Morbidity of VOMITING in a CKD patient

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A 75 year old male who is farmer by occupation came to the OPD for MHD for CKD

HISTORY OF PRESENT ILLNESS:

Normal routine of the patient:

He used to get up at 6 in the morning, used to have tea and did some household work, then breakfast at 8 (rice) then used to go for farming, he used to have lunch at 2 which is rice again. He used to return home by 6 in the evening then he used to freshen up and have dinner at 8 PM and sleep after that.

The Patient was apparently asymptomatic 3 months back then he had fever first which didn't subside even after 4 days. He then experienced shortness of breath while still having fever. 

He went to a local doctor, symptoms did not subside and then came to our OPD where he was diagnosed with CKD and hypertension 

Since the patient joined the hospital, he is undergoing dialysis twice per week and sometimes he used to have only shortness of breath while walking after initiation of treatment. No complaint of fever, edema also. 

The patient is experiencing vomiting from past 6 days which is not preceded by nausea, not associated with other symptoms, it is non bilious, the content is only undigested food which is ejected out as soon as he eats (around 5 minutes). 

HISTORY OF PAST ILLNESS:

The patient is not a known case of diabetes, epilepsy,tuberculosis,asthma

The patient has undergone an abdominal surgery 30 years back which was because of stomach pain (no detailed history given by attendant)

The patient had occasional acidity since 3 years.

PERSONAL HISTORY

- the patient has no loss of appetite

- bladder movements are normal

-no sleep disturbances 

FAMILY HISTORY:

There are no similar complaints in the family members

TREATMENT HISTORY:

The patient is not a known case of drug allergy

GENERAL EXAMINATION:

-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-No lymphadenopathy 

-No cyanosis 

-No clubbing of fingers

-No edema of feet

VITALS - temperature:98.4F

-pulse rate:86bpm

-respiration rate:18/min

-bp:110/70

-spo2-98%

SYSTEMIC EXAMINATION:

CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

RESPIRATORY SYSTEM 

- Position of trachea is central 

- Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds

PER ABDOMEN 

- abdomen is not tender

- no palpable mass or free fluid

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal

INVESTIGATIONS

TREATMENT:

Fluid restriction <1lit daily 

Salt restriction <2G/day

T.Nicardia 10mg BD 

T.Nodosis 500mg OD 

T.shelcal 500mg OD 

T.Lasix 40mg BD 

T. Orofer BD

Discussion : 

The vomiting (acute) may be due to food poisoning, gastritis, ulcer, bulimia nervosa.

Since the patient had a history of occasional acidity from past 5 years, an ulcer or gastritis may be present causing vomiting.

Since the patient is suffering from CKD, nausea and vomiting is very common. 

That may be due to uremic toxins accumulation, medications, gall bladder disease.

May be we can rule out uremic toxin accumulation because he has no mental confusion, itching, metallic taste

Since the vomit was not having contents of bile, it is not gall bladder disease.

Medications would be the cause for his vomiting as few of them have vomiting as a side effect.

"Nausea and vomiting are one of the most common causes of hemodialysis (28.5% and 11% respectively)"

The symptoms may be attributed to rapid drop in blood pressure or urea while hemodialyzing. 

Other causes include the effects of ESRD and its treatment on the digestive system, the patient’s diet, medication regimen, and developed disabilities.

Increased dialysate sodium and calcium may aggravate nausea and vomiting in dialysis patients. Eating while on dialysis machine or less than one hour before the start of dialysis can cause nausea during hemodialysis. Body position during hemodialysis also affects the incidence of nausea; the supine position causes more nausea and vomiting compared to the half-sitting position.

One of the Complications of nausea and vomiting during dialysis is dehydration and loss of homeostasis.

Reference : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5414519/