Causes of Cyclic vomiting syndrome

• Inflammatory
  –Gastroesophageal reflux disease
  –Peptic ulcer disease
  –Pyelonephritis
  –Meningitis
  –Encephalitis
  –Eosinophilic enteropathy
• Central nervous system
  –Brain tumor
  –Trauma
  –Lead encephalopathy
  –Acute intracranial hemorrhage
  –Hydrocephalus
• Metabolic/endocrine
  –Congenital adrenal hyperplasia
  –Hypercalcemia
  –Wolman disease
  –Phenylketonuria

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Hematemesis: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Anthrax (GI)

Initial signs and symptoms after eating contaminated meat from an animal infected with the gram-positive, spore-forming bacterium Bacillus anthracis include a loss of appetite, nausea, vomiting, and a fever

Signs and symptoms may progress to hematemesis, abdominal pain, and severe bloody diarrhea.

Coagulation disorders

Any disorder that disrupts normal clotting may result in GI bleeding and moderate to severe hematemesis Bleeding may occur in other body systems as well, resulting in such signs as epistaxis and ecchymosis

Other associated effects vary, depending on the specific coagulation disorder, such as thrombocytopenia or hemophilia.

Esophageal cancer

A late sign of esophageal cancer, hematemesis may be accompanied by steady chest pain that radiates to the back Other features include substernal fullness, severe dysphagia, nausea, vomiting with nocturnal regurgitation and aspiration, hemoptysis, a fever, hiccups, a sore throat, melena, and halitosis.

Esophageal rupture

The severity of hematemesis depends on the cause of the rupture When an instrument damages the esophagus, hematemesis is usually slight

However, rupture due to Boerhaave’s syndrome (increased esophageal pressure from vomiting or retching) or other esophageal disorders typically causes more severe hematemesis. This life-threatening disorder may also produce severe retrosternal, epigastric, neck, or scapular pain accompanied by chest and neck edema. Examination reveals subcutaneous crepitation in the chest wall, supraclavicular fossa, and neck. The patient may also show signs of respiratory distress, such as dyspnea and cyanosis.

Esophageal varices (ruptured)

Life-threatening rupture of esophageal varices may produce coffee-ground or massive, bright red vomitus Signs of shock, such as hypotension or tachycardia, may follow or even precede hematemesis if the stomach fills with blood before vomiting occurs

Other symptoms may include abdominal distention and melena or painless hematochezia, ranging from slight oozing to massive rectal hemorrhage.

Gastric cancer

Painless bright red or dark brown vomitus is a late sign of gastric cancer, which usually begins insidiously with upper abdominal discomfort The patient then develops anorexia, mild nausea, and chronic dyspepsia unrelieved by antacids and exacerbated by food

Later symptoms may include fatigue, weakness, weight loss, feelings of fullness, melena, altered bowel habits, and signs of malnutrition, such as muscle wasting and dry skin.

Gastritis (acute)

Hematemesis and melena are the most common signs of acute gastritis They may even be the only signs, although mild epigastric discomfort, nausea, a fever, and malaise may also occur. Massive blood loss precipitates signs of shock. Typically, the patient has a history of alcohol abuse or has used aspirin or some other NSAID. Gastritis may also occur secondary to Helicobacter pylori infection.

Mallory-Weiss syndrome

Characterized by a mucosal tear of the mucous membrane at the junction of the esophagus and stomach, this syndrome may produce hematemesis and melena

It’s commonly triggered by severe vomiting, retching, or straining (as from coughing), most commonly in alcoholics or in people whose pylorus is obstructed Severe bleeding may precipitate signs of shock, such as tachycardia, hypotension, dyspnea, and cool, clammy skin.

Peptic ulcer

Massive — and possibly life-threatening — hematemesis is typical when an artery is penetrated. Other features include melena or hematochezia, chills, a fever, and signs and symptoms of shock and dehydration, such as tachycardia, hypotension, poor skin turgor, and thirst. The patient may have a history of nausea, vomiting, epigastric tenderness, and epigastric pain that’s relieved by foods or antacids. He may also have a history of habitually using tobacco, alcohol, or NSAIDs.

Other causes

Treatments

Traumatic NG or endotracheal intubation may cause hematemesis associated with swallowed blood

Nose or throat surgery may also cause this sign in the same way.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Nausea: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Adrenal insufficiency

Common GI findings in adrenal insufficiency include nausea, vomiting, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze skin; hypotension; a weak, irregular pulse; vitiligo; and depression.

Anthrax (GI)

Initial signs and symptoms include nausea, vomiting, loss of appetite, and a fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

With acute appendicitis, a brief period of nausea may accompany the onset of abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe stabbing pain localized in the right lower quadrant (McBurney’s sign). Associated findings usually include abdominal rigidity and tenderness, cutaneous hyperalgesia, a fever, constipation or diarrhea, tachycardia, anorexia, moderate malaise, and positive psoas (increased abdominal pain occurs when the examiner places his hand above the patient’s right knee and the patient flexes his right hip against resistance) and obturator signs (internal rotation of the right leg with the leg flexed to 90 degrees at the hip and knee with a resulting tightening of the internal obturator muscle that causes abdominal discomfort).

Cholecystitis (acute)

With acute cholecystitis, nausea commonly follows severe right upper quadrant pain that may radiate to the back or shoulders, usually following meals. Associated findings include mild vomiting, flatulence, abdominal tenderness and, possibly, rigidity and distention, a fever with chills, diaphoresis, and a positive Murphy’s sign.

Cholelithiasis

With cholelithiasis, nausea accompanies attacks of severe right upper quadrant or epigastric pain after eating fatty foods. Other associated findings include vomiting, abdominal tenderness and guarding, flatulence, belching, epigastric burning, tachycardia, and restlessness. Occlusion of the common bile duct may cause jaundice, clay-colored stools, a fever, and chills.

Cirrhosis

Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, abdominal pain, and constipation or diarrhea. As the disease progresses, jaundice and hepatomegaly may occur with abdominal distention, spider angiomas, palmar erythema, severe pruritus, dry skin, fetor hepaticus, enlarged superficial abdominal veins, mental changes, and bilateral gynecomastia and testicular atrophy or menstrual irregularities.

Diverticulitis

Besides nausea, diverticulitis causes intermittent crampy abdominal pain, constipation or diarrhea, a low-grade fever, and commonly a palpable, tender, firm, fixed mass.

Escherichia coli O157:H7

Gastritis

Nausea is common with gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Vomiting of mucus or blood, epigastric pain, belching, a fever, and malaise may also occur.

Gastroenteritis

Usually viral, gastroenteritis causes nausea, vomiting, diarrhea, and abdominal cramping. A fever, malaise, hyperactive bowel sounds, abdominal pain and tenderness, and possible dehydration and electrolyte imbalances may also develop.

Heart failure

Heart failure may produce nausea and vomiting, particularly with right-sided heart failure. Associated findings include tachycardia, a ventricular gallop, profound fatigue, dyspnea, crackles, peripheral edema, jugular vein distention, ascites, nocturia, and diastolic hypertension.

Hepatitis

Nausea is an insidious early symptom of viral hepatitis. Vomiting, fatigue, myalgia and arthralgia, a headache, anorexia, photophobia, pharyngitis, a cough, and a fever also occur early in the preicteric phase.

Hyperemesis gravidarum

Unremitting nausea and vomiting that persist beyond the first trimester are characteristic of hyperemesis gravidarum, a pregnancy disorder. Vomitus ranges from undigested food, mucus, and bile early in the disorder to a coffee-ground appearance in later stages. Associated findings include weight loss, signs of dehydration, a headache, and delirium.

Intestinal obstruction

Nausea commonly occurs, especially with high small-intestinal obstruction. Vomiting may be bilious or fecal; abdominal pain is usually episodic and colicky, but can become severe and steady with strangulation. Constipation occurs early in large-intestinal obstruction and later in small-intestinal obstruction; obstipation may signal complete obstruction. Bowel sounds are typically hyperactive in partial obstruction and hypoactive or absent in complete obstruction. Abdominal distention and tenderness occur, possibly with visible peristaltic waves and a palpable abdominal mass.

Labyrinthitis

Nausea and vomiting commonly occur with labyrinthitis, an acute inner ear inflammation. More significant findings include severe vertigo, progressive hearing loss, nystagmus, tinnitus and, possibly, otorrhea.

Listeriosis

Signs and symptoms include nausea, vomiting, diarrhea, a fever, myalgia, and abdominal pain. If listerosis spreads to the nervous system and causes meningitis, signs and symptoms include a fever, a headache, nuchal rigidity, and a change in the level of consciousness (LOC).

Gender Cue:Listeriosis infection during pregnancy may lead to premature delivery, infection of the neonate, or still birth.

Ménière’s disease

Ménière’s disease causes sudden, brief, recurrent attacks of nausea, vomiting, vertigo, tinnitus, diaphoresis, and nystagmus. It also causes hearing loss and ear fullness.

Mesenteric venous thrombosis

An insidious or acute onset of nausea, vomiting, and abdominal pain occurs, with diarrhea or constipation, abdominal distention, hematemesis, and melena.

Metabolic acidosis

Metabolic acidosis is an acid-base imbalance that may produce nausea and vomiting, anorexia, diarrhea, Kussmaul’s respirations, and a decreased LOC.

Migraine headache

Nausea and vomiting may occur in the prodromal stage, along with photophobia, light flashes, increased sensitivity to noise, light-headedness and, possibly, partial vision loss and paresthesia of the lips, face, and hands.

Motion sickness

With motion sickness, nausea and vomiting are brought on by motion or rhythmic movement. A headache, dizziness, fatigue, diaphoresis, hypersalivation, and dyspnea may also occur.

Myocardial infarction

Nausea and vomiting may occur, but the cardinal symptom is severe substernal chest pain that may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, altered blood pressure, and arrhythmias also occur.

Pancreatitis (acute)

Nausea, usually followed by vomiting, is an early symptom of pancreatitis. Other common findings include steady, severe pain in the epigastrium or left upper quadrant that may radiate to the back; abdominal tenderness and rigidity; anorexia; diminished bowel sounds; and a fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.

Peptic ulcer

With peptic ulcer, nausea and vomiting may follow attacks of sharp or gnawing, burning epigastric pain. Attacks typically occur when the stomach is empty or after the ingestion of alcohol, caffeine, or aspirin; they’re relieved by eating food or taking an antacid or antisecretory. Hematemesis or melena may also occur.

Peritonitis

Nausea and vomiting usually accompany acute abdominal pain localized to the area of inflammation. Other findings include a high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness (including rebound tenderness); a positive obturator sign and obturator weakness; pale, cold skin; diaphoresis; hypotension; shallow respirations; and hiccups.

