Nausea and Vomiting

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Nausea and Vomiting As the symptoms
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Goals

• Briefly define
• Outline the prominent disease states associated
  with nausea and vomiting.
• Characterize Nausea and Vomiting caused by the
  prominent disorders
• Discriminate the accompanying symptoms.
• Suggest diagnostic strategies of the symptoms.

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Definition of Nausea and Vomiting
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• Nausea the inclination or feeling of imminent
  desire to vomit, usually felt in the throat or
  epi-gastrum. Associated with decreased activity
  of the stomach.
• Vomiting the forceful oral expulsion of gastric
  contents via retro-peristalsis.
• Nausea-Vomiting simultaneity or separateness

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Nausea and Vomiting
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Definition of emesis. (Three phases) ??????(????)
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1. Nausea - the inclination or feeling of
imminent desire to vomit, usually felt in the
throat or epigastrum. Associated with decreased
activity of the stomach. 2. Retching - the
labored rhythmic contraction of respiratory and
abdominal musculature that frequently precedes or
accompanies vomiting. 3. Vomiting - the forceful
oral expulsion of gastric contents via
retroperistalsis. (Abdominal effects).
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Mechanisms of emesis
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CTZ Emetic Center (Vomiting center)
Emetic Center(??????????)?????????????????????????
(CTZ)???
CTZ????????(??????)???????????(?????????????)
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CTZ Emetic Center (Vomiting center)
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Emetic Center
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??ICP??
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ICPInductively Coupled Plasma ????????
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Neurotransmitters in CTZ Emetic Center

• Neurotransmitters involved in stimulating the
  emetic center, chemo-receptor trigger zone and GI
  tract include
• 5-HT, acetylcholine, histamine, dopamine
  (opiates and receptors for benzodiazepines are
  also found here)

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Emetic Center

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nausea and vomiting
1. Reflective vomiting ????? 2.Central
vomiting ????? 3. Neurological
vomiting ?????
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Reflective vomiting (?????)
Pharyngeal Mechanisms Gastrointestinal
Mechanisms Disease of biliary tract Peritoneal
and mesentery the five sense organs Cardiovascula
r diseases kidney Pelvic
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Pharyngal Mechanisms
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Gastrointestinal Mechanisms
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Central vomiting (?????)
Intra-cranial infection Cerebrovascular
disorders Craniocerebral injury Epilepsy Metaboli
c disorders Drugs
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Drug
Antibiotics Anti-carcinoma Digitalis morphia
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Neurologic and Psychogenic causes
Neurologic Psychogenic causes
????????(Gastrointestinal tract
neurosis) ?????(apositia)
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Characteristics of Nausea and Vomiting

1. Time
2. Taking food
3. Characteristics
4. Characters of contents

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???????? ( Timing with meals)
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The accompanying symptoms
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History/Background

• g) Odor
• h) Frequency
• i) Fever
• j) Weight loss
• k) Precipitating factors
• l) Myalgias(??), visual disturbances, headache,
  pain outside abdomen

• a) Age
• b) GI history required
• c) Food intolerance
• d) Timing with meals
• e) Consistency
• f) Content

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CAUSES OF NAUSEA/VOMITING

• Early pregnancy
• Psychogenesis vomiting
• Bulimia(???)
• Pyloric channel ulcer
• Acute gastritis
• Gastric retention(??)
• Viral gastroenteritis(??????)
• Acute gastroenteritis

• Myocardial infarction
• Peritonitis(???)
• Acute obstruction
• Neurological emergency
• Drug toxicity
• Cancer therapy
• Drug withdrawal

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PHYSICAL EXAM

• Vital signs
• Skin
• HEENT (head,eyes,ear,nose,throat)
• Abdomen
• Neurological

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LABORATORY

• Rule out obstruction and peritonitis
• HCG
• Urinalysis
• Electrolytes, BUN, creatinine, glucose
• Transaminases, amylase
• EKG, head CT, upper GI /or endoscopies

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Break
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Constipation

• Shanghai Second Medical university
• Renji clinical medical college

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Background
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Constipation Is a Constellation of Symptoms
C

