![]() ![]() Gastroparesis may be best treated by metoclopramide and perhaps haloperidol/droperidol as a 2nd line agent.Vestibular etiologies may respond best to anticholinergic or antihistamine agents.However, one exception to this is that certain conditions may be more sensitive to specific agents. Antiemetics generally have similar efficacy, so selection is based largely on selecting medications with the most favorable side effect profiles.Sharkey KA and MacNaughton MK, in Goodman & Gillman's Pharmacological Basis of Therapeutics 13th edition. Consequently, most broad-spectrum antiemetic drugs will inhibit one or more of these receptors. Most other causes of nausea seem to involve several receptors (especially the 5HT-3 serotonin receptors, D2 dopamine receptors, M1 muscarinic acetylcholine receptors, and the H1 histamine receptors).Consequently, antihistamine and anticholinergic medications may be useful to treat these etiologies of nausea. Vestibular etiologies of nausea involve H1 histamine and M1 muscarinic acetylcholine receptors.Blocking receptors involved in these pathways may alleviate emesis. Treatment of emesis involves understanding the neural pathways involved.Neuroimaging, if history and physical examination suggest elevated intracranial pressure.Abdominal X-ray may be considered, to evaluate for obstruction or ileus.Cortisol level, if adrenal insufficiency is suspected.Lipase, if clinical concern for pancreatitis.Measurement of gastric residual volume (for intubated patients with a gastric tube).ii) Small bowel peristalsis may be assessed, to evaluate for obstruction.i) Gastric ultrasonography may estimate size and contents of the stomach.Abdominal examination, ideally using ultrasonography.If concern for elevated intracranial pressure, assess this using optic nerve ultrasonography.For patients in whom initial investigation is unrevealing, the following studies may be considered (with an evaluation tailored to the patient). ![]() In many cases, these may reveal the etiology without additional evaluation. History and physical examination are the highest yield investigations. Cyclic vomiting syndrome, cannabinoid hyperemesis syndromeĮvaluation of the patient with nausea and vomiting.Ear and labyrinthine disorders (often associated with vertigo).Hypomotility (e.g., gastroparesis, ileus).Obstruction (e.g., intestinal obstruction, gastric outlet obstruction).Hyperparathyroidism, hypoparathyroidism.Ketoacidosis (e.g., diabetic ketoacidosis).Pregnancy (generally within the first nine weeks of pregnancy).Parkinson's disease medications (dopaminergic).Antihypertensives (beta-blockers, calcium channel blockers).Differential diagnosis of nausea and vomiting
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