Common causes and medication for vomitting
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common causes of vomiting and antiemetic medications treatment 2024
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Nausea and Vomiting: Causes and Medications
What is Vomiting?
Vomiting (emesis) is the forceful expulsion of gastric or intestinal contents through the mouth. It is coordinated by the vomiting center in the medulla oblongata, which receives signals from:
- The chemoreceptor trigger zone (CTZ) in the area postrema (outside the blood-brain barrier, sensitive to toxins and drugs)
- Vagal afferents from the GI tract
- The vestibular system
- Higher cortical centers (pain, emotion)
The process is mediated through multiple neurotransmitters: histamine, dopamine, serotonin (5-HT3), acetylcholine, and neurokinin (NK-1).
Common Causes
1. Abdominal / GI Causes
- Mechanical obstruction: gastric outlet obstruction, small bowel obstruction (SBO)
- Motility disorders: gastroparesis, chronic intestinal pseudo-obstruction, functional dyspepsia
- Inflammatory conditions: acute appendicitis, acute cholecystitis, acute hepatitis, pancreatitis, peritonitis
- Peptic ulcer disease (gastric/duodenal ulcers)
- GI infections: viral gastroenteritis (norovirus, rotavirus), bacterial (Staphylococcus aureus, Bacillus cereus)
- Crohn's disease
- GI malignancies (gastric, pancreatic, duodenal)
2. Drug-Induced
A very common cause. Key offenders include:
- Chemotherapy agents: cisplatin, cyclophosphamide, methotrexate, 5-fluorouracil
- Opioids / narcotics
- NSAIDs and aspirin
- Antibiotics: erythromycin, tetracycline, sulfonamides, anti-TB drugs
- Cardiovascular drugs: digoxin, antiarrhythmics, calcium channel blockers, beta-blockers
- CNS drugs: levodopa, anticonvulsants, dopamine agonists
- Oral contraceptives
- Theophylline
3. Infections (Non-GI / Systemic)
- Viral and bacterial gastroenteritis
- Meningitis, otitis media
- Systemic infections
4. Metabolic and Endocrine
- Pregnancy (morning sickness, hyperemesis gravidarum)
- Diabetic ketoacidosis (DKA)
- Hypercalcemia (hyperparathyroidism)
- Hyponatremia
- Addison's disease (adrenal insufficiency)
- Hyperthyroidism
- Acute intermittent porphyria
5. Nervous System Causes
- Increased intracranial pressure (brain tumor, hemorrhage, abscess, infarction)
- Migraine headaches
- Motion sickness (labyrinthine/vestibular stimulation)
- Labyrinthitis / Meniere's disease
- Meningitis
- Seizure disorders
6. Other Causes
- Postoperative nausea and vomiting (PONV)
- Radiation therapy (especially abdominal/pelvic)
- Cyclic vomiting syndrome and cannabinoid hyperemesis syndrome
- Cardiac disease (myocardial infarction, heart failure)
- Anxiety and depression
- Alcohol abuse
- Eating disorders
- Intense pain
Antiemetic Medications
Antiemetics are selected based on the suspected cause and the neurotransmitter pathway involved.
1. Dopamine (D2) Antagonists
These are among the most widely used antiemetics.
| Drug | Notes |
|---|---|
| Metoclopramide | Blocks D2 in CTZ and vomiting center; also a prokinetic (speeds gastric emptying). Used for gastroparesis, PONV, chemotherapy-induced N&V. Risk: extrapyramidal effects with prolonged use. |
| Domperidone | Weaker than metoclopramide; useful in Parkinson's patients on levodopa because it doesn't cross the blood-brain barrier. Risk: prolongs QT interval. |
| Prochlorperazine (Compazine) | Phenothiazine class; used parenterally for acute intense vomiting, vertigo, migraine. |
| Promethazine (Phenergan) | Phenothiazine with antihistaminic and antimuscarinic effects; strong sedative properties. |
| Chlorpromazine | Phenothiazine; used for refractory nausea. |
| Droperidol | Butyrophenone; dose should not exceed 1 mg due to QT prolongation risk. |
| Haloperidol | Butyrophenone; used off-label for chemotherapy-induced and opioid-induced N&V. |
| Olanzapine | Second-generation antipsychotic; strong antiemetic with fewer extrapyramidal effects. Used in chemotherapy-induced N&V, often in combination with dexamethasone. |
2. Serotonin (5-HT3) Antagonists
Highly effective for chemotherapy-, radiation-, and surgery-induced vomiting.
