Understanding Nausea and Vomiting

Nausea is the feeling of unease and discomfort in the stomach that can lead to vomiting. Vomiting is the forceful expulsion of stomach contents through the mouth. The chemoreceptor trigger zone (CTZ) is an area in the brainstem that is highly sensitive to drugs and toxins and can trigger nausea and vomiting.

Common symptoms include nausea, vomiting, anorexia (loss of appetite), dehydration, electrolyte imbalance, metabolic alkalosis, and weight loss. Dehydration is a major concern due to fluid loss from vomiting.

Vomiting expels acidic stomach contents, leading to the loss of acid from the body and causing a rise in blood pH, resulting in metabolic alkalosis. This leads to symptoms like irritability, muscle twitching, cramps, and tingling in the fingers and toes.

Metabolic alkalosis also has a close association with hypocalcemia, a condition where the blood calcium levels are low.

The LES (Lower Esophageal Sphincter) is a muscle that acts like a valve at the junction of the esophagus and stomach, preventing the backflow of stomach contents into the esophagus. When this sphincter weakens, it allows stomach acid and contents to reflux back up, leading to heartburn and other symptoms.

Risk factors include alcohol, chocolate, peppermint, tea, coffee, some medications, obesity, smoking, and certain medications.

GERD is characterized by frequent heartburn, a burning sensation in the chest and throat, as well as other symptoms such as dysphagia (difficulty swallowing), dyspepsia (indigestion), regurgitation (backflow of food or liquid), wheezing, coughing, dyspnea (difficulty breathing), and globus sensation (feeling of a lump in the throat).

Heartburn is the burning sensation experienced in the chest and is a common symptom of GERD.

Dyspepsia refers to epigastric pain or indigestion, a common symptom of GERD.

Globus sensation is the feeling of a lump in the throat, even though there's no physical obstruction. It's a common symptom of GERD.

Regurgitation is the backflow of stomach contents, such as hot, sour liquid, into the mouth. This is a common symptom of GERD.

Complications of GERD include esophagitis (inflammation of the esophagus), Barrett's esophagus (metaplasia of the esophageal lining), and pneumonia (PNA) from aspiration of gastric secretions.

Barrett's esophagus is a condition where the normal flat epithelial cells lining the distal esophagus are replaced by columnar epithelial cells, similar to those found in the small intestine. This can happen as a consequence of chronic GERD.

Metaplasia is a reversible change in the type of cells in a tissue due to an abnormal stimulus. For example, in GERD, chronic reflux can cause the flat cells in the esophagus to transform into columnar cells.

Pneumonia (PNA) is an infection of the lungs that can occur as a complication of GERD. Aspiration of gastric secretions, containing stomach acid and digestive enzymes, can irritate the upper airway and lead to pneumonia.

An endoscopy with biopsy involves inserting a flexible tube with a camera into the esophagus to visualize the lining and take a sample of tissue for examination. The nurse's role is to assist the physician during the procedure and provide sedation to the patient. The procedure can reveal inflammation, erosions, or other abnormalities in the esophageal lining.

An esophagram involves swallowing a contrast dye and then performing an X-ray. It can show the protrusion of gastric mucosa through the esophageal hiatus, a common finding in hiatal hernias.

Proton pump inhibitors (PPIs), such as Protonix, block the production of stomach acid by inhibiting the proton pump in the stomach lining. Histamine (H2) receptor blockers, such as Pepcid, reduce stomach acid production by blocking histamine receptors. Antiulcers, such as Sucralfate, protect the stomach lining from acid damage. Antacids, such as Tums and Mylanta, neutralize stomach acid.

Lifestyle modifications play a crucial role in managing GERD. These include avoiding trigger foods like chocolate, peppermint, fatty foods, coffee, and tea. It's also important to avoid late-night meals, nocturnal snacking, and milk. Eating smaller, more frequent meals and drinking fluids can help reduce reflux. Elevating the head of the bed by 30 degrees can reduce reflux during sleep.

Surgical options for GERD include Nissen and Toupet fundoplication. These procedures involve wrapping the fundus of the stomach around the lower portion of the esophagus to strengthen the lower esophageal sphincter (LES) and prevent reflux.

The LES, or Lower Esophageal Sphincter, is a muscle ring located at the junction of the esophagus and stomach. It acts as a valve, preventing the backflow of stomach contents into the esophagus.

The main goal of the LES is to prevent the reflux of gastric contents into the esophagus, thus protecting the esophagus from the damaging effects of stomach acid.

GERD occurs when the LES weakens or malfunctions, allowing stomach acid and contents to reflux back up into the esophagus. This weakening can be caused by various factors, including lifestyle habits, medications, and underlying conditions.

A hiatal hernia is a condition where a portion of the stomach protrudes through an opening in the diaphragm, called the esophageal hiatus, into the chest cavity. This can put pressure on the LES, contributing to GERD.

