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nausea

An unpleasant, but not painful sensation generally perceived in the upper abdomen. It is generally accompanied by hypersalivation & the desire to vomit or the feeling that vomiting is imminent. It may be brief, prolonged & sometimes occurs in waves. See vomiting. Etiology: - gut wall dilation -constipation, bowel obstruction, ileus (GUT)* - gut mucosal injury - radiation therapy, chemotherapy, infection, inflammation (gastritis), direct tumor invasion (GUT)* - drugs, metabolites, bacterial toxins (CTZ)* - new narcotic use is a likely cause of nausea - motion sickess, labyrinthine disorders (vesibular)* - anticipatory nausea (cerebral cortex)* - increased intracranial pressure (?)* * see pathology for mechanism at site or origin Pathology: - mediated by - dopamine D2 receptors or 5-HT3 receptors in GI tract - dopamine D2 receptors, 5-HT3 receptors or neurokinin-1 receptors in the chemoreceptor trigger zone (CTZ) - histamine H1 receptors & muscarinic receptors in the vestibular system - unknown mediators in the cerebral cortex (putative) Management: 1) sucking of hard candy or popsicle especially in children 2) anticholinergics for motion sickness - scopolamine 3) antihistamines - inner ear dysfunction or motion sickness a) dimenhydrinate (Dramamine) 50 mg PO/IV/IM every 4 hours b) promethazine (Phenergan) 25-50 mg PO/IV/IM every 4-6 hours 4) dopaminergic antagonist (metochlopramide, prochlorperazine, haloperidol) for dopamine D2 receptor mediated nausea 5) antacids for nausea due to gastritis [2] 6) serotonin antagonists (ondansetron, granisetron) for 5-HT3 receptor (chemotherapy) mediated nausea 7) aprepitant for resistant chemotherapy-induced nausea [2] 8) benzodiazepines for anticipitory nausea 9) glucocorticoids for increased intracranial pressure 10) octreotide for nausea due to bowel obstruction 11) do not use topical agents for treatment of nausea [2] 12) treatment of nausea in palliative care a) if due to constipation, bowel obstruction, ileus - dopaminergic antagonists - metoclopramide, prochlorperazine, haloperidol, olanzapine - olanzapine improves chronic nausea in patients with advanced incurable cancer [3,4] b) if due to chemotherapy, radiation, inflammation, advanced incurable cancer - ondansetron, granisetron - if intractable nausea & vomiting use ondanstetron 4 mg every 8 hours around the clock [2] - ondansetron contraindicated wiht allergy to another 5-HT3 antagonist. i.e. alosetron c) if due to drugs, metabolites, bacterial toxins - dopaminergic antagonists, glucocorticoids, serotonin receptor antagonists - neurokinin-1 receptor antagonists: aprepitant, netupitant - aprepitant relies on CYP3A4 metabolism as does oxycodone d) if due to labyrinthine disorder, motion sickness - anticholinergic agents: scopolamine, diphenhydraine, promethazine e) increased intracranial pressure: glucocorticoids 13) also see vomiting

Related

vomiting

Specific

nausea/vomiting - chemotherapy induced post-operative nausea & vomiting

General

sign/symptom

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  2. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  3. Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  4. Navari RM, Pywell CM, Le-Rademacher JG, et al. Olanzapine for the treatment of advanced cancer-related chronic nausea and/or vomiting: a randomized pilot trial. JAMA Oncol. 2020;6:895-899. PMID: 32379269
  5. Moorthy GS, Letizia M. The Management of Nausea at the End of Life. J Hosp Palliat Nurs. 2018 Oct;20(5):442-449. PMID: 30188436