Preeclampsia

Nausea and vomiting commonly occur with preeclampsia — a pregnancy disorder — along with rapid weight gain, epigastric pain, oliguria, a severe frontal headache, hyperreflexia, and blurred or double vision. The classic diagnostic triad of signs include hypertension, proteinuria, and edema.

Q Fever

Signs and symptoms include nausea, vomiting, diarrhea, a fever, chills, a severe headache, malaise, and chest pain. The fever may last up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.

Rhabdomyolysis

Signs and symptoms include nausea, vomiting, muscle weakness or pain, a fever, malaise, and dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidneys’attempt to filter myoglobin from the bloodstream.

Typhus

An abrupt onset of nausea, vomiting, a fever, and chills follows the initial symptoms of a headache, myalgia, arthralgia, and malaise.

Other causes

Drugs

Common nausea-producing drugs include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, cardiac glycosides, theophylline (overdose), and nonsteroidal anti-inflammatory drugs.

Herb Alert

Herbal remedies, such as ginkgo biloba and St. John’s wort, can produce adverse reactions, including nausea.

Radiation and surgery

Radiation therapy can cause nausea and vomiting. Postoperative nausea and vomiting are common, especially after abdominal surgery.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Vomiting: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Adrenal insufficiency

Common GI findings with the disorder include vomiting, nausea, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze skin; orthostatic hypotension; and weak, irregular pulse.

Anthrax (GI)

Initial signs and symptoms after eating contaminated meat from an infected animal include vomiting, loss of appetite, nausea, and fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

Vomiting and nausea may follow or accompany abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe, stabbing pain in the right lower quadrant. The patient generally has a positive McBurney’s sign — severe pain and tenderness on palpation about 2" (5 cm) from the right anterior superior spine of the ilium, on a line between that spine and the umbilicus. Associated findings usually include abdominal rigidity and tenderness, anorexia, constipation or diarrhea, cutaneous hyperalgesia, fever, tachycardia, and malaise.

Cholecystitis (acute)

With cholecystitis, nausea and mild vomiting commonly follow severe right-upper-quadrant pain that may radiate to the back or shoulders. Associated findings include abdominal tenderness and, possibly, rigidity and distention, fever, and diaphoresis.

Cholelithiasis

Nausea and vomiting accompany severe unlocalized right-upper-quadrant or epigastric pain after ingestion of fatty foods. Other findings include abdominal tenderness and guarding, flatulence, belching, epigastric burning, pyrosis, tachycardia, and restlessness.

Cholera

Signs and symptoms include vomiting and abrupt watery diarrhea. Severe water and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Cirrhosis

Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, aching abdominal pain, and constipation or diarrhea. Later findings include jaundice, hepatomegaly, and abdominal distention.

Electrolyte imbalances

Such disturbances as hyponatremia, hypernatremia, hypokalemia, and hypercalcemia frequently cause nausea and vomiting. Other effects include arrhythmias, tremors, seizures, anorexia, malaise, and weakness.

Escherichia coli (E. coli)

O157:H7. The signs and symptoms of this infection include vomiting, watery or bloody diarrhea, nausea, fever, and abdominal cramps. In children younger than age 5 and the elderly, hemolytic uremic syndrome may develop in which the red blood cells are destroyed, and this may ultimately lead to acute renal failure.

Food poisoning

Vomiting is a common finding of food poisoning, caused by preformed toxins produced by bacteria typically found in foods, such as Bacillus cereus, Clostridium, and Staphylococcus. Diarrhea and fever also usually occur.

Gastric cancer

This rare cancer may produce mild nausea, vomiting (possibly of mucus or blood), anorexia, upper abdominal discomfort, and chronic dyspepsia. Fatigue, weight loss, melena, and altered bowel habits are also common.

Gastritis

Nausea and vomiting of mucus or blood are common with gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Epigastric pain, belching, and fever may occur.

Gastroenteritis

Gastroenteritis causes nausea, vomiting (often of undigested food), diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, and abdominal pain and tenderness may also occur.

Heart failure

Nausea and vomiting may occur, especially with right-sided heart failure. Associated findings include tachycardia, ventricular gallop, fatigue, dyspnea, crackles, peripheral edema, and jugular vein distention.

Hepatitis

Vomiting commonly follows nausea as an early sign of viral hepatitis. Other early findings include fatigue, myalgia, arthralgia, headache, photophobia, anorexia, pharyngitis, cough, and fever.

Hyperemesis gravidarum

Unremitting nausea and vomiting that last beyond the first trimester characterize this disorder of pregnancy. Vomitus contains undigested food, mucus, and small amounts of bile early in the disorder; later, it has a coffee-ground appearance. Associated findings include weight loss, headache, and delirium. Thyroid dysfunction may be associated with this condition.

Increased intracranial pressure

Projectile vomiting that isn’t preceded by nausea is a sign of increased intracranial pressure. The patient may exhibit a decreased LOC and Cushing’s triad (bradycardia, hypertension, and respiratory pattern changes). He may also have headache, widened pulse pressure, impaired motor movement, visual disturbances, pupillary changes, and papilledema.

Intestinal obstruction

Nausea and vomiting (bilious or fecal) are common with intestinal obstruction, especially of the upper small intestine. Abdominal pain is usually episodic and colicky but can become severe and steady. Constipation occurs early in large intestinal obstruction and late in small intestinal obstruction. Obstipation, however, may signal complete obstruction. In partial obstruction, bowel sounds are typically high pitched and hyperactive; in complete obstruction, bowel sounds are typically hypoactive or absent. Abdominal distention and tenderness also occur, possibly with visible peristaltic waves and a palpable abdominal mass.

Labyrinthitis

Nausea and vomiting commonly occur with this acute inner ear inflammation. Other findings include severe vertigo, progressive hearing loss, nystagmus, and possibly otorrhea.

Listeriosis

After the ingestion of food contaminated with the bacterium Listeria monocytogenes, vomiting, fever, myalgias, abdominal pain, nausea, and diarrhea occur. If the infection spreads to the nervous system, meningitis may develop. Signs and symptoms may include fever, headache, nuchal rigidity, and change in LOC. The food-borne illness primarily affects pregnant women, neonates, and those with weakened immune systems.

Gender Cue:Infections that occur during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Mesenteric venous thrombosis

Insidious or acute onset of nausea, vomiting, and abdominal pain occurs here, with diarrhea or constipation, abdominal distention, hematemesis, and melena.

Migraine headache

Nausea and vomiting are prodromal signs and symptoms, with fatigue, photophobia, light flashes, increased noise sensitivity, and possibly partial vision loss and paresthesia.

Motion sickness

Nausea and vomiting may be accompanied by headache, vertigo, dizziness, fatigue, diaphoresis, and dyspnea.

Pancreatitis (acute)

Vomiting, usually preceded by nausea, is an early sign of pancreatitis. Associated findings include steady, severe epigastric or left-upper-quadrant pain that may radiate to the back, abdominal tenderness and rigidity, hypoactive bowel sounds, anorexia, vomiting, and fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.

Peritonitis

Nausea and vomiting usually accompany acute abdominal pain in the area of inflammation. Other findings include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness; weakness; pale, cold skin; diaphoresis; hypotension; signs of dehydration; and shallow respirations.

Preeclampsia

Nausea and vomiting are common with preeclampsia, a disorder of pregnancy. Rapid weight gain, epigastric pain, generalized edema, elevated blood pressure, oliguria, severe frontal headache, and blurred or double vision also occur.

Q fever

Signs and symptoms of Q fever, a rickettsial infection, include vomiting, fever, chills, severe headache, malaise, chest pain, nausea, and diarrhea. Fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Renal and urologic disorders

Cystitis, pyelonephritis, calculi, and other disorders of this system can cause vomiting. Accompanying findings reflect the specific disorder. Persistent nausea and vomiting are typical findings in patients with acute or worsening chronic renal failure.

Rhabdomyolysis

Signs and symptoms of this disorder include vomiting, muscle weakness or pain, fever, nausea, malaise, and dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidney’s attempt to filter the myoglobin from the bloodstream.

Typhus

Typhus is a rickettsial disease transmitted to humans by fleas, mites, or body louse. Initial symptoms include headache, myalgia, arthralgia, and malaise, followed by an abrupt onset of vomiting, nausea, chills, and fever. A maculopapular rash may be present in some cases.

Other causes

Drugs

Drugs that commonly cause vomiting include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium, chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, and overdoses of cardiac glycosides and theophylline. Syrup of ipecac is a mixture of ipecac fluid extract, glycerin, and syrup. It’s used to treat overdoses by inducing vomiting.

Radiation and surgery

Radiation therapy may cause nausea and vomiting if it disrupts the gastric mucosa. Postoperative nausea and vomiting are common, especially after abdominal surgery.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Hematemesis: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Achalasia

Hematemesis is a rare effect of this disorder, which usually causes passive regurgitation and painless, progressive dysphagia. Regurgitation of undigested food may cause hoarseness, coughing, aspiration, and recurrent pulmonary infections.

Anthrax, GI

GI anthrax is caused by eating meat contaminated with the gram-positive, spore-forming bacterium Bacillus anthracis. Initial signs and symptoms of anorexia, nausea, vomiting, and fever may progress to hematemesis, abdominal pain, and severe bloody diarrhea.

Coagulation disorders

Any disorder that disrupts normal clotting, such as thrombocytopenia or hemophilia, may result in GI bleeding and moderate to severe hematemesis. Bleeding may occur in other body systems as well, resulting in such signs as epistaxis and ecchymosis. Associated effects depend on the specific coagulation disorder.

Esophageal cancer

A late sign of this cancer, hematemesis may be accompanied by steady chest pain that radiates to the back. Other features include substernal fullness, severe dysphagia, nausea, vomiting with nocturnal regurgitation and aspiration, hemoptysis, fever, hiccups, sore throat, melena, and halitosis.

Esophageal injury by caustic substances

Ingestion of corrosive acids or alkalies produces esophageal injury associated with grossly bloody or coffee-ground vomitus. Hematemesis is accompanied by epigastric and anterior or retrosternal chest pain that’s intensified by swallowing. With ingestion of alkaline agents, the oral and pharyngeal mucosa may produce a soapy white film. The mucosa becomes brown and edematous with time. Dysphagia, marked salivation, and fever may develop in 3 to 4 weeks and worsen as strictures form.

Esophageal rupture

The severity of hematemesis depends on the cause of the rupture. When an instrument damages the esophagus, hematemesis is usually slight. However, rupture due to Boerhaave’s syndrome (increased esophageal pressure from vomiting or retching) or other esophageal disorders typically causes more severe hematemesis. This life-threatening disorder may also produce severe retrosternal, epigastric, neck, or scapular pain accompanied by chest and neck edema. Examination reveals subcutaneous crepitation in the chest wall, supraclavicular fossa, and neck. The patient may also show signs of respiratory distress, such as dyspnea and cyanosis.

