Nausea and vomiting

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Background

Nausea and Vomiting Algorithm

Work-Up

  1. CBC
  2. Chemistry
  3. Urine pregnancy
  4. LFTs
  5. Lipase
  6. APAP, ASA, digoxin levels
  7. UA
  8. ?Abd xray
  9. ?CT
  10. ?US

DDX by organ system

GI

  1. Peptic ulcer disease
  2. Obstruction
    1. Adhesion
    2. Small bowel obstruction/LBO
    3. Gastric outlet obstruction
  3. Pancreatitis
  4. Gastroparesis
  5. Appendicitis
  6. Cholecystitis
  7. Cholangitis
  8. Acute Hepatitis
  9. IBD
  10. Intussusception
  11. Tumor
  12. Strangulated hernia
  13. Volvulus
  14. Mesenteric ischemia
  15. Esophageal disorders (e.g. achalasia)
  16. Functional disorders
    1. Psychogenic
    2. IBS
  17. Pyloric stenosis

Neurologic

  1. Head injury
  2. CVA
  3. Pseudotumor
  4. Hydrocephalus
  5. Mass lesion
  6. Meningitis
  7. Migraines
  8. Labyrinthitis
  9. Meniere disease
  10. Motion sickness
  11. Cannabinoid hyperemesis syndrome

Infectious

  1. Bacterial toxins
  2. PNA
  3. SBP
  4. UTI
  5. Viruses (adeno, norwalk, rota

Drugs/Toxins

  1. Toxic doses
    1. Digoxin
    2. ASA
    3. APAP
  2. NSAIDs
  3. Opiates
  4. ETOH
  5. Anticonvulsants
  6. Abx
  7. Antiarrhythmics
  8. Toxins
    1. Organophosphates
    2. CO
    3. Ricin

Endocrine

  1. Pregnancy
  2. Hyponatremia
  3. Adrenal insufficiency
  4. DKA
  5. Thyroid/parathyroid disorders
  6. Uremia

Miscellaneous

  1. ACS
  2. Gonadal torsion
  3. Nephrolithiasis
  4. Pain
  5. Acute glaucoma
  6. Anorexia/bulimia
  7. Depression

DDx by Severity

Critical

  1. Boerhaave's
  2. Ischemic bowel
  3. ICH
  4. Meningitis
  5. DKA
  6. AMI
  7. Sepsis

Emergent

  1. Gastric outlet obstruction
  2. Pancreatitis
  3. Cholecystitis
  4. Bowel obstruction/ileus
  5. Ruptured viscus
  6. Appendicitis
  7. Peritonitis
  8. Migraine
  9. CNS tumor
  10. raised ICP
  11. Adrenal insuffciency
  12. Hyperemesis gravidarum
  13. Tylenol
  14. Digoxin
  15. ASA
  16. Theophyline
  17. Gonadal torsion
  18. CO
  19. Electrolyte Disorders

Nonemergent

  1. Gastritis
  2. Gastroparesis
  3. PUD
  4. Gastroenteritis
  5. Biliary colic
  6. Hepatitis
  7. Thyroid
  8. Pregnancy
  9. Erythromycin
  10. Ibuprofen
  11. Chemotherapy
  12. Narcotics/wdwl from
  13. ETOH
  14. UTI
  15. Renal colic
  16. Motion sickness
  17. Labyrinthitis

Complications

  1. Hypovolemia
  2. Metabolic alkalosis
  3. Hypokalemia
  4. Mallory-Weiss (tear)
  5. Boerhaave (rupture)
  6. Aspiration

Peds

Newborn 
Obstructive intestinal anomalies Esophageal stenosis/atresia, pyloric stenosis, intestinal stenosis/atresia, malrotation ± volvulus, incarcerated hernia, meconium ileus/plug, Hirschsprung disease, imperforate anus, enteric duplications
Neurologic Intracranial bleed/mass, hydrocephalus, cerebral edema, kernicterus
Renal Urinary tract infection, obstructive uropathy, renal insufficiency
Infectious Viral illness, gastroenteritis, meningitis, sepsis
Metabolic/endocrine Inborn errors of metabolism (urea cycle, amino/organic acid, carbohydrate), congenital adrenal hyperplasia
Miscellaneous Ileus, gastroesophageal reflux, necrotizing enterocolitis, milk allergy, GI perforation
Infant (<12 mo) 
Obstructive intestinal anomalies Pyloric stenosis, malrotation ± volvulus, incarcerated hernia, Hirschsprung disease, enteric duplications, intussusception, foreign body, bezoars, Meckel diverticulum
Neurologic Intracranial bleed/mass, hydrocephalus, cerebral edema
Renal Urinary tract infection, obstructive uropathy, renal insufficiency
Infectious Viral illness, gastroenteritis, meningitis, sepsis, otitis media, pneumonia, pertussis, hepatitis
Metabolic/endocrine Inborn errors of metabolism, adrenal insufficiency, renal tubular acidosis
Miscellaneous Ileus, gastroesophageal reflux, post-tussive, peritonitis, drug overdose
Child (>12 mo)   
Obstructive intestinal anomalies Malrotation ± volvulus, incarcerated hernia, Hirschsprung disease, intussusception, foreign body, bezoars, Meckel diverticulum, acquired esophageal stricture, peptic ulcer disease, adhesions, superior mesenteric artery syndrome
Neurologic Intracranial bleed/mass, cerebral edema, postconcussive, migraine
Renal Urinary tract infection, obstructive uropathy, renal insufficiency
Infectious Viral illness, gastroenteritis, meningitis, sepsis, otitis media, pneumonia, hepatitis, streptococcal pharyngitis
Metabolic/endocrine Inborn errors of metabolism, adrenal insufficiency, renal tubular acidosis, diabetes mellitus, Reye syndrome, porphyria
Miscellaneous Ileus, gastroesophageal reflux, post-tussive, peritonitis, drug overdose, appendicitis, pancreatitis, gastritis, Crohn disease, pregnancy, psychogenic, cyclic vomiting syndrome

Source

  • Rosen
  • Tintinalli
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