Nausea and Vomitting

Nausea ,vomitting are common go to side effects of a drug, when external examiner asks during viva of a medical student. But, these symptoms can reveal many underlying conditions and diseases apart from the side effects of many drugs.

Nausea is imminent desire to vomit and often precedes or accompanies vomitting. vomiting is the forceful expulsion of the gastric contents through mouth.

    PATHOPHYSIOLOGY:                  

    1. Activation of the CTZ ,sends the impulses to the vomiting centre in brainstem,

    2. Gastric fundus and gastroesophageal sphincter relaxes inturn cause raise in intra-abdominal pressure increase,due to increase in abdominal and diaphragm muscle contraction causes the gastric contents to enter the oesophagus ,

   3. Increased intra-thoracic pressure results in further movement of food material to mouth

4.Reflex elevation of the soft palate  and closure of glottis protect the nasopharynx and     trachea and completes the vomiting

Causes of vomiting: 
  1. DRUGS:
              -Cancer chemotherapy
              -Antibiotics
              -Cardiac antiarrhythmics
              -Digoxin
              -Oral hypoglycemics
              -Oral contraceptives
2.Metabolic and endocrine causes:
               -Pregnancy
               -Uremia
               -Ketoacidosis
               -Thyroid and parathyroid disease.
               -Adrenal insufficiency
3.Toxins:
              -Liver failure
              -Ethanol
4.Labyrinthine disease
             - Motion sickness 
             - Labyrinthitis
             - Malignancy
5. Bowel obstructing disorder
6. Cardiopulmonary disorders and cardiomyopathies
7.Enteric infections
      -viral
      -Bacterial
8.Inflammatory dieases.
      - cholecystitis.
      -Pancreatitis
      -Appendicitis
      -Hepatitis.
9.Intracerebral disorders
      -Intracerebral disorders  
      -Malignancy 
      -Abscess 
      -Hydrocephalus
10. Post operative vomiting
11.Impaired motor functions.
Careful clinical examination, will reveal the underlying 
 cause for nausea and vomiting, like ,vomiting that occurs
 predominantly in the morning is often seen in pregnancy,
 uremia, and alcoholic gastritis;projectile vomiting suggests
 increased intracranial pressure,vomiting during or shortly
 after a meal may be due to psychogenic causes or peptic 
 ulcer disease.

complications, can be Rupture of the esophagus,hematemesis
from a mucosal tear,dehydration, malnutrition, dental caries 
and erosions, metabolic alkalosis, hypokalemia, 
and aspiration pneumonitis.
Treatment is mainly based on the treatment of the underlying cause,
  -Antihistamines such as meclizine and dimenhydrinate are effective
for nausea due to inner ear dysfunction
  -Anticholinergics such as scopolamine are effective for nausea 
   associated with motion sickness
  -Haloperidol and phenothiazine derivatives such as
    prochlorperazine are often effective in controlling mild nausea 
    and vomiting, but sedation, hypotension, and parkinsonian 
    symptoms are common side effects.
  -Metoclopramide may be superior to the phenothiazines in treating 
   severe nausea and vomiting.IV metoclopramide may be effective 
   as prophylaxis against nausea when given before chemotherapy.
  -Ondansetron and granisetron, serotonin receptor blockers, 
   and glucocorticoids are used for treating nausea and vomiting 
    associated with cancer chemotherapy.
  -Aprepitant, a neurokinin receptor blocker, is effective at
    controlling nausea from highly emetic drugs like cisplatin

Post Extraction Uncontrolled Bleeding

As private practice is one of the huge forms of practice in India for dentists, bleeding is an important complication encountered day in and day out. The idea of this post is to just have a Gist in the post Extraction bleeding control,many techniques are followed by many clinicians.so no technique is the gold standard for the control of Extraction bleeding.

In a clinical perspective, basics of bleeding control is proper evaluation of the preoperative blood investigation. It should be made mandatory for any kind of procedure either be a impression making or invasive oral surgery. Basic blood picture should comprise of CBC,BT,CT,PT, Thromboplastin Time, Complete Blood Sugar (CBG). Many ignore advising of PT and Thromboplastin Time but it can reveal bleeding disorders like hemophilia. If you suspect the patient to be having any renal or hepatic impairment do not hesitate to order for LFT and RFT. Though these tests cost some amount it’s important that patient is not harmed by our negligence after our procedure.

Post extraction bleeding is one of the commonest emergency for every dentist in a clinical setup. It can be arrested with packing of gel sponge and closing the area with sutures,if the Extraction site had not been closed with sutures.close inspection of the socket should be done and the previous formed clot in the socket should be retracted or removed by irrigation of the socket first with saline then with betadine and finally with again saline. After the induction of fresh bleeding from the socket pack the area with gel sponge and suture the socket. This gel sponge can degrade by itself ,so there will not be any need for reexploration of the site. There are many day to day update in the management of bleeding and new hemostats and hemostatic techniques are developing.

In cases where the haemostasis is not achieved even after the closure of the socket suspect for a systemic cause which might have been missed during pre-op evaluation.patients on oral anticoagulants usually have irreversible action of prevention of aggregation of Thromboxin A2 which is responsible for platelet aggregation.Even aspirin and Acetaminophen have revesible inhibition of Thromboxane A2. This history to be noted. Bleeding disorders like hemophilia A ,B,C can invlove the deficiency of the clotting factors hence, the PT and thromboplastin time can be prolonged. Vitamin K Antagonist therapy patients, malnutrition patients are suseptible to uncontrolled bleeding.

Proper evaluation of the patient preoperatively and keeping the conditions which can cause bleeding are to be kept in mind so that the clinician can rule out a diagnosis and refer to the appropriate specialist.

Common causes of bleeding which should always be in mind

  • Uncontrolled Diabetes Mellitus with irregular HbA1c level can also increase bleeding tendency
  • Patient under anti-platelet therapy like aspirin
  • Acetaminophen and NSAIDs like ibuprofen which are non selective COX inhibitor
  • Patient under blood thinners like warfarin,
  • Patient who are malnutritioned may be suseptible to prolonged bleeding.