Nausea and vomiting

Definition

Nausea is the sensation of being about to vomit. Vomiting, or emesis, is the expelling from the stomach of undigested food through the mouth.

Description

Nausea is a reaction to a number of causes that include overeating, infection, or irritation of the throat or stomach lining. Persistent or recurrent nausea and vomiting should be checked by a doctor.

A doctor should be called if nausea and vomiting occur in the following instances:

• after eating rich or spoiled food or taking a new medication
• repeatedly or for 48 hours or longer
• following intense dizziness

It is important to see a doctor if nausea and vomiting are accompanied by the following:

• yellowing of the skin and whites of the eyes
• pain in the chest or lower abdomen
• trouble with swallowing or urination
• dehydration or extreme thirst
• drowsiness or confusion
• constant, severe abdominal pain
• a fruity breath odor

Demographics

Nausea and vomiting are commonly experienced. There are no distinctive patterns of age, gender, or race.

Causes and symptoms

Persistent, unexplained, or recurring nausea and vomiting can be symptoms of a variety of serious illnesses. They can be caused by overeating or drinking too much alcohol. These symptoms can be due to stress, certain medications, or illness. For example, people who are given morphine or other opioid medications for pain relief after surgery sometimes feel nauseated by the drug. Such poisonous substances as arsenic and other heavy metals cause nausea and vomiting. Morning sickness is a consequence of pregnancy-related hormone changes. Motion sickness can be induced by traveling in a vehicle, plane, or on a boat. Many people experience nausea after eating spoiled food or foods to which they are allergic. Individuals who suffer migraine headache often experience nausea. Cancer patients receiving chemotherapy are often nauseated. Gallstones, gastroenteritis , and stomach ulcer may cause nausea and vomiting. These symptoms should be evaluated by a physician.

Nausea and vomiting may also be psychological in origin. Some people vomit under such conditions of emotional stress as family arguments, academic tests, airplane travel, losing a job, and similar high-stress situations. In addition, some eating disorders are characterized by self-induced vomiting.

When to call the doctor

A doctor should be notified if vomiting is heavy and/or bloody, if the vomitus looks like feces, or if the affected person has been unable to keep food down for 24 hours. Most vomiting episodes should stop in eight to 12 hours of onset. The pediatrician should be consulted if vomiting continues beyond that time, if the child shows signs of dehydration, seems extremely lethargic, or if the child is a very young infant.

An ambulance or emergency response number should be called immediately if the following occurs:

• The child's mouth and tongue are very dry.
• The child has very rapid heartbeat and breathing.
• The child cries but has no tears.
• The child has sunken eyes.
• Diabetic shock is suspected.
• Nausea and vomiting continue after other symptoms of viral infection have subsided.
• The person has a severe headache.
• The person is sweating and having chest pain and trouble breathing.
• The person is known or suspected to have swallowed a drug overdose or poisonous substance.
• The person has a high body temperature, muscle cramps , and other signs of heat exhaustion or heat stroke.
• Nausea, vomiting, and breathing problems occur after exposure to a known allergen.

Diagnosis

Diagnosis is based on the severity, frequency, and duration of symptoms, and other factors that could indicate the presence of a serious illness.

Diagnosis is based on a careful medical history that includes foods recently eaten, travel, and occupation. In some cases, the doctor may order laboratory tests or imaging studies to determine the presence of drugs or poisonous substances in the person's blood or urine, or evidence of head injuries or abnormalities in the digestive tract. If the nausea and vomiting appear to be related to anxiety , stress, or an eating disorder, the doctor may refer the person to a psychiatrist for further evaluation.

Treatment

Getting a breath of fresh air or getting away from whatever is causing the nausea can solve the problem. Eating olives or crackers or sucking on a lemon can calm the stomach by absorbing acid and excess fluid. Cola syrup is another proven remedy.

Vomiting relieves nausea quickly but can cause dehydration. Sipping clear juices, weak tea, and some sports drinks helps replace lost fluid and minerals without irritating the stomach. Infants and small children under age two do best with an oral rehydration solution like Pedialyte. The solution should be given a teaspoon at a time, at frequent intervals, starting 30–60 minutes after vomiting has ceased. Food should be reintroduced gradually, several hours after vomiting stops, beginning with small amounts of dry, bland food like crackers and toast.

Medications that are given to relieve nausea and vomiting are called antiemetics. Meclizine (Bonine), a medication for motion sickness, also diminishes the feeling of queasiness in the stomach. Dimenhydrinate (Dramamine), another motion-sickness drug, is not effective on other types of nausea and may cause drowsiness.

Other drugs that have been developed to treat postoperative or post-chemotherapy nausea and vomiting include ondansetron (Zofran) and granisetron (Kytril). Intravenous administration of supplemental fluid before the operation can lower the risk of nausea after surgery.