| Drug | Notes |
|---|---|
| Ondansetron | First-line for chemotherapy- and radiation-induced N&V; also used for PONV. Can prolong QT interval. |
| Granisetron | Similar to ondansetron; available as oral, IV, and transdermal patch. |
| Palonosetron | Longer-acting; preferred for multi-day chemotherapy. |
3. NK-1 (Neurokinin-1) Receptor Antagonists
Used in combination regimens for highly emetogenic chemotherapy.
| Drug | Notes |
|---|---|
| Aprepitant | Oral; combined with ondansetron + dexamethasone for CINV. |
| Fosaprepitant | IV prodrug of aprepitant. |
4. Antihistamines (H1 Antagonists)
Best for motion sickness and vestibular-related vomiting.
| Drug | Notes |
|---|---|
| Dimenhydrinate (Dramamine) | Motion sickness, postoperative vomiting. |
| Meclizine | Vestibular disorders, motion sickness. |
| Cyclizine | Motion sickness and vestibular disease; dose 50 mg three times daily orally. |
| Diphenhydramine | Used for motion sickness and mild N&V. |
5. Anticholinergic (Muscarinic) Agents
| Drug | Notes |
|---|---|
| Scopolamine | Transdermal patch; highly effective for motion sickness and PONV. May cause visual disturbances. |
6. Corticosteroids
| Drug | Notes |
|---|---|
| Dexamethasone | Used in combination antiemetic regimens for chemotherapy; mechanism not fully understood. |
7. Benzodiazepines
| Drug | Notes |
|---|---|
| Lorazepam | Used for anticipatory nausea and vomiting (anxiety-related) and as adjunct in CINV. |
8. Cannabinoids
| Drug | Notes |
|---|---|
| Dronabinol (THC) | Used for chemotherapy-induced N&V refractory to other agents. |
| Nabilone | Synthetic cannabinoid; similar indication. |
9. Natural Remedies
- Ginger: shown in studies to relieve nausea from motion sickness, morning sickness of pregnancy, and chemotherapy-induced N&V. - Sleisenger and Fordtran's GI and Liver Disease
Quick Treatment Guide by Cause
| Situation | Preferred Agent(s) |
|---|---|
| Chemotherapy (highly emetogenic) | 5-HT3 antagonist + NK-1 antagonist + dexamethasone ± olanzapine |
| Postoperative N&V | Ondansetron, scopolamine, dexamethasone |
| Motion sickness | Scopolamine, dimenhydrinate, meclizine |
| Pregnancy (morning sickness) | Metoclopramide, antihistamines (meclizine, doxylamine), ginger |
| Gastroparesis | Metoclopramide, domperidone, ondansetron |
| Vestibular/labyrinthine | Antihistamines (meclizine), phenothiazines |
| Opioid-induced | Metoclopramide, ondansetron, haloperidol |
| Migraine-related | Prochlorperazine, metoclopramide |
Clinical note: Serotonin antagonists (ondansetron, granisetron) and some dopamine antagonists (metoclopramide) can prolong the QT interval on ECG, so cardiac monitoring may be needed in at-risk patients. Use of 5-HT3 antagonists is contraindicated when vomiting is from apomorphine therapy - trimethobenzamide is the preferred alternative in that setting.
Sources: Sleisenger and Fordtran's Gastrointestinal and Liver Disease; Katzung's Basic and Clinical Pharmacology, 16th Edition; Harrison's Principles of Internal Medicine 22E; Yamada's Textbook of Gastroenterology
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