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Chapter 36: Gastrointestinal Emergencies

Scott McAninch; Clinton C. Smithson III

EVALUATION OF VOMITING

MANAGEMENT OF NAUSEA AND VOMITING

Vomiting has many causes originating inside and outside the gastrointestinal (GI) system, and may be age specific. Common causes in all ages are viral gastroenteritis and medication side effects. In infants, vomiting may be due to overfeeding or gastroesophageal reflux disease (GERD). However, other conditions may be present: projectile vomiting suggests pyloric stenosis, bilious/green vomiting may be present in obstructive conditions such as midgut volvulus. Associated intermittent abdominal pain and altered mentation suggests intussusception. Associated bloody diarrhea suggests bowel necrosis, invasive bowel infections, or in older children, inflammatory bowel disease (IBD). See Table 36–1 for lists of other causes to be considered.

Table 36–1.Pediatric causes of vomiting.
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Table 36–1. Pediatric causes of vomiting.
Type of Vomiting Potential Cause
GI-bilious vomiting Midgut volvulus, duodenal atresia, meconium ileus
GI-nonbilious vomiting Pyloric stenosis (<6 wk), gastroenteritis, imperforate anus, GERD, hernia, TE fistula, diaphragmatic hernia, necrotizing enterocolitis (0–3 wk), Hirschsprung disease (toxic megacolon), tracheoesophageal fistula, intussusception (3–24 mo), pancreatitis
Metabolic DKA, thyroid disorders, inborn errors of metabolism, congenital adrenal hyperplasia, acute kidney injury
Infections Meningitis, UTI, pneumonia, streptococcal pharyngitis
Neurologic Hydrocephalus, subdural hematoma, nonaccidental trauma
Toxins Ingestions, alcohol
Other Gonadal torsion, tumors, vaso-occlusive crisis in sickle cell disease, HSP, black widow spider envenomation

DKA, diabetic ketoacidosis; GERD, gastroesophageal reflux disease; GI, gastrointestinal; HSP, hemiplegic shoulder pain; TE, tracheoesophageal; UTI, urinary tract infection.

Adults with vomiting have additional differential considerations often related to medication use, acquired diseases, pregnancy and substance abuse (Table 36–2). Hematemesis and GI bleed are discussed in Chapter 16.

Table 36–2.Adult causes of vomiting.
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Table 36–2. Adult causes of vomiting.
Type of Vomiting Potential Cause
GI Gastroenteritis, bacterial colitis, obstruction (adhesions, hernia, volvulus, tumors, intussusception), ileus, esophageal disorders, appendicitis, gallbladder disease, liver disease, SBP, peptic ulcer disease, mesenteric ischemia
Neurologic Head injury, headache syndromes, symptomatic cerebral aneurysm with SAH, meningitis, encephalitis, cerebral abscess, intracranial hypertension, hydrocephalus, vertigo disorders (BPV)
Medications, toxins Chemotherapy, aspirin, NSAIDs, opioids, alcohol, antibiotics, hormones, antiarrhythmics, carbon monoxide, lead exposure, cholinergic exposures, nicotine, marijuana use
Endocrine Pregnancy, DKA, AKA, uremia, adrenal insufficiency, parathyroid disorders, hyperthyroidism
Other Myocardial ischemia, ectopic pregnancy, response to severe pain of any cause, sepsis syndromes, renal colic, gonadal torsion, increased intraocular pressure (acute glaucoma), anaphylaxis, psychogenic (bulimia, anxiety)

AKA, alcoholic ketoacidosis; BPV, benign positional vertigo; DKA, diabetic ketoacidosis; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; SAH, subarachnoid hemorrhage; SBP, spontaneous bacterial peritonitis.

Physical Examination

Fever may be present in infection, toxicologic causes (aspirin, MDMA, bath salts), and systemic conditions. Tachycardia may be present with dehydration, pain, blood loss, infection/sepsis syndromes. Assess for signs of decreased perfusion due to intravascular volume depletion (cool, pale skin; altered mentation; prolonged capillary refill, decreased urinary output; dry mucous membranes). ...

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