Esophageal varices (ruptured)

Life-threatening rupture of esophageal varices may produce coffee-ground or massive bright red vomitus. Signs of shock, such as hypotension and tachycardia, may follow or even precede hematemesis if the stomach fills with blood before vomiting occurs. Other symptoms may include abdominal distention and melena or painless hematochezia (ranging from slight oozing to massive rectal hemorrhage).

Gastric cancer

Painless bright red or dark brown vomitus is a late sign of this uncommon cancer, which usually begins insidiously with upper abdominal discomfort. The patient then develops anorexia, mild nausea, and chronic dyspepsia that’s unrelieved by antacids and exacerbated by food. Later symptoms may include fatigue, weakness, weight loss, feelings of fullness, melena, altered bowel habits, and signs of malnutrition, such as muscle wasting and dry skin.

Gastritis (acute)

Hematemesis and melena are the most common signs of acute gastritis. They may even be the only signs, although mild epigastric discomfort, nausea, fever, and malaise may also occur. Massive blood loss precipitates signs of shock. Typically, the patient has a history of alcohol abuse or has used aspirin or another NSAID. Gastritis may also occur secondary to Helicobacter pylori infection.

Gastroesophageal reflux disease

Although rare in this disorder, hematemesis may produce significant blood loss. It’s accompanied by pyrosis, flatulence, dyspepsia, and postural regurgitation that can be aggravated by lying down or stooping over. Related effects include dysphagia, retrosternal angina-like chest pain, weight loss, halitosis, and signs of aspiration, such as dyspnea and recurrent pulmonary infections.

Leiomyoma

This benign tumor occasionally involves the GI tract, eroding the mucosa or vascular supply to produce hematemesis. Other features vary with the tumor’s size and location. For example, esophageal involvement may cause dysphagia and weight loss.

Mallory-Weiss syndrome

Characterized by a mucosal tear of the mucous membrane at the junction of the esophagus and the stomach, this syndrome may produce hematemesis and melena. It’s commonly triggered by severe vomiting, retching, or straining (as from coughing), usually in alcoholics or in people whose pylorus is obstructed. Severe bleeding may precipitate signs of shock, such as tachycardia, hypotension, dyspnea, and cool, clammy skin.

Peptic ulcer

Hematemesis may occur when a peptic ulcer penetrates an artery, vein, or highly vascular tissue. Massive—and possibly life-threatening—hematemesis is typical when an artery is penetrated. Other features include melena or hematochezia, chills, fever, and signs and symptoms of shock and dehydration, such as tachycardia, hypotension, poor skin turgor, and thirst. Most patients have a history of nausea, vomiting, epigastric tenderness, and epigastric pain that’s relieved by foods or antacids. Some may also have a history of habitual use of tobacco, alcohol, or NSAIDs.

Other causes

Treatments

Traumatic NG or endotracheal intubation may cause hematemesis associated with swallowed blood. Nose or throat surgery may also cause this sign in the same way.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Nausea: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Adrenal insufficiency

Common GI findings in this endocrine disorder include nausea, vomiting, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze skin; hypotension; a weak, irregular pulse; vitiligo; and depression.

Anthrax (GI)

Initial signs and symptoms include nausea, vomiting, loss of appetite, and fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

With acute appendicitis, a brief period of nausea may accompany onset of abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe stabbing pain localized in the right lower quadrant (McBurney’s sign). Associated findings usually include abdominal rigidity and tenderness, cutaneous hyperalgesia, fever, constipation or diarrhea, tachycardia, anorexia, moderate malaise, and positive psoas (increased abdominal pain occurs when the examiner places his hand above the patient’s right knee and the patient flexes his right hip against resistance) and obturator signs (internal rotation of the right leg with the leg flexed to 90 degrees at the hip and knee with a resulting tightening of the internal obturator muscle that causes abdominal discomfort).

Cholecystitis (acute)

With this disease, nausea often follows severe right-upper-quadrant pain that may radiate to the back or shoulders, often following meals. Associated findings include mild vomiting, flatulence, abdominal tenderness and, possibly, rigidity and distention, fever with chills, diaphoresis, and a positive Murphy’s sign.

Cholelithiasis

With this disease, nausea accompanies attacks of severe right-upper-quadrant or epigastric pain after ingestion of fatty foods. Other associated findings include vomiting, abdominal tenderness and guarding, flatulence, belching, epigastric burning, tachycardia, and restlessness. Occlusion of the common bile duct may cause jaundice, clay-colored stools, fever, and chills.

Cirrhosis

Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, abdominal pain, and constipation or diarrhea. As the disease progresses, jaundice and hepatomegaly may occur with abdominal distention, spider angiomas, palmar erythema, severe pruritus, dry skin, fetor hepaticus, enlarged superficial abdominal veins, mental changes, and bilateral gynecomastia and testicular atrophy or menstrual irregularities.

Diverticulitis

Besides nausea, diverticulitis causes intermittent crampy abdominal pain, constipation or diarrhea, low-grade fever, and often a palpable, tender, firm, fixed mass.

Ectopic pregnancy

Nausea, vomiting, vaginal bleeding, and lower abdominal pain occur in this potentially life-threatening disorder. Suspect ectopic pregnancy in a female of childbearing age with a 1- to 2-month history of amenorrhea.

Electrolyte imbalances

Such disturbances as hyponatremia or hypernatremia, hypokalemia, and hypercalcemia commonly cause nausea and vomiting. Other effects include cardiac arrhythmias, tremors or seizures, anorexia, malaise, and weakness.

Escherichia coli O157:H7

Signs and symptoms include nausea, watery or bloody diarrhea, vomiting, fever, and abdominal cramps. In children younger than age 5 and in the elderly, hemolytic uremic syndrome may develop in which red blood cells are destroyed, which may ultimately lead to acute renal failure.

Gastric cancer

This rare cancer may produce vague GI symptoms—mild nausea, anorexia, upper abdominal discomfort, and chronic dyspepsia. Fatigue, weight loss, weakness, hematemesis, melena, and altered bowel habits are also common.

Gastritis

Nausea is common with this disorder, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Vomiting of mucus or blood, epigastric pain, belching, fever, and malaise may also occur.

Gastroenteritis

Usually viral, this disorder causes nausea, vomiting, diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, abdominal pain and tenderness, and possible dehydration and electrolyte imbalances may also develop.

Heart failure

This disorder may produce nausea and vomiting, particularly with right-sided heart failure. Associated findings include tachycardia, ventricular gallop, profound fatigue, dyspnea, crackles, peripheral edema, jugular vein distention, ascites, nocturia, and diastolic hypertension.

Hepatitis

Nausea is an insidious early symptom of viral hepatitis. Vomiting, fatigue, myalgia and arthralgia, headache, anorexia, photophobia, pharyngitis, cough, and fever also occur early in the preicteric phase.

Hyperemesis gravidarum

Unremitting nausea and vomiting that persist beyond the first trimester are characteristic of this pregnancy disorder. Vomitus ranges from undigested food, mucus, and bile early in the disorder to a coffee-ground appearance in later stages. Associated findings include weight loss, signs of dehydration, headache, and delirium.

Infection

Acute localized or systemic infection typically produces nausea. Other common findings include fever, headache, fatigue, and malaise.

Inflammatory bowel disease

The most common symptom is recurrent diarrhea with blood, pus, and mucus. Nausea, vomiting, abdominal pain, and anorexia may also occur.

Intestinal obstruction

Nausea commonly occurs, especially with high small-intestinal obstruction. Vomiting may be bilious or fecal; abdominal pain is usually episodic and colicky but can become severe and steady with strangulation. Constipation occurs early in large-intestinal obstruction and later in small-intestinal obstruction; obstipation may signal complete obstruction. Bowel sounds are typically hyperactive in partial obstruction, and hypoactive or absent in complete obstruction. Abdominal distention and tenderness occur, possibly with visible peristaltic waves and a palpable abdominal mass.

Irritable bowel syndrome

Nausea, dyspepsia, and abdominal distention may occur with this syndrome especially during periods of increased stress. Other findings include lower abdominal pain and abdominal tenderness, which is generally relieved by moving the bowels; diurnal diarrhea alternating with constipation or normal bowel function; and small stools with visible mucus and a feeling of incomplete evacuation.

Labyrinthitis

Nausea and vomiting commonly occur with this acute inner ear inflammation. More significant findings include severe vertigo, progressive hearing loss, nystagmus, tinnitus and, possibly, otorrhea.

Lactose intolerance

Depending on the individual, signs and symptoms may include nausea, diarrhea, cramps, bloating, and gas, and they occur after eating dairy products.

Listeriosis

Signs and symptoms include nausea, vomiting, diarrhea, fever, myalgias, and abdominal pain. If the infection spreads to the nervous system and causes meningitis, signs and symptoms include fever, headache, nuchal rigidity, and change in level of consciousness.

Ménière’s disease

This disease causes sudden, brief, recurrent attacks of nausea, vomiting, vertigo, tinnitus, diaphoresis, and nystagmus. It also causes hearing loss and ear fullness.

Mesenteric artery ischemia

With this condition, nausea and vomiting may accompany severe cramping abdominal pain, especially after meals. Other findings include diarrhea or constipation, abdominal tenderness and bloating, anorexia, weight loss, and abdominal bruits.

Mesenteric venous thrombosis

Insidious or acute onset of nausea, vomiting, and abdominal pain occurs, with diarrhea or constipation, abdominal distention, hematemesis, and melena.

Metabolic acidosis

This acid-base imbalance may produce nausea and vomiting, anorexia, diarrhea, Kussmaul’s respirations, and decreased level of consciousness.

Migraine headache

Nausea and vomiting may occur in the prodromal stage, along with photophobia, light flashes, increased sensitivity to noise, light-headedness and, possibly, partial vision loss and paresthesia of the lips, face, and hands.

Motion sickness

With this disorder, nausea and vomiting are brought on by motion or rhythmic movement. Headache, dizziness, fatigue, diaphoresis, hypersalivation, and dyspnea may also occur.

Myocardial infarction

Nausea and vomiting may occur, but the cardinal symptom is severe substernal chest pain that may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, altered blood pressure, and arrhythmias also occur.

Norovirus infection

Acute gastroenteritis from noroviruses commonly causes infected individuals to experience nausea. Frequent accompanying symptoms include vomiting, diarrhea, and abdominal pain or cramping. Less commonly, individuals may develop low-grade fever, headache, chills, muscle aches, and generalized tiredness. These viruses are carried in the stool or vomit of infected individuals, and are often spread through contaminated food or water. Duration of illness is brief, with healthy individuals recovering in 24 to 60 hours.

