Nausea and Vomiting – Evaluation of Symptoms
Guest: Dr. Todd Dantzler – Gastroenterology-Hepatology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin and I am interviewing, today, Dr. Todd Dantzler who is Assistant Professor of Internal Medicine and a gastroenterologist working in the MUSC Digestive Disease Center. Dr. Dantzler, let’s talk about what must be a very common complaint, nausea and vomiting. When a patient comes to you with that chief complaint, how do begin to evaluate what is going on with them?
Dr. Todd Dantzler: Thanks for asking. It is a very seemingly simple problem to a lot of people because immediately you think of several disorders that are quite common that you think may apply to the great majority of people. But, the truth is, especially here at MUSC, as a referral center, many of the cases of nausea and vomiting that we do end up with are not quite so straight forward. But, having said that, the overall approach to nausea and vomiting, of course, takes an outstanding history and physical to start with. You need to know everything from their pertinent past medical history to their past surgical history, the medications that they are taking to any allergies and such that they may have before you launch into very specific questions regarding the nature of their nausea and vomiting.
Just by taking that history, alone, will help you narrow down the possibilities or at least get you thinking about certain things that may be highest on the list, other potential causes of their nausea and vomiting.
Dr. Linda Austin: So, on that list, what are some of the more common causes? You mentioned medications. I am sure medication side effects can be one such cause. What are some other things that people may not think about?
Dr. Todd Dantzler: Peptic ulcer disease, certainly, is a very common cause, especially in this day and age when patients are often taking non-steroidal anti-inflammatory drugs over the counter. Nsaids, non-steroidal anti-inflammatory drugs, would be the number two cause of peptic ulcer disease, referring to ulcers which occur in the stomach or in the first part of the small intestine, the duodenum. The first most common cause, nowadays, would be Helicobacter pylori, or H. pylori.
We have found, over the years, that by treating this bacteria and eradicating it, we have significantly decreased the risk of recurrent ulcers in these folks. Of course, they can present with nausea and vomiting. The ulcer can be in a place in the stomach, in the pyloric channel, where it causes significant edema and gastric outlet obstruction, which can present with complete obstruction out of the stomach, resulting in nausea and vomiting. Or, you can have a seemingly mild case of gastritis, or inflammation of the stomach, which also manifests as nausea and vomiting. You can have a normal-looking stomach which has the H. pylori infection, which also manifests as nausea and vomiting.
Dr. Linda Austin: So, in trying to evaluate, then, you start with getting a good history. I am sure you have been taught how to do that by very brilliant faculty in the past.
Dr. Todd Dantzler: Including, yourself.
Dr. Linda Austin. Right, back in the early 90s; I have to throw that in. What is the next step in the evaluation of these patients?
Dr. Todd Dantzler: After your history, you want to follow up with an excellent physical examination to look for any focal findings on the physical exam that will point in any certain direction. The most common things we would be looking for would be, first of all, any abdominal pain, any focal abdominal pain. If they have distention of the abdomen, that would certainly be concerning, or absence of bowel sounds, or high-pitched tinkling bowel sounds, potentially suggestive of an obstruction within the gastrointestinal system. Certainly, that would be a potential etiology of nausea and vomiting. If there was a focal neurologic deficit anywhere on your neurologic exam, that might suggest a central cause of nausea and vomiting.
Dr. Linda Austin: What is a focal neurologic deficit?
Dr. Todd Dantzler: A focal neurologic deficit has two parts. One part is, focal. It is in an isolated part of the body, for instance, the arm or the leg, or even just a hand, or maybe one side of your face, as opposed to an entire side of your body which would be something more concerning, such as a large event, like stroke. If you were to have a focal neurologic deficit such that a very small area is affected, that would suggest, perhaps, you have a tumor that may also be causing pressure on the brain, which can result in associated nausea and vomiting.
Dr. Linda Austin: So, what would be next? You do your history, your physical and then, I am sure, like all doctors do, you order tests.
Dr. Todd Dantzler: Of course.
Dr. Linda Austin: What sorts of test might you order?
Dr. Todd Dantzler: You always have to throw in some labs there. I like to start by casting a broad net, including a CBC (complete blood count) to see if the patient is anemic, to see if they might have an elevated white blood cell count and, of course, their platelet count to see if, perhaps, they have liver disease. Patients with underlying significant liver disease can also have associated nausea and vomiting. Also, we like to look for their chemistry panel to check out their electrolytes, their potassium and magnesium, as well as their kidney function to see if, perhaps, they have a metabolic cause for their nausea and vomiting.
Certainly, patients with nausea and vomiting may be at risk for low levels of their electrolytes, such as magnesium and potassium, in which case it would be more of an emergency and we would need to replete those. We may even need to admit them to the hospital for this.
Dr. Linda Austin: Okay. So, you check their blood work. Then, what do you do?
Dr. Todd Dantzler: At that point, you can do several things. For most of our outpatients who have nausea and vomiting to the point where it is a chronic condition but they are able to keep most of their food down and stay generally hydrated, in other words, they do not meet the criteria for coming into the hospital, we can often prescribe symptomatic medications to treat their symptoms, such as the nausea, like phenergan, compazine or zofran. All three are examples of anti-nausea medicines that can work in the short term. But, in the longer term, we would like to figure out what is causing these symptoms. An example of a test that I would order, as a gastroenterologist, to further evaluate this, would be an upper endoscopy, to look into the esophagus and the stomach to look for a potential luminal cause of these symptoms.
Dr. Linda Austin: Luminal, meaning?
Dr. Todd Dantzler: Referring to the lining of the gastrointestinal tract. Anything that ails or afflicts the lining of the gastrointestinal tract can be considered a luminal cause of these symptoms.
Many of these tests are normal, in patients with these symptoms, but it still needs to be done because many of them are also abnormal. It is quite gratifying to actually be able to go in, after seeing one of these patients in clinic, and find an ulcer or, certainly, a mass, something more concerning such as a cancer in the stomach or further down in the small bowel, that is causing these symptoms. Gratifying, not so much in that I am excited, but that it is nice to find a cause so that we will be able to fix their symptoms and hopefully get to a cure for these patients.
Dr. Linda Austin: Exactly. Every human being, virtually, that has ever lived has had nausea and vomiting, I would assume, at some point. So, the question becomes, how long should someone let those symptoms go on before they seek medical attention? Do you have any rules of thumb about that?
Dr. Todd Dantzler: It is true that many common things such as a viral gastroenteritis may result in symptoms of nausea, vomiting, with or without diarrhea, for several days. I would not go beyond anywhere between three to five days with persistent symptoms before seeking medical attention. That is only in the instance that you are, for the most part, able to maintain your hydration. You are not dizzy. In other words, you are not weak. You are not having pounding or fluttering of the heart. You are not having chest pains, certainly. For the most part, you are able to maintain your hydration. Otherwise, you need to seek immediate medical attention.
Dr. Linda Austin: Right. And, obviously, if anybody is concerned, they should always give their doctor a call. And often their medications, even if it is viral medication, can shorten a very unpleasant experience.
Dr. Todd Dantzler: Most definitely.
Dr. Linda Austin: I remember seeing a study asking chemotherapy patients what they feared the most. People feared nausea and vomiting more than they feared actual pain. It is just so darned unpleasant.
Dr. Todd Dantzler: Having seen a lot of my patients in clinic, I certainly understand that.
Dr. Linda Austin: Yes. Thanks so much for talking with us today.
Dr. Todd Dantzler: Well, thank you.
If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection: (843) 792-1414.