Nausea and vomiting: Difference between revisions

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''This page is for adult patients; for pediatric patients see [[nausea and vomiting (peds)]]''
==Background==
==Background==
[[File:Nausea_and_vomiting.png|thumb|Nausea and Vomiting Algorithm]]
[[File:Nausea_and_vomiting.png|thumb|Nausea and Vomiting Algorithm]]
==Work-Up==
#CBC
#Chemistry
#Urine pregnancy
#LFTs
#Lipase
#APAP, ASA, digoxin levels
#UA
#?Abd xray
#?CT
#?US


== DDX by organ system ==
==Clinical Features==
===GI===
#[[Peptic ulcer disease]]
#Obstruction
##Adhesion
##[[Small bowel obstruction]]/LBO
##Gastric outlet obstruction
#[[Pancreatitis]]
#Gastroparesis
#[[Appendicitis]]
#[[Cholecystitis]]
#[[Cholangitis]]
#[[Acute Hepatitis]]
#IBD
#[[Intussusception]]
#Tumor
#Strangulated hernia
#[[Volvulus]]
#[[Mesenteric ischemia]]
#Esophageal disorders (e.g. achalasia)
#Functional disorders
##Psychogenic
##[[IBS]]
#[[Pyloric Stenosis]]


===Neurologic===
#Head injury
#[[CVA]]
#Pseudotumor
#Hydrocephalus
#Mass lesion
#[[Meningitis]]
#Migraines
#[[Labyrinthitis]]
#Meniere disease
#Motion sickness
#[[Cannabinoid hyperemesis syndrome]]


===Infectious===
==Differential Diagnosis==
#Bacterial toxins
{{Nausea and vomiting DDX}}
#[[PNA]]
#[[SBP]]
#[[UTI]]
#Viruses (adeno, norwalk, rota
===Drugs/Toxins===
#Toxic doses
##Digoxin
##ASA
##APAP
#NSAIDs
#Opiates
#ETOH
#Anticonvulsants
#Abx
#Antiarrhythmics
#Toxins
##Organophosphates
##CO
##Ricin
===Endocrine===
#Pregnancy
#[[Hyponatremia]]
#Adrenal insufficiency
#[[DKA]]
#Thyroid/parathyroid disorders
#[[Uremia]]


===Miscellaneous===
===By organ system===
#[[ACS]]
====GI====
#Gonadal torsion
*[[Peptic ulcer disease]]
#[[Nephrolithiasis]]
*Obstruction
#Pain
**Adhesion
#Acute glaucoma
**[[Small bowel obstruction]]/LBO
#Anorexia/bulimia
***[[SMA syndrome]]
#Depression
**Gastric outlet obstruction
**[[Gastric volvulus]]
**[[Bezoar]]
*[[Pancreatitis]]
*[[Gastroparesis]]
*[[Appendicitis]]
*[[Cholecystitis]]
*[[Cholangitis]]
*[[Acute Hepatitis]]
*[[IBD]]
*[[Intussusception]]
*Tumor
*Strangulated [[hernia]]
*[[Volvulus]]
*[[Mesenteric ischemia]]
*Esophageal disorders (e.g. [[achalasia]])
*Functional disorders
**Psychogenic
**[[IBS]]
*[[Pyloric Stenosis]]


==DDx by Severity==
====Neurologic====
=== Critical ===
*[[Head injury]]
#[[Esophageal Perforation|Boerhaave's]]
*[[CVA]]
#Ischemic bowel
*[[Idiopathic intracranial hypertension]]
#[[ICH]]
*[[Hydrocephalus]]
#[[Meningitis]]
*[[Intracranial mass|Mass lesion]]
#[[DKA]]
*[[Meningitis]]
#[[AMI]]
*[[Migraine]]
#[[Sepsis]]
*[[Labyrinthitis]]
*[[Meniere's disease]]
*[[Motion sickness]]
*[[Cannabinoid hyperemesis syndrome]]


=== Emergent ===
====Infectious====
#Gastric outlet obstruction
*Bacterial toxins
#[[Pancreatitis]]
*[[Pneumonia]]
#[[Cholecystitis]]
*[[SBP]]
#Bowel obstruction/ileus
*[[UTI]]
#Ruptured viscus
*Viruses ([[adenovirus]], [[norovirus]], [[rotavirus]])
#[[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


== Complications ==
====Drugs/Toxins====
#Hypovolemia
*Toxic doses
#Metabolic alkalosis
**[[Digoxin toxicity]]
#Hypokalemia
**[[Aspirin toxicity]]
#Mallory-Weiss (tear)
**[[Acetaminophen toxicity]]
#Boerhaave (rupture)
**[[Ipecac toxicity]]
#Aspiration
*[[NSAIDs]]
*[[Opioids]]
*[[Alcohol]]
*[[Anticonvulsants]]
*[[Antibiotics]]
*[[Antiarrhythmics]]
*Toxins
**[[Organophosphates]]
**[[Carbon monoxide]]
**[[Ricin]]
*[[Acute radiation syndrome]]


== Peds ==
====Endocrine====
*[[Pregnancy]]
*[[Hyponatremia]]
*[[Adrenal insufficiency]]
*[[DKA]]
*[[Thyroid]]/parathyroid disorders
*[[Uremia]]


{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" width="100%"
====Miscellaneous====
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
*[[ACS]]
| 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''' 
*[[Ovarian torsion|ovarian]]/[[testicular torsion]]
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
*[[Nephrolithiasis]]
| 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
*Pain
| 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
*[[Acute angle-closure glaucoma]]
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
*[[Anorexia nervosa]]/[[bulimia nervosa]]
| 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
*[[Depression]]
| 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
|}


== Source ==
==Evaluation==
*Rosen
''Varies widely depending on clinical presentation''
*Tintinalli
*CBC
*Chemistry
*Urine pregnancy
*[[LFTs]]
*Lipase
*APAP, ASA, digoxin levels
*[[Urinalysis]]
*?Abdominal xray
*?CT
*?[[Ultrasound]]
 
==Management==
 
 
==Disposition==
 
 
==Complications==
*[[Hypovolemia]]
*[[Metabolic alkalosis]]
*[[Hypokalemia]]
*[[Mallory-Weiss]] (tear)
*[[Boerhaave]] (rupture)
*Aspiration
 
==See Also==
*[[Nausea and vomiting (peds)]]
 
==External Links==
 
 
==References==
<references/>


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

Revision as of 18:26, 14 September 2019

This page is for adult patients; for pediatric patients see nausea and vomiting (peds)

Background

Nausea and Vomiting Algorithm

Clinical Features

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

Complications

See Also

External Links

References

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