Pancreatitis (acute)

Nausea, usually followed by vomiting, is an early symptom of pancreatitis. Other common findings include steady, severe pain in the epigastrium or left upper quadrant that may radiate to the back; abdominal tenderness and rigidity; anorexia; diminished bowel sounds; and fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.

Peptic ulcer

With this disorder, nausea and vomiting may follow attacks of sharp or gnawing, burning epigastric pain. Attacks typically occur when the stomach is empty, or after ingestion of alcohol, caffeine, or aspirin; they’re relieved by eating food or taking an antacid or an antisecretory. Hematemesis or melena may also occur.

Peritonitis

Nausea and vomiting usually accompany acute abdominal pain localized to the area of inflammation. Other findings include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness (including rebound tenderness); positive obturator sign and obturator weakness; pale, cold skin; diaphoresis; hypotension; shallow respirations; and hiccups.

Preeclampsia

Nausea and vomiting commonly occur with this disorder of pregnancy, along with rapid weight gain, epigastric pain, oliguria, severe frontal headache, hyperreflexia, and blurred or double vision. The classic diagnostic triad of signs include hypertension, proteinuria, and edema.

Q Fever

Signs and symptoms include nausea, vomiting, diarrhea, fever, chills, severe headache, malaise, and chest pain. Fever may last up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.

Renal and urologic disorders

Cystitis, pyelonephritis, calculi, uremia, and other disorders of the renal system can cause nausea. Related findings reflect the specific disorder.

Rhabdomyolysis

Signs and symptoms include nausea, vomiting, muscle weakness or pain, fever, malaise, and dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidneys’attempt to filter the myoglobin from the bloodstream.

Thyrotoxicosis

With this disorder, nausea and vomiting may accompany the classic findings of severe anxiety, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremor, tachycardia, and palpitations. Other signs include exophthalmos, ventricular or atrial gallop, and an enlarged thyroid gland.

Typhus

An abrupt onset of nausea, vomiting, fever, and chills follows the initial symptoms of headache, myalgia, arthralgia, and malaise.

Other causes

Drugs

Common nausea-producing drugs include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, cardiac glycosides, theophylline (overdose), and nonsteroidal anti-inflammatories.

Herb alert  Herbal remedies, such as ginkgo biloba and St. John’s wort, can produce adverse reactions, including nausea.

Radiation and surgery

Radiation therapy can cause nausea and vomiting. Postoperative nausea and vomiting are common, especially after abdominal surgery.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Vomiting: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Adrenal insufficiency

Common GI findings in the disorder include nausea and vomiting, anorexia, and diarrhea. Other findings include weakness, fatigue, weight loss, bronze skin, orthostatic hypotension, and a weak, irregular pulse.

Anthrax, GI

Initial signs and symptoms after ingestion of contaminated meat from an infected animal include nausea and vomiting, anorexia, and fever. Later, abdominal pain, severe bloody diarrhea, and hematemesis may occur.

Appendicitis

Nausea and vomiting may follow or accompany abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe, stabbing pain in the right lower quadrant. The patient generally has a positive McBurney’s sign—severe pain and tenderness at a point two-thirds the distance from the umbilicus to the right anterior superior spine of the ilium. Associated findings usually include abdominal rigidity and tenderness, anorexia, constipation or diarrhea, cutaneous hyperalgesia, fever, tachycardia, and malaise.

Bulimia

Most common in women ages 18 to 29, bulimia is characterized by polyphagia that alternates with self-induced vomiting, fasting, or diarrhea. It’s commonly accompanied by anorexia. The patient typically weighs less than normal but has a morbid fear of obesity. Self-induced vomiting may be evidenced by calloused knuckles and changes in teeth (enamel loss).

Cholecystitis (acute)

With this disorder, nausea and mild vomiting commonly follow severe right-upper-quadrant pain that may radiate to the back or shoulders. Associated findings include abdominal tenderness and, possibly, rigidity and distention, fever, and diaphoresis.

Cholelithiasis

Nausea and vomiting accompany severe unlocalized right-upper-quadrant or epigastric pain after ingestion of fatty foods. Other findings include abdominal tenderness and guarding, flatulence, belching, epigastric burning, pyrosis, tachycardia, and restlessness.

Cholera

Signs and symptoms of cholera include vomiting and abrupt watery diarrhea. Severe water and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Cirrhosis

Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, aching abdominal pain, and constipation or diarrhea. Later findings include jaundice, hepatomegaly, and abdominal distention.

Escherichia coli O157:H7

The signs and symptoms of this infection include nausea and vomiting, watery or bloody diarrhea, fever, and abdominal cramps. Children younger than age 5 and elderly people may develop hemolytic uremic syndrome, which causes red blood cell destruction and may eventually lead to acute renal failure.

Ectopic pregnancy

Nausea, vomiting, vaginal bleeding, and lower abdominal pain occur in this potentially life-threatening disorder.

Electrolyte imbalances

Such disturbances as hyponatremia, hypernatremia, hypokalemia, and hypercalcemia commonly cause nausea and vomiting. Other effects include arrhythmias, tremors, seizures, anorexia, malaise, and weakness.

Food poisoning

Vomiting, diarrhea, and fever are common findings in food poisoning, which is caused by ingestion of preformed toxins produced by bacteria typically found in foods, such as Bacillus cereus, Clostridium, and Staphylococcus.

Gastric cancer

This rare type of cancer may produce mild nausea, vomiting (possibly of mucus or blood), anorexia, upper abdominal discomfort, and chronic dyspepsia. Fatigue, weight loss, melena, and altered bowel elimination habits are also common.

Gastritis

Nausea and vomiting of mucus or blood are common in gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Epigastric pain, belching, and fever may also occur.

Gastroenteritis

This disorder causes nausea, vomiting (often of undigested food), diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, and abdominal pain and tenderness may also occur.

Heart failure

Nausea and vomiting may occur, especially in right-sided heart failure. Associated findings include tachycardia, ventricular gallop, fatigue, dyspnea, crackles, peripheral edema, and jugular vein distention.

Hepatitis

Vomiting commonly follows nausea as an early sign of viral hepatitis. Other early findings include fatigue, myalgia, arthralgia, headache, photophobia, anorexia, pharyngitis, cough, and fever.

Hyperemesis gravidarum

Unremitting nausea and vomiting that last beyond the first trimester characterize this disorder of pregnancy. Vomitus contains undigested food, mucus, and small amounts of bile early in the disorder; later, it has a coffee-ground appearance. Associated findings include weight loss, headache, delirium and, possibly, thyroid dysfunction.

Increased intracranial pressure

Projectile vomiting that isn’t preceded by nausea is a sign of increased intracranial pressure. The patient may exhibit a decreased level of consciousness (LOC) and Cushing’s triad (bradycardia, hypertension, and respiratory pattern changes). He may also have a headache, widened pulse pressure, impaired movement, visual disturbances, pupillary changes, and papilledema.

Infection

Acute localized or systemic infection may cause vomiting and nausea. Other common findings include fever, headache, malaise, and fatigue.

Intestinal obstruction

Nausea and vomiting (bilious or fecal) are common in this type of obstruction, especially of the upper small intestine. Abdominal pain is usually episodic and colicky but can become severe and steady. Constipation occurs early in large intestinal obstruction and late in small intestinal obstruction. Obstipation, however, may signal complete obstruction. In partial obstruction, bowel sounds are typically high pitched and hyperactive; in complete obstruction, hypoactive or absent. Abdominal distention and tenderness also occur, possibly with visible peristaltic waves and a palpable abdominal mass.

Labyrinthitis

Nausea and vomiting commonly occur in this acute inner ear inflammation. Other findings include severe vertigo, progressive hearing loss, nystagmus and, possibly, otorrhea.

Listeriosis

After ingesting food contaminated with the bacterium Listeria monocytogenes, the patient develops nausea, vomiting, abdominal pain, diarrhea, fever, and myalgia. If the infection spreads to the nervous system, he may develop meningitis. Signs and symptoms may include fever, headache, nuchal rigidity, and altered LOC. This food-borne illness primarily affects pregnant women, newborns, and those with weakened immune systems.

Gender Cue: Listeriosis that occurs during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Ménière’s disease

This disorder results in sudden, brief, recurrent attacks of nausea and vomiting, dizziness, vertigo, hearing loss, tinnitus, diaphoresis, and nystagmus.

Mesenteric artery ischemia

This life-threatening disorder may cause nausea and vomiting and severe, cramping abdominal pain, especially after meals. Other findings include diarrhea or constipation, abdominal tenderness and bloating, anorexia, weight loss, and abdominal bruits.

Mesenteric venous thrombosis

Insidious or acute onset of nausea, vomiting, and abdominal pain occurs along with diarrhea or constipation, abdominal distention, hematemesis, and melena.

Metabolic acidosis

This imbalance may produce nausea, vomiting, anorexia, diarrhea, Kussmaul’s respirations, and decreased LOC.

Migraine headache

Prodromal signs and symptoms of migraine include nausea and vomiting, fatigue, photophobia, light flashes, increased noise sensitivity and, possibly, partial vision loss and paresthesia.

Motion sickness

Nausea and vomiting may be accompanied by headache, vertigo, dizziness, fatigue, diaphoresis, and dyspnea.

Myocardial infarction

Nausea and vomiting may occur, but the cardinal symptom is severe substernal chest pain, which may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, and restlessness also occur.

Norovirus infection

Violent vomiting may occur frequently and without warning in this infection. Children infected with noroviruses tend to experience acute-onset vomiting more often than adults. Additional symptoms include nausea, diarrhea, and abdominal pain or cramping. There are no drugs or vaccines for noroviruses, but symptomatic therapy may be necessary to replace fluids and correct electrolyte disturbances resulting from frequent vomiting and diarrhea. Young children, elderly people, and those who are otherwise ill are at increased risk for dehydration.

Pancreatitis (acute)

Vomiting, usually preceded by nausea, is an early sign of pancreatitis. Associated findings include steady, severe epigastric or left-upper-quadrant pain that may radiate to the back; abdominal tenderness and rigidity; hypoactive bowel sounds; anorexia; vomiting; and fever. Severe pancreatitis may result in tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities.

Peptic ulcer

Nausea and vomiting may follow sharp, burning or gnawing epigastric pain, especially when the stomach is empty or after ingestion of alcohol, caffeine, or aspirin. Attacks are relieved by eating or taking antacids. Hematemesis or melena may also occur.

Peritonitis

Nausea and vomiting usually accompany acute abdominal pain in the area of inflammation. Other findings include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness; weakness; pale, cold skin; diaphoresis; hypotension; signs of dehydration; and shallow respirations.