The muscles of the diaphragm, which separates the chest from the abdomen, can weaken over time. This weakening allows a portion of the stomach to push through the esophageal hiatus and into the chest cavity, resulting in a hiatal hernia.

The two main types of hiatal hernias are the sliding hiatal hernia and the rolling hiatal hernia (also known as paraesophageal hernia).

The esophageal hiatus is the natural opening in the diaphragm that allows the esophagus to pass through and connect to the stomach.

A sliding hiatal hernia occurs when a portion of the stomach slides up through the esophageal hiatus into the chest cavity, usually when the patient is lying down. The hernia usually returns to the abdominal cavity when the patient stands up.

A rolling hiatal hernia, also known as a paraesophageal hiatal hernia, occurs when the fundus and greater curvature of the stomach roll up through the diaphragm alongside the esophagus, forming a pocket. Unlike a sliding hernia, the esophagogastric junction remains in its normal position.

The diaphragm plays a crucial role in preventing acid reflux. It acts like a barrier, preventing stomach contents from flowing back up into the esophagus.

Risk factors for hiatal hernias include ascites (fluid buildup in the abdomen), obesity, pregnancy, heavy lifting, and tumors. These conditions can increase pressure on the diaphragm, making it more likely to weaken and allow a part of the stomach to bulge through.

Symptoms of a hiatal hernia often mirror those of GERD, including pyrosis (heartburn), dysphagia (difficulty swallowing), dyspepsia (indigestion), regurgitation (backflow of food or liquid), wheezing, coughing, dyspnea (difficulty breathing), and globus sensation (feeling of a lump in the throat).

Complications associated with hiatal hernias include GERD, esophagitis (inflammation of the esophagus), hemorrhage (bleeding), stenosis (narrowing of the esophagus), ulceration (sores in the esophagus), strangulation of the hernia (cutting off blood flow), and regurgitation with tracheal aspiration (inhaling stomach contents into the airways).

Diagnostic tests for hiatal hernias include an esophagram (barium swallow) and an endoscopy. An esophagram uses a contrast dye to visualize the esophagus on X-ray, while an endoscopy allows the doctor to directly view the esophagus with a camera and take biopsies.

Lifestyle modifications can help manage hiatal hernias. This involves eliminating constricting garments that may put pressure on the abdomen, and avoiding lifting or straining activities that increase pressure on the diaphragm.

Surgical options for hiatal hernias include herniotomy, herniorrhaphy, gastropexy, and Nissen and Toupet fundoplication. Herniotomy involves surgically removing the herniated sac. Herniorrhaphy involves closing the hiatal defect. Gastropexy involves attaching the stomach to the diaphragm to prevent re-herniation. Nissen and Toupet fundoplication are procedures that reinforce the LES to prevent reflux.

A herniotomy is a surgical procedure that involves removing the herniated sac, the portion of the stomach that is protruding through the esophageal hiatus. This reduces the hernia and restores normal LES pressure.

Herniorrhaphy is a surgical procedure that involves closing the hiatal defect, the opening in the diaphragm where the hernia occurs. This aims to prevent the stomach from bulging through again.

Gastropexy is a surgical procedure that involves attaching the stomach to the diaphragm to prevent re-herniation. This helps to keep the stomach from pushing back through the opening and prevent the hernia from recurring.

Similar to GERD, medications used to treat hiatal hernias include PPIs (proton pump inhibitors), H2 receptor blockers, antacids, and antiulcers. These medications help reduce acid production or protect the lining of the esophagus from acid damage.

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus characterized by an infiltration of eosinophils, a type of white blood cell involved in allergic reactions.

Eosinophils are a type of white blood cell involved in allergic reactions. They are recruited to the site of inflammation in the esophagus in EoE.

The cause of EoE is not fully understood, but it involves an abnormal immune response to certain allergens, leading to an infiltration of eosinophils into the esophageal lining. A family history of allergic disease is often present in individuals with EoE.

Common food triggers of EoE include milk, eggs, wheat, rye, and beef. These foods can trigger an allergic response in the esophagus, leading to inflammation.

Besides food triggers, some environmental factors like pollens, molds, cats, dogs, and dust mites can also trigger EoE. These triggers may cause allergic reactions in the esophagus, leading to inflammation and symptoms.

Symptoms of EoE can include pyrosis (heartburn), dysphagia (difficulty swallowing), dyspepsia (indigestion), regurgitation (backflow of food or liquid), food impaction (food getting stuck), nausea, vomiting, and weight loss. Similar to GERD, but may also involve food impaction.

Diagnostic tests for EoE include endoscopy with biopsy to visualize the esophageal lining and examine eosinophil levels, esophagram (barium swallow) to evaluate the swallowing process, and allergy skin testing to identify specific food and environmental triggers.

Treatment of EoE involves identifying and eliminating food and environmental triggers through allergy testing. Medications like proton pump inhibitors (PPIs) and corticosteroids (prednisone, fluticasone) can help reduce inflammation and symptoms.