Nausea and Vomiting

Causes of nausea and vomiting

• Illness.
• Medication.
• Medical treatments.
• Constipation.
• Food.
• Smells, sights, sounds.
• Feeling anxious.
• Pain.
• Motion (nausea of any cause is often made worse by movement).

Triggers of nausea and vomiting

• This may be due to:
  • Side effects of medications such as some chemotherapy treatments.
  • A weak liver or kidneys that are unable to clear the bloodstream.

• The stomach emptying too slowly
• Constipation
• A blockage, such as a tumour, in the intestine (also called a bowel obstruction)
• Irritation of the lining of the stomach or intestines – which can be caused by:
  • Radiation treatments
  • Infections
  • Some medications

Irritation of the motion centre in the brain

• The motion centre is the system in the body that controls our balance, coordination, and sense of motion and position.
• Illness can upset this system, triggering nausea and vomiting. 
• Motion sickness is the most common example. The movement of cars, boats, or airplanes can make people nauseated.
• Nausea of any cause is often made worse by movement.

Increased pressure on the brain

• A brain tumour, for example, can create increased pressure.
• Movement often makes this worse.

Anxiety, association, and anticipatory nausea

• It’s common to feel nauseated when anxious.
  • Stage fright is a good example.
• Some people feel nauseated seeing or smelling things that remind them of past treatments or thinking about something that made them nauseated in the past.
  • This is known as association.
• Some people become nauseated as they prepare for their next chemotherapy treatment.
  • This is called anticipatory nausea.

Nausea, vomiting, and emotions

• It’s hard for someone who’s nauseated to concentrate or enjoy life. 
• Some people become isolated.
  • They feel embarrassed to eat around others for fear they’ll become nauseated or vomit.
  • They try to avoid smells they know will make them feel worse such as food, cooking and perfumes.
  • For these reasons, they stay home and avoid socializing with friends.  
• They may develop anticipatory nausea as they think about trying to eat. This can be a difficult cycle to break.
• They may become anxious or depressed.

Assessing and diagnosing

The healthcare provider will want to understand what’s causing nausea and vomiting for several reasons:

• It may be a sign of something more serious that the person is not aware of.
  • For example, if nausea is caused by a bowel obstruction, finding and treating it is the best way to treat the nausea and potential serious complications of the obstruction.
• The drugs and therapy they prescribe will depend on the suspected cause.
• Without treatment, new medical problems might develop, such as dehydration. 

Questions 

• Do you always feel nauseated, or does this come and go?
• What seems to trigger the nausea and vomiting or make it worse?
  • Eating?
  • Certain medications or treatments?
  • Feeling anxious?
  • Movement or certain body positions?
  • Smells?
  • A hot stuffy room?
• What makes it better?
  • Staying still?
  • Eating plain foods?
  • Drinking liquids slowly?
• How long does the nausea last?
• How long does the vomiting last?
• Do you always feel nauseous before vomiting?
• What does the vomit look like?
  • Is there bright red blood?
  • Does it have a dark or black appearance? (This might suggest old blood and is sometimes called “coffee ground vomiting.”)
• Does it taste or smell of stool?
• What medicines are you taking for nausea and vomiting?
  • When do you take them?
  • How long have you been taking the medication (days, weeks, months)?
  • Are the medications working?
  • How long do they work?
  • Are you having any side effects?
• Does your nausea and vomiting interfere with normal activities?
• What other medications are you taking?
  • Prescription medications?
  • Over-the-counter medications?
  • Herbal medications and naturopathic remedies?
• What else are you doing to help the nausea and vomiting?
  • Herbal remedies?
  • Relaxation techniques?

Physical exam

• A blockage of the bowel.
• More tenderness than expected.

Tests

• Blood tests to look for chemical imbalances in the blood such as:
  • Weakness of liver or kidney function. 
  • A high calcium level.
  • Evidence of dehydration.
• X-rays to check for blockages in the intestine.

Medications and other treatment

Medications

Motility agents

• These help the upper bowel to move.
• They also work at the vomiting centre in the brain, to lessen nausea.

5 HT3 receptor antagonists 

• These work at several sites in the body to reduce nausea. 
• They can be particularly effective with nausea related to chemotherapy and radiation therapy.
• One example is Ondansetron.

Steroids – specifically the anti-inflammatory kind. 

• Most commonly used is dexamethasone.

Anti-psychotics

• These can be very effective in reducing nausea, depending on the cause.

Anti-anxiety medications

• These are used if anxiety is felt to be a significant contributing factor.

Possible side effects of anti-nausea medication

Sleepiness

• This is more noticeable when a new medication is first started but tends to lessen with ongoing use. 
• It may impact the safety of some activities such as driving.
• Other medications may add to this side effect such as opioids or medications used to reduce anxiety.

Confusion

• This is a less common side effect and varies with the medication. 
• Some people may be more likely to develop this side effect, depending on other existing medical conditions and other medications they’re taking.

Tremors or muscle rigidity

• This side effect is similar to some symptoms of Parkinson’s disease.
• It occurs more common in the elderly. 
• Children and young adults are more likely to experience spasms in face or neck muscles.
• Medications that may cause this side effect include:
  • Metoclopramide. 
  • Antipsychotics, such as haloperidol, prochlorperazine and methotrimeprazine.

