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Rohan Mudkavi Nausea and vomitingCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. Two ways to split the differential diagnosis 2. Anatomical/physiological method 3. History-based method 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. ANTI-EMETICS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING N&V 1. Bowel obstruction 2. NVP 3. Ménière‘s disease 6. QUIZ NUMBER 2CONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. Two ways to split the differential diagnosis 2. Anatomical/physiological method 3. History-based method 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. ANTI-EMETICS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING N&V 1. Bowel obstruction 2. NVP 3. Ménière‘s disease 6. QUIZ NUMBER 2Two methods to split the diagnosis 1. Anatomical/physiological – consider the inputs to the vomiting centre and what can affect these inputs 2. History based – split the differential based on symptoms Anatomical/physiological method Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press. HANDS! History-based method Acute Chronic Headache Abdominal pain None of these Dizziness Shortly after food Weight loss No weight loss • Meningitis Fever No fever • Drugs • Labyrinthitis • Gastric outlet • Upper GI • Oesophagiti • Encephalitis • Psychogenic • Ménière’s obstruction obstruction s • Raised ICP • Gastroenteriti • Bowel (anxiety) disease • Coeliac • Pharyngeal • Migraine s obstruction • Hyperthyroidis • Vestibular disease pouch • Cholecystitis • Diabetic m neuronitis • Pancreatitis ketoacidosis • Renal failure + • Acoustic • Appendicitis • Drugs uraemia neuroma • Mesenteric • Toxins • Cyclic vomiting • BPPV adenitis • Mesenteric syndrome • Motion • Pyelonephritis ischaemia • Pregnancy sickness • MI • Kidney stones • Testicular torsion Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press.CONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. Two ways to split the differential diagnosis 2. Anatomical/physiological method 3. History-based method 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. ANTI-EMETICS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING N&V 1. Bowel obstruction 2. NVP 3. Ménière‘s disease 6. QUIZ NUMBER 2HISTORY T AKING HISTORY OF PRESENTING COMPLAINT PAST MEDICAL HISTORY DRUG HISTORY FAMILY HISTORY SOCIAL HISTORY Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press.HPC Questions about the vomit: Associated symptoms: 1. Contents 1. HANDS a. Undigested – high up (ie oesophagus) 1. Headache b. partially digested (gastric outlet obstruction, 2. Abdominal pain gastroparesis) c. bilious – small bowel, after ampulla of vater 3. fever d. faeculent – Distal intestinal/ colonic 4. Dizziness obstruction 2. Weight loss e. blood – haematemesis 3. Bowel movements 2. Volume 1. Constipation – bowel obstruction a. large volume makes organic more likely 3. Timing 2. Diarrhoea – gastroenteritis a. Duration (acute vs chronic) 3. Blood – from constipation or b. early morning – pregnancy, raised ICP gastroenteritis c. after eating – gastroparesisPMH Diabetes Makes DKA and gastroparesis more likely Makes mesenteric ischaemia/ MI more likely Psychiatric conditions Important to ask when considering functional cause Gallstones Makes pancreatitis and cholecystitis more likely History of abdominal surgery Makes bowel obstruction more likely Malignancy can cause bowel obstructionDHX The drugs which cause N&V can be remembered with the of 2 Cs: chemotherapy, contraception 2 Os: opiates, overdose (ie paracetamol, aspirin)FHX 1. Any conditions in PMH (ie CV disease, diabetes, psychiatric conditions, gallstones, cancer)SHx 1. Exposure to infectious bowel pathogens a. Close contact with someone with similar symptoms b. Living in close quarters c. Recent foreign travel d. Recent unusual meals 2. Exposure to dangerous chemicals a. Organophosphate fertilizers 3. Lifestyle factors a. Ie alcohol 4. Any chance of being pregnant?CONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. Two ways to split the differential diagnosis 2. Anatomical/physiological method 3. History-based method 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. ANTI-EMETICS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING N&V 1. Bowel obstruction 2. NVP 3. Ménière‘s disease 6. QUIZ NUMBER 2 Anti-emetics Drug M.O.A Uses Haloperidol