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PubMed1995

Cyclic vomiting: the pattern and syndrome paradigm.

Although it remains a mysterious disorder since its description over a century ago, cyclic vomiting syndrome appears to be more prevalent than previously thought. With the goal of improving detection of affected children, two quantitative historical criteria-peak intensity > or = 4 emeses/h) and a episode frequency < or = 9/ month-can differentiate those with an explosive, intermittent cyclic pattern from those with a low-grade, daily chronic pattern. Diagnoses that can cause a cyclic vomiting pattern includes abdominal migraine, chronic sinusitis, intracranial neoplasm, anomalies of and mucosal injury to the gastrointestinal tract, urologic abnormalities, and metabolic and endocrine disorders. Because many organic disorders can mimic cyclic vomiting syndrome, a systematic diagnostic evaluation of potential underlying disorders is recommended. The following terminology is proposed: a cyclic pattern is differentiated from a chronic pattern of vomiting on the basis of a higher peak intensity of emesis and lower frequency of episodes; and of those with a cyclic vomiting pattern, an idiopathic subgroup who is not found to have an underlying disorder on diagnostic testing can be labeled as having cyclic vomiting syndrome.

Child↗
PubMed1998

Vomiting and gastroesophageal motor activity in children with disorders of the central nervous system.

BACKGROUND: Vomiting is common in children with disorders of the central nervous system (CNS) and is usually ascribed to gastroesophageal reflux (GER). However, recent acquisitions on the pathophysiology of vomiting suggest that the dysmotility of the foregut may be more widespread. METHODS: Fifty-five children with CNS disorders, 50 of whom suffered from retching and/or vomiting (18 following fundoplication) were studied. We assessed GER by 24 hour pH monitoring and endoscopy, gastric electrical activity by electrogastrography, and gastric half-emptying time (T1/2) of a milk meal be electrical impedance tomography. RESULTS: Of the 50 vomiting patients, 29 had GER (reflux index of 5.7%-87.4%; controls: < 5%), and 31 had gastric dysrhythmias (12 tachyarrhythmia at 5.5-11.2 cpm, 4 bradyarrhythmia at 1.7-1.9 cpm, 15 unstable electrical activity; controls; 2.2-4.0 cpm). Sixteen patients had GER and gastric dysrhythmias. Eleven of 18 patients with fundoplication had gastric dysrhythmias. Gastric T1/2 was delayed in 12 of 13 patients with gastric dysrhythmia (6 with GER), versus 2 of 5 with GER alone. No abnormalities were detected in the 5 patients who did not suffer from vomiting. CONCLUSIONS: Children with CNS disorders who vomit have abnormal gastric motility as often as GER. Following fundoplication, many patients continue to have symptoms possibly related to gastric dysrhythmias, the effects of which may be unmasked by fundoplication. Foregut dysmotility may be related to abnormal modulation of the enteric nervous system by the CNS or to involvement of the enteric nervous system by the same process affecting the brain.

Adolescent↗
PubMed2004

The vomiting neonate: a review of the ACR appropriateness criteria and ultrasound's role in the workup of such patients.

Ultrasound (US) plays a central role in the diagnostic imaging workup for infantile vomiting. This paper reviews the major causes of vomiting in the first months of life and the use of US and other modalities for their imaging assessment. The differential diagnostic possibilities are reviewed by examining 3 clinical scenarios of bilious vomiting during the first days of life, nonbilious vomiting since birth, and projectile vomiting first occurring after several weeks of life. These are the 3 scenarios that were used for the American College of Radiology (ACR) Appropriateness Criteria for Vomiting in Infants up to 3 Months of Age.

Education, Medical, Continuing↗
PubMed1988

Regulation of nausea and vomiting in cancer chemotherapy. A review with emphasis on opiate mediators.

