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Case: Nausea in a Young Woman /Community Med

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Yazan Mousa

on 10 February 2014

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Transcript of Case: Nausea in a Young Woman /Community Med

Nausea in a Young Woman

Community Medicine
Dr. Abdul Hakeem Okour
Jordan University of Science
and Technology

A 36-year-old woman with a history of depression presents with a chief complaint of nausea. She states that for about 2 weeks she has felt nauseated most of the day, but denies vomiting, abdominal pain, and change in bowel habits. Her nausea is partially relieved by eating and by taking over-the-counter antacids, but made worse by taking her antidepressant medication (fluoxetine) on an empty stomach. She denies a history of gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), or previous abdominopelvic surgery. She takes fluoxetine 40 mg one daily and ibuprofen 400 mg as needed for tension headaches. She has been pregnant once and had an uncomplicated, full-term vaginal delivery 1 year ago. Her menses are usually regular, but since her pregnancy they have been quite irregular. Her last menstrual period was 7 weeks ago.

The patient currently is sexually active with her husband only, and uses a diaphragm with spermicide for birth control. She drinks a glass of wine two nights a week and denies tobacco or illicit drug use. Review of systems is notable only for mild fatigue. A cursory physical exam is unremarkable; specifically her abdomen is soft, nontender, and nondistended, without hepatosplenomegaly.

Nausea
is an unpleasant sensation of wanting to vomit, and is generally associated with
cold sweat, pallor, salivation
.

Causes
- Infectious causes
- Endocrine causes (Pregnancy).
- Drug/treatment induced
- Irritation of the stomach and
duodenum
- Changes in body chemicals
- Motion Sickness

Differential Diagnosis
for our case
-
Fluoxetine
(SSRI cause nausea) 5HT3 effective control of nausea & vomiting
-
Depression
-
Nausea Gravidarum
(Morning Sickness) –> Present in early hours and reduces as day progresses, stops around 12th week (1st trimester) of pregnancy

+ Duodenal ulcer
+ Chron’s Disease
+ Ibuprofen
+ Migraine
+ Diaphragm/IUD -> UTI

DDx
continued
DDx

SSRI Mechanism of Action
:
- Increasing the inhibition of
serotonin reuptake, so serotonin
released persists for a longer time

- Thus, more of the neurotransmitter is available to interact with any of these receptors or subtype receptors.

- Therefore, most SSRI side effects are
dose related and can be attributed
to serotonergic effects.

Association of Nausea
& Antidepressants
- Nausea
common SE of SSRI therapy

- Most likely from stimulation of 5-HT3 receptors & can usually be improved
by reducing the dose of the SSRI.
-
FLUVOXAMINE
: highest frequency of GI disturbances
-
CITALOPRAM
: the best-tolerated SSRI,
followed by fluoxetine, sertraline,
paroxetine, and fluvoxamine.
The latter 2 drugs:
1. most side effects
2. highest discontinuation rates
because of SE in
clinical trials.

Adverse SE of Antidepressants
Clinical trials
What determines
tolerability of SSRI?

Clinical trials have shown that
selectivity and their absence of
interaction with other receptors,
such as histaminic, cholinergic,
dopaminergic, and noradrenergic
are the factors to determine
the best tolerable drug.

Study comparing GI transit time with SSRI(Citalopram)
Other Associations
1 - DEPRESSION itself:
depression in emotion, pain in addition
to sight smell and taste

- the experience of of these sensations -> information sent to higher centres in the brain
-> then information relayed to the vomiting centre and CTZ via neurotransmitters most
commonly acetylcholine, or Ach.

 
NEUROTRANSMITTERS STIMULATE
AND ACTIVATE THE
VOMITING REFLEX
- Sexually active
- Did not have menses for 7 weeks
- Suspicion of PREGNANCY

2 - PREGNANCY
- Hormonal changes during
pregnancy cause Nausea.

- Nausea and vomiting are common during the 1ST trimester of the stages of pregnancy.

- Exact mechanisms of pregnancy-induced nausea and vomiting still is not clear, MAYBE elevated level of pregnancy hormones can play a role in inducing nausea and vomiting.