Alternative treatment

Advocates of alternative treatments suggest biofeedback, acupressure and the use of herbs to calm the stomach. Biofeedback uses exercise and deep relaxation to control nausea. Acupressure (applying pressure to specific areas of the body) can be applied by wearing a special wristband or by applying firm pressure to the following:

• the back of the jawbone
• the webbing between the thumb and index finger
• the top of the foot
• the inside of the wrist
• the base of the rib cage

Acupuncture is an alternative treatment found to be effective in relieving nausea. A few people, however, experience nausea as a side effect of acupuncture.

Chamomile (Matricaria recutita ) or lemon balm (Melissa officinalis ) tea may relieve symptoms. Ginger (Zingiber officinale ), another natural remedy, can be ingested as tea or taken as candy, cookies, or powdered capsules.

Prognosis

Most instances of nausea and vomiting respond well to appropriate treatment, including removing any substance or condition that precipitates the nausea.

Prevention

Massage, meditation, yoga , and other relaxation techniques can help prevent stress-induced nausea. Antinausea medication taken before traveling can prevent motion sickness. Sitting in the front seat, focusing on the horizon, and traveling after dark can also minimize symptoms.

Food should be fresh, properly prepared, and eaten slowly. Overeating, tight-fitting clothes, and strenuous activity immediately after a meal should be avoided.

Vomiting related to emotional upsets may be avoided by forms of psychotherapy that teach people to manage stress in healthier ways.

Nutritional concerns

Prolonged vomiting can lead to fluid and electrolyte depletion. Nausea can curtail appetite. Over time, this can lead to nutritional problems.

Parental concerns

Parents should be especially concerned about prolonged vomiting in children younger than two years of age. This concern intensifies if the vomiting is accompanied by diarrhea that accelerates fluid and electrolyte depletion. Parents should consult a pediatrician for treatment options if an infant younger than six months of age vomits multiple times within several hours.

KEY TERMS

Antiemetic drug —A medication that helps control nausea; also called an antinausea drug.

Dehydration —An excessive loss of water from the body. It may follow vomiting, prolonged diarrhea, or excessive sweating.

Diabetic coma —A life-threatening, reduced level of consciousness that occurs in persons with uncontrolled diabetes mellitus.

Emesis —An act or episode of vomiting.

Resources

BOOKS

Diagnostic and Statistical Manual of Mental Disorders,4th ed., text revision. Washington, DC: American Psychiatric Association, 2000.

"Functional Vomiting." Section 3, Chapter 21 in The Merck Manual of Diagnosis and Therapy. Edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Hasler, Willliam L. "Nausea, Vomiting, and Indigestion." In Harrison's Principles of Internal Medicine, 15th ed. Edited by Eugene Braunwald, et al. New York: McGraw-Hill, 2001, pp. 236–40.

Pelletier, Kenneth R. The Best Alternative Medicine, Part I: Western Herbal Medicine. New York: Simon and Schuster, 2002.

PERIODICALS

Antonarakis, E. S., and R. D. Hain. "Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practice." Archives of Disease in Childhood 89, no. 9 (2004): 220–3.

Baggley A., et al. "Determinants of women's decision making on whether to treat nausea and vomiting of pregnancy pharmacologically." Journal of Midwifery and Women's Health 49, no. 4 (2004): 350–4.

Czeizel, A. E., et al. "Association between severe nausea and vomiting in pregnancy and lower rate of preterm births." Pediatric and Perinatal Epidemiology 18, no. 4 (2004): 253–9.

Donohew, B. E., and M. J. Griffin. "Motion sickness: effect of the frequency of lateral oscillation." Aviation, Space, and Environmental Medicine 75, no. 8 (2004): 649–56.

Einarson, A., et al. "The safety of ondansetron for nausea and vomiting of pregnancy: a prospective comparative study." British Journal of Obstetrics and Gynecology 111, no. 9 (2004): 940–3.

Hockenberry, M. "Symptom management research in children with cancer." Journal of Pediatric Oncology Nursing 21, no. 3 (2004): 132–6.

Shin, Y. H., et al. "Effect of acupressure on nausea and vomiting during chemotherapy cycle for Korean postoperative stomach cancer patients." Cancer Nursing 27, no. 4 (2004): 267–74.

ORGANIZATIONS

American Academy of Emergency Medicine. 611 East Wells Street, Milwaukee, WI 53202. Web site: <www.aaem.org/>.

American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: <www.aafp.org/>.

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007–1098. Web site: <www.aap.org/default.htm>.

American Academy of Physical Medicine and Rehabilitation. One IBM Plaza, Suite 2500, Chicago, IL 60611–3604. Web site: <www.aapmr.org/>.

