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[[Ginger]] has also been shown to be potentially effective in treating several types of nausea.<ref name="medind">{{cite journal|last=Marx|first=WM|author2=Teleni L|author3=McCarthy AL|author4=Vitetta L|author5=McKavanagh D|author6=Thomson D|author7=Isenring E.|title=Ginger (Zingiber officinale) and chemotherapy-induced nausea and vomiting: a systematic literature review|journal=Nutr Rev|volume=71|issue=4|pages=245–54|doi=10.1111/nure.12016|pmid=23550785|year=2013}}</ref><ref name="ernst-meta">{{cite journal | last = Ernst | first = E. |author2=Pittler, M.H.| date=1 March 2000| title = Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials | journal = British Journal of Anesthesia | volume = 84 | issue = 3 | pages = 367–371 | url = http://bja.oxfordjournals.org/cgi/reprint/84/3/367 | format = PDF | accessdate =6 September 2006 | pmid = 10793599 | doi=10.1093/oxfordjournals.bja.a013442}}</ref>
[[Ginger]] has also been shown to be potentially effective in treating several types of nausea.<ref name="medind">{{cite journal|last=Marx|first=WM|author2=Teleni L|author3=McCarthy AL|author4=Vitetta L|author5=McKavanagh D|author6=Thomson D|author7=Isenring E.|title=Ginger (Zingiber officinale) and chemotherapy-induced nausea and vomiting: a systematic literature review|journal=Nutr Rev|volume=71|issue=4|pages=245–54|doi=10.1111/nure.12016|pmid=23550785|year=2013}}</ref><ref name="ernst-meta">{{cite journal | last = Ernst | first = E. |author2=Pittler, M.H.| date=1 March 2000| title = Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials | journal = British Journal of Anesthesia | volume = 84 | issue = 3 | pages = 367–371 | url = http://bja.oxfordjournals.org/cgi/reprint/84/3/367 | format = PDF | accessdate =6 September 2006 | pmid = 10793599 | doi=10.1093/oxfordjournals.bja.a013442}}</ref>

=== Alternative Treatments ===
Efforts have been made to find easy, non-invasive, and cost-effective ways to manage nausea. Although there are many drugs on the market that help to alleviate the symptoms of nausea and vomiting, they often cause adverse side-effects. Because of this, there are many ongoing studies exploring the efficacy of alternative treatment options for nausea<ref>{{Cite book|title = Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting|url = http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003281.pub4/abstract|publisher = John Wiley & Sons, Ltd|date = 2015-11-02|isbn = 1465-1858|doi = 10.1002/14651858.cd003281.pub4/abstract|language = en|first = Anna|last = Lee|first2 = Simon KC|last2 = Chan|first3 = Lawrence TY|last3 = Fan}}</ref>.

==== PC6 acupuncture ====
The pericardium (PC6) acupuncture point is a point that lies in between several tendons near the wrist. Based on traditional Chinese medicine, stimulation of this point prevents imbalance of ''Qi'' and blood-flow from the stomach<ref>{{Cite journal|title = P6 acupoint stimulation for prevention of postoperative nausea and vomiting in patients undergoing craniotomy: study protocol for a randomized controlled trial|url = http://www.trialsjournal.com/content/14/1/153/abstract|journal = Trials|date = 2013-05-28|issn = 1745-6215|pmc = 3668145|pmid = 23710881|pages = 153|volume = 14|issue = 1|doi = 10.1186/1745-6215-14-153|language = en|first = Jian-qin|last = Lv|first2 = Rui-zhi|last2 = Feng|first3 = Ning|last3 = Li}}</ref>. The mechanism of PC6 acupoint stimulation is not explained by Western medicine. There is evidence showing that PC6 acupoint stimulation may improve symptoms of post-operative nausea and vomiting<ref>{{Cite book|title = Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting|url = http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003281.pub4/abstract|publisher = John Wiley & Sons, Ltd|date = 2015-11-02|isbn = 1465-1858|doi = 10.1002/14651858.cd003281.pub4/abstract|language = en|first = Anna|last = Lee|first2 = Simon KC|last2 = Chan|first3 = Lawrence TY|last3 = Fan}}</ref>. Multiple recent studies also showed that there was no significant difference in efficacy between PC6 stimulation and standard anti-emetic drugs in terms of preventing post-operative nausea and vomiting.


