Fluid Resuscitation and Management

Initiation of Fluid Resuscitation

• Initiate IV fluid resuscitation with balanced crystalloid solution in patients presenting with signs of dehydration, as recommended by the World Journal of Emergency Surgery guidelines 1

Management of Refractory Vomiting

• For patients with refractory vomiting, add haloperidol 0.5-2 mg IV/PO every 4-6 hours, and consider dexamethasone 8 mg IV as adjunct, according to the World Journal of Emergency Surgery guidelines 2
• Antiemetic therapy is crucial for managing nausea and vomiting in patients receiving high-emetic risk agents, with the National Comprehensive Cancer Network and the American Society of Clinical Oncology providing guidelines for its use 3, 4
• The National Comprehensive Cancer Network recommends a first-line combination therapy consisting of a 5-HT3 receptor antagonist (ondansetron 8 mg IV or palonosetron 0.25 mg IV), dexamethasone 12 mg IV, and aprepitant 125 mg orally (if not previously administered) for patients receiving high-emetic risk agents, with a strength of evidence of high 3, 4

Diagnostic Evaluation

• A Complete Blood Count (CBC) with differential and platelet count is recommended to evaluate for cytopenias, leukocytosis, leukopenia, or abnormal cells suggesting hematologic malignancy, and to identify anemia which may occur with splenic sequestration or GI blood loss, as suggested by the National Comprehensive Cancer Network, with a strength of evidence of high 5, 6, 7
• A Comprehensive Metabolic Panel is recommended to assess liver function tests, basic metabolic profile, and serum lactate (if acute presentation), with a strength of evidence of high 6, 7
• Coagulation Studies, including prothrombin time (PT) and activated partial thromboplastin time (aPTT), are recommended, with a strength of evidence of high 7
• Liver function tests, including AST, ALT, and bilirubin, are recommended to evaluate for hepatitis or biliary disease in patients with nausea and vomiting, as suggested by the National Comprehensive Cancer Network and the American Gastroenterological Association, with a strength of evidence of high 8, 9
• Abdominal ultrasound is recommended as the initial imaging for splenic size assessment and evaluation of portal hypertension, with a strength of evidence of high 5
• CT angiography (CTA) or MR venography (MRV) is recommended to evaluate for splanchnic vein thrombosis (portal, mesenteric, or splenic vein) and to assess for other abdominal pathology, with a strength of evidence of high 5, 7

Cyclic Vomiting Syndrome (CVS) Diagnosis and Management

• CVS is a functional disorder characterized by stereotypical episodes of acute-onset, intense nausea and vomiting that last less than 7 days, occur at least 3 times per year with 2 episodes in the prior 6 months, are separated by symptom-free intervals of at least 1 week, and have no vomiting between episodes, as defined by the Rome IV criteria, with a strength of evidence of high 10
• Conditions to be ruled out in CVS diagnosis include:

3, 11, 10

• First-line interventions for acute CVS episodes include placing the patient in a dark, quiet room, aggressive IV hydration with dextrose-containing fluids, and antiemetics (ondansetron), with sumatriptan (nasal spray or subcutaneous) considered for refractory vomiting, as suggested by the American Academy of Family Physicians, with a strength of evidence of moderate 12
• Medications for acute episodes:

13, 10

• Essential components for long-term management include identifying and avoiding personal triggers, maintaining regular sleep patterns, avoiding prolonged fasting, implementing stress management techniques, and addressing comorbid conditions, such as anxiety, depression, migraines, and sleep disorders, as recommended by the American Gastroenterological Association, with a strength of evidence of high 10

Stent Management

• Consider stent removal if no longer needed, as suggested by the Clinical Nutrition guidelines 14