Nausea and vomiting: Difference between revisions
 
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{{Adult top}} [[nausea and vomiting (peds)]]. For nausea and vomiting during pregnancy, see [[hyperemesis gravidarum]].''
==Background==
==Background==
[[File:Nausea_and_vomiting.png|thumb|Nausea and Vomiting Algorithm]]
[[File:Nausea_and_vomiting.png|thumb|Nausea and Vomiting Algorithm]]


==Clinical Features==
==Clinical Features==
*Nausea and/or vomiting
*Additional features of underlying process


== DDX by organ system ==
==Differential Diagnosis==
===GI===
{{Nausea and vomiting DDX}}
 
===By organ system===
====GI====
*[[Peptic ulcer disease]]
*[[Peptic ulcer disease]]
*Obstruction
*[[Bowel obstruction|Obstruction]]
**Adhesion
**Adhesion
**[[Small bowel obstruction]]/LBO
**[[Small bowel obstruction]]/LBO
***[[SMA syndrome]]
**Gastric outlet obstruction
**Gastric outlet obstruction
**[[Gastric volvulus]]
**[[Bezoar]]
*[[Pancreatitis]]
*[[Pancreatitis]]
*Gastroparesis
*[[Gastroparesis]]
*[[Appendicitis]]
*[[Appendicitis]]
*[[Cholecystitis]]
*[[Cholecystitis]]
*[[Cholangitis]]
*[[Cholangitis]]
*[[Acute Hepatitis]]
*[[Acute Hepatitis]]
*IBD
*[[IBD]]
*[[Intussusception]]
*[[Intussusception]]
*Tumor
*Tumor
*Strangulated hernia
*Strangulated [[hernia]]
*[[Volvulus]]
*[[Volvulus]]
*[[Mesenteric ischemia]]
*[[Mesenteric ischemia]]
*Esophageal disorders (e.g. achalasia)
*Esophageal disorders (e.g. [[achalasia]])
*Functional disorders
*Functional disorders
**Psychogenic
**Psychogenic
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*[[Pyloric Stenosis]]
*[[Pyloric Stenosis]]


===Neurologic===
====Neurologic====
*Head injury
*[[Head injury]]
*[[CVA]]
*[[CVA]]
*Pseudotumor
*[[Idiopathic intracranial hypertension]]
*Hydrocephalus
*[[Hydrocephalus]]
*Mass lesion
*[[Intracranial mass|Mass lesion]]
*[[Meningitis]]
*[[Meningitis]]
*Migraines
*[[Migraine]]
*[[Labyrinthitis]]
*[[Labyrinthitis]]
*Meniere disease
*[[Meniere's disease]]
*Motion sickness
*[[Motion sickness]]
*[[Cannabinoid hyperemesis syndrome]]
*[[Cannabinoid hyperemesis syndrome]]


===Infectious===
====Infectious====
*Bacterial toxins
*[[Bacteria]]l toxins
*[[PNA]]
*[[Pneumonia]]
*[[SBP]]
*[[SBP]]
*[[UTI]]
*[[UTI]]
*Viruses (adeno, norwalk, rota
*Viruses ([[adenovirus]], [[norovirus]], [[rotavirus]])
===Drugs/Toxins===
 
====Drugs/Toxins====
*Toxic doses
*Toxic doses
**Digoxin
**[[Digoxin toxicity]]
**ASA
**[[Aspirin toxicity]]
**APAP
**[[Acetaminophen toxicity]]
*NSAIDs
**[[Ipecac toxicity]]
*Opiates
*[[NSAIDs]]
*ETOH
*[[Opioids]]
*Anticonvulsants
*[[Alcohol]]
*Abx
*[[Anticonvulsants]]
*Antiarrhythmics
*[[Antibiotics]]
*[[Antiarrhythmics]]
*Toxins
*Toxins
**Organophosphates
**[[Organophosphates]]
**CO
**[[Carbon monoxide]]
**Ricin
**[[Ricin]]
===Endocrine===
*[[Acute radiation syndrome]]
*Pregnancy
 
