American Gastroenterological AssociationAGA technical review on nausea and vomiting☆
Section snippets
Definitions
Before reviewing the evaluation and management of nausea and vomiting, it is important to be clear on their definitions, the definition of related symptoms, and, in particular, their differentiation from a number of other symptoms prone to cause confusion (Table 1).Nausea is entirely subjective and is commonly described as the sensation (or sensations) that immediately precede vomiting. Patients state that they feel as if they are about to vomit, or use such terms as “sick to the stomach” or
Socioeconomic impact of nausea and vomiting
Nausea and vomiting, from all causes, involve significant social and economic costs to affected patients, their employers, and the health care industry.5, 6, 7 A recent analysis suggested that acute enteric infectious illnesses increase medical expenses by $1.25 billion and lead to $21.8 billion in lost productivity in the United States each year.8 Two British studies reported that 8.5 million working days are lost each year because of the nausea of pregnancy and that severely affected patients
Differential diagnosis of nausea and vomiting
The differential diagnosis of nausea and vomiting is extensive and includes a broad range of pathologic and physiologic conditions affecting the gastrointestinal tract, the peritoneal cavity, and the CNS as well as endocrine and metabolic functions (Table 2).Medications and toxic etiologies Disorders of the gut and peritoneum Cancer chemotherapy Mechanical obstruction Severe—cisplatinum, dacarbazine, nitrogen mustard Gastric outlet obstruction
Clinical approach to nausea and vomiting
Given the vast number and diversity of potential causes of nausea and vomiting, a carefully considered and orderly approach to the evaluation and treatment of patients with nausea and vomiting is needed to maintain cost effectiveness and avoid misdiagnosis (see Medical Position Statement). A comprehensive history and physical examination form the framework on which the diagnostic evaluation of these patients is based. A clear understanding of each patient's symptoms, and precisely what they
General principles
Treatment of the patient with nausea and vomiting must address a number of important issues.94 These include (1) correction of any fluid, electrolyte, or nutritional deficiencies that may have resulted from vomiting itself or the food aversion that may accompany these symptoms; (2) identification and elimination of the underlying cause of the symptoms where possible; and (3) suppression or elimination of the symptoms themselves if the primary cause cannot be identified easily and promptly
Intractable nausea and vomiting related to gastroparesis
Surgical treatment of gastroparesis and motility disorders has proven disappointing in general, and the temptation to proceed to bypass procedures should be particularly resisted. Results of resection in patients with diabetic gastroparesis have also been disappointing. However, for patients with postoperative gastroparesis in whom medical management has failed, resection may be considered. If resection is performed, a subtotal gastrectomy, rather than less extensive resections, appears to give
Acknowledgements
The Clinical Practice and Practice Economics Committee acknowledges the following individuals, whose critiques of this review paper provided valuable guidance to the authors: Robert Hammer, M.D., Ken Koch, M.D., and Joseph Murray, Ph.D.
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