==Prognosis==
==Prognosis==

Revision as of 04:32, 6 November 2015

For other uses, see Nausea (disambiguation).
Nausea
SpecialtyGastroenterology

Nausea (Latin nausea, from Greek ναυσία - nausia,[1] "ναυτία" - nautia, motion sickness", "feeling sick or queasy"[2]) is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit.[3] It occasionally precedes vomiting. A person can suffer nausea without vomiting. (Greek ναῦς - naus, "ship"; ναυσία started as meaning "seasickness".) When prolonged, it is a debilitating symptom.[4]

Nausea is a non-specific symptom, which means that it has many possible causes. Some common causes of nausea are motion sickness, dizziness, migraine, fainting, gastroenteritis (stomach infection) or food poisoning. Nausea is a side effect of many medications including chemotherapy, nauseants or morning sickness in early pregnancy. Nausea may also be caused by anxiety, disgust and depression.[5][6][7]

Medications taken to prevent and treat nausea are called antiemetics. The most commonly prescribed antiemetics in the US are promethazine, metoclopramide and ondansetron.

Differential diagnosis

There are many causes of nausea. One organization listed 700 in 2009.[8] Gastrointestinal infections (37%) and food poisoning are the two most common causes.[3][9] Side effects from medications (3%) and pregnancy are also relatively frequent.[3][9] In 10% of people the cause remains unknown.[9]

Food poisoning

Food poisoning usually causes an abrupt onset of nausea and vomiting one to six hours after ingestion of contaminated food and lasts for one to two days.[10] It is due to toxins produced by bacteria in food.[10]

Medications

Many medications can potentially cause nausea.[10] Some of the most frequently associated include cancer and systemic chemotherapy regimens and general anaesthetic agents.

Pregnancy

Nausea or "morning sickness" is common during early pregnancy but may occasionally continue into the second and third trimesters. In the first trimester nearly 80% of women have some degree of nausea.[11] Pregnancy should therefore be considered as a possible cause of nausea in any women of child bearing age.[10] While usually it is mild and self-limiting, severe cases known as hyperemesis gravidarum may require treatment.[12]

Disequilibrium

A number of conditions involving balance such as motion sickness and vertigo can lead to nausea and vomiting.

Stress and depression

Nausea may be caused by stress and depression.

Potentially serious

While most causes of nausea are not serious, some serious causes do occur. These include: Intercranial Pressure secondary to head trauma or hemorrhagic stroke, diabetic ketoacidosis, brain tumor, surgical problems, heart attack,[13] pancreatitis, small bowel obstruction, meningitis, appendicitis, cholecystitis, Addisonian crisis, Choledocholithiasis (from gallstones), hepatitis, as a sign of carbon monoxide poison and many others.[3]

Other causes

Diagnostic approach

Often, a good oral history of the symptom will lead to appropriate treatment where few investigations are needed; however, basic lab tests may be appropriate.[3] If a bowel obstruction is possible, abdominal x-rays may be useful.[3] For instance, if severe anxiety appears to be the cause of nausea, then a short course of an anti-anxiety medication such as lorazepam (Ativan) may be all that is needed. If pain is present the nausea can be caused by pain or by opioids used to treat the pain. These may include codeine, hydrocodone, meperidine, morphine, oxycodone, hydromorphone, or fentanyl. These drugs cause nausea in several ways. They may stimulate the eighth cranial nerve which causes vestibular effects such as dizziness or they may stimulate what is called the Chemo Receptor Trigger zone (CTZ) which in turn stimulates the Vestibular Apparatus in the brain which in turn causes nausea and perhaps vomiting. In addition, opioids may slow gastric emptying, causing constipation, which is often accompanied by nausea. If changing opioids does not abate the symptom then addition of antiemetics becomes necessary? Choice of treatment then is indicated by causation. If pain and anxiety are present then drugs or doses need to be increased; if nausea is caused by movement then adding an over-the-counter medication such as meclizine is indicated; if constipation is the cause then a laxative is in order; if these fail then often addition of metacloperamide (to stimulate gastric emptying) and haloperidol in very low doses (to block stimulation of the CTZ) will often give relief. If the nausea is very acute, followed by vomiting, in an otherwise healthy person, it is often best to with hold food and then give clear liquids at least in the first 24 hours may be best as the nausea/vomiting may be a defense mechanism where the body is ridding itself of a toxin. If this is done, however, the age and general condition of the person has to be considered. An infant or small child can become dangerously dehydrated in 2–3 hours, while a healthy adult can withstand the fluid loss for somewhat longer. In no case should the person be left alone, they should be watched and medical help called for if symptoms of dehydration such as very concentrated (very yellow) urine, poor skin turgor (pull gently on a pinch of skin and if it stays pinched for even a few seconds), confusion, dry eyes and mouth, occur. Nausea can also be caused by poor kidney or liver function. Acutely this is a medical emergency. If the person has a chronic condition then often judicious use of metacloperamide and haloperidol can be very helpful as these conditions cause toxins to accumulate in the blood which stimulate the CTZ, like opioids, and the nausea/vomiting usually respond to the same treatment. Nausea/vomiting caused by chemotherapy is caused in yet a different way and therefore needs medications such as ondansetron for control. Note that there is no all purpose antiemetic. Successful treatment depends on identification of cause.