Preeclampsia

Nausea and vomiting are common in this disorder of pregnancy. Rapid weight gain, epigastric pain, generalized edema, elevated blood pressure, oliguria, a severe frontal headache, and blurred or double vision also occur.

Q fever

Signs and symptoms of this rickettsial infection include nausea and vomiting, fever, chills, severe headache, malaise, chest pain, and diarrhea. Fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Renal and urologic disorders

Cystitis, pyelonephritis, calculi, and other renal and urologic disorders can cause vomiting. Accompanying findings reflect the specific disorder. Persistent nausea and vomiting are typical findings in patients with acute or worsening chronic renal failure.

Rhabdomyolysis

Signs and symptoms of this disorder include nausea and vomiting, muscle weakness or pain, fever, malaise, and dark urine. Acute renal failure, the most commonly reported complication of rhabdomyolysis, results from renal structure obstruction and injury during the kidneys’attempt to filter the myoglobin from the bloodstream.

Thyrotoxicosis

Nausea and vomiting may accompany the classic findings of severe anxiety, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, tachycardia, and palpitations. Other findings include exophthalmos, ventricular or atrial gallop, and an enlarged thyroid gland.

Typhus

Typhus is a rickettsial disease transmitted to humans by fleas, mites, or body louse. Initial symptoms include headache, myalgia, arthralgia, and malaise, followed by an abrupt onset of nausea, vomiting, chills, and fever. A maculopapular rash may be present in some cases.

Ulcerative colitis

Nausea, vomiting, and anorexia may occur, but the most common sign is recurrent diarrhea with blood, pus, and mucus. Fever, chills, and weight loss are other common signs and symptoms.

Other causes

Drugs

Drugs that commonly cause vomiting include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium, chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, and overdoses of cardiac glycosides and theophylline. Syrup of ipecac, a mixture of ipecac fluid extract, glycerin, and syrup, is used to treat drug overdoses by inducing vomiting.

Radiation and surgery

Radiation therapy may cause nausea and vomiting if it disrupts the gastric mucosa. Postoperative nausea and vomiting are common, especially after abdominal surgery.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Nausea/Vomiting: Differential Overview
(Field Guide to Bedside Diagnosis)

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

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Source: Field Guide to Bedside Diagnosis, 2007

Hematemesis: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Achalasia

Anthrax, GI

Coagulation disorders

Any disorder that disrupts normal clotting may result in GI bleeding and moderate to severe hematemesis. Bleeding may occur in other body systems as well, resulting in such signs as epistaxis and ecchymosis. Other associated effects vary, depending on the specific coagulation disorder, such as thrombocytopenia or hemophilia.

Esophageal cancer

A late sign of esophageal cancer, hematemesis may be accompanied by steady chest pain that radiates to the back. Other features include substernal fullness, severe dysphagia, nausea, vomiting with nocturnal regurgitation and aspiration, hemoptysis, fever, hiccups, sore throat, melena, and halitosis.

Esophageal injury by caustic substances

Ingestion of corrosive acids or alkalis produces esophageal injury associated with grossly bloody or coffee-ground vomitus. Hematemesis is accompanied by epigastric and anterior or retrosternal chest pain that’s intensified by swallowing. With ingestion of alkaline agents, the oral and pharyngeal mucosa may produce a soapy white film. The mucosa becomes brown and edematous with time. Dysphagia, marked salivation, and fever may develop in 3 to 4 weeks and worsen as strictures form.

Esophageal rupture

The severity of hematemesis depends on the cause of the rupture. When an instrument damages the esophagus, hematemesis is usually slight. However, rupture due to Boerhaave’s syndrome (increased esophageal pressure from vomiting or retching) or other esophageal disorders typically causes more severe hematemesis. This life-threatening disorder may also produce severe retrosternal, epigastric, neck, or scapular pain accompanied by chest and neck edema. Examination reveals subcutaneous crepitation in the chest wall, supraclavicular fossa, and neck. The patient may also show signs of respiratory distress, such as dyspnea and cyanosis.

Esophageal varices (ruptured)

Life-threatening rupture of esophageal varices may produce coffee-ground or massive, bright red vomitus. Signs of shock, such as hypotension or tachycardia, may follow or even precede hematemesis if the stomach fills with blood before vomiting occurs. Other symptoms may include abdominal distention and melena or painless hematochezia, ranging from slight oozing to massive rectal hemorrhage.

Gastric cancer

Gastritis (acute)

Gastroesophageal reflux disease (GERD)

Although rare with GERD, hematemesis may produce significant blood loss. It’s accompanied by pyrosis, flatulence, dyspepsia, and postural regurgitation that can be aggravated by lying down or stooping over. Related effects include dysphagia, retrosternal angina-like chest pain, weight loss, halitosis, and signs of aspiration, such as dyspnea and recurrent pulmonary infection.

GI leiomyoma

GI leiomyoma is a benign tumor that occasionally involves the GI tract, eroding the mucosa or vascular supply to produce hematemesis. Other features vary with the tumor’s size and location. For example, esophageal involvement may cause dysphagia and weight loss.

Mallory-Weiss syndrome

Characterized by a mucosal tear of the mucous membrane at the junction of the esophagus and the stomach, Mallory-Weiss syndrome may produce hematemesis and melena. It’s commonly triggered by severe vomiting, retching, or straining (as from coughing), most commonly in alcoholics or in people whose pylorus is obstructed. Severe bleeding may precipitate signs of shock, such as tachycardia, hypotension, dyspnea, and cool, clammy skin.

Peptic ulcer

Hematemesis may occur when a peptic ulcer penetrates an artery, vein, or highly vascular tissue. Massive — and possibly life-threatening — hematemesis is typical when an artery is penetrated. Other features include melena or hematochezia, chills, fever, and signs and symptoms of shock and dehydration, such as tachycardia, hypotension, poor skin turgor, and thirst. Most patients have a history of nausea, vomiting, epigastric tenderness, and epigastric pain that’s relieved by foods or antacids. The patient may also have a history of habitual use of tobacco, alcohol, or NSAIDs.

Other causes

Treatments

Traumatic NG or endotracheal intubation may cause hematemesis associated with swallowed blood. Nose or throat surgery may also cause this sign in the same way.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Vomiting: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Adrenal insufficiency

Common GI findings with adrenal insufficiency include vomiting, nausea, anorexia, and diarrhea. Other findings include weakness, fatigue, weight loss, bronze skin, orthostatic hypotension, and a weak, irregular pulse.

Anthrax (GI)

Initial signs and symptoms after eating contaminated meat from an infected animal include vomiting, loss of appetite, nausea, and fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

Bulimia

Cholecystitis (acute)

With acute cholecystitis, nausea and mild vomiting commonly follow severe right upper quadrant pain that may radiate to the back or shoulders. Associated findings include abdominal tenderness and, possibly, rigidity and distention, fever, and diaphoresis.

Cholelithiasis

Nausea and vomiting accompany severe unlocalized right upper quadrant or epigastric pain after eating fatty foods. Other findings include abdominal tenderness and guarding, flatulence, belching, epigastric burning, pyrosis, tachycardia, and restlessness.

Cholera

Signs and symptoms include vomiting and abrupt watery diarrhea. Severe water and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Cirrhosis

Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, aching abdominal pain, and constipation or diarrhea. Later findings include jaundice, hepatomegaly, and abdominal distention. O157:H7. The signs and symptoms of E. coli O157:H7 infection include vomiting, watery or bloody diarrhea, nausea, fever, and abdominal cramps. In children younger than age 5 and in elderly people, hemolytic uremic syndrome may develop in which the red blood cells are destroyed, and this may ultimately lead to acute renal failure.

Ectopic pregnancy

Vomiting, nausea, vaginal bleeding, and lower abdominal pain occur in ectopic pregnancy, a potentially life-threatening disorder.

Electrolyte imbalances

Such disturbances as hyponatremia, hypernatremia, hypokalemia, and hypercalcemia commonly cause nausea and vomiting. Other effects include arrhythmias, tremors, seizures, anorexia, malaise, and weakness.

Food poisoning

Gastric cancer

This rare cancer may produce mild nausea, vomiting (possibly of mucus or blood), anorexia, upper abdominal discomfort, and chronic dyspepsia. Fatigue, weight loss, melena, and altered bowel habits are also common.

Gastritis

Nausea and vomiting of mucus or blood are common with gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Epigastric pain, belching, and fever may also occur.

Gastroenteritis

Gastroenteritis causes nausea, vomiting (commonly of undigested food), diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, and abdominal pain and tenderness may also occur.

Heart failure

Nausea and vomiting may occur, especially with right-sided heart failure. Associated findings include tachycardia, ventricular gallop, fatigue, dyspnea, crackles, peripheral edema, and jugular vein distention.

Hepatitis

Vomiting commonly follows nausea as an early sign of viral hepatitis. Other early findings include fatigue, myalgia, arthralgia, headache, photophobia, anorexia, pharyngitis, cough, and fever.

Hyperemesis gravidarum

Unremitting nausea and vomiting that last beyond the first trimester characterize hyperemesis gravidarum, a disorder of pregnancy. Vomitus contains undigested food, mucus, and small amounts of bile early in the disorder; later, it has a coffee-ground appearance. Associated findings include weight loss, headache, and delirium. Thyroid dysfunction may be associated with this condition.

Increased ICP

Projectile vomiting that isn’t preceded by nausea is a sign of increased ICP. The patient may exhibit a decreased level of consciousness (LOC) and Cushing’s triad (bradycardia, hypertension, and respiratory pattern changes. He may also have headache, widened pulse pressure, impaired motor movement, vision disturbances, pupillary changes, and papilledema.

Infection

Acute localized or systemic infection may cause vomiting and nausea. Other common findings include fever, headache, malaise, and fatigue.

Intestinal obstruction

Nausea and vomiting (bilious or fecal) are common with intestinal obstruction, especially of the upper small intestine. Abdominal pain is usually episodic and colicky but can become severe and steady. Constipation occurs early in large intestinal obstruction and late in small intestinal obstruction. Obstipation, however, may signal complete obstruction. In partial obstruction, bowel sounds are typically high pitched and hyperactive; in complete obstruction, hypoactive or absent. Abdominal distention and tenderness also occur, possibly with visible peristaltic waves and a palpable abdominal mass.

Labyrinthitis

Nausea and vomiting commonly occur with labyrinthitis, an acute inner ear inflammation. Other findings include severe vertigo, progressive hearing loss, nystagmus and, possibly, otorrhea.

Listeriosis

Ménière’s disease

Ménière’s disease causes sudden, brief, recurrent attacks of nausea and vomiting, dizziness, vertigo, hearing loss, tinnitus, diaphoresis, and nystagmus.

