Nausea & Vomiting

Essentials of Diagnosis

• Nausea is a vague, intensely disagreeable sensation of sickness or "queasiness"

• Distinguished from anorexia (a loss of appetite)

• Retching (spasmodic respiratory and abdominal movements) often follows

• Vomiting may or may not follow

• Vomiting should be distinguished from regurgitation, the effortless reflux of liquid or solid (food) stomach contents, and from rumination, the chewing and swallowing of food that is regurgitated volitionally after meals

General Considerations

• May be caused by wide variety of conditions that stimulate the vagal afferent receptors, the brainstem vomiting center, or the chemoreceptor trigger zone (Table 15–1)

• May lead to serious complications, including electrolyte disturbances (hypokalemia, metabolic alkalosis), dehydration, aspiration pneumonia, Mallory-Weiss tear, and esophageal rupture

Symptoms and Signs

• Acute symptoms without abdominal pain suggest

  • Food poisoning

  • Infectious gastroenteritis

  • Drugs

  • Systemic illness

• Vomiting with acute pain suggests

  • Peritoneal irritation

  • Acute gastric or intestinal obstruction

  • Pancreaticobiliary disease

• Persistent vomiting suggests

  • Pregnancy

  • Gastric outlet obstruction

  • Gastroparesis

  • Intestinal dysmotility

  • Psychogenic disorders

  • CNS or systemic disorders

• Vomiting that occurs in the morning before breakfast is common with

  • Pregnancy

  • Uremia

  • Alcohol intake

  • Increased intracranial pressure

• Vomiting immediately after meals suggests bulimia or psychogenic causes

• Vomiting of undigested food suggests gastroparesis or a gastric outlet obstruction; physical examination reveals a succussion splash

  • Inquire about neurologic symptoms such as

  • Headaches

  • Stiff neck

  • Vertigo

  • Focal paresthesias or weakness

Differential Diagnosis

• Visceral afferent stimulation (Table 15–1)

  • Infections

  • Mechanical obstruction

  • Dysmotility

  • Peritoneal irritation

  • Hepatobiliary or pancreatic disorders

  • Topical GI irritants

  • Postoperative

• CNS disorders

  • Vestibular disorders

  • Increased intracranial pressure

  • Migraine

  • Infections

  • Psychogenic

• Irritation of chemoreceptor trigger zone

  • Cancer chemotherapy

  • Drugs and medications

  • Radiation therapy

  • Systemic disorders

• Cannabinoid hyperemesis syndrome

  • Suspect in patients with long-term use, especially in those who report compulsive showering or bathing

Laboratory Tests

• Serum electrolytes

• Serum glucose

• Serum creatinine

• Serum calcium

• Serum amylase

• Liver enzymes

• Thyroid-stimulating hormone

• Urine or serum pregnancy test

Imaging Studies

• Flat and upright abdominal radiographs

• Ultrasound or CT scan of abdomen

• Barium upper GI series

• Nuclear scintigraphic study for gastroparesis

Diagnostic Procedures

• Upper endoscopy

Medications

• Antiemetic medications (Table 15–2) given to control vomiting

• Combinations of drugs from different classes may provide better control

Therapeutic Procedures

• For mild, self-limited, acute vomiting

  • No specific treatment

  • Clear liquids and small quantities of dry foods

  • Ginger may be effective

• For moderate to severe vomiting

  • Nothing by mouth

  • Give intravenous saline 0.45% solution with 20 mEq/L of potassium chloride

• Nasogastric suction for gastric decompression in patients with

  • GI obstruction

  • Ileus or gastroparesis

  • Peritonitis

Complications

• Dehydration

• Hypokalemia

• Metabolic alkalosis

• Aspiration

• Rupture of the esophagus (Boerhaave syndrome)

• Bleeding secondary to a mucosal tear at the gastroesophageal junction (Mallory-Weiss syndrome)

Prevention

• Antiemetic medications (especially 5-HT₃ antagonists) can be given to prevent vomiting in patients undergoing chemotherapy and abdominal surgery

When to Admit

• Patients who have severe acute vomiting for rehydration, evaluation, and specific therapy