Possible side effects of steroids

• Agitation.
• Restlessness.
• Interrupted sleep.
• Increased blood sugars.
• Increased appetite.
• Thrush. 
• Increased bleeding if used with non-steroidal anti-inflammatory drugs (NSAIDs).
  • NSAIDs are not recommended.

• Weight gain.
• Muscle weakness.
• Osteoporosis. 
• Osteonecrosis (extremely rare).

When swallowing medication is difficult

• By injection:
  • Into a vein (intravenously).
  • Under the skin (subcutaneously).
• By patch so the drug is absorbed through the skin.
• Under the tongue.
• By a suppository that’s inserted into the rectum.

Complementary therapies

• Lessen nausea and vomiting.
• Distract a person.
• Relax a person.

• Talk with a healthcare provider, in case they have concerns about a certain therapy and a patient’s particular health circumstances. For example:
  • Some herbal remedies may affect how prescribed medications work.
  • Heat therapies are best avoided with certain disorders, such as reduced ability of the skin to feel hot temperatures (risk of burns).
• After discussion and approval from a healthcare provider, experiment with different approaches until perhaps a helpful one is found.
  • A therapy that works for one person might not work for another. 

• Acupuncture. 
• Biofeedback.
• Breathing and relaxation exercises.
• Distraction.
• Herbal remedies such as ginger.
• Hypnosis.
• Massage.
• Mindfulness meditation.
• Music therapy.

What you can do

Urgent situations 

• Blood in the vomit.
  • The blood could be bright red or dark brown/black (the colour of coffee grounds).
• Severe pain in the abdomen.
• Projectile vomiting (vomit shoots straight out and travels far).
• Vomit that smells like stool or bowel movements.
• The person becomes increasingly sleepy and hard to wake up. 

When you are living with illness

Talk with your healthcare provider

• Tell them about your nausea and vomiting. 
• Show them your daily symptom diary. 

Watch what you eat and drink

• Eat smaller, more frequent meals, and only if you feel like it.
• Eat foods that appeal to you.
• Eat foods cold or at room temperature.
• Avoid:
  • Fried and fatty foods.
  • Spicy foods.
  • Acidic foods such as oranges, lemons, and vinegar.
• Eat foods that have little or no flavor such as crackers and dry toast.
• If you’re nauseated in the morning, eat dry foods like toast, crackers, or handfuls of dry cereal before getting out of bed.
• Avoid the smells and sights of cooking.
  • Make sure you have good air flow if you’re near the kitchen.
• Drink small amounts of liquids frequently to prevent dehydration.
• Sip slowly when drinking.
• Drink cold or chilled liquids. Freeze liquids into popsicles.
• Suck on ice cubes, mints, or hard sugarless candies.
• Don’t drink large amounts of fluid with solid food.
• Drink liquids an hour before or after meals.

After throwing up

• Clean out your mouth using one of these methods:
  • Put a teaspoon of baking soda in a glass of warm water, use the solution to rinse your mouth, then spit it out. 
  • Rinse your mouth with water.
  • Brush your teeth.
• Avoid alcohol-based mouthwashes as these can irritate the mouth.
• Clean out your throat by taking a small sip or two of water.
• Drink small sips of clear liquids such as water or apple juice once your stomach settles.
• After your stomach is settled or your medication is working, try to drink extra liquids to replace the fluid you lost when you threw up. 

Find support

• Talk with someone you trust, like a friend or family member. Sometimes just talking with someone can help you feel better.
• Ask a healthcare provider to refer you to a counsellor such as a psychologist or social worker. They can offer:
  • Counselling and emotional support.
  • Education.
  • Practical suggestions to help you manage your symptoms.
• Talk with a spiritual care specialist.
• Find information online.
  • Canadian Virtual Hospice has information on many topics related to serious illness and palliative care.
• Join online discussion forums such as:
  • Canadian Virtual Hospice Discussion Forums.
  • Cancer Chat Canada.    
• If you can manage it, join a support group where you can meet people who may have similar health concerns.
• Learn more about Programs and Services in your area.

When someone you care about is living with illness

Find support

• Talk with someone you trust. Sometimes just talking with a friend or family member can help you to feel better.  
• Ask the healthcare provider to refer you to a counsellor such as a psychologist or social worker. They can offer:
  • Counselling and emotional support.
  • Education.
  • Practical suggestions to help with stress.
• Talk with a spiritual care specialist.
• Ask about a support group for caregivers.
• Find information online
  • Canadian Virtual Hospice has information on many topics related to serious illness and palliative care.
• Join online discussion forums such as:
  • Canadian Virtual Hospice Discussion Forums.
  • Cancer Chat Canada.      
• Learn more about Programs and Services in your area.

Try complementary therapies

• Various therapies such as relaxation techniques, meditation and yoga can be helpful to manage stress. 
• To learn more, go to Complementary therapies.

Take time for yourself

• Choose an activity or something you enjoy. It might be reading, praying, listening to music, watching sports – or something else.
• Regular exercise is important to manage stress. What physical activities do you enjoy? Walking? Biking? Something else?

Respecting choices