American Association of Poison Control Centers. 3201 New Mexico Avenue NW, Washington, DC 20016. Web site: <www.aapcc.org/>.

American Board of Obstetrics and Gynecology. 2915 Vine Street Suite 300, Dallas TX. 75204. Web site: <www.abog.org/>.

American College of Gastroenterology. 4900 B South 31st Street, Arlington VA 22206. Web site: <www.acg.gi.org/>.

WEB SITES

"About Nausea and Vomiting." Cleveland Clinic. Available online at <www.clevelandclinic.org/health/health-info/docs/1800/1810.asp?index=8106> (accessed November 30, 2004).

"Nausea and Vomiting." National Cancer Institute. Available online at <http://cancer.gov/cancerinfo/pdq/supportivecare/nausea/patient/> (accessed November 30, 2004).

"Nausea and Vomiting." National Library of Medicine. Available online at <www.nlm.nih.gov/medlineplus/nauseaandvomiting.html> (accessed November 30, 2004).

"Nausea and Vomiting, Age 4 and Older." Web MD. Available online at <http://my.webmd.com/hw/parenting_and_pregnancy/hw96999.asp> (accessed November 30, 2004).

L. Fleming Fallon, Jr., MD, DrPH

Nausea and Vomiting

Definition

Nausea is the sensation of being about to vomit. Vomiting, or emesis, is the expelling of undigested food through the mouth.

Description

Nausea is a reaction to a number of causes that include overeating, infection, or irritation of the throat or stomach lining. Persistent or recurrent nausea and vomiting should be checked by a doctor.

A doctor should be called if nausea and vomiting occur:

• after eating rich or spoiled food or taking a new medication
• repeatedly or for 48 hours or longer
• following intense dizziness

It is important to see a doctor if nausea and vomiting are accompanied by:

• yellowing of the skin and whites of the eyes
• pain in the chest or lower abdomen
• trouble with swallowing or urination
• dehydration or extreme thirst
• drowsiness or confusion
• constant, severe abdominal pain
• a fruity breath odor

A doctor should be notified if vomiting is heavy and/or bloody, if the vomitus looks like feces, or if the patient has been unable to keep food down for 24 hours.

An ambulance or emergency response number should be called immediately if:

• Diabetic shock is suspected
• Nausea and vomiting continue after other symptoms of viral infection have subsided
• The patient has a severe headache
• The patient is sweating and having chest pain and trouble breathing
• The patient is known or suspected to have swallowed a drug overdose or poisonous substance
• The patient has a high body temperature, muscle cramps, and other signs of heat exhaustion or heat stroke

• Nausea, vomiting, and breathing problems occur after exposure to a known allergen

Causes and symptoms

Persistent, unexplained, or recurring nausea and vomiting can be symptoms of a variety of serious illnesses. It can be caused by simply overeating or drinking too much alcohol. It can be due to stress, certain medications, or illness. For example, people who are given morphine or other opioid medications for pain relief after surgery sometimes feel nauseated by the drug. Such poisonous substances as arsenic and other heavy metals cause nausea and vomiting. Morning sickness is a consequence of pregnancy-related hormone changes. Motion sickness can be induced by traveling in a vehicle, plane, or on a boat. Many patients experience nausea after eating spoiled food or foods to which they are allergic. Patients who suffer migraine headache often experience nausea. Cancer patients on chemotherapy are nauseated. Gallstones, gastroenteritis and stomach ulcer may cause nausea and vomiting. These symptoms should be evaluated by a physician.

Nausea and vomiting may also be psychological in origin. Some people vomit under such conditions of emotional stress as family arguments, academic tests, airplane travel, losing a job, and similar high-stress situations. In addition, some eating disorders are characterized by self-induced vomiting.

Diagnosis

Diagnosis is based on the severity, frequency, and duration of symptoms, and other factors that could indicate the presence of a serious illness.

Diagnosis is based on the taking of a careful patient history. In some cases, the doctor may order laboratory tests or imaging studies to determine the presence of drugs or poisonous substances in the patient's blood or urine, or evidence of head injuries or abnormalities in the digestive tract. If the nausea and vomiting appear to be related to anxiety, stress, or an eating disorder, the doctor may refer the patient to a psychiatrist for further evaluation.

Treatment

Getting a breath of fresh air or getting away from whatever is causing the nausea can solve the problem. Eating olives or crackers or sucking on a lemon can calm the stomach by absorbing acid and excess fluid. Coke syrup is another proven remedy.

Vomiting relieves nausea right away but can cause dehydration. Sipping clear juices, weak tea, and some sports drinks help replace lost fluid and minerals without irritating the stomach. Food should be reintroduced gradually, beginning with small amounts of dry, bland food like crackers and toast.