Chemotherapy-induced nausea and vomiting are primarily regulated by chemoreceptor trigger zone (CTZ)-vomiting center (VC) pathways. Dopaminergic (D2), histaminic (H1), and muscarinic cholinergic (Ach) receptors are present in these sites, and specific receptor antagonists are potent but not "universal" antiemetics when used alone or in combination. Recently, neurons containing the endogenous opiate enkephalin were also identified near the CTZ and the VC. Furthermore, opiates stimulate vomiting at the CTZ and inhibit vomiting at the VC in dogs and in cats. A dose-related increase in nausea and vomiting in response to the opiate antagonist naloxone has also been demonstrated in patients receiving cancer chemotherapy. These observations support a role for endogenous opiates in regulating chemotherapy-induced nausea and vomiting; further, they suggest that narcotic agents may be effective antiemetics in this setting.

Antineoplastic Agents↗
PubMed2006

Correlates of self-induced vomiting and laxative misuse in a community sample of women.

The correlates of self-induced vomiting and laxative misuse were examined in a large community sample of young adult women (N = 5255). Scores on measures of eating disorder psychopathology, general psychological distress, functional impairment, as well as the use of health services for an eating or weight problem were compared among participants who reported regular self-induced vomiting, but not laxative misuse (N = 59), and those who reported regular misuse of laxatives, but not vomiting (N = 39). Individuals who misused laxatives were older, perceived poorer physical health, and were less likely to have sought treatment specifically for a problem with eating than those who engaged in self-induced vomiting. In all other respects, the groups were similar. However, individuals who regularly engaged in both forms of purging (N = 8) had particularly high levels of eating disorder and comorbid psychopathology. The perception among women of normal weight that only syndromes involving the use of self-induced vomiting constitute an eating disorder may need to be addressed in prevention programs. The combination of self-induced vomiting and laxative misuse may indicate a particularly severe psychiatric disturbance.

Adolescent↗
PubMed1994

Single dose intravenous ondansetron for the 24-hour treatment of postoperative nausea and vomiting.

Postoperative nausea and vomiting is a major concern for patients undergoing outpatient surgery under general anaesthesia, and may complicate and delay discharge from hospital. This paper evaluates the safety and efficacy of ondansetron, a 5-HT3 receptor antagonist, in the treatment of postoperative nausea and vomiting. One thousand patients in 30 centres in the United States who received general anaesthesia and developed postoperative nausea and vomiting were studied. In a randomised, double-blind, stratified and parallel designed protocol, patients received either ondansetron 1, 4, 8 mg or placebo for nausea or vomiting occurring within 2 h of entry into the Post Anaesthesia Care Unit. Subsequent episodes of vomiting, nausea scores, laboratory and clinical safety data and adverse events were evaluated during the 24-h study period. In a separate study, pharmacokinetic data were compared for intramuscularly and intravenously administered ondansetron. Each dose of ondansetron was significantly better than placebo in reducing nausea from control values during the initial 2-h study period, and in preventing further emesis over 24 h. There were no significant differences in the incidence of adverse events, changes in laboratory values or measures of vital signs in the ondansetron groups compared to the placebo group. Dose comparisons between the three treatment groups showed that ondansetron 4 mg is the optimal dose to treat postoperative nausea and vomiting. Ondansetron is a well tolerated, efficacious antiemetic which has a similar side effect profile to placebo. Intramuscular administration has the same systemic availability as intravenous administration.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1997

Propofol anaesthesia and vomiting after myringoplasty in children.