D2 antagonist Chemical causes (uraemia, drug induced) Cyclizine H1 and AChm Vestibular system antagonist issues (ie Meniere’s) Metoclopramide D2 antagonist and Bowel stasis 5-HT4 agonist, pro- motility Levomepromazine Broad mechanism Anxiety (D2, H1, AChm, 5- N&V of unknown HT2) origin Ondansetron 5-HT3 antagonist Chemical causes, radiation from bowelCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. Two ways to split the differential diagnosis 2. Anatomical/physiological method 3. History-based method 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. ANTI-EMETICS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING N&V 1. Bowel obstruction 2. NVP 3. Ménière‘s disease 6. QUIZ NUMBER 21. How can you differentiate vestibular neuronitis and labyrinthitis? 1. Vestibular neuronitis is more severe 2. Labyrinthitis causes vomiting 3. Vestibular neuronitis causes hearing loss 4. Labyrinthitis causes hearing loss 5. Vestibular neuronitis causes dizziness2. Undigested vomit suggests an obstruction where? 1. High up (ie oesophagus) 2. Past the stomach 3. Small intestine 4. Large intestine3. Which of the following receptors are involved in the connection between the CTZ and the vomiting centre? 1. 5-HT2 and GABA receptors 2. 5-HT3 and D2 receptors 3. AChm and H1 receptors 4. 5-HT3, 5-HT4 and D2 receptors 5. Achm, H1 and 5-HT2 receptors4. Which of the following is themechanism of action of cyclizine? 1. D2 antagonist 2. 5-HT4 agonist 3. H1 and AChm antagonist 4. 5-HT3 antagonist 5. Broad mechanismCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. Two ways to split the differential diagnosis 2. Anatomical/physiological method 3. History-based method 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. ANTI-EMETICS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING N&V 1. Bowel obstruction 2. NVP 3. Ménière‘s disease 6. QUIZ NUMBER 2Bowel obstructionWhat is bowel obstruction? Bowel obstruction is when the passage of contents through the bowel becomes blockedCAUSES The ’big three’ ‘Other’ causes 1. Adhesions (small bowel) 1. Volvulus 2. Hernias (small bowel) 2. Diverticular disease 3. Malignancy (large bowel) 3. Strictures (ie Chron’s) 4. Intussusception 1.Lockwood, J. and Carr, D. (2014). Drug-induced aseptic meningitis seconda.y to trimethoprim/sulfamethoxazole: a headache to be aware of. PubMed, 16(5), pp.421–4Symptoms 1. Nausea and vomiting – bilious vomiting 3. Abdominal pain – diffuse 4. Absolute constipation 5. ‘Tinkling’ bowel sounds 6. Signs/ symptoms of underlying conditionDIAGNOSIS Bloods Imaging 1. Blood gas – raised 1. Abdominal X ray lactate and metabolic 2. Erect chest X ray alkalosis 3. Abdominal CT scan 2. UsandEs - Electrolyte abnormality Images - https://medizzy.com/feed/36288543Diagnosis – SBO vs LBO Remember 3/6/9 rule! 1. https://geekymedics.com/bowel- obstruction/#:~:text=Abdominal%20X%2Dray%3A%20may%20demonstrate,severity%2C%20underlying%20aetiology%20and%20complications 2. https://www.radiologymasterclass.co.uk/gallery/abdo/abdominal_xray/small_bowel_obstructionManagement Drip and Suck Surgery (exact surgery depends on 1. Nil by mouth cause): 2. IV fluids a. Exploratory (if cause 3. NG tube b. Adhesiolysis c. Hernia repair d. Resection of tumorCOMPLICA TIONS 1. The main complication is perforation 2. And subsequent peritonitis Mohan, S., Rogan, E.A., Batty, R., Raghavan, A., Whitby, E.H., Hart, A.R. and Connolly, D.J.A. (2013). CT of the neonatal head. Clinical Radiology, [online] 68(11), pp.1155–1166CONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. Two ways to split the differential diagnosis 2. Anatomical/physiological method 3. History-based method 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. ANTI-EMETICS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING N&V 1. Bowel obstruction 2. NVP 3. Ménière‘s disease 6. QUIZ NUMBER 2Nausea and vomiting in pregnancy/ hyperemesis gravidarumWhat is NVP/ HE? • Nausea and vomiting in pregnancy (NVP) is very common in early stages. • Hyperemesis gravidarum (HG) is used to describe the extreme end of the condition.Causes/ risk factors Cause: Risk factors human chorionic 1. Multiple pregnancy (higher hCG) gonadotrophin 2. Molar pregnancy (higher hCG) (hCG) 3. Nulliparity (first pregnancy) 4. Obesity 5. Family history 6. Non-smokerSYMPTOMS Characteristics of NVP: 1. Worse in mornings and early