Medications that are given to relieve nausea and vomiting are called antiemetics. Meclizine (Bonine), a medication for motion sickness, also diminishes the feeling of queasiness in the stomach. Dimenhydrinate (Dramamine), another motion-sickness drug, is not effective on other types of nausea and may cause drowsiness.

Newer drugs that have been developed to treat postoperative or postchemotherapy nausea and vomiting include ondansetron (Zofran) and granisetron (Kytril). Another treatment that has been found to lower the risk of nausea after surgery is intravenous administration of supplemental fluid before the operation.

Alternative treatment

Advocates of alternative treatments suggest biofeedback, acupressure and the use of herbs to calm the stomach. Biofeedback uses exercise and deep relaxation to control nausea. Acupressure (applying pressure to specific areas of the body) can be applied by wearing a special wristband or by applying firm pressure to:

• the back of the jawbone
• the webbing between the thumb and index finger
• the top of the foot
• the inside of the wrist
• the base of the rib cage

Acupuncture is another alternative treatment found to be effective in relieving nausea. A few people, however, experience nausea as a side effect of acupuncture.

Chamomile (Matricaria recutita ) or lemon balm (Melissa officinalis ) tea may relieve symptoms. Ginger (Zingiber officinale ), another natural remedy, can be drunk as tea or taken as candy or powered capsules.

Prevention

Massage, meditation, yoga, and other relaxation techniques can help prevent stress-induced nausea. Anti-nausea medication taken before traveling can prevent motion sickness. Sitting in the front seat, focusing on the horizon, and traveling after dark can also minimize symptoms.

Food should be fresh, properly prepared, and eaten slowly. Overeating, tight-fitting clothes, and strenuous activity immediately after a meal should be avoided.

Vomiting related to emotional upsets may be avoided by forms of psychotherapy that teach patients to manage stress in healthier ways.

KEY TERMS

Acupuncture— A treatment technique associated with traditional Chinese medicine, in which thin needles are inserted into specific points located along energy channels in the human body known as meridians.

Antiemetic— A preparation or medication that relieves nausea and vomiting. Coke syrup, ginger, and motion sickness medications are examples of antiemetics.

Dehydration— Loss of fluid and minerals following vomiting, prolonged diarrhea, or excessive sweating.

Diabetic coma— Reduced level of consciousness that requires immediate medical attention.

Emesis— The medical term for vomiting.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., revised. Washington, DC: American Psychiatric Association, 2000.

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Functional Vomiting." Section 3, Chapter 21 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Pelletier, Dr. Kenneth R. The Best Alternative Medicine, Part I: Western Herbal Medicine. New York: Simon and Schuster, 2002.

PERIODICALS

Ali, S. Z., A. Taguchi, B. Holtmann, and A. Kurz. "Effect of Supplemental Pre-Operative Fluid on Postoperative Nausea and Vomiting." Anaesthesia 58 (August 2003): 780-784.

Cepeda, M. S., J. T. Farrar, M. Baumgarten, et al. "Side Effects of Opioids During Short-Term Administration: Effect of Age, Gender, and Race." Clinical Pharmacology and Therapeutics 74 (August 2003): 102-112.

Chung, A., L. Bui, and E. Mills. "Adverse Effects of Acupuncture. Which Are Clinically Significant?" Canadian Family Physician 49 (August 2003): 985-989.

O'Brien, C. M., G. Titley, and P. Whitehurst. "A Comparison of Cyclizine, Ondansetron and Placebo as Prophylaxis Against Postoperative Nausea and Vomiting in Children." Anaesthesia 58 (July 2003): 707-711.

Quinla, J. D., and D. A. Hill. "Nausea and Vomiting of Pregnancy." American Family Physician 68 (July 1, 2003): 121-128.

Ratnaike, R. N. "Acute and Chronic Arsenic Toxicity." Postgraduate Medical Journal 79 (July 2003): 391-396.

Tan, M. "Granisetron: New Insights Into Its Use for the Treatment of Chemotherapy-Induced Nausea and Vomiting." Expert Opinion in Pharmacotherapy 4 (September 2003): 1563-1571.

Tiwari, A., S. Chan, A. Wong, et al. "Severe Acute Respiratory Syndrome (SARS) in Hong Kong: Patients' Experiences." Nursing Outlook 51 (September-October 2003): 212-219.

Walling, Anne D. "Ginger Relieves Nausea and Vomiting During Pregnancy." American Family Physician 64 (November 15, 2001): 1745.

ORGANIZATIONS

American Gastroenterological Association (AGA). 7910 Woodmont Ave., 7th Floor, Bethesda, MD 20814. (310) 654-2055. 〈http://www.gastro.org/index.html〉. aga001@aol.com.