====Endocrine====
*[[Pregnancy]], [[hyperemesis gravidarum]]
*[[Hyponatremia]]
*[[Hyponatremia]]
*Adrenal insufficiency
*[[Adrenal insufficiency]]
*[[DKA]]
*[[DKA]]
*Thyroid/parathyroid disorders
*[[Thyroid]]/parathyroid disorders
*[[Uremia]]
*[[Uremia]]


===Miscellaneous===
====Miscellaneous====
*[[ACS]]
*[[ACS]]
*Gonadal torsion
*[[Ovarian torsion|ovarian]]/[[testicular torsion]]
*[[Nephrolithiasis]]
*[[Nephrolithiasis]]
*Pain
*Pain
*Acute glaucoma
*[[Acute angle-closure glaucoma]]
*Anorexia/bulimia
*[[Anorexia nervosa]]/[[bulimia nervosa]]
*Depression
*[[Depression]]
 
==DDx by Severity==
=== Critical ===
*[[Esophageal Perforation|Boerhaave's]]
*Ischemic bowel
*[[ICH]]
*[[Meningitis]]
*[[DKA]]
*[[AMI]]
*[[Sepsis]]
 
=== Emergent ===
*Gastric outlet obstruction
*[[Pancreatitis]]
*[[Cholecystitis]]
*Bowel obstruction/ileus
*Ruptured viscus
*[[Appendicitis]]
*Peritonitis
*Migraine
*CNS tumor
*raised ICP
*Adrenal insuffciency
*Hyperemesis gravidarum
*Tylenol
*Digoxin
*ASA
*Theophyline
*Gonadal torsion
*CO
*[[Electrolyte Disorders]]
===Nonemergent===
*[[Gastritis]]
*Gastroparesis
*PUD
*Gastroenteritis
*Biliary colic
*Hepatitis
*Thyroid
*Pregnancy
*Erythromycin
*Ibuprofen
*Chemotherapy
*Narcotics/wdwl from
*ETOH
*UTI
*Renal colic
*Motion sickness
*Labyrinthitis


==Diagnosis==
==Evaluation==
===Work-Up===
''Varies widely depending on clinical presentation''
*CBC
*CBC
*Chemistry
*Chemistry
*Urine pregnancy
*Urine pregnancy
*LFTs
*[[LFTs]]
*Lipase
*Lipase
*APAP, ASA, digoxin levels
*APAP, ASA, digoxin levels
*UA
*[[Urinalysis]]
*?Abd xray
*?[[Abdominal xray]]
*?CT
*?CT
*?US
*?[[Ultrasound]]
 
===Evaluation===


==Management==
==Management==
*Treat underlying pathology
*Address [[electrolyte derangements]] and [[dehydration]] as needed
*[[Antiemetics]]
*Inhaled isopropyl alcohol (sniffing an alcohol wipe) has been shown to reduce mild to moderate nausea and vomiting<ref>Lindblad AJ, Ting R, Harris K. Inhaled isopropyl alcohol for nausea and vomiting in the emergency department. Can Fam Physician. 2018;64(8):580.</ref>


==Disposition==
==Disposition==
*Depends on cause
*Most non-specific episodes of acute nausea and vomiting may be discharged, if:
**No emergent/urgent cause identified or suspected
**Patient tolerating fluids after treatment


