Nausea

Vomiting is the forceful ejection of the Stomach’s contents from the mouth resulting from disharmony of the Stomach and rebellion of Stomach Qi. Nausea shares the same etiology and pathology as vomiting in TCM, so the two are discussed together.

Classically, Chinese medicine distinguished between heaving (//ŏu// = vomiting accompanied by sound), disgorgement (//tù=// = = vomiting without any sound), and retching (//gān ŏu// = involuntary effort to vomit accompanied by sound but without actual emesis). Despite these classical distinctions, today vomiting is looked upon as one disorder (//ŏu tù//).

Relevant Biomedical Diseases
-Acute or chronic gastritis -Acute hepatitis -Acute pancreatitis -Acute cholecystitis -Acute appendicitis -Meniere’s disease -Morning sickness -Viral or bacterial infection -Esophageal obstruction -Pyloric obstruction -Head trauma (concussion) -Peptic ulcer -Renal failure -Medication induced

**Etiology and Pathology**
Invasion of Wind, Cold, Damp, or Summer-Heat pathogens -> rebellious Stomach Qi -Improper diet (excessive consumption of raw, cold, greasy food or consumption of contaminated food or excessive antibiotic use) -> injury to Spleen/Stomach -> Food stagnation or Phlegm-Fluids -> rebellious ST Qi -Rumination or excessive worry -> Qi stagnation in the Stomach or impairment of T & T fxn of SP -> Phlegm-Fluids -> rebellious ST Qi -Anger and frustration -> stagnation of Liver Qi -> Liver Qi overacting on Stomach or LV Qi overacting on SP -> impairment of T & T fxn of SP -> Phlegm-Fluids -> rebellious ST Qi -Chronic disease, congenital vacuity, taxation fatigue, chronic poor diet or chronic emotional distress -> SP/ST vacuity -> Cold rebellious ST Qi -Chronic disease, congenital vacuity, taxation fatigue, febrile disease, chronic poor diet or chronic emotional distress -> ST Yin vacuity -> rebellious ST Qi Note: the pathology of nausea and vomiting ultimately involves rebellion of Stomach Qi regardless of the pattern.

Differential Dx of Nausea (//Ĕ Xĭn//) and Vomiting (//Ŏu Tù//)
**Acid reflux (**//**tūn suān**//**):** the swallowing of upwelling stomach acid; nausea and vomiting uncommon


 * Hiccup (**//**è nì**//**):** involuntary contraction of the diaphragm causing sudden, audible inspiration that is checked by a spasodic closure of the glottis; nausea and vomiting uncommon


 * Stomach reflux (**//**făn wèi**//**):** vomiting of undigested food that was ingested many hours before


 * Dysphagia-occlusion (**//**yē gé**//**):** //yē// means difficulty swallowing; //gé// means blockage that prevents the downward passage of food and liquids after swallowing; dysphagia may occur alone but often leads to occlusion


 * Sudden turmoil disorder (**//**huò luàn**//**):** a disease characterized by simultaneous vomiting and diarrhea usually followed by severe cramps; overlaps with cholera and acute gastroenteritis in biomedicine

**Accompanying s/s:**
-Headache and fever: exogenous pathogen -Acute with cramping abdominal pain: exogenous pathogen, LV Qi stagnation -With epigastric distention, belching and bad breath: Stagnation of Food in the ST -Symptoms aggravated by emotional stress: LV Qi attacking the ST

**Type of vomitus:**
-Scanty vomitus or dry retching: ST Yin vacuity -Watery vomitus: Phlegm-Fluids or SP/ST vacuity Cold

**Vomiting Manifesting as Exogenous Pathogen Attacking the Stomach**
1.Accompanied by fever, chills, headache, no sweating, thin, white tongue coating and floating tight pulse if caused by pathogenic Wind-Cold. 2.Accompanied by fever, sweating, dysphoria, thirst, red tongue with yellow greasy coating and moderate rapid pulse if caused by Summer-Heat and Dampness. 3.Accompanied by fever, aversion to wind, headache, spontaneous sweating, red tongue with thin yellow coating and floating rapid pulse if caused by pathogenic Wind-Heat [Huo Xiang (12g.), Zi Su Ye (6g.), Bai Zhi (6g.), Chen Pi (9g.), Da Fu Pi (9g.), Hou Po (9g.), Bai Zhu (12g.), Fu Ling (9g.), Jie Geng (9g.), Sheng Jiang (6g.), Da Zao (2pc.), Zhi Gan Cao (3g.)] **Modifications:** Heat type: Use Yin Qiao San Summer-heat type: Use Xiang Jia Xiang Ru Yin If abnormal sweating: also consider Gui Zhi Tang (if scratchy throat + Jie Geng)
 * Main Symptoms ** **:** sudden onset of vomiting with a history of contraction of EPI
 * Additional Symptoms, Tongue, Pulse: **
 * Treatment Principles: ** Dispel exogenous pathogenic factors, transform turbidity with aromatic herbs to harmonize the Stomach and descend Stomach Qi
 * Acupuncture Treatment:** LI-4, GB-20 + [CV-12, ST-36, SP-4, PC-6]
 * Herbal Treatment:**__ Huo ____ Xiang ____ Zheng __ __ Qi ____ San __ __ ( ____ Agastache ____ /Patchouli ____ Qi ____ Righting Powder) __