pregnancy 2. Timeline: o Start at 4-7 weeks o Worst at 10-12 weeks o Resolve by 16-20 weeksDIAGNOSIS PUQE HG diagnosis • Score out of 15 Protracted N&V plus: • <7 - mild 1. >5% pre-pregnancy weight loss • 7-12 – moderate 2. Dehydration • >12 - severe 3. Electrolyte imbalanceMANAGEMENT 1. Conservative therapies: Ginger, acupressure at PC6 point in inner wrist, avoid triggers, bland foods Remember PCOM for 2. Anti-emetics: anti-emetics in NVP a. Prochlorperazine, cyclizine, ondansetron, metoclopramide (PCOM) 3. Omeprazole/ ranitidine 4. Admit if any of the following: Unable to tolerate oral fluids, Ketonuria (>2+ ketones) , Weight loss > 5%, Comorbidities being affected 5. Inpatient treatment involves IV/IM antiemetics, IV fluids, thiamine supplementation, thromboprophylaxisCOMPLICA TIONS • Wernicke’s encephalopathy • VTE • Dehydration and AKI • Esophagitis and Mallory Weiss tearCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. Two ways to split the differential diagnosis 2. Anatomical/physiological method 3. History-based method 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. ANTI-EMETICS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING N&V 1. Bowel obstruction 2. NVP 3. Ménière‘s disease 6. QUIZ NUMBER 2What is Ménière‘s? • Ménière’s disease is a long term disorder of the inner ear which causes vertigo, tinnitus and hearing loss.What causes it? • Buildup of endolymph in the labyrinth of the inner ear (endolymphatic hydrop) • What causes this build up of endolymph is unknownSYMPTOMS AND SIGNS Classic triad: ‘Other’ features 1. Vertigo 1. Feeling of fullness in the ear 2. Unexplained falls without LOC 2. Tinnitus 3. Sensorineural hearing loss 3. Nystagmus during attack 4. Positive Romberg’s testDIAGNOSIS 1. Clinical diagnosis (made by ENT specialist) 2. Audiometry – characterize hearing loss Management Driving rules Management Prophylaxis 1. Patients should inform the during acute 1. Betahistine DVLA and not drive until they attack 2. Vestibular have control of symptoms rehabilitation exercises 1. Prochlorperazine 2. Antihistamines (cyclizine, cinnarizine, promethazine)COMPLICA TIONS The symptoms of Meniere’s disease should resolve within 5-10 years however there are two main complications: 1. Degree of hearing loss 2. Psychological distressCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. Two ways to split the differential diagnosis 2. Anatomical/physiological method 3. History-based method 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. ANTI-EMETICS 4. QUIZ NUMBER 1 5. CONDITIONS CAUSING N&V 1. Bowel obstruction 2. NVP 3. Ménière‘s disease 6. QUIZ NUMBER 21. Which of the following is the most common cause of small bowel obstruction? 1. Tumours 2. Adhesions 3. Volvulus 4. Intussusception 5. Hernias2. Which of the following is not a symptom of bowel obstruction? 1. Absent bowel sounds 2. Bloating 3. Abdominal pain 4. Absolute constipation 5. Vomiting3. What is the cut off for small bowel diameter for small bowel obstruction? 1. 3cm 2. 6cm 3. 9cm 4. 12cm 5. 15cm4. What is not a risk factor for NVP? 1. Molar pregnancy 2. Multiple pregnancy 3. Obesity 4. First pregnancy 5. Smoking5. Which of the following is not part of the diagnostic criteria for hyperemesis gravidarum? 1. Protracted N&V 2. Dehydration 3. Ketosis 4. >5% pre-pregnancy weight loss 5. Electrolyte balance6. What is the first line medical management of NVP? 1. Ondansetron 2. Metoclopramide 3. Prochlorperazine 4. Levomepromazine 5. Cinnarizine7. Which of the following is not a symptom/sign of Ménière’s disease? 1. Conductive hearing loss 2. Fullness in ear 3. Positive Romberg’s test 4. Tinnitus 5. Vertigo8. Which of the following is used as prophylaxis for Ménière’s disease? 1. Prochlorperazine 2. Cyclizine 3. Cinnarizine 4. Promethazine 5. Betahistine @prescribing_the_essentials THANK YOU!REFERENCES 1. Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press. 2. Anon, (n.d.). Zero To Finals – Tools for Medical School. [online] Available at: https://zerotofinals.com. 3. passmedicine.com. (n.d.). Passmedicine. [online] Available at: https://passmedicine.com. 4. https://geekymedics.com/bowel- obstruction/#:~:text=Abdominal%20X%2Dray%3A%20may%20demonstrate,severity%2C%20underly ing%20aetiology%20and%20complications 5. https://www.radiologymasterclass.co.uk/gallery/abdo/abdominal_xray/small_bowel_obstruction