== Complications ==
==Complications==
*Hypovolemia
*[[Hypovolemia]]
*Metabolic alkalosis
*[[Metabolic alkalosis]]
*Hypokalemia
*[[Hypokalemia]]
*Mallory-Weiss (tear)
*[[Mallory-Weiss]] (tear)
*Boerhaave (rupture)
*[[Boerhaave]] (rupture)
*Aspiration
*Aspiration
== Peds ==
{| cellspacing="1" cellpadding="3" border="0" bgcolor="*666666" width="100%"
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" colspan="2" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | '''Newborn'''&nbsp;
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Obstructive intestinal anomalies
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Esophageal stenosis/atresia, pyloric stenosis, intestinal stenosis/atresia, malrotation ± volvulus, incarcerated hernia, meconium ileus/plug, Hirschsprung disease, imperforate anus, enteric duplications
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Neurologic
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Intracranial bleed/mass, hydrocephalus, cerebral edema, kernicterus
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Renal
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Urinary tract infection, obstructive uropathy, renal insufficiency
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Infectious
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Viral illness, gastroenteritis, meningitis, sepsis
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Metabolic/endocrine
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Inborn errors of metabolism (urea cycle, amino/organic acid, carbohydrate), congenital adrenal hyperplasia
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Miscellaneous
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Ileus, gastroesophageal reflux, necrotizing enterocolitis, milk allergy, GI perforation
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" colspan="2" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | '''Infant (<12 mo)'''&nbsp;
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Obstructive intestinal anomalies
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Pyloric stenosis, malrotation ± volvulus, incarcerated hernia, Hirschsprung disease, enteric duplications, intussusception, foreign body, bezoars, Meckel diverticulum
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Neurologic
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Intracranial bleed/mass, hydrocephalus, cerebral edema
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Renal
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Urinary tract infection, obstructive uropathy, renal insufficiency
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Infectious
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Viral illness, gastroenteritis, meningitis, sepsis, otitis media, pneumonia, pertussis, hepatitis
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Metabolic/endocrine
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Inborn errors of metabolism, adrenal insufficiency, renal tubular acidosis
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Miscellaneous
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Ileus, gastroesophageal reflux, post-tussive, peritonitis, drug overdose
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | '''Child (>12 mo)'''&nbsp;
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | &nbsp;
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Obstructive intestinal anomalies
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Malrotation ± volvulus, incarcerated hernia, Hirschsprung disease, intussusception, foreign body, bezoars, Meckel diverticulum, acquired esophageal stricture, peptic ulcer disease, adhesions, superior mesenteric artery syndrome
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Neurologic
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Intracranial bleed/mass, cerebral edema, postconcussive, migraine
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Renal
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Urinary tract infection, obstructive uropathy, renal insufficiency
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Infectious
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Viral illness, gastroenteritis, meningitis, sepsis, otitis media, pneumonia, hepatitis, streptococcal pharyngitis
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Metabolic/endocrine
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Inborn errors of metabolism, adrenal insufficiency, renal tubular acidosis, diabetes mellitus, Reye syndrome, porphyria
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Miscellaneous
| valign="top" bgcolor="*ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Ileus, gastroesophageal reflux, post-tussive, peritonitis, drug overdose, appendicitis, pancreatitis, gastritis, Crohn disease, pregnancy, psychogenic, cyclic vomiting syndrome
|}


==See Also==
==See Also==
*[[Nausea and vomiting (peds)]]
*[[Nausea and vomiting (peds)]]
*[[Nausea and vomiting of pregnancy]]
*[[Antiemetics]]
==External Links==


== References ==
==References==
<references/>


[[Category:GI]]
[[Category:GI]]
[[Category:Peds]]
[[Category:Symptoms]]

Latest revision as of 22:49, 3 May 2023

This page is for adult patients. For pediatric patients, see: nausea and vomiting (peds). For nausea and vomiting during pregnancy, see hyperemesis gravidarum.

Background

Nausea and Vomiting Algorithm

Clinical Features

  • Nausea and/or vomiting
  • Additional features of underlying process

Differential Diagnosis

Nausea and vomiting

Critical

Emergent

Nonemergent

By organ system

GI

Neurologic

Infectious

Drugs/Toxins

Endocrine

Miscellaneous

Evaluation

Varies widely depending on clinical presentation

Management

Disposition

  • Depends on cause
  • Most non-specific episodes of acute nausea and vomiting may be discharged, if:
    • No emergent/urgent cause identified or suspected
    • Patient tolerating fluids after treatment

Complications

See Also

External Links

References

  1. ↑ Lindblad AJ, Ting R, Harris K. Inhaled isopropyl alcohol for nausea and vomiting in the emergency department. Can Fam Physician. 2018;64(8):580.
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