Nausea/Vomiting

Nausea/Vomiting: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

Presenting Symptom

❑ Gastroesophageal reflux

❑ Pregnancy

❑ Psychogenic

❑ Bulimia

❑ Rumination

❑ Diabetic ketoacidosis

❑ Hepatitis

❑ Inferior myocardial infarction

❑ Uremia

❑ Adrenal insufficiency

With Abdominal Pain

❑ Viral gastroenteritis

❑ Food poisoning

❑ Peptic ulcer disease

❑ Renal colic

❑ Pancreatitis

❑ Pyelonephritis

❑ Appendicitis

❑ Cholecystitis

❑ Small bowel obstruction

❑ Peritonitis

With Neurologic Signs

❑ Migraine headache

❑ Vestibular disturbance

❑ Autonomic dysfunction

❑ Increased intracranial pressure

❑ Hypercalcemia

❑ Cerebellar hemorrhage

Diagnostic Approach

Neurological vomiting may be projectile (forceful emesis without prior nausea), positional, or associated with other neurological signs. Central vomiting (chemoreceptor trigger zone stimulation, usually caused by toxins) is alleviated by antidopaminergic medications, which do not work well when treating nausea due to mechanical causes such as obstruction.

Early morning nausea suggests pregnancy or metabolic causes (e.g., uremia). Vomiting of a large amount of undigested food 4 to 6 hours after eating is consistent with gastric retention resulting from pyloric obstruction
or gastroparesis or to esophageal disorders such as achalasia or Zencker diverticulum. Feculent vomiting suggests intestinal obstruction or gastrocolic fistula.

Clinical Findings

Gastroesophageal reflux  Effortless return of acid and small amounts of undigested food occurs in a patient with chronic heartburn. Nausea appears infrequently.

Pregnancy  Morning sickness occurs in more than 50% of pregnant women. It usually begins after the first missed period and ends after the first trimester. Severe symptoms can develop in women who have a history of vomiting during psychologically stressful situations.

Psychogenic  Anxiety, when causal, is manifest. A cyclic vomiting syndrome has been described, characterized by periods of nausea and vomiting lasting days, separated by symptom-free periods.

Bulimia  Vomiting is not accompanied by nausea. Clues on physical exam include posterior dental enamel erosion, parotid gland enlargement, and calluses on the dorsal suface of the hand.

Rumination  Effortless regurgitation of undigested food within minutes of a meal is caused by abdominal muscle contraction and relaxation of the lower esophageal sphincter.

Diabetic ketoacidosis  Tachypnea, disorientation, and fruity breath odor (due to exhaled ketones) are important clues.

Hepatitis  Anorexia, nausea, and vomiting dominate the prodromal phase. Mild liver tenderness might be found at this stage.

Inferior myocardial infarction  Nausea appears at the onset in 70%, due to
stimulation of vagal afferents, along with diaphoresis. Substernal pressure/pain is present.

Uremia  Fatigue and sallow, gray-colored, dry skin are found.

Adrenal insufficiency  The patient is asthenic, with poorly localized abdominal pain and orthostatic hypotension. Look for hyperpigmentation, with accentuation in the palmar creases and buccal mucosa.

Viral gastroenteritis  The nausea is associated with watery diarrhea, cramping abdominal pain, fever, myalgias, and mild diffuse abdominal tenderness.

Food poisoning  Vomiting is a prominent manifestation of staphylococcal toxin-mediated food poisoning, occurring 1 to 6 hours after eating suspect food. Fever is not present.

Peptic ulcer disease  Postprandial vomiting temporarily relieves pain, especially with pyloric channel ulcers. The vomitus contains undigested food.

Renal colic  Severe nausea and flank pain are the major symptoms. The pain is unrelieved by position and may radiate to the groin.

Pancreatitis Left upper quadrant pain radiating to the back is the cardinal sign, found in 95% of patients.

Pyelonephritis  Nausea is often prominent and is associated with fever, dysuria, flank pain, and tenderness.

Appendicitis  Anorexia, nausea, and vomiting are early symptoms, followed by periumbilical pain which eventually localizes to the right lower quadrant.

Cholecystitis  Emesis develops when sudden obstruction of the common bile duct occurs.

Small bowel obstruction  It presents with marked nausea and vomiting. The higher the obstruction is in the intestinal tract, the earlier and more severe the vomiting. Intermittent cramping abdominal pain, distension, and tinkling bowel sounds are usually present. Vomitus may contain undigested food or clear intestinal secretions. Feculent emesis may be found in distal small bowel obstruction.

Peritonitis  Early vomiting and abdominal rigidity are characteristic. The patient lies motionless.

Migraine headache  Suggested by photophobia and throbbing unilateral headache, a migraine is unmistakable when a visual aura occurs.

Vestibular disturbance  Vertigo is prominent and nystagmus may be observed.

Autonomic dysfunction  It is characterized by vomiting of food eaten hours previously. A succussion splash may be found on examination. Diabetic autonomic neuropathy is a common cause, and it may be accompanied by a vasomotor neuropathy (orthostatic hypotension) or diarrhea.

Increased intracranial pressure  It presents with projectile vomiting, especially on arising from sleep, associated with bifrontal or bitemporal headache. Papilledema occurs, but absence of spontaneous retinal venous pulsations is the earliest sign.

Hypercalcemia  The most common scenario is intractable vomiting in a patient with an underlying neoplasm.

Cerebellar hemorrhage  Nausea and vomiting are severe and associated with ataxia and headache.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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