• Most commonly reported symptoms
• Hard, lumpy stools
• Increased straining
• Infrequent bowel movements
• Sensation of incomplete evacuation
• Bloating/fullness
• Chronic constipation
• More persistent than intermittent or episodic
• Several months duration

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Constipation Is More Than Just Infrequent Passage
of Stool
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Constipation symptoms reported most often
n 1128
Sandler RS, et al. Dig Dis Sci. 198732841-845.
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Reduced Stool Frequency Is Not the Most Commonly
Reported Symptom in Constipation
C
Constipation symptoms reported most often
Stewart (EPOC) 19991
Paré 20012
n 1476
n 1149
EPOC Epidemiology of constipation BM Bowel
movement. 1. Stewart WF, et al. Am J
Gastroenterol. 1999943530-3540. 2. Paré P, et
al. Am J Gastroenterol. 2001963130-3137.
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Prevalence in the General Population
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Population n Criteria Prevalence, n () Prevalence, n ()
US1 10,018 Rome I Rome I 461 (4.6)
US2 5430 Rome I Rome I 195 (3.6)
US3 15,183 Rome II Rome II 2429 (16)
Canada4 1149 Rome II Rome II 171 (14.9)
China (18-70ys) ? RomeII RomeII ?(6.07)
China(gt60ys) ? RomeII RomeII ?(15-20)
1. Stewart WF, et al. Am J Gastroenterol.
1999943530-3540. 2. Drossman DA, et al. Dig Dis
Sci. 1993381569-1580. 3. Harris Interactive
Study, Wave 2. Data on file. 4. Paré P, et al.
Am J Gastroenterol. 2001963130-3137.
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Epidemiology
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• Chronic constipation is common
• Slightly more common in women
• F/M ratio range 1.3 to 2.5 (China41)
• Affects all age groups

Stewart WF, et al. Am J Gastroenterol.
1999943530-3540. Paré P, et al. Am J
Gastroenterol. 2001963130-3137. Sandler RS, et
al. Dig Dis Sci. 198732841-845.
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Constipation Affects All Age Groups
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N 1149
n 378
n 367
n 217
n 187
Canadian population. Paré P, et al. Am J
Gastroenterol. 2001963130-3137.
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Profile of a Typical Chronic Constipation Patient
in My Practice
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• Generally female
• Symptomatic for gt 10 yr
• Majority have tried lifestyle changes, fiber, and
  OTC laxatives prior to seeking care
• Manages condition with multiple therapies
• Most often referred by a primary care physician
• Copes with condition, but is not completely
  satisfied

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Constipation Can Have a Negative Impact on
Quality of Life
C

• People with CC reported significant impairment in
  QoL on SF-36 scale (n 126)1
• In Canada, people with self-reported or Rome II
  constipation had significantly worse SF-36 scores
  than the normal population (n 472)2
• In Australia, people with constipation had
  significantly worse SF-12 scores on both mental
  and physical scales (n 227)3

1. OKeefe EA, et al. J Gerontol A Biol Sci Med
Sci. 199550M184-M189.2. Irvine EJ, et al. Am J
Gastroenterol. 2002971986-1993. 3. Koloski NA,
et al. Am J Gastroenterol. 20009567-71.
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Constipation Significantly Impacts Healthcare
Utilization
C

• 5.7 million constipation-related outpatient
  visits annually1,2
• 4.1 million physician office-based visits
• 991,000 emergency room visits
• 587,000 hospital outpatient visits
• 2752/patient for tertiary care evaluation3

1. National Ambulatory Medical Care Survey, 2001.
www.cdc.gov 2. National Hospital Ambulatory Care
Survey, 2001. www.cdc.gov 3. Rantis PC Jr, et al.
Dis Colon Rectum. 199740280-286.
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Complications related with constipation

• Colonic and rectal carcinoma
• Other colon-rectal-anus disorders
• hepatic coma
• acute myocardial infarction
• mammary gland disorders
• presenile dementia(?????)
• psycho-problems
• appearance

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Definition Causes of Chronic Constipation

• Secondary
• Drug induced
• Metabolic factors
• Comorbid conditions
• Primary
• Impaired colonic transit/motility
• Altered neuroenteric function and reflexes
• Failure of muscular apparatus
• Ineffective defecation (functional outlet
  obstruction)
• Pelvic dyssynergia and anismus
• Normal transit constipation

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Presentation Objectives
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• Define constipation
• The pathophysiological mechanisms
• Etiologies of constipation
• Characterize manifestation
• Discriminate the accompanying symptoms.
• Suggest diagnostic strategies of the symptoms.

