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Diarrhea and vomiting are common reasons for Emergency Department visits. Although the majority of cases are of an infectious, self-limiting nature, the differential diagnosis is broad with the potential for significant morbidity and mortality. Many pathologic processes involve gastrointestinal (GI) symptoms. Included are intracranial pathology (trauma, masses, infections), cardiac disease (myocardial infarction, angina), toxic exposures (digoxin, carbon monoxide, heavy metals), acute abdominal pathology (intestinal obstruction, mesenteric ischemia), and endocrine abnormalities (diabetic ketoacidosis, adrenal insufficiency), among others. In addition, infectious causes of diarrhea and vomiting can cause significant harm, especially in the elderly, in infants, and in immunocompromised individuals (Figure 36–1).

Figure 36–1.

Approach to the patient with vomiting and diarrhea, part 1. NSAIDs, nonsteroidal anti-inflammatory drugs. Approach to the patient with vomiting and diarrhea, part 2.


Hypotension and Shock

Essentials of Diagnosis

  • Signs of decreased perfusion
  • Hypotension, tachycardia, oliguria, and orthostasis
  • Cool, pale skin; dry mucous membranes; and altered mentation

Clinical Findings

Obtain complete vital signs. Look for signs of decreased perfusion (ie, cool, pale skin; altered mentation; decreased urinary output; dry mucous membranes). Hypotension (systolic pressure <90 mm Hg), tachycardia, oliguria, and orthostasis may indicate impending hemodynamic instability. Look for evidence of sepsis, GI bleed, cardiac pump dysfunction, surgical abdominal pathology, toxic exposures, endocrine abnormalities, or anaphylaxis.

Treatment and Disposition

Insert a large-bore intravenous catheter and draw blood for a complete blood count (CBC), electrolytes, renal and liver function, serum lipase, and a pregnancy test, if indicated. Type and crossmatch if significant blood loss is reported or suspected. Start supplemental oxygen, cardiac monitoring, and pulse oximetry together with normal saline volume resuscitation while the underlying cause is sought. If appropriate, initiate empiric antibiotic therapy. Hospitalize the patient for continuous monitoring, supportive treatment, and further investigation if the cause is uncertain. Initiate specific treatment once the cause is determined.

Acute Abdominal Emergencies

Essentials of Diagnosis

  • Focal abdominal pain or signs of peritoneal inflammation (rebound)
  • Pain that precedes the vomiting or diarrhea
  • Pain out of proportion to the physical examination

Clinical Findings

Patients with acute surgical abdominal pathology may present with diarrhea and vomiting and are at risk of being mislabeled as having gastroenteritis. Inquire about the nature and location of pain and the existence of upper GI symptoms (vomiting) and lower GI symptoms (diarrhea). Determine which symptom began first. Signs and symptoms suggestive of an acute abdominal emergency include focal abdominal pain, an examination consistent with peritoneal inflammation, pain that precedes the vomiting and diarrhea, protracted vomiting with nonspecific abdominal pain, and pain out of proportion to the physical examination. Consider entities such as acute appendicitis, intestinal obstruction, mesenteric ischemia, ectopic pregnancy, GI bleed, intussusception, and gonadal torsion (Table 36–4). Serial abdominal examinations in the ED may help ...

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