Pathophysiology

Research on nausea and vomiting has relied on using animal models to mimic the anatomy and neuropharmacologic features of the human body.[14] The physiologic mechanism of nausea is a complex process that has yet to be fully elucidated. There are four general pathways that are activated by specific triggers in the human body that go on to create the sensation of nausea and vomiting.[15]

  • Central nervous system (CNS): Stimuli can affect areas of the CNS including the cerebral cortex and the limbic system. These areas are activated by elevated intracranial pressure, irritation of the meninges (i.e. blood or infection), and extreme emotional triggers such as anxiety.
  • Chemoreceptor trigger zonee (CTZ): The CTZ is located in the area postrema in the floor of the fourth ventricle within the brain. This area is outside the blood brain barrier, and is therefore readily exposed to substances circulating through the blood and cerebral spinal fluid. Common triggers of the CTZ include metabolic abnormalities, toxins, and medications. Activation of the CTZ is mediated by dopamine (D2) receptors, serotonin (5HT3) receptors, and neurokinin receptors (NK1).
  • Vestibular system: This system is activated by disturbances to the vestibular apparatus in the inner ear. These include movements that cause motion sickness and dizziness. This pathway is triggered via histamine (H1) receptors and acetylcholine (ACh) receptors.
  • Peripheral Pathways: These pathways are triggered via chemoreceptors and mechanoreceptors in the gastrointestinal tract, as well as other organs such as the heart and kidneys. Common activators of these pathways include toxins present in the gastrointestinal lumen and distension of the gastrointestinal lumen from blockage or dysmotility of the bowels. Signals from these pathways travel via multiple neural tracts including the vagus, glossopharyngeal, splanchnic, and sympathetic nerves.

Signals from any of these pathways then travel to the brainstem, activating several structures including the nucleus of the solitary tract, the dorsal motor nucleus of the vagus, and central pattern generator.[16] These structures go on to signal various downstream effects of nausea and vomiting. The body's motor muscle responses involve halting the muscles of the gastrointestinal tract, and in fact causing reversed propulsion of gastric contents towards the mouth while increasing abdominal muscle contraction. Autonomic effects involve increased salivation and the sensation of feeling faint that often occurs with nausea and vomiting.

Treatment

If dehydration is present due to loss of fluids from severe vomiting, rehydration with oral electrolyte solutions is preferred.[3] If this is not effective or possible, intravenous rehydration may be required.[3] NIH Medline recommends drinking clear fluids, sitting quietly and eating bland foods.[17] Medline recommends you call a doctor if you:

  • Cannot keep any food or liquid down
  • Vomit 3 or more times in 1 day
  • Are nauseated for more than 48 hours
  • Feel weakness
  • Have fever
  • Have stomach pain
  • Do not have to urinate for 8 hours or more [17]

Medications

Main article: Antiemetic

Dimenhydrinate (Gravol) is an inexpensive and effective over the counter medication for preventing postoperative nausea and vomiting.[18] Meclizine is another antihistamine antiemetic. In certain people, cannabinoids may be effective in reducing chemotherapy associated nausea and vomiting.[19][20] Ondansetron (Zofran) is effective for nausea and vomiting.[10] Pyridoxine or metoclopramide are the first line treatments for pregnancy-related nausea and vomiting.[12] Many consider medical marijuana to be an effective herbal remedy for nausea.[citation needed] Several studies have demonstrated the therapeutic effects of cannabinoids for nausea and vomiting in the advanced stages of illnesses such as cancer and AIDS.[21][22]

