Chronic vomiting

Nota:

• absence of evidence of mechanical obstruction other causes of vomiting should consider

1. causes
   1. METABOLIC: 1) Hypercalcaemia 2)hypoadrenalism (Addison's disease) 3) Uraemia
   2. INFLAMMATORY DISEASE: 1)visceral inflammation e.g. Hepatitis, Pancreatitis, etc. 2) Remote infection e.g. Pneumonia
   3. DRUGS: 1)cytotoxics, 2)analgesics(especially opioids), 3)antibiotics
   4. NEUROGENIC: 1)intracranial tumours2) unpleasant stimulus, 3)Psychogenic, 4)vestibulocochlear disease
   5. GI CAUSES: 1)obstruction. 2)gastroeteritis
2. History
   1. 1) Duration of the symptoms and whether its getting worse 2) Drugs including overcounter drugs 3)Headaches or others that raised INC.pressure 4)unusual foods, restaurants, travel 5)Hearing, balance
3. Examinations
   1. 1) general: overall appearance and presence of pathology. State of hydration, particularly postural blood pressure. 2) abdominal examination . usually unrewarding but may reveal sign of intestinal obstruction
4. investigations
   1. 1) blood test 2)cortisol 3) chest x-ray 4)endoscopy 5) small bowel imaging 6) CT or MRI scan of the head

      Nota:

      • 1) FBC, ESR and biochem, including renal and liver function, aodium , potassium and calcium, amylase  2)cortisol: short Synacthen test if hypoadrenalism is suspected 3)for in fection( including aspiration pneumonia), neoplasm  4)SBI, may be indicated in difficult cases to exclude occult subacute obstruction 5)CT or MRI last resort if other pathology not identified
5. Management
   1. 1) treat the underlying cause. 2) antiemetics:empirical treatment with this may needed if mechanical obstruction has been excluded. Domperidone does not cross the blood-brain barrier and is useful for long-term 'as needed' treatment. other agents (e.g.metoclopramide, prochloperazine) are increasingly being replaced by centrally acting serotonin antagonists (e.g.ondansetron)