To determine whether propofol anaesthesia reduces the incidence of nausea and vomiting after ear surgery, 40 children aged 4-16 years were randomly assigned to receive either propofol or inhalational anaesthesia. Children in the propofol group had anaesthesia induced with propofol and maintained with propofol-nitrous oxide and those in the inhalational group had anaesthesia induced with thiopentone and maintained with isoflurane-nitrous oxide. Nausea and vomiting were recorded for 24 h after surgery and metoclopramide was offered to children who vomited more than twice. We found that 11 children (55%) who had propofol and 14 children (70%) who had inhalational anaesthesia vomited one or more times after surgery (difference not significant). The incidence of vomiting was lower in the propofol group during the first 2 h after surgery (0% and 25% propofol and inhalational groups, respectively) (p < 0.05) but was similar at all other time intervals. Rescue anti-emetic was given to two (10%) and eight (40%) children in the propofol and inhalational groups, respectively (p < 0.05). We conclude that propofol anaesthesia alone is not an effective means of preventing vomiting after middle ear surgery in children.

Adolescent↗
PubMed1994

Postoperative nausea and vomiting. A comparison between intravenous and inhalation anaesthesia in breast surgery.

Nausea and vomiting during the first 24 postoperative hours after breast surgery were studied. Ninety patients scheduled for elective breast surgery were randomly assigned to one of three anaesthetic methods: total intravenous anaesthesia with propofol, or propofol or thiopental for induction followed by isoflurane anaesthesia. All three groups received fentanyl for peroperative analgesia. A total of 46 (51%) patients experienced emetic sequelae: 19 (21%) complained about nausea and another 27 (30%) vomited once or more during the postoperative course. More than 50% of the patients with nausea and 70% with vomiting first suffered from these symptoms in the surgical wards after leaving the postoperative unit. Nausea and vomiting were seen in 18 (60%), 13 (43%) and 15 (50%) for the groups propofol-propofol, propofol-isoflurane and thiopental-isoflurane, respectively. In conclusion, every second patient experienced nausea or vomiting after breast surgery, the majority of these emetic symptoms occurring after leaving the postoperative unit. Propofol for induction or as a main anaesthetic did not make any major difference with regard to postoperative nausea or vomiting.

Aged↗
PubMed2000

Vomiting and common paediatric surgery.

Postoperative vomiting is a common and unpleasant complication. The purpose of the present study was to verify if dexamethasone reduces the incidence of vomiting when injected IV in children anaesthetized with halothane for common paediatric operations. We also studied the incidence of vomiting when sevoflurane was used instead. Five hundred and 69 boys, aged 2-12 years (ASA physical status I, II), scheduled for inguinal field surgery were randomly assigned to receive halothane, halothane and dexamethasone and sevoflurane in three groups: halothane (n=180), halothane and IV dexamethasone (n=188) and sevoflurane (n=201). Anaesthesia was induced by inhalation of halothane or sevoflurane in oxygen and nitrous oxide and was maintained at minimum alveolar concentration of each agent throughout the surgery. For intra- and postoperative pain control iliac crest block was used in all the boys. Vomiting was defined as any expulsion of liquid gastric contents. The incidence of postoperative vomiting was 23% in the halothane group, which was significantly greater than that in the other groups (halothane and dexamethasone group, 9%; sevoflurane group, 13%). In conclusion, dexamethasone reduces the incidence and frequency of multiple emetic episodes when administered intravenously after halothane anaesthesia; sevoflurane reduces the overall incidence of vomiting, but not multiple emetic episodes.

Anesthetics, Inhalation↗
PubMed1990

Digestive tract motor correlates of vomiting and nausea.

The digestive tract from the upper esophageal sphincter to the ileum participates in the vomiting process, but the role of the digestive tract in nausea is unclear. In preparation for vomiting, the proximal stomach relaxes and the small intestine is evacuated orad in a single mass movement by a retrograde giant contraction and caudad in a stripping fashion by a series of phasic contractions. Orad evacuation of the small intestine may not only remove offending substances but may also dilute. or buffer gastric contents with intestinal and pancreaticobiliary secretions. In association with retching and vomiting, the striated muscle of the esophagus contracts longitudinally, pulling the relaxed proximal stomach into the thoracic cavity forming a funnel from stomach to esophagus. However, gastric evacuation does not occur until the hiatal fibers of the diaphragm relax during vomitus expulsion. Nausea is a subjective feeling in humans that is difficult to identify in animals. Various changes in digestive tract activity have been associated with nausea, but no evidence suggests that these events cause nausea. The prodromal signs of vomiting (e.g., increased heart rate and respiration) that occur concomitantly with the gastrointestinal motor correlates of vomiting have been considered autonomic indices of nausea in animals, but this has not been proven. Regardless, the gastrointestinal motor correlates of vomiting do not cause the prodromata. The emetic central pattern generator may be organized in parallel with respect to its individual autonomic correlates, but as groups of responses, the autonomic and somatomotor correlates may be organized in series.

