Nausea

September 17, 2011

Nausea is a common symptom that is associated with a wide variety of conditions. Nausea is an unpleasant sensation in the upper abdomen often referred to as “queasiness,” which is usually accompanied by an urge to vomit. Vomiting, usually preceded by nausea, is defined as the forceful ejection of stomach contents up to and out of the mouth. It is important to recognize that nausea and vomiting are not diseases in and of themselves but rather symptoms of an underlying process. Usually nausea and vomiting are due to an illness that improves on its own or is easily treated.

CAUSES

The list of conditions that can cause nausea and vomiting is long and includes disorders affecting the digestive tract, abdominal organs, central nervous system, metabolism, and endocrine system. Examples of digestive tract disorders that may be associated with nausea include gastroparesis (poor stomach emptying in the absence of an anatomical obstruction), gastroesophageal reflux disease, irritable bowel syndrome, peptic ulcer disease, and gastrointestinal obstruction. Nausea may be due to infections involving the digestive tract like viral gastroenteritis and food poisoning. Inflammatory abdominal conditions like gallbladder disease, hepatitis, and pancreatitis frequently cause nausea. Nausea is a common symptom reported by patients with balance and equilibrium problems (such as motion sickness), other intracerebral disorders (such as migraine headaches, tumor, hemorrhage, meningitis), and psychiatric disorders (such as anxiety, depression, anorexia nervosa, bulimia). Endocrine and metabolic causes of nausea and vomiting include pregnancy (nausea occurs in 70% of women during the first trimester), diabetes, kidney failure, and thyroid disorders. Medications are among the most common causes of nausea and vomiting, usually during the first few weeks the medication is used. Examples of medications that frequently cause nausea and vomiting are aspirin, nonsteroidal antiinflammatory drugs (such as ibuprofen), digoxin, theophylline, oral contraceptives, narcotics, and many cancer chemotherapy agents. Nausea and vomiting may also occur in patients with heart attacks, congestive heart failure, or during the first few days following surgery.

DIAGNOSIS

Although the causes of nausea and vomiting are numerous, careful consideration of each patient’s individual circumstances gives clues to the likely cause. This, along with a thorough history and physical examination, can narrow down the diagnosis. Important factors to consider are duration, severity, and frequency of symptoms as well as recent ingestions (e.g., spoiled foods, toxins), new medications, similar illness in family or friends, description of vomit (if any), and any other associated symptoms. Acute nausea and vomiting, lasting on the order of hours to a few days, is typically due to infection (e.g., gastroenteritis, meningitis), medications, acute inflammatory conditions (e.g., gallbladder disease), or toxins (e.g., alcohol). Nausea and vomiting symptoms lasting more than 1 month may be due to a number of chronic medical conditions (e.g., gastroparesis, irritable bowel syndrome, cancer, and diabetes), pregnancy, medications, or psychiatric disorders. Vomiting early in the morning may suggest causes including pregnancy, kidney failure, alcohol, narcotic withdrawal, and increased intracranial pressure (increased pressure on the brain due to causes like cerebral hemorrhage, tumor, or meningitis). Vomiting occurring 1-3 hr after meals is seen in gastric outlet obstruction and gastroparesis whereas symptoms during or immediately after meals are often associated with psychiatric disorders (e.g., anorexia nervosa and bulimia). Associated symptoms that may aid in the evaluation and diagnosis include fever, abdominal pain, diarrhea, red blood or black “coffee grounds” in the vomit, weight loss, chest pain, headache, stiff neck, ringing in the ears, and vertigo.

A complete physical examination is performed not only to provide diagnostic information but to determine whether any complications of nausea and vomiting have occurred. The patient is specifically assessed for signs of weight loss, dehydration, fever, jaundice, abdominal tenderness and location, abdominal masses, enlarged lymph nodes, neurologic abnormalities, and blood in the stool.

A number of diagnostic tests may be used to evaluate nausea and vomiting, and the choice is dictated by the clinical situation. Laboratory studies may include blood, urine, and stool tests. A pregnancy test should be considered in women of reproductive age. A variety of radiologic studies may also be useful, including abdominal x-rays, abdominal ultrasound, abdominal or head CT scan, and contrast imaging studies (where the patient drinks barium and then x-rays are taken of the stomach and small intestine). At times, endoscopy (insertion of a flexible tube containing a camera into the mouth or rectum) may be required to diagnose the underlying cause of nausea and vomiting.

TREATMENT

Treatment of nausea and vomiting will depend on the severity and cause. Important issues to be addressed are: correction of fluid and electrolyte losses; identification and treatment, or removal, of the underlying cause; and symptom treatment. Minor self-limited symptoms can often be managed with rest and a bland diet consisting of cold or room-temperature clear liquids (e.g., ginger ale, broth) and small frequent meals of nonfatty foods (e.g., crackers, toast). Oral rehydration fluids (e.g., sports drinks) provide important sugar and salt in addition to water when vomiting has persisted for more than 24 hr. However, young children and infants should not be given sports drinks, and should be rehydrated under medical supervision. Medical attention should be sought if nausea lasts more than a week or if pregnancy is suspected. Immediate attention should be sought if there is persistent vomiting, vomiting with diarrhea, severe abdominal pain, severe headache, stiff neck, high fever, red blood or “coffee grounds” in the vomit, lightheadedness, confusion, decreased consciousness, chest pain, rapid heart rate, or shortness of breath.

At times, hospital admission may be necessary for intravenous fluids, testing, and/or treatment. Specific treatments are directed at the underlying cause and can range from simple measures such as over-the-counter medications for motion sickness to invasive treatments such as dialysis for kidney failure or surgery for gallbladder disease. Sometimes the cause of symptoms cannot be identified or treatment is unsuccessful or incomplete. In these cases, antiemetic (“antivomiting”) medications may be given. There is a wide variety of antiemetic agents available and the clinician must decide which is most appropriate given the situation and severity of symptoms. Acupuncture and acupressure have been effective in reducing nausea and vomiting in chemotherapy patients and in people with symptoms following surgery. Acupressure may reduce nausea in pregnancy. In cases of chronic nausea and vomiting in which a physical explanation has been ruled out, a psychiatric evaluation may be helpful.

SEE ALSO: Abdominal pain, Acupuncture, Bulimia, nervosa, Migraine

Suggested Reading

  • Hasler, W. L. (1999). Approach to the patient with nausea and vomiting. In T. Yamada, D. H. Alpers, L. Laine, C. Owyang, & D. W. Powell (Eds.), Textbook of gastroenterology (3rd ed., pp. 775-794). Philadelphia: Lippincott.
  • Koch, K. L., & Frissora, C. L. (2003). Nausea and vomiting during pregnancy. Gastroenterology Clinics of North America, 32(1), 201-234.
  • Quigley, E. M., Hasler, W. L., & Parkman, H. P. (2001). AGA technical review on nausea and vomiting. Gastroenterology, 120, 263-286.

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Category: N