Nausea and vomiting

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

• ACS/MI
• Boerhaave's
• DKA
• Intracranial hemorrhage
• Ischemic bowel
• Meningitis
• Sepsis

Emergent

• Acute radiation syndrome
• Acute gastric dilation
• Adrenal insufficiency
• Appendicitis
• Bowel obstruction/ileus
• Carbon monoxide poisoning
• Cholecystitis
• CNS tumor
• Electrolyte abnormalities
• Elevated ICP
• Gastric outlet obstruction, gastric volvulus
• Hyperemesis gravidarum
• Medication related
  • Acetaminophen toxicity
  • Aspirin toxicity
  • Digoxin toxicity
  • Theophylline toxicity
  • GLP-1 receptor agonist toxicity
• Pancreatitis
• Peritonitis
• Ruptured viscus
• Testicular torsion/ovarian torsion

Nonemergent

• Acute gastroenteritis
• Biliary colic
• Cannabinoid hyperemesis syndrome
• Chemotherapy
• Cyclic vomiting syndrome
• ETOH
• Gastritis
• Gastroenteritis
• Gastroparesis
• Hepatitis
• Labyrinthitis
• Migraine
• Medication related
  • Disulfiram effect
  • Erythromycin
  • Ibuprofen
  • Ipecac toxicity
• Motion sickness
• Narcotic withdrawal
• Thyroid
• Pregnancy
• Peptic ulcer disease
• Renal colic
• UTI

By organ system

GI

• Peptic ulcer disease
• Obstruction
  • Adhesion
  • Small bowel obstruction/LBO
    • SMA syndrome
  • 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

Neurologic

• Head injury
• CVA
• Idiopathic intracranial hypertension
• Hydrocephalus
• Mass lesion
• Meningitis
• Migraine
• Labyrinthitis
• Meniere's disease
• Motion sickness
• Cannabinoid hyperemesis syndrome

Infectious

• Bacterial toxins
• Pneumonia
• SBP
• UTI
• Viruses (adenovirus, norovirus, rotavirus)

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

Endocrine

• Pregnancy, hyperemesis gravidarum
• Hyponatremia
• Adrenal insufficiency
• DKA
• Thyroid/parathyroid disorders
• Uremia

Miscellaneous

• ACS
• 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
• Inhaled isopropyl alcohol (sniffing an alcohol wipe) has been shown to reduce mild to moderate nausea and vomiting

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)
• Nausea and vomiting of pregnancy
• Antiemetics