Animals↗
PubMed2002

Mechanisms of airway protection during retching, vomiting, and swallowing.

We investigated the mechanisms of airway protection and bolus transport during retching and vomiting by recording responses of the pharyngeal, laryngeal, and hyoid muscles and comparing them with responses during swallowing and responses of the gastrointestinal tract. Five dogs were chronically instrumented with electrodes on the striated muscles and strain gauges on smooth muscles. Retching and vomiting were stimulated by apomorphine (5-10 ug/kg iv). During retching, the hyoid and thyroid descending and laryngeal abductor muscles were activated; between retches, the hyoid, thyroid, and pharyngeal elevating, and laryngeal adductor muscles were activated. Vomiting always occurred during the ascending phase of retching and consisted of three sequential phases of hyoid and pharyngeal muscle activation culminating in simultaneous activation of all recorded elevating and descending laryngeal, hyoid, and pharyngeal muscles. Retrograde activation of esophagus and pharyngeal muscles occurred during the later phases, and laryngeal adductor was maximally activated in all phases of the vomit. During swallowing, the laryngeal adductor activation was followed immediately by brief activation of the laryngeal abductor. We concluded that retching functions to mix gastric contents with refluxed intestinal secretions and to impart an orad momentum to the bolus before vomiting. During retches, the airway is protected by glottal closure, and between retches, it is protected by ascent of the larynx and closure of the upper esophageal sphincter. The airway is protected by maximum glottal closure during vomiting. During swallowing, the airway is protected by laryngeal elevation and glottal closure followed by brief opening of the glottis, which may release subglottal pressure expelling material from the laryngeal vestibule.

Animals↗
PubMed1993

Pharyngeal, esophageal, and proximal gastric responses associated with vomiting.

The motor activities of the pharynx, esophagus, and proximal stomach associated with vomiting were characterized and quantified in 25 awake chronically instrumented dogs. These motor events were correlated temporally with motor responses of the gastrointestinal and respiratory tracts. Vomiting was stimulated by apomorphine or UK-14304, and motor activities of striated and smooth muscles were recorded by electromyography and strain-gauge transducers, respectively. We found responses that began 1) before retching: increased swallow frequency, relaxation of the lower esophageal sphincter (LES) and proximal stomach, and tonic contraction of the cricopharyngeus and cervical esophagus; 2) during retching: rhythmic relaxation and contraction of the pharynx and cervical esophagus 180 degrees out of phase with retching; and 3) during vomitus expulsion: relaxation of the pharynx and cervical esophagus but strong contraction of the geniohyoideus and a retrograde contraction of the cervical esophagus and pharynx. The increased pharyngoesophageal tone occurred in an all-or-none fashion independent of vomiting or the gastrointestinal correlates of vomiting. Cervical vagal blockade increased swallow frequency but did not alter the other pharyngoesophageal responses associated with vomiting. We concluded that the motor events of the pharynx and esophagus play a significant role in gastrooral evacuation during vomiting and that these motor events (except LES relaxation) are not controlled by subnodose vagal pathways.

Adrenergic alpha-Agonists↗
PubMed2000

Hypnosis in the treatment of anticipatory nausea and vomiting in patients receiving cancer chemotherapy.