In hospital settings topical anti-nausea gels are not indicated because of lack of research backing their efficacy.[23] Topical gels containing lorazepam, diphenhydramine, and haloperidol are sometimes used for nausea but are not equivalent to more established therapies.[23]

Ginger has also been shown to be potentially effective in treating several types of nausea.[24][25]

Alternative Treatments

Efforts have been made to find easy, non-invasive, and cost-effective ways to manage nausea. Although there are many drugs on the market that help to alleviate the symptoms of nausea and vomiting, they often cause adverse side-effects. Because of this, there are many ongoing studies exploring the efficacy of alternative treatment options for nausea[26].

PC6 acupuncture

The pericardium (PC6) acupuncture point is a point that lies in between several tendons near the wrist. Based on traditional Chinese medicine, stimulation of this point prevents imbalance of Qi and blood-flow from the stomach[27]. The mechanism of PC6 acupoint stimulation is not explained by Western medicine. There is evidence showing that PC6 acupoint stimulation may improve symptoms of post-operative nausea and vomiting[28]. Multiple recent studies also showed that there was no significant difference in efficacy between PC6 stimulation and standard anti-emetic drugs in terms of preventing post-operative nausea and vomiting.

Prognosis

While short-term nausea and vomiting are generally harmless, they may sometimes indicate a more serious condition. When associated with prolonged vomiting, it may lead to dehydration and/or dangerous electrolyte imbalances. Repeated intentional vomiting, characteristic of bulimia, can cause stomach acid to wear away at the enamel in teeth.[29]

Epidemiology

Nausea and or vomiting is the main complaint in 1.6% of visits to family physicians in Australia.[9] However, only 25% of people with nausea visit their family physician.[3] It is most common in those 15–24 years old and less common in other ages.[9]