Mesenteric artery ischemia

A life-threatening disorder, mesenteric artery ischemia may cause nausea and vomiting and severe, cramping abdominal pain, especially after meals. Other findings include diarrhea or constipation, abdominal tenderness and bloating, anorexia, weight loss, and abdominal bruits.

Mesenteric venous thrombosis

An insidious or an acute onset of nausea, vomiting, and abdominal pain occur with mesenteric venous thrombosis and may be accompanied by diarrhea or constipation, abdominal distention, hematemesis, and melena.

Metabolic acidosis

Metabolic acidosis is an imbalance that may produce nausea, vomiting, anorexia, diarrhea, Kussmaul’s respirations, and a decreased LOC.

Migraine headache

Nausea and vomiting are prodromal signs and symptoms, with fatigue, photophobia, light flashes, increased noise sensitivity and, possibly, partial vision loss and paresthesia.

Motion sickness

Nausea and vomiting may be accompanied by headache, vertigo, dizziness, fatigue, diaphoresis, and dyspnea.

Myocardial infarction

Nausea and vomiting may occur, but the cardinal symptom is severe substernal chest pain, which may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, and restlessness also occur.

Pancreatitis (acute)

Vomiting, usually preceded by nausea, is an early sign of pancreatitis. Associated findings include steady, severe epigastric or left upper quadrant pain that may radiate to the back, abdominal tenderness and rigidity, hypoactive bowel sounds, anorexia, vomiting, and fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.

Peptic ulcer

Nausea and vomiting may follow sharp, burning or gnawing epigastric pain, especially when the stomach is empty or after the ingestion of alcohol, caffeine, or aspirin. Attacks are relieved by eating or taking antacids. Hematemesis or melena may also occur.

Peritonitis

Nausea and vomiting usually accompany acute abdominal pain in the area of inflammation. Other findings include abdominal distention, rigidity, and tenderness as well as high fever with chills, tachycardia, hypoactive or absent bowel sounds, weakness, and pale, cold skin. The patient may also experience diaphoresis, hypotension, signs of dehydration, and shallow respirations.

Preeclampsia

Nausea and vomiting are common with preeclampsia, a disorder of pregnancy. Rapid weight gain, epigastric pain, generalized edema, elevated blood pressure, oliguria, severe frontal headache, and blurred or double vision also occur.

Q fever

Signs and symptoms of Q fever, a rickettsial infection, include vomiting, fever, chills, severe headache, malaise, chest pain, nausea, and diarrhea. Fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Renal and urologic disorders

Cystitis, pyelonephritis, calculi, and other disorders of this system can cause vomiting. Accompanying findings reflect the specific disorder. Persistent nausea and vomiting are typical findings in patients with acute or worsening chronic renal failure.

Rhabdomyolysis

Signs and symptoms of rhabdomyolisis include vomiting, muscle weakness or pain, fever, nausea, malaise, and dark urine. Acute renal failure is the most commonly reported complication. It results from renal structure obstruction and injury during the kidney’s attempt to filter myoglobin from the bloodstream.

Thyrotoxicosis

Nausea and vomiting may accompany the classic findings of severe anxiety, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, tachycardia, and palpitations. Other findings include exophthalmos, ventricular or atrial gallop, and an enlarged thyroid gland.

Typhus

Typhus is a rickettsial disease transmitted to humans by fleas, mites, or body lice. Initial symptoms include headache, myalgia, arthralgia, and malaise, followed by an abrupt onset of vomiting, nausea, chills, and fever. A maculopapular rash may be present in some cases.

Ulcerative colitis

Vomiting, nausea, and anorexia may occur, but the most common sign is recurrent diarrhea with blood, pus, and mucus. Fever, chills, and weight loss are also common.

Other causes

Drugs

Drugs that commonly cause vomiting include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium, chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, and overdoses of cardiac glycosides and theophylline. Syrup of ipecac, a mixture of ipecac fluid extract, glycerin, and syrup, is used to treat overdoses by inducing vomiting.

Radiation and surgery

Radiation therapy may cause nausea and vomiting if it disrupts the gastric mucosa. Postoperative nausea and vomiting are common, especially after abdominal surgery.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Hematemesis: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Anthrax (GI)

With GI anthrax, initial signs and symptoms, including loss of appetite, nausea, vomiting, and fever, appear after eating contaminated meat from an animal infected with the gram-positive, spore-forming bacterium Bacillus anthracis. Signs and symptoms may progress to hematemesis, abdominal pain, and severe bloody diarrhea.

Coagulation disorders

Any disorder that disrupts normal clotting may result in GI bleeding and moderate to severe hematemesis. Bleeding may occur in other body systems as well, resulting in such signs as epistaxis and ecchymosis. Other associated effects vary, depending on the specific coagulation disorder, such as thrombocytopenia or hemophilia.

Esophageal cancer

A late sign of esophageal cancer, hematemesis may be accompanied by steady chest pain that radiates to the back. Other features include substernal fullness, severe dysphagia, nausea, vomiting with nocturnal regurgitation and aspiration, hemoptysis, fever, hiccups, sore throat, melena, and halitosis.

Esophageal injury by caustic substances

Ingestion of corrosive acids or alkalis produces esophageal injury associated with grossly bloody or coffee-ground vomitus. Hematemesis is accompanied by epigastric and anterior or retrosternal chest pain that’s intensified by swallowing. With ingestion of alkaline agents, the oral and pharyngeal mucosa may produce a soapy white film. The mucosa becomes brown and edematous with time. Dysphagia, marked salivation, and fever may develop in 3 to 4 weeks and worsen as strictures form.

Esophageal rupture

With esophageal rupture, the severity of hematemesis depends on the cause of the rupture. When an instrument damages the esophagus, hematemesis is usually slight. However, rupture due to Boerhaave’s syndrome (increased esophageal pressure from vomiting or retching) or other esophageal disorders typically causes more severe hematemesis. This life-threatening disorder may also produce severe retrosternal, epigastric, neck, or scapular pain accompanied by chest and neck edema. Examination reveals subcutaneous crepitation in the chest wall, supraclavicular fossa, and neck. The patient may also show signs of respiratory distress, such as dyspnea and cyanosis.

Esophageal varices (ruptured)

Life-threatening rupture of esophageal varices may produce coffee-ground or massive, bright red vomitus. Signs of shock, such as hypotension or tachycardia, may follow or even precede hematemesis if the stomach fills with blood before vomiting occurs. Other symptoms may include abdominal distention and melena or painless hematochezia, ranging from slight oozing to massive rectal hemorrhage.

Gastric cancer

Painless bright red or dark brown vomitus is a late sign of gastric cancer, an uncommon cancer that usually begins insidiously with upper-abdominal discomfort. The patient then develops anorexia, mild nausea, and chronic dyspepsia unrelieved by antacids and exacerbated by food. Later symptoms may include fatigue, weakness, weight loss, feelings of fullness, melena, altered bowel habits, and signs of malnutrition, such as muscle wasting and dry skin.

Gastritis (acute)

Hematemesis and melena are the most common signs of acute gastritis. They may even be the only signs, although mild epigastric discomfort, nausea, fever, and malaise may also occur. Massive blood loss precipitates signs of shock. Typically, the patient has a history of alcohol abuse or has used aspirin or some other NSAID. Gastritis may also occur secondary to Helicobacter pylori infection.

GI leiomyoma

GI leiomyoma is a benign tumor that occasionally involves the GI tract, eroding the mucosa or vascular supply to produce hematemesis. Other features vary with the tumor’s size and location. For example, esophageal involvement may cause dysphagia and weight loss.

Mallory-Weiss syndrome

Characterized by a mucosal tear of the mucous membrane at the junction of the esophagus and the stomach, Mallory-Weiss syndrome may produce hematemesis and melena. It’s commonly triggered by severe vomiting, retching, or straining (as from coughing), most commonly in alcoholics or in people whose pylorus is obstructed. Severe bleeding may precipitate signs of shock, such as tachycardia, hypotension, dyspnea, and cool, clammy skin.

Peptic ulcer

Hematemesis may occur when a peptic ulcer penetrates an artery, vein, or highly vascular tissue. Massive — and possibly life-threatening — hematemesis is typical when an artery is penetrated. Other features include melena or hematochezia, chills, fever, and signs and symptoms of shock and dehydration, such as tachycardia, hypotension, poor skin turgor, and thirst. Most patients have a history of nausea, vomiting, epigastric tenderness, and epigastric pain that’s relieved by foods or antacids. The patient may also have a history of habitual use of tobacco, alcohol, or NSAIDs.

Other causes

Treatments

Traumatic NG or endotracheal intubation may cause hematemesis associated with swallowed blood. Nose or throat surgery may also cause this sign in the same way.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Nausea: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Adrenal insufficiency

Common GI findings in adrenal insufficiency include nausea, vomiting, anorexia, and diarrhea. Other findings include weakness, fatigue, weight loss, bronze skin, hypotension, vitiligo, depression, and a weak, irregular pulse.

Anthrax (GI)

Initial signs and symptoms of GI anthrax include nausea, vomiting, loss of appetite, and fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

With acute appendicitis, a brief period of nausea may accompany onset of abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe stabbing pain localized in the right lower quadrant (McBurney’s sign). Associated findings usually include abdominal rigidity and tenderness, cutaneous hyperalgesia, fever, constipation or diarrhea, tachycardia, anorexia, moderate malaise, and positive psoas (increased abdominal pain occurs when the examiner places his hand above the patient’s right knee and the patient flexes his right hip against resistance) and obturator signs (internal rotation of the right leg with the leg flexed to 90 degrees at the hip and knee with a resulting tightening of the internal obturator muscle that causes abdominal discomfort).

Cholecystitis (acute)

With acute cholecystitis, nausea typically follows severe right-upper-quadrant pain that may radiate to the back or shoulders, commonly following meals. Associated findings include mild vomiting, flatulence, abdominal tenderness and, possibly, rigidity and distention, fever with chills, diaphoresis, and a positive Murphy’s sign.

Cholelithiasis

With cholelithiasis, nausea accompanies attacks of severe right-upper-quadrant or epigastric pain after ingestion of fatty foods. Other associated findings include vomiting, abdominal tenderness and guarding, flatulence, belching, epigastric burning, tachycardia, and restlessness. Occlusion of the common bile duct may cause jaundice, clay-colored stools, fever, and chills.

Cirrhosis

Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, abdominal pain, and constipation or diarrhea. As the disease progresses, jaundice and hepatomegaly may occur with abdominal distention, spider angiomas, palmar erythema, severe pruritus, dry skin, fetor hepaticus, enlarged superficial abdominal veins, mental changes, and bilateral gynecomastia and testicular atrophy or menstrual irregularities.

Diverticulitis

Besides nausea, diverticulitis causes intermittent crampy abdominal pain, constipation or diarrhea, low-grade fever and, in many cases, a palpable, tender, firm, fixed mass. Signs and symptoms may also include anorexia, bloody stools, and flatulence.