AIMS AND BACKGROUND: In addition to nausea and vomiting following chemotherapy treatment, cancer patients can experience these side effects prior to a treatment session, the so-called anticipatory nausea and vomiting. As various psychological and neurophysiological aspects have been claimed to be implied in its etiopathogenesis, the present paper aims to shortly review the etiological, epidemiological and therapeutical assumptions on the topic, in particular the psychological-behavioral therapies. PATIENTS AND METHODS: The present study was carried out on 16 consecutive adult cancer patients affected by chemotherapy-induced anticipatory nausea and vomiting who had received at least four treatment cycles. All of them were submitted to induction of relaxation followed by hypnosis. RESULTS: In all subjects anticipatory nausea and vomiting disappeared, and major responses to chemotherapy-induced emesis control were recorded in almost all patients. CONCLUSIONS: The experience highlights the potential value of hypnosis in the management of anticipatory nausea and vomiting; furthermore, the susceptibility to anticipatory nausea and vomiting is discussed under the psychoanalytic point of view.

Adult↗
PubMed2002

Comparison of ondansetron with metoclopramide in the symptomatic relief of uremia-induced nausea and vomiting.

BACKGROUND: Nausea and vomiting are well-known gastrointestinal complications in chronic renal failure and are frequent indications for the commencement of dialysis. Although the administration of antiemetic drugs (metoclopramide and, recently, ondansetron) is usually mentioned, there are scanty data on their effects. METHODS: A double-blind crossover study was done in 10 uremic patients. All the patients were uremic and suffered from nausea and vomiting. The drugs were randomly administered intravenously (either metoclopramide 10 mg or ondansetron 8 mg) 2 h after blood drawing for laboratory tests either on the 1st or on the 3rd study day at the same time. The outcomes were scored after 24 h of follow-up by (1) one of us (D.P.; 1-3 points: 1 = no effect; 2 = moderate effect - decreased frequency of vomiting, and 3 = good effect - no vomiting), and (2) by the patients (1-5 points). RESULTS: The results obtained showed that ondansetron was more effective in controlling nausea and vomiting than metoclopramide, either objectively (2.80 +/- 0.422 vs. 1.40 +/- 0.699, p < 0.005) or subjectively (4.10 +/- 0.738 vs. 2.10 +/- 0.994, p < 0.005). CONCLUSIONS: We conclude that at the dosage level studied ondansetron is about twice as effective as metoclopramide in the symptomatic relief of uremia-induced nausea and vomiting.

Adult↗
PubMed1990

[Ondansetron (GR 38032F), a competitive 5-HT3 receptor antagonist as an antiemetic in cytostatic drug-induced nausea and vomiting. An open, substance-oriented phase II/III study].

In an open, drug-oriented phase-II/III-study 24 patients were treated with the 5-HT3-antagonist Ondansetron as an antiemetic drug for chemotherapy-induced nausea and emesis. Patients with treatment regimen containing cisplatin were excluded. All patients had suffered from severe nausea and vomiting under conventional antiemetic drugs during a previous identical chemotherapy cycle and were treated with 8 mg Ondansetron t.d. on the day of the chemotherapy and on the four following days. The drug was given with 90 cytostatic cycles ranging from 1 to 14 cycles per patient. Only 2 patients (8%) did not experience an improvement of their symptoms in any of the treatment cycles as measured by a self-conducted grading of nausea and by the frequency of vomiting in comparison to a previous treatment cycle under conventional antiemetic therapy. Eleven out of 18 patients, who were treated with Ondansetron more than once (61%) noted a diminished frequency of vomiting in each treatment cycle with Ondansetron. Sixty of the 90 therapy cycles with Ondansetron resulted in complete (no vomiting) or major (one to two vomits within 24 h following chemotherapy) protection from emesis (37 and 29 per cent, respectively). The most frequent side effect noted was obstipation (7 patients), followed by slight diffuse abdominal pain (4 patients, probably also due to chemotherapy) and slight to severe headache (3 patients, 1 patient was therefore withdrawn from the study). No other side effects were seen. In conclusion, our study indicates that Ondansetron is an effective and safe drug for the treatment of cytostatic drug-induced nausea and vomiting.