See also

References

  1. ^ ναυσία, Henry George Liddell, Robert Scott,.A Greek-English Lexicon, on Perseus
  2. ^ ναυτία, Henry George Liddell, Robert Scott, A Greek-English Lexicon, on Perseus
  3. ^ a b c d e f g h i Metz A, Hebbard G (September 2007). "Nausea and vomiting in adults--a diagnostic approach". Aust Fam Physician. 36 (9): 688–92. PMID 17885699.
  4. ^ "Nausea".
  5. ^ "Stress symptoms: Effects on your body, feelings and behavior". Mayo Clinic.
  6. ^ "Diagnostic Criteria: Clinical Guidelines for the Management of Anxiety". PubMed.
  7. ^ "Disease Information for Stress/Emotional/Physical: Clinical Manifestations".
  8. ^ "Differential Diagnosis for Nausea".
  9. ^ a b c d e Helena Britt; Fahridin, S (September 2007). "Presentations of nausea and vomiting" (PDF). Aust Fam Physician. 36 (9): 673–784. PMID 17885697.
  10. ^ a b c d e Scorza K, Williams A, Phillips JD, Shaw J (July 2007). "Evaluation of nausea and vomiting". Am Fam Physician. 76 (1): 76–84. PMID 17668843.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Koch KL, Frissora CL (March 2003). "Nausea and vomiting during pregnancy". Gastroenterol. Clin. North Am. 32 (1): 201–34, vi. doi:10.1016/S0889-8553(02)00070-5. PMID 12635417.
  12. ^ a b Sheehan P (September 2007). "Hyperemesis gravidarum--assessment and management". Aust Fam Physician. 36 (9): 698–701. PMID 17885701.
  13. ^ O’Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O’Neil BJ, Travers AH, Yannopoulos D. Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S788.
  14. ^ Horn, Andrews (2006). "Signals for nausea and emesis: implications for models of upper gastrointestinal disease". Autonomic Neuroscience. doi:10.1016/j.autneu.2006.01.008. Retrieved 2015-01-11.
  15. ^ Lien, C (2012). Principles and Practice of Hospital Medicine. New York, NY: McGraw HIll. pp. Chapter 217: Domains of Care: Physical Aspects of Care.
  16. ^ Bashashati, Mohammad; McCallum, Richard W. (2014-01-05). "Neurochemical mechanisms and pharmacologic strategies in managing nausea and vomiting related to cyclic vomiting syndrome and other gastrointestinal disorders". European Journal of Pharmacology. 722: 79–94. doi:10.1016/j.ejphar.2013.09.075. ISSN 1879-0712. PMID 24161560.
  17. ^ a b "When you have nausea and vomiting: MedlinePlus Medical Encyclopedia". Nlm.nih.gov. Retrieved 2014-03-20.
  18. ^ Kranke P, Morin AM, Roewer N, Eberhart LH (March 2002). "Dimenhydrinate for prophylaxis of postoperative nausea and vomiting: a meta-analysis of randomized controlled trials". Acta Anaesthesiol Scand. 46 (3): 238–44. doi:10.1034/j.1399-6576.2002.t01-1-460303.x. PMID 11939912.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Tramèr MR, Carroll D, Campbell FA, Reynolds DJ, Moore RA, McQuay HJ (July 2001). "Cannabinoids for control of chemotherapy induced nausea and vomiting: quantitative systematic review". BMJ. 323 (7303): 16–21. doi:10.1136/bmj.323.7303.16. PMC 34325. PMID 11440936.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  20. ^ Drug Policy Alliance (2001). "Medicinal Uses of Marijuana: Nausea, Emesis and Appetite Stimulation". Retrieved 2007-08-02. {{cite web}}: |author= has generic name (help)
  21. ^ World health Organization, Cannabis - epidemiology. http://www.who.int/substance_abuse/facts/cannabis/en/
  22. ^ "Cannabinoids for medical use: A systematic review and meta-analysis". JAMA. 313 (24): 2456–2473. 2015-06-23. doi:10.1001/jama.2015.6358. ISSN 0098-7484.
  23. ^ a b American Academy of Hospice and Palliative Medicine, "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American Academy of Hospice and Palliative Medicine, retrieved August 1, 2013, which cites
    • Smith, T. J.; Ritter, J. K.; Poklis, J. L.; Fletcher, D.; Coyne, P. J.; Dodson, P.; Parker, G. (2012). "ABH Gel is Not Absorbed from the Skin of Normal Volunteers". Journal of Pain and Symptom Management. 43 (5): 961–966. doi:10.1016/j.jpainsymman.2011.05.017. PMID 22560361.
    • Weschules, D. J. (2005). "Tolerability of the Compound ABHR in Hospice Patients". Journal of Palliative Medicine. 8 (6): 1135–1143. doi:10.1089/jpm.2005.8.1135. PMID 16351526.
  24. ^ Marx, WM; Teleni L; McCarthy AL; Vitetta L; McKavanagh D; Thomson D; Isenring E. (2013). "Ginger (Zingiber officinale) and chemotherapy-induced nausea and vomiting: a systematic literature review". Nutr Rev. 71 (4): 245–54. doi:10.1111/nure.12016. PMID 23550785.
  25. ^ Ernst, E.; Pittler, M.H. (1 March 2000). "Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials" (PDF). British Journal of Anesthesia. 84 (3): 367–371. doi:10.1093/oxfordjournals.bja.a013442. PMID 10793599. Retrieved 6 September 2006.
  26. ^ Lee, Anna; Chan, Simon KC; Fan, Lawrence TY (2015-11-02). Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting. John Wiley & Sons, Ltd. doi:10.1002/14651858.cd003281.pub4/abstract. ISBN 1465-1858. {{cite book}}: Check |isbn= value: length (help)
  27. ^ Lv, Jian-qin; Feng, Rui-zhi; Li, Ning (2013-05-28). "P6 acupoint stimulation for prevention of postoperative nausea and vomiting in patients undergoing craniotomy: study protocol for a randomized controlled trial". Trials. 14 (1): 153. doi:10.1186/1745-6215-14-153. ISSN 1745-6215. PMC 3668145. PMID 23710881.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  28. ^ Lee, Anna; Chan, Simon KC; Fan, Lawrence TY (2015-11-02). Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting. John Wiley & Sons, Ltd. doi:10.1002/14651858.cd003281.pub4/abstract. ISBN 1465-1858. {{cite book}}: Check |isbn= value: length (help)
  29. ^ "Bulimia Nervosa-Topic Overview". WebMD. Retrieved 26 July 2012.
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