ginger root preparations may be useful in controlling nausea and vomiting in outpatient surgery. (21) Shogaol is thought to give ginger its antiemetic effect. (22)

Also of interest, ginger was reported to decrease the gastric emptying delays associated with using the chemotherapeutic agent cisplatin when administered concurrently with ginger juice – this was reported more effective than ondansetron. (23) Ginger was also reported to decrease nausea associated with 8-MOP therapy. (24)


Chamomile

Chamomile has been used as a medicinal herb for centuries. It is most frequently used as a mild sedative for individuals with minor anxiety or nervousness. (25) It does not induce drowsiness or impair motor activity. Chamomile has also been used to soothe digestive upset and is considered a carminative (anti-gas) agent. (26) Chamomile has been used topically for various conditions such as acne, infections, burns, and wounds. (27) Apigenin has been reported to be a ligand for the central benzodiazepine receptors exerting anxiolytic and slight sedative effects but not being anticonvulsant or myorelaxant. (28)

References

  1. Friedman LS, Isselbacher KJ. Nausea, Vomiting, and Indigestion. In: Fauci AS, Braunwald E, Isselbacher KJ et al. eds. Harrison’s Principles of Internal Medicine 14th ed. New York. McGraw-Hill. 1998:230-232.
  2. Feldman M. Nausea and vomiting. In: Sleisenger MH, Fordtran JS, eds. Gastrointestinal Disease. Philadelphia. Saunders. 1983:160-177.
  3. Friedman LS, Isselbacher KJ. Nausea, Vomiting, and Indigestion. In: Fauci AS, Braunwald E, Isselbacher KJ et al. eds. Harrison’s Principles of Internal Medicine 14th ed. New York. McGraw-Hill. 1998:230-232.
  4. Taylor AT. Nausea and Vomiting. In: DiPiro JT et al eds. Pharmacotherapy, A Pathophysiologic Approach, 4th ed. Stanford CT. Appleton & Lange. 1999:586-596.
  5. Redd WH. Control of nausea and vomiting in chemotherapy patients: Four effective behavioral methods. Postgrad Med. 1984;75:105-113.
  6. View Abstract: Eyre HJ, Ward JH. Control of cancer chemotherapy-induced nausea and vomiting. Cancer. 1984;54:2642-2648.
  7. View Abstract: Sahakian V, et al. Vitamin B6 is effective therapy for nausea and vomiting of pregnancy: a randomized, double-blind placebo-controlled study. Obstet Gynecol. Jul1991;78(1):33-6.
  8. View Abstract: Vutyavanich T, et al. Pyridoxine for nausea and vomiting of pregnancy: a randomized, double-blind, placebo-controlled trial. Am J Obstet Gynecol. Sep1995;173(3 Pt 1):881-4.
  9. View Abstract: Robinson JN, et al. Coagulopathy secondary to vitamin K deficiency in hyperemesis gravidarum. Obstet Gynecol. Oct1998;92(4 Pt 2):673-5.
  10. View Abstract: Emelianova S, et al. Prevalence and severity of nausea and vomiting of pregnancy and effect of vitamin supplementation. Clin Invest Med. Jun1999;22(3):106-10.
  11. Mowry DB, et al. Motion Sickness, Ginger, and Psychophysics. Lancet. 1982; 1(8273):655-67.
  12. View Abstract: Grontved A, et al. Ginger Root Against Seasickness. A Controlled Trial on the Open Sea. Acta Otolaryngol. 1988;105:45-49.
  13. View Abstract: Qian DS, et al. Pharmacologic Studies of Antimotion Sickness Actions of Ginger. Chung Kuo Chung Hsi I Chieh Ho Tsa Chih. 1992;12(2):95-98.
  14. View Abstract: Stewart JJ, et al. Effects of Ginger on Motion Sickness Susceptibility and Gastric Function. Pharmacology. 1991;42(2):111-20.
  15. View Abstract: Holtmann S, et al. The Anti-motion Sickness Mechanism of Ginger. A Comparative Study with Placebo and Dimenhydrinate. Acta Otolaryngol. 1989;108(3-4):168-74.
  16. View Abstract: Fischer-Rasmussen W, et al. Ginger Treatment of Hyperemesis Gravidarum. Eur J Obstet Gynecol Reprod Biol. 1991;38(1): 19-24.
  17. View Abstract: Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for nausea and vomiting in pregnancy: randomized, double-masked, placebo-controlled trial. Obstet Gynecol. 2001 Apr;97(4):577-82.
  18. View Abstract: Smith C, Crowther C, Willson K, Hotham N, McMillian V. A randomized controlled trial of ginger to treat nausea and vomiting in pregnancy. Obstet Gynecol. Apr2004;103(4):639-45.
  19. View Abstract: Borrelli F. Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting. Obstet Gynecol. 2005 Apr;105(4):849-56.
  20. View Abstract: Bone ME, et al. Ginger Root--A New Antiemetic. The Effect of Ginger Root on Postoperative Nausea and Vomiting After Major Gynaecological Surgery. Anaesthesia. Aug1990;45(8)669-71.
  21. View Abstract: Phillips S, et al. Zingiber officinale (Ginger)--An Antiemetic for Day Case Surgery. Anaesthesia. Aug1993;48(8):715-17.
  22. Lumb AB. Mechanism of Antiemetic Effect of Ginger. Anaesthesia. 1993;48(12): 1118.
  23. View Abstract: Sharma SS, et al. Reversal of Cisplatin-induced Delay in Gastric Emptying in Rats by Ginger (Zingiber officinale). J Ethnopharmacol. Aug1998;62(1):49-55.
  24. View Abstract: Meyer K, et al. Zingiber officinale (ginger) Used to Prevent 8-Mop Associated Nausea. Dermatol Nurs. Aug1995;7(4):242-44.
  25. Wichtl M, in N. A. Bisset, ed. Herbal Drugs and Phytopharmaceuticals. Stuttgart: Scientific Press. 1994; 140-42.
  26. Kell T. More on Infant Colic. Birth Gaz. 1977;13(2):3.
  27. Kell T. More on Infant Colic. Birth Gaz. 1977;13(2):3.
  28. View Abstract: Viola H, et al. Apigenin, A Component of Matricaria Recutita Flowers, Is a Central Benzodiazepine Receptors-ligand With Anxiolytic Effects. Planta Med. Jun1995;61(3):213-16.