Adult↗
PubMed1989

Anticipatory nausea and vomiting: prevalence and predictors in chemotherapy patients.

One hundred and seventy-five patients selected at random were prospectively studied. All patients were assessed at least after the first cycle of treatment by a self-report questionnaire which covered the occurrence of nausea and vomiting 24 before chemotherapy, as well as information regarding 22 clinical parameters. Forty-six (26%) patients developed anticipatory nausea. 'Intolerable' posttreatment vomiting and age under 45 were statistically significant parameters (p less than 0.05) in the multivariate analysis. Twenty-one (12%) of the 175 patients experienced anticipatory vomiting. Three variables, age under 45, 'intolerable' posttreatment vomiting and more than three cycles of treatment were found to be significant (p less than 0.05). The relative risk of developing anticipatory nausea and vomiting according to combination of significant clinical predictors in the multivariate analysis is proposed. Therefore recognition of these clinical predictors may serve as a marker for patients with high risk of presenting anticipatory nausea and vomiting, who may benefit from prophylactic behavioral approaches.

Adolescent↗
PubMed2004

Efficacy of low-dose dexamethasone for preventing postoperative nausea and vomiting following strabismus repair in children.

We studied the efficacy of a range of doses of dexamethasone for prevention of postoperative nausea and vomiting following strabismus repair in children in a hospital-based, prospective, double-blinded, randomized, placebo-controlled trial. Two hundred and ten children were randomized to receive either dexamethasone in one of four dosages: 50 microg/kg (Group 1), 100 microg/kg (Group 2), 200 microg/kg (Group 3) and 250 microg/kg (Group 4) or normal saline (Group 5) prior to corrective surgery for strabismus. Anaesthesia was standardized and included nitrous oxide, pethidine, intubation and the use of muscle relaxant and reversal with neostigmine. Postoperative nausea and vomiting were evaluated in epochs of 0-2 hours, 2-6 hours and 6-24 hours after surgery. Parent satisfaction was assessed 24 hours after surgery and the operated eye was examined for wound infection and delayed healing one week later Dexamethasone was effective in preventing nausea and vomiting after strabismus repair: 57.1% children in Group 1, 42.9% in Group 2, 52.4% in Group 3, and 59.5% in Group 4 were free from postoperative nausea and vomiting compared with 7.1% in placebo group. The lowest dose of 50 microg/kg was as efficacious as the higher dosages of dexamethasone during the 24 hours studied. Of the children who developed postoperative nausea and vomiting those who received dexamethasone had significantly fewer episodes than those in the placebo group. We conclude that dexamethasone 50 microg/kg is effective for the prevention of postoperative nausea and vomiting following strabismus repair in children.

Adolescent↗
PubMed1996

Acupuncture and postoperative vomiting in day-stay paediatric patients.

The stimulation of the acupuncture point P6 has been used to prevent nausea and vomiting in the adult population. It has, however, been subject to limited comparative evaluation in children. We proposed that stimulation of P6 and the analgesic point Li4 would reduce the incidence of postoperative vomiting. Eighty-four unpremedicated paediatric patients having day-stay surgery (circumcision or herniotomy/orchidopexy) were included in a randomized, double-blind, placebo-controlled study of transcutaneous stimulation of P6 and Li4, or no stimulation. The incidence of vomiting was recorded for 24 hours postoperatively. There was no statistically significant difference in total postoperative vomiting in those patients who were stimulated, compared with the control group (P = 0.909), or between any group for postoperative vomiting in the recovery ward, day-stay ward or at home. For all groups, vomiting was more common within the first four hours and more likely to occur in the day-stay ward.

Acupuncture Points↗