Nausea

Specialties > Palliative care & EoL care

Background knowledge 🧠

Definition

Nausea: sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit
Commonly a symptom rather than a diagnosis
Associated with a variety of conditions, both gastrointestinal and systemic

Epidemiology

Affects all age groups
More common in females, particularly during pregnancy (up to 80% in the first trimester)
Prevalence in the general population: around 12% experience chronic nausea
Frequent in patients undergoing chemotherapy or surgery
Common in motion sickness, affecting up to 30% of the population

Aetiology and pathophysiology

Gastrointestinal causes: gastroenteritis, peptic ulcer disease, bowel obstruction, gastroparesis
Central causes: raised intracranial pressure, migraine, vestibular disorders
Metabolic/endocrine: uremia, ketoacidosis, hypercalcemia, adrenal insufficiency
Medications: chemotherapy, opioids, antibiotics
Pathophysiology: stimulation of the chemoreceptor trigger zone (CTZ), vagal afferents, vestibular system, or higher cortical centers
Involves neurotransmitters: serotonin, dopamine, acetylcholine, histamine

Types

Acute: sudden onset, often related to infection, toxins, or obstruction
Chronic: lasting for weeks to months, associated with chronic conditions like gastroparesis, functional dyspepsia
Cyclic vomiting syndrome: recurrent episodes of severe nausea and vomiting with asymptomatic periods
Anticipatory: occurs before chemotherapy or other triggers

Clinical Features 🌡️

Symptoms

Subjective feeling of nausea
May be associated with vomiting
Often accompanied by autonomic symptoms: sweating, pallor, tachycardia
May report related symptoms: bloating, abdominal pain, early satiety

Signs

Signs often non-specific and depend on underlying cause
Dehydration signs: dry mucous membranes, decreased skin turgor
Tachycardia, hypotension (especially in cases of significant vomiting)
Abdominal tenderness or distension may indicate GI causes
Neurological signs may suggest central causes: headache, papilledema

Investigations 🧪

Tests

Blood tests: FBC, U&E, LFTs, amylase, glucose, calcium
Imaging: abdominal X-ray, CT scan (if obstruction or central cause suspected)
Endoscopy: if peptic ulcer disease or other GI pathology suspected
Electrolyte levels: particularly potassium and sodium if vomiting is severe
Special tests: MRI brain if neurological cause suspected
ECG: if electrolyte abnormalities or cardiac causes suspected

Management 🥼

Management

Identify and treat the underlying cause
Symptomatic relief: antiemetics (e.g., ondansetron, metoclopramide)
Rehydration: oral or IV fluids depending on severity
Nutritional support: consider NG tube or parenteral nutrition in severe cases
Address complications: electrolyte imbalance correction
Patient education: diet modification, avoiding triggers

Complications

Dehydration and electrolyte imbalances
Malnutrition and weight loss in chronic cases
Aspiration pneumonia (if vomiting is severe)
Esophageal tears (Mallory-Weiss syndrome) from forceful vomiting
Psychological impact: anxiety, depression related to chronic symptoms

Prognosis

Depends on underlying cause: generally good if cause identified and treated
Chronic nausea may require long-term management
Pregnancy-related nausea typically resolves after the first trimester
Cyclic vomiting syndrome: can be challenging to manage, often recurrent
Post-operative nausea often resolves within 24-48 hours with appropriate treatment

Key points

Nausea is a common symptom with diverse causes
Thorough history and examination are essential to identify the underlying cause
Management focuses on treating the cause and symptomatic relief
Early recognition and treatment can prevent complications
Patient education and reassurance are key in chronic cases

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