Electrolyte imbalances

Electrolyte imbalances such as hyponatremia or hypernatremia, hypokalemia, and hypercalcemia commonly cause nausea and vomiting. Other effects include cardiac arrhythmias, tremors or seizures, anorexia, malaise, and weakness.

Escherichia coli 0157:H7

Signs and symptoms of E. coli 0157:H7 include nausea, watery or bloody diarrhea, vomiting, fever, and abdominal cramps. In children under age 5 and in elderly people, hemolytic uremic syndrome may develop, which may ultimately lead to acute renal failure.

Gastritis

Nausea is common with gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Vomiting of mucus or blood, epigastric pain, belching, fever, and malaise may also occur.

Gastroenteritis

Usually viral, gastroenteritis causes nausea, vomiting, diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, abdominal pain and tenderness, and possible dehydration and electrolyte imbalances may also develop.

Heart failure

Heart failure may produce nausea and vomiting, particularly with right-sided heart failure. Associated findings include tachycardia, ventricular gallop, profound fatigue, dyspnea, crackles, peripheral edema, jugular vein distention, ascites, nocturia, and diastolic hypertension.

Hepatitis

Nausea is an insidious early symptom of viral hepatitis. Vomiting, fatigue, myalgia and arthralgia, headache, anorexia, photophobia, pharyngitis, cough, and fever also occur early in the preicteric phase.

Hyperemesis gravidarum

In hyperemesis gravidarum, unremitting nausea and vomiting that persist beyond the first trimester of pregnancy are characteristic. Vomitus ranges from undigested food, mucus, and bile in the early stages of the disorder to a coffee-ground appearance in later stages. Associated findings include weight loss, signs of dehydration, headache, and delirium.

Inflammatory bowel disease

The most common symptom of inflammatory bowel disease is recurrent diarrhea with blood, pus, and mucus. Nausea, vomiting, abdominal pain, and anorexia may also occur. The patient may report abdominal cramps and spasms after meals.

Intestinal obstruction

Nausea commonly occurs, especially with high small-intestinal obstruction. Vomiting may be bilious or fecal; abdominal pain is usually episodic and colicky but can become severe and steady with strangulation. Constipation occurs early in large-intestinal obstruction and later in small-intestinal obstruction; obstipation may signal complete obstruction. Bowel sounds are typically hyperactive in partial obstruction and hypoactive or absent in complete obstruction. Abdominal distention and tenderness occur, possibly with visible peristaltic waves and a palpable abdominal mass.

Irritable bowel syndrome

Nausea, dyspepsia, and abdominal distention may occur with irritable bowel syndrome, especially during periods of increased stress. Other findings include lower abdominal pain and abdominal tenderness, which is generally relieved by moving the bowels; diurnal diarrhea alternating with constipation or normal bowel function; and small stools with visible mucus and a feeling of incomplete evacuation.

Labyrinthitis

Nausea and vomiting commonly occur with labyrinthitis (acute inner ear inflammation). More significant findings in this disorder include severe vertigo, progressive hearing loss, nystagmus, tinnitus and, possibly, otorrhea.

Lactose intolerance

Depending on the individual, signs and symptoms of lactose intolerance may include nausea, diarrhea, cramps, bloating, and gas that occurs after eating dairy products. Borborygmi may be heard on auscultation.

Ménière’s disease

Ménière’s disease causes sudden, brief, recurrent attacks of nausea, vomiting, vertigo, tinnitus, diaphoresis, and nystagmus. It also causes hearing loss and ear fullness.

Metabolic acidosis

Metabolic acidosis is an acid-base imbalance that may produce nausea and vomiting, anorexia, diarrhea, Kussmaul’s respirations, and decreased level of consciousness. The patient may also exhibit central nervous system depression, drowsiness, lethargy, and stupor.

Migraine headache

Nausea and vomiting may occur in the prodromal stage, along with photophobia, light flashes, increased sensitivity to noise, light-headedness and, possibly, partial vision loss and paresthesia of the lips, face, and hands.

Motion sickness

With motion sickness, nausea and vomiting are brought on by motion or rhythmic movement. Headache, dizziness, fatigue, diaphoresis, hypersalivation, and dyspnea may also occur.

Myocardial infarction

Nausea and vomiting may occur, but the cardinal symptom of myocardial infarction is severe substernal chest pain that may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, altered blood pressure, and arrhythmias also occur.

Pancreatitis (acute)

Nausea, usually followed by vomiting, is an early symptom of pancreatitis. Other common findings include steady, severe pain in the epigastrium or left upper quadrant that may radiate to the back; abdominal tenderness and rigidity; anorexia; diminished bowel sounds; and fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.

Peptic ulcer

With a peptic ulcer, nausea and vomiting may follow attacks of sharp or gnawing, burning epigastric pain. Attacks typically occur when the stomach is empty or after ingesting alcohol, caffeine, or aspirin; they’re relieved by eating food or taking an antacid or an antisecretory. Hematemesis or melena may also occur.

Peritonitis

Nausea and vomiting usually accompany acute abdominal pain localized to the area of inflammation. Other findings in peritonitis include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness (including rebound tenderness); positive obturator sign and obturator weakness; pale, cold skin; diaphoresis; hypotension; shallow respirations; and hiccups.

Preeclampsia

Nausea and vomiting commonly occur with this disorder of pregnancy, along with rapid weight gain, epigastric pain, oliguria, severe frontal headache, hyperreflexia, and blurred or double vision. The classic diagnostic triad of signs includes hypertension, proteinuria, and edema.

Renal and urologic disorders

Cystitis, pyelonephritis, calculi, uremia, and other disorders of the renal system can cause nausea. Related findings reflect the specific disorder.

Rhabdomyolysis

Signs and symptoms of rhabdomyolysis include nausea, vomiting, fever, malaise, and dark urine. The patient may also report tenderness, swelling, and muscle weakness that’s caused by muscle trauma and pressure.

Thyrotoxicosis

With thyrotoxicosis, nausea and vomiting may accompany the classic findings of severe anxiety, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremor, tachycardia, and palpitations. Other signs include exophthalmos, ventricular or atrial gallop, and an enlarged thyroid gland.

Other causes

Drugs

Common nausea-producing drugs include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, cardiac glycosides, theophylline (upon overdose), and nonsteroidal anti-inflammatories.

Radiation and surgery

Radiation therapy can cause nausea and vomiting. Postoperative nausea and vomiting are common, especially after abdominal surgery.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Vomiting: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Adrenal insufficiency

Common GI findings associated with adrenal insufficiency include vomiting, nausea, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze skin; orthostatic hypotension; and weak, irregular pulse.

Anthrax (GI)

With anthrax, initial signs and symptoms after eating contaminated meat from an infected animal include vomiting, loss of appetite, nausea, and fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

With appendicitis, vomiting and nausea may follow or accompany abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe, stabbing pain in the right lower quadrant. The patient generally has a positive McBurney’s sign — severe pain and tenderness on palpation about 2"(5 cm) from the right anterior superior spine of the ilium, on a line between that spine and the umbilicus. Associated findings usually include abdominal rigidity and tenderness, anorexia, constipation or diarrhea, cutaneous hyperalgesia, fever, tachycardia, and malaise.

Bulimia

Most common in women ages 18 to 29, bulimia is characterized by polyphagia that alternates with self-induced vomiting, fasting, or diarrhea. It’s commonly accompanied by anorexia. The patient typically weighs less than normal but has a morbid fear of obesity. Self-induced vomiting may be evidenced by calloused knuckles.

Cholecystitis (acute)

With acute cholecystitis, nausea and mild vomiting commonly follow severe right-upper-quadrant pain that may radiate to the back or shoulders. Associated findings include abdominal tenderness and, possibly, rigidity and distention, fever, and diaphoresis.

Cholelithiasis

Nausea and vomiting accompany severe unlocalized right-upper-quadrant or epigastric pain after ingestion of fatty foods. Other findings in cholelithiasis include abdominal tenderness and guarding, flatulence, belching, epigastric burning, pyrosis, tachycardia, and restlessness.

Cirrhosis

Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, aching abdominal pain, and constipation or diarrhea. Later findings include jaundice, hepatomegaly, and abdominal distention.

Escherichia coli 0157:H7

The signs and symptoms of E. coli include vomiting, watery or bloody diarrhea, nausea, fever, and abdominal cramps. In children younger than age 5 and elderly patients, hemolytic uremic syndrome may develop in which the red blood cells are destroyed, and this may ultimately lead to acute renal failure.

Ectopic pregnancy

Vomiting, nausea, vaginal bleeding, and lower abdominal pain occur in ectopic pregnancy, a potentially life-threatening disorder. The patient with an ectopic pregnancy may have a tender adrenal mass and a 1- to -2-month history of amenorrhea.

Electrolyte imbalances

Electrolyte imbalances such as hyponatremia, hypernatremia, hypokalemia, and hypercalcemia frequently cause nausea and vomiting. Other effects include arrhythmias, tremors, seizures, anorexia, malaise, and weakness.

Food poisoning

Vomiting is a common finding in food poisoning. Diarrhea, severe, cramping abdominal pain, prostration, and fever also usually occur.

Gastritis

Nausea and vomiting of mucus or blood are common with gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Epigastric pain, belching, and fever may occur.

Gastroenteritis

Gastroenteritis causes nausea, vomiting (often of undigested food), diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, and abdominal pain and tenderness may also occur.

Heart failure

Nausea and vomiting may occur, especially with right-sided heart failure. Associated findings include tachycardia, ventricular gallop, fatigue, dyspnea, crackles, peripheral edema, and jugular vein distention.

Hepatitis

Vomiting commonly follows nausea as an early sign of viral hepatitis. Other early findings include fatigue, myalgia, arthralgia, headache, photophobia, anorexia, pharyngitis, cough, and fever.

Hyperemesis gravidarum

Unremitting nausea and vomiting that last beyond the first trimester characterize hyperemesis gravidarum, a disorder of pregnancy. Vomitus contains undigested food, mucus, and small amounts of bile early in the disorder; later, it has a coffee-ground appearance. Associated findings include weight loss, headache, and delirium.

Increased intracranial pressure

Projectile vomiting that isn’t preceded by nausea is a sign of increased ICP. The patient may exhibit a decreased level of consciousness (LOC) and Cushing’s triad (bradycardia, hypertension, and respiratory pattern changes). He may also have headache, widened pulse pressure, impaired motor movement, vision disturbances, pupillary changes, and papilledema.