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What is Constipation?

• Passage of hard, dry, lumpy stools Infrequent
  bowel movements, usually fewer than three times a
  week
• Symptoms
• painful bowel movements
• straining
• Uncomfortable(Sensation of incomplete evacuation)
• bloated
• sluggish

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Rome II Defines Functional Constipation Based on
Multiple Symptoms
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• Rome II diagnostic criteria for functional
  constipation
• At least 12 wk, which need not be consecutive,
  over the past 12 months of 2 or more of
• Straining
• Lumpy or hard stools
• Sensation of incomplete evacuation
• Sensation of anorectal obstruction/blockage
• Manual maneuvers to facilitate defecation
• lt 3 defecations/wk
• Loose stools not present
• Insufficient criteria for IBS

gt 1/4 of defecations. Drossman DA, et al. In
Rome II The Functional Gastrointestinal
Disorders. 2000382-391.
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Normal metabolism

• As food moves through your intestines, it absorbs
  water while forming waste products
• Muscles contract in the colon, pushing the stool
  toward the rectum

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Defecation Process

• Yield awareness of defecation
• Anal intra- and extra-sphincter Relaxation
• Abdominal effects

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1. Yield awareness of defecation
Mechanical stimulation
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2. Anal intra- and extra-sphincter Relaxation
intra- sphincter
extra-sphincter
Levator ani muscle
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2. Abdominal effects
gastric contents via anus
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What Causes Constipation?

• Eating too little fiber
• Not drinking enough liquids
• Lack of exercise/physical activity

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What Causes Constipation?

• Change in routine
• travel
• Older age
• Slower metabolism
• Frequent use of laxatives
• Certain diseases or conditions

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What Causes Constipation?

• Certain diseases or conditions
• Rectal and Anal disorders
• Colonic disorders
• Systemic diseases or conditions

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What Causes Constipation?

• Medications

• pain (narcotics??)
• antacids containing aluminum
• antidepressants
• iron supplements
• diuretics (water pills)

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Classification of etiologies
Functional etiologies

• Frequent use of laxatives
• tediously long Colon
• Medications
• Travel
• pain (narcotics??)
• antacids containing aluminum
• antidepressants
• iron supplements
• diuretics (water pills)

• Eating too little fiber
• Not drinking enough liquids
• Lack of exercise/physical activity
• Change in routine
• Travel
• psycho-related
• Older age
• Slower metabolism

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psycho-related
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Tediously long Colon
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Classification of etiologies
Organic constipation (certain diseases or
conditions cause constipation)

• Rectal and Anal disorders
• Benign or malignancy tumor
• Tumor or mass outside
• Systemic diseases or conditions (e.g. disorders
  make dyscinesia spasm and paralysis)

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Rectal and Anal disorders
Cancer Nevus anal fissure anal fistula Proctoptosi
s (????)
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intestinal obstruction
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Benign or malignancy tumor
Polyp
Cancer
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Outside tumor or mass
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Systemic diseases or conditions
Gastro-paresis Diabetes mellitus
DM Uremia Myasthenia gravis Hypothyroidism Hematop
orphyria Lead poisoning
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Characteristics of manifestation
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1.??2.??3.??4.??5.?6.?7.?
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Accompanying symptoms
1??????????,????? 2?????????????Crohn? 3????????
???IBS?UC 4??????????????
Intestinal obstruction Tumor,TB,Crhons
disease TB,IBS,UC Functional constipation
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Important information for etiological diagnosis

• g) Frequency
• h) form, texture, Odor, Content,
• i) Increased straining, Sensation of incomplete
• j) Weight loss
• k) Precipitating factors
• l) Medications
• m) Disorders outside gastroenterology

• a) Age
• b) GI history required
• c) Food habit
• d) Condition related (living,working,
  communicating, psychology)
• e) Consistency
• f) course of diseases

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