Difference between revisions of "Nausea and vomiting"

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{{Adult top}} [[nausea and vomiting (peds)]].''
 
==Background==
 
==Background==
 +
[[File:Nausea_and_vomiting.png|thumb|Nausea and Vomiting Algorithm]]
  
==Work-Up==
+
==Clinical Features==
#CBC
+
*Nausea and/or vomiting
#Chemistry
+
*Additional features of underlying process
#Urine pregnancy
 
#LFTs
 
#Lipase
 
#APAP, ASA, digoxin levels
 
#UA
 
#?Abd xray
 
#?CT
 
#?US
 
  
== Complications ==
+
==Differential Diagnosis==
#Hypovolemia
+
{{Nausea and vomiting DDX}}
#Metabolic alkalosis
 
#Hypokalemia
 
#Mallory-Weiss (tear)
 
#Boerhaave (rupture)
 
#Aspiration
 
  
== DDX by organ system ==
+
===By organ system===
===GI===
+
====GI====
#Peptic ulcer disease
+
*[[Peptic ulcer disease]]
#Obstruction
+
*[[Bowel obstruction|Obstruction]]
##Adhesion
+
**Adhesion
##SBO/LBO
+
**[[Small bowel obstruction]]/LBO
##Gastric outlet obstruction
+
***[[SMA syndrome]]
#Pancreatitis
+
**Gastric outlet obstruction
#Gastroparesis
+
**[[Gastric volvulus]]
#Appendicitis
+
**[[Bezoar]]
#Cholecystitis
+
*[[Pancreatitis]]
#Cholangitis
+
*[[Gastroparesis]]
#Hepatitis
+
*[[Appendicitis]]
#IBD
+
*[[Cholecystitis]]
#Intussusception
+
*[[Cholangitis]]
#Tumor
+
*[[Acute Hepatitis]]
#Strangulated hernia
+
*[[IBD]]
#Volvulus
+
*[[Intussusception]]
#Mesenteric ischemia
+
*Tumor
#Esophageal disorders (e.g. achalasia)
+
*Strangulated [[hernia]]
#Functional disorders
+
*[[Volvulus]]
##Psychogenic
+
*[[Mesenteric ischemia]]
##IBS
+
*Esophageal disorders (e.g. [[achalasia]])
#Pyloric stenosis
+
*Functional disorders
===Neurologic===
+
**Psychogenic
#Head injury
+
**[[IBS]]
#[[CVA]]
+
*[[Pyloric Stenosis]]
#Pseudotumor
 
#Hydrocephalus
 
#Mass lesion
 
#[[Meningitis]]
 
#Migraines
 
#[[Labyrinthitis]]
 
#Meniere disease
 
#Motion sickness
 
#[[Cannabinoid hyperemesis syndrome]]
 
  
===Infectious===
+
====Neurologic====
#Bacterial toxins
+
*[[Head injury]]
#[[PNA]]
+
*[[CVA]]
#[[SBP]]
+
*[[Idiopathic intracranial hypertension]]
#[[UTI]]
+
*[[Hydrocephalus]]
#Viruses (adeno, norwalk, rota
+
*[[Intracranial mass|Mass lesion]]
===Drugs/Toxins===
+
*[[Meningitis]]
#Toxic doses
+
*[[Migraine]]
##Digoxin
+
*[[Labyrinthitis]]
##ASA
+
*[[Meniere's disease]]
##APAP
+
*[[Motion sickness]]
#NSAIDs
+
*[[Cannabinoid hyperemesis syndrome]]
#Opiates
 
#ETOH
 
#Anticonvulsants
 
#Abx
 
#Antiarrhythmics
 
#Toxins
 
##Organophosphates
 
##CO
 
##Ricin
 
===Endocrine===
 
#Pregnancy
 
#[[Hyponatremia]]
 
#Adrenal insufficiency
 
#[[DKA]]
 
#Thyroid/parathyroid disorders
 
#[[Uremia]]
 
  
===Miscellaneous===
+
====Infectious====
#[[ACS]]
+
*[[Bacteria]]l toxins
#Gonadal torsion
+
*[[Pneumonia]]
#[[Nephrolithiasis]]
+
*[[SBP]]
#Pain
+
*[[UTI]]
#Acute glaucoma
+
*Viruses ([[adenovirus]], [[norovirus]], [[rotavirus]])
#Anorexia/bulimia
 
#Depression
 
  
==DDx by Severity==
+
====Drugs/Toxins====
=== Critical ===
+
*Toxic doses
#[[Boerhaave]]
+
**[[Digoxin toxicity]]
#Ischemic bowel
+
**[[Aspirin toxicity]]
#[[ICH]]
+
**[[Acetaminophen toxicity]]
#[[Meningitis]]
+
**[[Ipecac toxicity]]
#[[DKA]]
+
*[[NSAIDs]]
#[[AMI]]
+
*[[Opioids]]
#[[Sepsis]]
+
*[[Alcohol]]
 +
*[[Anticonvulsants]]
 +
*[[Antibiotics]]
 +
*[[Antiarrhythmics]]
 +
*Toxins
 +
**[[Organophosphates]]
 +
**[[Carbon monoxide]]
 +
**[[Ricin]]
 +
*[[Acute radiation syndrome]]
  
=== Emergent ===
+
====Endocrine====
#Gastric outlet obstruction
+
*[[Pregnancy]], [[hyperemesis gravidarum]]
#[[Pancreatitis]]
+
*[[Hyponatremia]]
#[[Cholecystitis]]
+
*[[Adrenal insufficiency]]
#Bowel obstruction/ileus
+
*[[DKA]]
#Ruptured viscus
+
*[[Thyroid]]/parathyroid disorders
#[[Appendicitis]]
+
*[[Uremia]]
#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
 
  
== Peds ==
+
====Miscellaneous====
 +
*[[ACS]]
 +
*[[Ovarian torsion|ovarian]]/[[testicular torsion]]
 +
*[[Nephrolithiasis]]
 +
*Pain
 +
*[[Acute angle-closure glaucoma]]
 +
*[[Anorexia nervosa]]/[[bulimia nervosa]]
 +
*[[Depression]]
  
{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" width="100%"
+
==Evaluation==
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
+
''Varies widely depending on clinical presentation''
| 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''' 
+
*CBC
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
+
*Chemistry
| 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
+
*Urine pregnancy
| 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
+
*[[LFTs]]
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
+
*Lipase
| 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
+
*APAP, ASA, digoxin levels
| 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
+
*[[Urinalysis]]
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
+
*?[[Abdominal xray]]
| 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
+
*?CT
| 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
+
*?[[Ultrasound]]
|- 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 ==
+
==Management==
*Rosen
+
*Treat underlying pathology
*Tintinalli
+
*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