What is the treatment for nausea, vomiting, diarrhea, epigastric pain, dizziness, and leukocytosis?

Management of Nausea, Vomiting, Diarrhea, Epigastric Pain, Dizziness, and Leukocytosis

Initial Diagnostic Approach

This clinical presentation with leukocytosis strongly suggests acute infectious gastroenteritis, and GI pathogen testing including Clostridium difficile should be obtained immediately, particularly given the leukocytosis. 1

Critical First Steps

• Obtain complete blood count, serum electrolytes, glucose, liver function tests, lipase, and urinalysis to exclude metabolic causes and assess for dehydration 2
• Test for GI pathogens including C. difficile culture, especially with leukocytosis present 1
• Consider urine drug screen to assess for cannabis use, as Cannabis Hyperemesis Syndrome can present with these symptoms 2
• Assess for dehydration and correct fluid/electrolyte imbalances immediately 3

Key Clinical Pitfall

Do not use antiemetics if mechanical bowel obstruction is suspected, as this can mask progressive ileus and gastric distension 2, 4. The epigastric pain warrants careful abdominal examination to exclude obstruction before initiating antiemetic therapy.

Immediate Supportive Care

• Ensure adequate fluid intake of at least 1.5 L/day and provide IV hydration if oral intake is not tolerated 2
• Correct electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, which commonly occur with prolonged vomiting 2
• Administer thiamin supplementation to prevent Wernicke's encephalopathy in patients with persistent vomiting 2

Pharmacologic Treatment Algorithm

First-Line Therapy

Initiate dopamine receptor antagonists as first-line treatment, titrated to maximum benefit and tolerance 3, 2, 4:

• Metoclopramide 10 mg PO/IV three times daily (particularly effective for gastric stasis and promotes gastric emptying) 2, 4
• Alternative: Prochlorperazine 10 mg PO/IV every 6-8 hours 2
• Alternative: Haloperidol 0.5-2 mg PO/IV every 4-6 hours 3, 2

Monitor for extrapyramidal side effects with all dopamine antagonists, particularly in young males 2, 4. Treat extrapyramidal symptoms with diphenhydramine 50 mg IV if they develop 2.

For Gastritis/Epigastric Pain Component

Add proton pump inhibitor or H2 receptor antagonist to address the epigastric pain, as gastritis or gastroesophageal reflux may be contributing 3, 4:

• Proton pump inhibitor (e.g., omeprazole 20-40 mg daily) 1, 3
• Separate dosing from other medications by 12 hours if using dasatinib or similar agents 1

Second-Line Therapy (If Symptoms Persist After 4 Weeks)

Add 5-HT3 receptor antagonist if symptoms persist despite dopamine antagonist therapy 3, 2, 4:

• Ondansetron 4-8 mg PO/IV 2-3 times daily 3, 2, 5
• Alternative: Granisetron 1 mg PO twice daily 3
• Use sublingual formulation if actively vomiting to improve absorption 4

Critical monitoring: Monitor QTc interval carefully when using ondansetron, especially in combination with other QT-prolonging agents 1, 2. Some institutions have hospital-wide protocols to monitor QTc and reduce risk of Torsades de pointes 1.

Important caveat: Ondansetron may increase stool volume/diarrhea, which could worsen the diarrhea component 2. However, this side effect is generally outweighed by antiemetic benefit.

Diarrhea Management

For diarrhea, use antidiarrheal medication once infectious workup is complete and bacterial pathogen is excluded 1:

• Loperamide 4 mg initially, then 2 mg after each loose stool (maximum 16 mg/day) in adults 1
• Avoid loperamide if fever is present or inflammatory diarrhea is suspected, as toxic megacolon may result 1
• If using bosutinib or similar medications, start diphenoxylate/atropine or loperamide at first sign of diarrhea 1

Combination Therapy Principles

Administer antiemetics on a scheduled basis rather than PRN, as prevention is far easier than treating established vomiting 2. Use agents from different drug classes simultaneously rather than sequential monotherapy, as different neuroreceptors are involved in the emetic response 2, 4.

For Anxiety-Related Component (If Dizziness Suggests Vestibular/Anxiety)

Consider adding benzodiazepines if anxiety is contributing to symptoms 3, 4:

• Lorazepam 0.5-1 mg PO/IV every 4-6 hours 3
• In elderly patients, reduce to 0.25 mg orally 2-3 times daily 3
• Avoid long-term use due to risk of dependence 4

Refractory Symptoms Management

If symptoms persist despite first and second-line therapy:

• Add dexamethasone 10-20 mg IV in combination with ondansetron, as this combination is superior to either agent alone 2
• Consider olanzapine 2.5-5 mg PO daily, especially in palliative care settings 3
• Dronabinol 2.5-7.5 mg PO every 4 hours as needed is FDA-approved for refractory nausea 2
• Consider continuous IV or subcutaneous infusion of antiemetics for severe, persistent symptoms 3, 2

Route of Administration Considerations

The oral route is often not feasible due to ongoing vomiting 4:

• Use rectal suppositories (promethazine or prochlorperazine) 4
• Use sublingual formulations (ondansetron, alprazolam) 4
• Use IV administration when other routes fail 2, 4

Special Diagnostic Considerations

Cannabis Hyperemesis Syndrome

If heavy cannabis use preceded symptom onset, Cannabis Hyperemesis Syndrome requires 6 months of cannabis cessation or at least 3 typical cycle lengths without vomiting for definitive diagnosis 2. Do not stigmatize patients with cannabis use—offer abortive and prophylactic therapy even with ongoing use, as treatments can still be effective 2.

When to Pursue Endoscopy

Avoid repeated endoscopy or imaging unless new symptoms develop 2. Consensus indications for prompt endoscopy include:

• Inability to tolerate sufficient liquid diet with ongoing dehydration/profound weight loss 1
• Suspected graft-versus-host disease in bone marrow transplant patients 1
• Immune-mediated colitis in patients receiving checkpoint inhibitors 1

Dosing Adjustments

Elderly patients require dose reduction of 25-50% initially when using antiemetics such as metoclopramide or haloperidol 3. Elderly patients are especially sensitive to benzodiazepines and antipsychotics and should be monitored closely 3.