**Vomiting Manifesting as Stagnation of Food in the Stomach**

 * Main Symptoms ** **:** vomiting of acidic, foul-smelling vomitus, aggravated by eating and relieved after vomiting
 * Additional Symptoms: ** fullness and distension in the epigastrium and abdomen, bad breath, abdominal pain relieved after vomiting, anorexia, foul-smelling loose or dry stools
 * Tongue: ** thick, greasy coating
 * Pulse: ** slippery
 * Treatment Principle: ** Disperse food, eliminate stagnation and relieve vomiting
 * Acupuncture Treatment:** CV-10, CV-21 + [CV-12, ST-36, SP-4, PC-6]
 * Herbal Treatment:** __ Bao ____ He Wan __ __ (Harmony Preserving Pill) __

**Vomiting Manifesting as Accumulation of Phlegm-Fluids in the Stomach**
__** Main Symptoms **__ __**:**__ vomiting of clear liquid and mucus [Ban Xia (10g.), Sheng Jiang (10g.), Fu Ling (10g.), Gui Zhi (5g.), Bai Zhu (10g.), Zhi Gan Cao (3g.)]
 * Additional Symptoms: ** distention in the chest and epigastrium, poor appetite, dizziness, palpitation
 * Tongue: ** white, greasy coating
 * Pulse: ** slippery
 * Treatment Principle: ** Warm and transform Phlegm-Fluids, harmonize the Stomach, relieve vomiting
 * Acupuncture Treatment:** CV-17, ST-40 + [CV-12, ST-36, SP-4, PC-6]
 * Herbal Treatment:** __ Xiao Ban Xia Tang __ + __ Ling ____ Gui ____ Zhu ____ Gan ____ Tang __ __ (Minor ____ Pinellia ____ Decoction) __ + __ Poria ____, Cinnamon, ____ Atractylodes ____ , and Licorice Decoction) __

**Vomiting Manifesting as by Liver Qi Attacking the Stomach**
__** Main Symptoms **__ __**:**__ vomiting accompanied by acid regurgitation and frequent eructation that temporarily relieves nausea, symptoms aggravated by emotional stress [Ban Xia (9-12g. ), Hou Po (9g.), Fu Ling (12g.), Sheng Jiang (15g.), Zi Su Ye (6g.)] + Huang Lian (3g.), Wu Zhu Yu (0.5g.)]
 * Additional Symptoms: ** fullness and pain in the chest and hypochondrium
 * Tongue: ** normal color or slightly red on the sides, thin, greasy coating
 * Pulse: ** wiry
 * Treatment Principle: ** Soothe the Liver, harmonize the Stomach to descend Qi and relieve vomiting
 * Acupuncture Treatment:** LR-3, LR-14, GB-34 + [CV-12, ST-36, SP-4, PC-6]
 * Herbal Treatment:** Ban Xia Hou Po Tang (Pinellia and Magnolia Bark Decoction) + Zuo Jin Wan

**Vomiting Manifesting as Spleen and Stomach Vacuity Cold**
[Ren Shen (10g.), Bai Zhu (10g.), Gan Jiang (6g.), Zhi Gan Cao (6g.)]
 * Main Symptoms ** : chronic, intermittent vomiting, often induced by a slight increase in food intake
 * Additional Symptoms: ** poor appetite, indigestion, epigastric fullness, lusterless face, lassitude, preference for warmth and aversion to cold, or cold extremities, loose stools, possible dry mouth without desire to drink
 * Tongue: ** pale with thin white coating
 * Pulse: ** thin, weak
 * Treatment Principle:** Warm Middle Jiao, strengthen the Spleen, harmonize the Stomach and descend rebellious Qi
 * Acupuncture Treatment:** BL-20, BL-21 + [CV-12, ST-36, SP-4, PC-6]
 * Herbal Treatment:** __ Li Zhong Tang ____ (Center Rectifying Decoction) __

**Vomiting Manifesting as Stomach Yin Vacuity**
Mai Men Dong (15-18g.), Ban Xia (15-18g.), Ren Shen (6g.), Jing Mi (15-30g.), Da Zao (3-4pc.), Gan Cao (6g.)]
 * Main Symptoms ** **:** chronic, recurrent vomiting with scant vomitus or simply dry heaves
 * Additional Symptoms: ** dry mouth and throat, hunger without desire to eat, dull epigastric pain or discomfort, dry stool
 * Tongue: ** dry, red with scanty coating
 * Pulse: ** thin, rapid
 * Treatment Principle: ** Nourish Stomach Yin, descend rebellious Qi, stop vomiting
 * Acupuncture Treatment:** SP-6, KI-3 + [CV-12, ST-36, SP-4, PC-6]
 * Herbal Treatment:** __ Mai Men Dong Tang __ (Ophiopogon Tuber Decoction)

Acupuncture for Nausea and Vomiting
__** Primary Points: **__ CV 12, ST 36, SP4, PC 6 __ Supplementary Points: __ **Exogenous pathogens:** LI 4, GB 20
 * Retention of Food:** CV 10, CV 21
 * Phlegm-Fluids:** CV 17, ST 40
 * LV Qi attacking the ST:** LV 3, LV 14, GB 34
 * SP/ST vacuity Cold:** BL 20, BL 21
 * ST Yin vacuity:** SP 6, KI 3

Clinical Tips for Treating Nausea and Vomiting
1. Referral to an acute-care medical facility is strongly recommended if dehydration due to severe vomiting is evident. Referral is also necessary if there is projectile vomiting with blood in the vomitus, high fever, severe headache, irritability, lethargy or unconsciousness. 2. It may be difficult for a patient who is nauseated or vomiting to take an herbal decoction. Therefore, it may be helpful to administer the daily dose of the decoction in smaller quantities at more frequent intervals. = = == =Potential Contributing Factors= -Variations in blood calcium levels -Potassium Excess

Dietary Recommendations
Avoid spicy meals, alcohol and fats.