Chapter 039. Nausea, Vomiting, and Indigestion (Part 4) pdf

Nausea, Vomiting, and Indigestion Part 4 Diagnostic Testing For intractable symptoms or an elusive diagnosis, selected diagnostic tests can direct clinical management.. Nausea and Vom

Chapter 039 Nausea, Vomiting,

and Indigestion

(Part 4)

Diagnostic Testing

For intractable symptoms or an elusive diagnosis, selected diagnostic tests can direct clinical management Electrolyte replenishment is indicated for hypokalemia or metabolic alkalosis Detection of iron-deficiency anemia mandates

a search for mucosal injury Pancreaticobiliary disease is indicated by abnormal pancreatic enzymes or liver biochemistries, whereas endocrinologic, rheumatologic, or paraneoplastic etiologies are suggested by specific hormone or serologic testing If luminal obstruction is suspected, supine and upright abdominal radiographs may show intestinal air-fluid levels with reduced colonic air Ileus is characterized by diffusely dilated air-filled bowel loops

Anatomic studies may be indicated if initial testing is nondiagnostic Upper endoscopy detects ulcers or malignancy, while small-bowel barium radiography diagnoses partial small-bowel obstruction Colonoscopy or contrast enema radiography can detect colonic obstruction Abdominal ultrasound or computed tomography (CT) defines intraperitoneal inflammatory processes, while CT or magnetic resonance imaging (MRI) of the head can delineate intracranial disease Mesenteric angiography or MRI is useful when ischemia is considered

Gastrointestinal motility testing may detect a motor disorder that contributes to symptoms when anatomic abnormalities are absent Gastroparesis commonly is diagnosed using gastric scintigraphy, by which emptying of a radiolabeled meal is measured Isotopic breath tests and telemetry capsule methods also have been validated Electrogastrography, a noninvasive test of gastric slow-wave activity using cutaneous electrodes placed over the stomach, has been proposed as an alternate means of diagnosing gastroparesis The diagnosis of intestinal pseudoobstruction often is suggested by abnormal barium transit and luminal dilation on small-bowel contrast radiography Small-intestinal manometry can confirm the diagnosis and further characterize the motor abnormality as neuropathic or myopathic based on contractile patterns Such investigation can obviate the need for open intestinal biopsy to evaluate for smooth muscle or neuronal degeneration

Nausea and Vomiting: Treatment

General Principles

Therapy of vomiting is tailored to correction of medically or surgically remediable abnormalities if possible Hospitalization is considered for severe dehydration especially if oral fluid replenishment cannot be sustained Once oral intake is tolerated, nutrients are restarted with liquids that are low in fat, as lipids delay gastric emptying Foods high in indigestible residues are avoided as these also prolong gastric retention

Antiemetic Medications

The most commonly used antiemetic agents act on sites within the central nervous system (Table 39-2) Antihistamines such as meclizine and dimenhydrinate and anticholinergic drugs like scopolamine act on labyrinthine-activated pathways and are useful in motion sickness and inner ear disorders Dopamine D2 antagonists treat emesis evoked by area postrema stimuli and are useful for medication, toxic, and metabolic etiologies Dopamine antagonists freely cross the blood-brain barrier and cause anxiety, dystonic reactions, hyperprolactinemic effects (galactorrhea and sexual dysfunction), and irreversible tardive dyskinesia

Table 39-2 Treatment of Nausea and Vomiting

ent

Indications

Antieme

tic agents

Antihistamine rgic

Dimenhydrinate, meclizine

Motion sickness, inner ear disease

Anticholinergi

c

Scopolamine Motion

sickness, inner ear disease

Antidopamine rgic

Prochlorperazine, thiethylperazine

Medication-, toxin-, or metabolic-induced emesis

5-HT3 antagonist

Ondansetron, granisetron

Chemothera py- and radiation-induced emesis, postoperative

emesis

NK1

antagonist

Aprepitant Chemothera

py-induced nausea and vomiting

Tricyclic antidepressant

Amitriptyline, nortriptyline

Chronic idiopathic nausea, functional

vomiting, cyclic vomiting syndrome

Prokinet

ic agents

5-HT4 agonist and

antidopaminergic

Metoclopramide Gastroparesi

s

Motilin agonist

Erythromycin Gastroparesi

s, ?intestinal pseudoobstruction

Peripheral antidopaminergic

Domperidone Gastroparesi

s

5-HT4 agonist

Tegaserod ?Gastropares

is, ?intestinal pseudoobstruction

Somatostatin analogue

Octreotide Intestinal

pseudoobstruction

Special

settings

Benzodiazepi nes

Lorazepam Anticipatory

nausea and vomiting with chemotherapy

Glucocorticoi

ds

Methylprednisolo

ne, dexamethasone

Chemothera py-induced emesis

Cannabinoids Tetrahydrocanna

binol

?Chemother apy-induced emesis

Other drug classes exhibit antiemetic properties Serotonin 5-HT3 antagonists such as ondansetron and granisetron exhibit utility in postoperative vomiting, after radiation therapy, and in the prevention of cancer chemotherapy– induced emesis The usefulness of 5-HT3 antagonists for other causes of emesis is less well established Low-dose tricyclic antidepressant agents provide symptomatic benefit in patients with chronic idiopathic nausea and functional vomiting as well as in diabetic patients with nausea and vomiting whose disease is

of long standing