Difference between revisions of "Nausea and vomiting"

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==Work-Up==
+
{{Adult top}} [[nausea and vomiting (peds)]].''
#CBC
+
==Background==
#Chemistry
+
[[File:Nausea_and_vomiting.png|thumb|Nausea and Vomiting Algorithm]]
#Urine pregnancy
 
#LFTs
 
#Lipase
 
#APAP, ASA, digoxin levels
 
#UA
 
#?Abd xray
 
#?CT
 
#?US
 
  
== Complications ==
+
==Clinical Features==
#Hypovolemia
+
*Nausea and/or vomiting
#Metabolic alkalosis
+
*Additional features of underlying process
#Hypokalemia
 
#Mallory-Weiss (tear)
 
#Boerhaave (rupture)
 
#Aspiration
 
  
== DDX by organ system ==
+
==Differential Diagnosis==
===GI===
+
{{Nausea and vomiting DDX}}
#Peptic ulcer disease
 
#Obstruction
 
##Adhesion
 
##SBO/LBO
 
##Gastric outlet obstruction
 
#Pancreatitis
 
#Gastroparesis
 
#Appendicitis
 
#Cholecystitis
 
#Cholangitis
 
#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
 
===Infectious===
 
#Bacterial toxins
 
#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
+
*[[Bowel obstruction|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]]
#Boerhaave
+
*[[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
+
*[[Bacteria]]l 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 disorder
 
===Nonemergent===
 
#Gastritis
 
#Gastroparesis
 
#PUD
 
#Gastroenteritis
 
#Biliary colic
 
#Hepatitis
 
#Thyroid
 
#Pregnancy
 
#Erythromycin
 
#Ibuprofen
 
#Chemotherapy
 
#Narcotics/wdwl from
 
#ETOH
 
#UTI
 
#Renal colic
 
#Motion sickness
 
#Labyrinthitis
 
  
== Peds ==
+
====Drugs/Toxins====
 +
*Toxic doses
 +
**[[Digoxin toxicity]]
 +
**[[Aspirin toxicity]]
 +
**[[Acetaminophen toxicity]]
 +
**[[Ipecac toxicity]]
 +
*[[NSAIDs]]
 +
*[[Opioids]]
 +
*[[Alcohol]]
 +
*[[Anticonvulsants]]
 +
*[[Antibiotics]]
 +
*[[Antiarrhythmics]]
 +
*Toxins
 +
**[[Organophosphates]]
 +
**[[Carbon monoxide]]
 +
**[[Ricin]]
 +
*[[Acute radiation syndrome]]
  
{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" width="100%"
+
====Endocrine====
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
+
*[[Pregnancy]], [[hyperemesis gravidarum]]
| 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''' 
+
*[[Hyponatremia]]
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
+
*[[Adrenal insufficiency]]
| 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
+
*[[DKA]]
| 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
+
*[[Thyroid]]/parathyroid disorders
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
+
*[[Uremia]]
| 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
 
|}
 
  
== Source ==
+
====Miscellaneous====
*Rosen
+
*[[ACS]]
*Tintinalli
+
*[[Ovarian torsion|ovarian]]/[[testicular torsion]]
 +
*[[Nephrolithiasis]]
 +
*Pain
 +
*[[Acute angle-closure glaucoma]]
 +
*[[Anorexia nervosa]]/[[bulimia nervosa]]
 +
*[[Depression]]
 +
 
 +
==Evaluation==
 +
''Varies widely depending on clinical presentation''
 +
*CBC
 +
*Chemistry
 +
*Urine pregnancy
 +
*[[LFTs]]
 +
*Lipase
 +
*APAP, ASA, digoxin levels
 +
*[[Urinalysis]]
 +
*?[[Abdominal xray]]
 +
*?CT
 +
*?[[Ultrasound]]
 +
 
 +
==Management==
 +
*Treat underlying pathology
 +
*Address [[electrolyte derangements]] and [[dehydration]] as needed
 +
*[[Antiemetics]]
 +
 
 +
==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==
 +
*[[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]]

Latest revision as of 05:59, 14 May 2020

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

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