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Nausea and vomiting — Clinical Guidelines

Overview

Chronic nausea and vomiting encompass symptoms from various gastrointestinal and non-gastrointestinal conditions, requiring a systematic diagnostic approach 1.

Diagnosis

Initial investigations should rule out structural, toxic, and metabolic disorders 1.

Assess digestive motility and gut-brain interaction disorders if initial tests are negative 1.

Diagnostic algorithm development recommended for structured evaluation 1.

Management

First-line treatments include antiemetic drugs such as neurokinin-1 receptor antagonists (e.g., aprepitant) 2.

Adjunctive therapies may involve acupuncture at PC6 point, though side effects are generally minor (e.g., minor bleeding, dizziness) 3.

Ketamine-propofol combination may lead to higher incidence of postoperative nausea and vomiting compared to remifentanil 4.

Compound ABHR (lorazepam, diphenhydramine, haloperidol, metoclopramide) is generally well-tolerated in hospice patients 7.

Special Populations

Pregnancy: Small, frequent meals recommended; vitamin B6 supplementation explored for nausea and vomiting management 9 10.

Elderly: Increased sensitivity to compounded treatments like ABHR noted, though statistically insignificant for extrapyramidal symptoms 7.

Key Recommendations

Conduct thorough initial investigations to exclude structural, toxic, and metabolic causes before assessing motility and gut-brain interactions 1 (Evidence: Moderate).

Consider neurokinin-1 receptor antagonists for chronic nausea and vomiting management 2 (Evidence: Weak).

Monitor for side effects in elderly patients receiving complex drug regimens, given their heightened sensitivity 7 (Evidence: Expert opinion).

Utilize PC6 acupuncture cautiously, noting potential minor side effects like dizziness and minor bleeding 3 (Evidence: Expert opinion).

Evaluate patient satisfaction and hemodynamic stability when choosing between ketamine-propofol and remifentanil for sedation 4 (Evidence: Moderate).

References

1 Malagelada C, Keller J, Sifrim D, Serra J, Tack J, Mulak A et al.. European Guideline on Chronic Nausea and Vomiting-A UEG and ESNM Consensus for Clinical Management. United European gastroenterology journal 2025. link 2 Chen F, Cai D, Wen H, Zhang L. Analyzing adverse event signals of aprepitant using FAERS database data in real-world settings: Broadening the adverse event spectrum of aprepitant and its clinical implications. Medicine 2025. link 3 Enblom A, Johnsson A. Type and frequency of side effects during PC6 acupuncture: observations from therapists and patients participating in clinical efficacy trials of acupuncture. Acupuncture in medicine : journal of the British Medical Acupuncture Society 2017. link 4 Oncul S, Gaygusuz EA, Yilmaz M, Terzi H, Balci C. Comparison of ketamine-propofol and remifentanil in terms of hemodynamic variables and patient satisfaction during monitored anaesthesia care. Anaesthesiology intensive therapy 2016. link 5 Enabulele J, Ibhawoh L. Resident obstetricians' awareness of the oral health component in management of nausea and vomiting in pregnancy. BMC pregnancy and childbirth 2014. link 6 Kinzl JF, Knotzer H, Traweger C, Lederer W, Heidegger T, Benzer A. Influence of working conditions on job satisfaction in anaesthetists. British journal of anaesthesia 2005. link 7 Weschules DJ. Tolerability of the compound ABHR in hospice patients. Journal of palliative medicine 2005. link 8 Vinson DR, Drotts DL. Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a randomized, controlled trial. Annals of emergency medicine 2001. link 9 Emelianova S, Mazzotta P, Einarson A, Koren G. Prevalence and severity of nausea and vomiting of pregnancy and effect of vitamin supplementation. Clinical and investigative medicine. Medecine clinique et experimentale 1999. link 10 DiIorio C, van Lier D, Manteuffel B. Recommendations by clinicians for nausea and vomiting of pregnancy. Clinical nursing research 1994. link

Nausea and vomiting