Introduction
The term "intractable vomiting" refers to vomiting that is difficult to control. It is often accompanied by nausea and does not reduce with time or traditional treatments. It can be a warning sign of many systemic conditions.
What Is Intractable Vomiting?
The term intractable vomiting refers to vomiting that is difficult to control. It is often accompanied by nausea and does not reduce with time or traditional treatments. Many systemic conditions might cause it. Intractable vomiting can be alarming as it can lead to dehydration and electrolyte imbalance, leading to tiredness and fatigue. Medical literature still does not have a good explanation of what "intractable vomiting" means. It can be challenging to diagnose and manage the condition. The patient's quality of life and ability to function can be affected.
What Are the Synonyms for Intractable Vomiting?
-
Chronic vomiting.
-
Recurrent vomiting.
-
Persistent vomiting.
What Is the Mechanism of Vomiting?
Many efficient neurotransmitter pathways are involved in vomiting. Studies about this mechanism have enabled the development of therapies to manage vomiting. Serotonin (5-HT3) and neurokinin NK1 are involved in the mechanism of vomiting. Stimuli that act on the vagal afferent pathway (a hypothalamic pathway, the vagus is a part of the hypothalamus that regulates food intake) activate serotonin 5HT3 receptors. The postrema (a part of the medulla oblongata) receives stimulus from bloodborne stimuli such as bacterial toxins like food poisoning, metabolic factors such as pregnancy, and other factors that cause emesis.
What Are the Causes of Intractable Vomiting?
Some of the causes of intractable vomiting include:
Acute Gastroenteritis: It occurs when the digestive tract is infected with an infectious microorganism and irritates the digestive tract. Staphylococcus aureus, norovirus, and rotavirus are some microorganisms that cause an infection of the digestive tract. Bacterial infections require proper treatments, while viral infections require supportive therapy. If the gastroenteritis is severe, intravenous fluids and antiemetic medications (drugs that help reduce nausea and vomiting, such as Ondansetron and Promethazine) may be required.
Post-operative Nausea: Intractable vomiting can also be associated with anesthesia and other medications given for a surgical procedure. Nausea and vomiting gradually stop as the effect of the anesthesia or the drugs causing them wears off. Women, non-smokers, and patients who receive opioid painkillers for surgery are found to be at higher risk of vomiting.
An Increase in Intracranial Pressure: The balance between blood, brain, and cerebrospinal fluid is referred to as intracranial pressure. Intracranial pressure may increase due to hydrocephalus (fluid buildup in the cavities of the brain), tumors, abscesses, brain infections, pseudotumor cerebri (a condition in which the pressure around the brain builds up, causing headache and vomiting, it is named so because its symptoms are similar to those of a brain tumor). Treatment for the condition depends on what is causing it. For example, if there is a tumor or blood clot in the brain, the doctor may remove it.
Chemotherapy and Other Medications: Certain medications, especially chemotherapy drugs, can cause intractable vomiting. Hence, antiemetics are usually prescribed as an adjuvant to the therapy. In most cases, antiemetics may not help control nausea and vomiting. Other medications that may cause nausea include antibiotics, digoxin, anti-epileptic drugs, opioids, and hormone therapy. Depending on the condition, the physician can prescribe an alternative to the drug.
Pyloric Stenosis (Gastric Outlet Obstruction): This can affect the stomach's ability to empty its contents. The pylorus is the segment where the stomach meets the small intestine. The undigested food materials do not pass through the small intestine, causing food accumulation and leading to nausea and vomiting. A long-standing peptic ulcer can be a cause of pyloric stenosis. At times, dilation or enlargement of the pylorus might be necessary to solve the problem.
Gastroparesis: This refers to the condition where the peristalsis (movements in the stomach) is reduced, affecting the proper flow of the ingested food through the digestive tract. Diabetes is a common cause of gastroparesis. Non-invasive methods such as ultrasound can aid in the diagnosis through observation of the GI (gastrointestinal) tract movements.
Hyperemesis Gravidarum: This condition is seen in 1 out of every 100 pregnant women and is characterized by increased vomiting during pregnancy. In some women, it can start around nine weeks of pregnancy and last for nine months. Hospitalization to provide intravenous fluids might be required in some cases. A small amount of food several times a day, as well as pregnancy-safe antiemetics, may help with this condition.
Chronic Nausea and Vomiting Syndrome: The patient will continuously have nausea and vomiting for three months (four weeks or more of symptoms can be considered for this criteria). Symptoms may include nausea occurring once a day, or at least once a week. Other causative agents, like infections, need to be ruled out.
Cyclic Vomiting Syndrome: In this syndrome, nausea and vomiting persist for three to six days and then subside. It is more common in children. The exact etiology is unknown, but studies show that food allergies can cause the condition.
Dengue Infection: Intractable vomiting might be a warning sign of dengue infection. Other symptoms of the condition include rashes, aches, usually behind the eyes, muscle and joint pain, and a high fever.
Neuromyelitis Optica Spectrum Disorder: It is a condition that is thought to be caused by autoantibodies that affect the central nervous system. A rare condition can manifest as intractable vomiting as its isolated presenting symptom. Neuromyelitis optica spectrum disorder is a demyelinating inflammatory disorder that can relapse. Left untreated, it can cause blindness, and the patient may be confined to a wheelchair. Patients have continuous vomiting and intractable hiccups.
How Is Intractable Vomiting Managed?
Medications used to treat intractable vomiting are divided into antiemetics, neuromodulators (which function by blunting the gastric sensory functions, thereby reducing the symptoms), and prokinetics (drugs that stimulate gut propulsion). The intra-nasal spray is very useful, especially for patients who cannot take drugs orally due to severe vomiting. This is because it acts faster as it is diffused through the nasal mucosa.
Conclusion
Vomiting that is difficult to control is called intractable vomiting. It does not reduce with time or home-remedies. The most common causes of intractable vomiting are functional and gastrointestinal disorders. Treatment should be started before the symptoms worsen, leading to dehydration and electrolyte imbalance.