Note: Adequate hydration should be
advised. Dietary modification
may help

A study was done in the Middle East in Beer Alsabea’

The objective of the study was to determine whether it is safe to use anti-nausea drug (Metoclopramide) on both the pregnant mother and the fetus

80% of expectant mothers suffer nausea morning sickness in the first trimester of pregnancy. For the lucky, it was controlled with saltines and frequent small meals.
Anti-nausea drug safe for fetuses
The study took 81,703
births in beer Alsabea’ in years
1998-2007.

Only 3,458 of the women used
metoclopramide during their pregnancy.

The Results were published in the New England Journal of Medicine stating that there were no significant increases in the incidence of birth
defects or low birth weight in the group
using the drug and a slight reduction in
the incidence of stillbirth.

Study and Results
Conclusion
The findings provided
reassurance regarding
the safety of
metoclopramide for
the fetus when the drug is given to women to relieve nausea and vomiting during pregnancy.

- Gerd & PUD cause N&V through Irritation

- Mediated through chemoreceptors : acetylcholine, histamine, serotonin

- Gut and adjacent organ
inflammation can trigger

3 - GERD & PUD
When to Consult a Doctor?
FOR ADULTS
- If the nausea lasts > few
days or if there is a possibility of
being PREGNANT.

- If home treatment is not working, DEHYDRATION is present, or a known INJURY has occurred (such as head injury or infection) that may be causing the vomiting.

- If vomiting occurs for more than one day,
diarrhea and vomiting last more than
24 hours, or there are signs of
moderate dehydration.

IMMEDIATE Medical Care
If any of the following
occur with vomiting:

- There is blood in the vomit (bright red or "coffee grounds" in appearance)
- Severe headache or stiff neck
- Lethargy, confusion, or a decreased alertness
- Severe abdominal pain
- Fever over 101 degrees
- Diarrhea
- Rapid breathing or pulse

Prevention
How to prevent nausea?

- Eat small meals Vs 3 large meals
- Eat slowly;
- Avoid hard-to-digest foods;
- Consume foods that are cold or at room temperature (Warm food or smell may induce nausea).
- Rest after eating and keep head elevated ̴̴12 inches above feet
- If you feel nauseated -> Eating cracker (in the morning) /high protein snack (lean meat or cheese) before going to bed.
- Drink liquids between (instead of during) meals,
- Drink at least 6-8 glasses(8-ounce) of water/day
to prevent dehydration.
- Try to eat when you feel
less nauseated.

- Consume small amounts of clear,
sweetened liquids such as soda pop,
fruit juices (except orange and grapefruit because these are too acidic).

- Drinks containing sugar calm the stomach

- Rest in a sitting position.

- Activity may worsen
nausea and thus induce
vomiting.

Once you feel
nauseated, how do you
prevent vomiting?
Management
Mild Cases
- Eat a diet high in protein and complex carbohydrates (ex. apple; nuts; cheese crackers; milk & yogurt). Bland foods (ex. frozen desserts, ginger ale) also soothe the stomach.

- Avoid fatty foods.

- SIMILAR EATING HABITS AS IN
PREVENTION

Diet
Lifestyle
Avoid smoking cigarettes.

Morning activities slow and calm.
Avoid poorly ventilated rooms that trap
food or other odors.

Get extra sleep and try to minimize stress as much as possible.

If you take vitamins try taking them at
night because the iron they contain
irritates stomach (or cut the
vitamin by half one morning
or at night)

Severe Cases
- Medicines health care provider
may recommend:
Anti-nausea medications: promethazine, metoclopramide, dimenhydrinate, or ondansetron are other options to manage nausea and vomiting during pregnancy.

- Vitamin B6: first line ttx for morning sickness. As recommended by The American College of Obstetricians and Gynecologists (ACOG)

- Doxylamine – trade name “Unisom,”
this medication is combined with
vitamin B6 to help treat
nausea and vomiting.

International Study on Nausea
NVP can affect 70-85 % of pregnant women -> 95% of them experience NVP beyond morning hours -> typically develop between 4th-6th weeks of pregnancy

Nausea Study in Malaysia
In this study, Karaca et al.
compared 56 pregnant women
with hyperemesis gravidarum to 90
pregnant women without hyperemesis
and detected specific serum IgG for H. pylori
by fluorescent enzyme immunoassay method in 82 percent subjects of the hyperemesis gravidarum group as compared to 64 percent in the controls, the difference being
statistically significant. Supporting this,
agents active against H. pylori have
been found to be very effective for the
treatment of hyperemesis.

Thank you!
Full transcript