Nausea and vomiting are very distressing symptoms. Without effective treatment people can rapidly decline through an inability to eat resulting in weakness, fatigue and often depression.
Identifying the cause leads to better success in controlling symptoms. Often there are multiple minor causes that tip the threshold into feeling sick.
Red flags
Exclude bowel obstruction
Key clinical features to assess in the community
- Review underlying diagnosis and recent treatment (e.g. site of tumours, organ failure, recent chemotherapy)
- Medication review - see table below
- Severity e.g. inability to take usual oral medication
- Overall condition: signs of dehydration or infection (UTI, chest infection, oral candida)
- Abdominal and rectal exam for constipation, ascites, masses, bowel sounds, tender epigastrium
- Assessment of anxiety levels as this can be a cause of nausea
- Associated symptoms e.g. headache suggesting a cerebral cause
An initial approach to treatment
- Stop or reduce dose of offending drugs
- Blood tests for a metabolic cause - Ca2+, liver and renal function
- Urinalysis for ketones and to exclude infection
- Give antiemetics regularly rather than PRN
- Once people feel sick, retroperistalsis may have started, and subcutaneous route often better than oral
- Consider more specific treatments/investigations according to cause - see table below
- Nutritional and hydration advice can be very effective
- Is patient safe to keep at home - inpatient care/tests may be needed for dehydration, diagnosis, electrolyte abnormalities
Top tips
- Beware worsening colic (or vomiting) with prokinetics e.g. metoclopramide - suggests bowel obstruction
- Levomepromazine has a broad spectrum of action but is sedating at doses > 12.5mg/24h
- Ondansetron can cause constipation
- Metoclopramide can cause neurological side effects e.g. akathisia/restlessness
- 25% of cases may need 2 antiemetics
- Olanzapine is an alternative broad-spectrum antiemetic starting in doses of 2.5mg OD
- Prochlorperazine (in buccal form Buccastem) is useful at home if no injections are available
- Bland food, avoiding cooking smells, and some complementary approaches e.g. ginger and Sea Bands may help
- Crushed ice or ice lollies can be incredibly helpful for nausea
Specialist care
- Advice on combination antiemetics
- Abdominal CT scan and ultrasound if symptoms persist to exclude obstruction
Specific treatments according to cause:
|
Cause |
Clinical Features |
Initial approach to treatment |
|
Drugs e.g. opioids*, antibiotics, SSRIs, NSAIDs, steroids, chemotherapy
*If dose of opioid is stable, it is unlikely to be the cause of nausea |
Constant background nausea |
Stop/reduce dose of offending drugs Consider gastroprotection with PPI Haloperidol Oral/subcutaneous dose: 0.5-1.5mg once or twice daily, up to 5 mg daily. Syringe pump: 2.5mg–5 mg/24 hrs Metoclopramide Oral/subcutaneous dose: 10 mg 3-4 x/24 hrs. Syringe pump: 30–40 mg /24 hours Ondansetron for chemotherapy nausea. Oral/subcutaneous dose 4mg-8mg b.d. |
|
Metabolic causes renal failure, liver failure, hypercalcaemia, hyponatraemia |
Co-existent delirium may suggest metabolic cause |
Haloperidol as above Hypercalcaemia will need IV hydration and bisphosphonates (if appropriate to admit) |
|
Gastric stasis, and severe constipation |
Large volume vomit, relief of symptoms after vomiting, oesophageal reflux, hiccups |
Stop/reduce anticholinergic drugs such as Buscopan, tricyclic antidepressants, Oxybutynin Use prokinetic antiemetics: e.g. Domperidone 10mg tds orally or Metoclopramide as above Treat constipation Prucalopride 1-2 mg once daily is a new option to help gastroparesis and severe constipation Erythromycin 250mg b.d. may help |
|
Physical obstruction (from tumour or external compression by ascites) |
Vomiting pattern depends on level of obstruction |
If possibility of reversal – use prokinetic Metoclopramide in a syringe pump as above Dexamethasone e.g. 8mg subcutaneously may help nausea and reduce compression If likely irreversible – a combination of Cyclizine +/- Haloperidol in a syringe pump CT may help to identify level/reversibility of blockage |
|
Toxins e.g. ischaemic bowel, tumour products, infection |
Waves of nausea and poor appetite |
Levomepromazine Oral or subcutaneous dose: 6.25 mg 8 hourly. Syringe pump dose: 12.5 mg-25mg /24 hrs Frail elderly - start at 2.5mg as can be sedative |
|
Raised intracranial pressure |
Effortless vomiting, often in the morning, associated with headache and papilloedema |
Cyclizine Oral dose: 25–50 mg up to 150 mg/24hrs Subcutaneous dose: 25mg up to 100mg/24 hrs CT head plus Dexamethasone /oncology review |
|
Motion-associated nausea |
Nausea or sudden vomiting on movement (e.g. turning in bed) |
For vestibular disturbance use Cyclizine as above |
|
Anxiety-related nausea |
Nausea may be triggered by an emotional stimulus |
CBT may help Lorazepam 0.5mg orally can be tried |