Intestinal obstruction

Nausea and vomiting (bilious or fecal) are common with intestinal obstruction, especially of the upper small intestine. Abdominal pain is usually episodic and colicky but can become severe and steady. Constipation occurs early in large intestinal obstruction and late in small intestinal obstruction. Obstipation, however, may signal complete obstruction. In partial obstruction bowel sounds are typically high pitched and hyperactive; in complete obstruction, hypoactive or absent. Abdominal distention and tenderness also occur, possibly with visible peristaltic waves and a palpable abdominal mass.

Labyrinthitis

Nausea and vomiting commonly occur with labyrinthitis, an acute inner ear inflammation. Other findings in labyrinthitis include severe vertigo, progressive hearing loss, nystagmus, and possibly otorrhea.

Ménière’s disease

Ménière’s disease causes sudden, brief, recurrent attacks of nausea and vomiting, dizziness, vertigo, hearing loss, tinnitus, diaphoresis, and nystagmus. Hearing loss may be progressive and tinnitus may persist between attacks.

Mesenteric artery ischemia

Mesenteric artery ischemia is a life-threatening disorder that may cause nausea and vomiting and severe, cramping abdominal pain, especially after meals. Other findings include diarrhea or constipation, abdominal tenderness and bloating, anorexia, weight loss, and abdominal bruits.

Mesenteric venous thrombosis

With mesenteric venous thrombosis, insidious or acute onset of nausea, vomiting, and abdominal pain occurs along with diarrhea or constipation, abdominal distention, hematemesis, and melena.

Metabolic acidosis

Metabolic acidosis may produce nausea, vomiting, anorexia, diarrhea, Kussmaul’s respirations, and decreased LOC.

Migraine headache

Nausea and vomiting are prodromal signs and symptoms of a migraine headache. Fatigue, photophobia, light flashes, increased noise sensitivity, and possibly partial vision loss and paresthesia also occur.

Motion sickness

Rhythmic or erratic motion causes nausea and vomiting that may be accompanied by headache, vertigo, dizziness, fatigue, diaphoresis, and dyspnea.

Myocardial infarction

Nausea and vomiting may occur, but the cardinal symptom of myocardial infarction is severe substernal chest pain, which may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, and restlessness also occur.

Pancreatitis (acute)

Vomiting, usually preceded by nausea, is an early sign of pancreatitis. Associated findings include steady, severe epigastric or left-upper-quadrant pain that may radiate to the back, abdominal tenderness and rigidity, hypoactive bowel sounds, anorexia, vomiting, and fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.

Peptic ulcer

Nausea and vomiting may follow sharp, burning or gnawing epigastric pain, especially when the stomach is empty or after ingestion of alcohol, caffeine, or aspirin. Attacks are relieved by eating or taking antacids. Hematemesis or melena may also occur.

Peritonitis

With peritonitis, nausea and vomiting usually accompany acute abdominal pain in the area of inflammation. Other findings include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness; weakness; pale, cold skin; diaphoresis; hypotension; signs of dehydration; and shallow respirations.

Preeclampsia

Nausea and vomiting are common with preeclampsia, a disorder of pregnancy. Rapid weight gain, epigastric pain, generalized edema, elevated blood pressure, oliguria, severe frontal headache, and blurred or double vision also occur.

Renal and urologic disorders

Cystitis, pyelonephritis, calculi, and other renal and urologic disorders can cause vomiting. Accompanying findings reflect the specific disorder. Persistent nausea and vomiting are typical findings in patients with acute or worsening chronic renal failure.

Thyrotoxicosis

With thyrotoxicosis, nausea and vomiting may accompany the classic findings of severe anxiety, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, tachycardia, and palpitations. Other findings include exophthalmos, ventricular or atrial gallop, and an enlarged thyroid gland.

Ulcerative colitis

Vomiting, nausea, and anorexia may occur, but the most common sign of ulcerative colitis is recurrent diarrhea with blood, pus, and mucus. Fever, chills, and weight loss are other common signs and symptoms.

Other causes

Drugs

Drugs that commonly cause vomiting include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium, chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, and overdoses of cardiac glycosides and theophylline. Syrup of ipecac is used to treat overdoses by inducing vomiting.

Radiation and surgery

Radiation therapy may cause nausea and vomiting if it disrupts the gastric mucosa. Postoperative nausea and vomiting are common, especially after abdominal surgery.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Regurgitation and Vomiting: Principal Causes of Regurgitation
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Normalvariations
2. Gastroesophageal reflux
3. Esophageal disorders
   1. Congenitalanomalies
      1. Esophagealatresia with or without tracheoesophageal fistula
      2. Esophageal stenosis
      3. Esophageal web
      4. Duplication
   2. Foreign body
   3. Stricture
4. Hiatal hernia
5. Rumination

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Hematemesis: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Anthrax (GI).Initial signs and symptoms after eating contaminated meat from an animal infected with the gram-positive, spore-forming bacterium Bacillus anthracis include a loss of appetite, nausea, vomiting, and a fever. Signs and symptoms may progress to hematemesis, abdominal pain, and severe bloody diarrhea.

Coagulation disorders.Any disorder that disrupts normal clotting may result in GI bleeding and moderate to severe hematemesis. Bleeding may occur in other body systems as well, resulting in such signs as epistaxis and ecchymosis. Other associated effects vary, depending on the specific coagulation disorder, such as thrombocytopenia or hemophilia.

Esophageal cancer.A late sign of esophageal cancer, hematemesis may be accompanied by steady chest pain that radiates to the back. Other features include substernal fullness, severe dysphagia, nausea, vomiting with nocturnal regurgitation and aspiration, hemoptysis, a fever, hiccups, a sore throat, melena, and halitosis.

Esophageal rupture.The severity of hematemesis depends on the cause of the esophageal rupture. When an instrument damages the esophagus, hematemesis is usually slight. However, rupture due to Boerhaave's syndrome (increased esophageal pressure from vomiting or retching) or other esophageal disorders typically causes more severe hematemesis. This life-threatening disorder may also produce severe retrosternal, epigastric, neck, or scapular pain accompanied by chest and neck edema. Examination reveals subcutaneous crepitation in the chest wall, supraclavicular fossa, and neck. The patient may also show signs of respiratory distress, such as dyspnea and cyanosis.

Esophageal varices (ruptured).Life-threatening rupture of esophageal varices may produce coffee-ground or massive, bright red vomitus. Signs of shock, such as hypotension or tachycardia, may follow or even precede hematemesis if the stomach fills with blood before vomiting occurs. Other symptoms may include abdominal distention and melena or painless hematochezia, ranging from slight oozing to massive rectal hemorrhage.

Gastric cancer.Painless bright red or dark brown vomitus is a late sign of gastric cancer, which usually begins insidiously with upper abdominal discomfort. The patient then develops anorexia, mild nausea, and chronic dyspepsia unrelieved by antacids and exacerbated by food. Later symptoms may include fatigue, weakness, weight loss, feelings of fullness, melena, altered bowel habits, and signs of malnutrition, such as muscle wasting and dry skin.

Gastritis (acute).Hematemesis and melena are the most common signs of acute gastritis. They may even be the only signs, although mild epigastric discomfort, nausea, a fever, and malaise may also occur. Massive blood loss precipitates signs of shock. Typically, the patient has a history of alcohol abuse or has used aspirin or some other NSAID. Gastritis may also occur secondary to Helicobacter pylori infection.

Mallory-Weiss syndrome.Characterized by a mucosal tear of the mucous membrane at the junction of the esophagus and stomach, this syndrome may produce hematemesis and melena. It's commonly triggered by severe vomiting, retching, or straining (as from coughing), most commonly in alcoholics or in people whose pylorus is obstructed. Severe bleeding may precipitate signs of shock, such as tachycardia, hypotension, dyspnea, and cool, clammy skin.

Peptic ulcer.Hematemesis may occur when a peptic ulcer penetrates an artery, vein, or highly vascular tissue. Massive—and possibly life-threatening—hematemesis is typical when an artery is penetrated. Other features include melena or hematochezia, chills, a fever, and signs and symptoms of shock and dehydration, such as tachycardia, hypotension, poor skin turgor, and thirst. The patient may have a history of nausea, vomiting, epigastric tenderness, and epigastric pain that's relieved by foods or antacids. He may also have a history of habitually using tobacco, alcohol, or NSAIDs.

Other causes

Treatments.Traumatic NG or endotracheal intubation may cause hematemesis associated with swallowed blood. Nose or throat surgery may also cause this sign in the same way.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Nausea: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Adrenal insufficiency.Common GI findings in adrenal insufficiency include nausea, vomiting, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze-colored skin; hypotension; a weak, irregular pulse; vitiligo; and depression.

Anthrax (GI).Initial signs and symptoms of GI anthrax include nausea, vomiting, loss of appetite, and fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis.With acute appendicitis, a brief period of nausea may accompany the onset of abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe stabbing pain localized in the right lower quadrant (McBurney's sign). Associated findings usually include abdominal rigidity and tenderness, cutaneous hyperalgesia, fever, constipation or diarrhea, tachycardia, anorexia, moderate malaise, and positive psoas (increased abdominal pain occurs when the examiner places his hand above the patient's right knee and the patient flexes his right hip against resistance) and obturator signs (internal rotation of the right leg with the leg flexed to 90 degrees at the hip and knee with a resulting tightening of the internal obturator muscle that causes abdominal discomfort).

Cholecystitis (acute).With acute cholecystitis, nausea commonly follows severe right upper quadrant pain that may radiate to the back or shoulders, usually following meals. Associated findings include mild vomiting, flatulence, abdominal tenderness and, possibly, rigidity and distention, fever with chills, diaphoresis, and a positive Murphy's sign.

Cholelithiasis.With cholelithiasis, nausea accompanies attacks of severe right upper quadrant or epigastric pain after eating fatty foods. Other associated findings include vomiting, abdominal tenderness and guarding, flatulence, belching, epigastric burning, tachycardia, and restlessness. Occlusion of the common bile duct may cause jaundice, clay-colored stools, fever, and chills.

Cirrhosis.Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, abdominal pain, and constipation or diarrhea. As the disease progresses, jaundice and hepatomegaly may occur with abdominal distention, spider angiomas, palmar erythema, severe pruritus, dry skin, fetor hepaticus, enlarged superficial abdominal veins, mental changes, and bilateral gynecomastia and testicular atrophy or menstrual irregularities.

Diverticulitis.Besides nausea, diverticulitis causes intermittent crampy abdominal pain, constipation or diarrhea, a low-grade fever, and commonly a palpable, tender, firm, fixed mass.

Escherichia coli O157:H7. Signs and symptoms of E. coli infection include nausea, watery or bloody diarrhea, vomiting, fever, and abdominal cramps. In children younger than age 5 and in the elderly, hemolytic uremic syndrome—in which red blood cells are destroyed—may develop. This may ultimately lead to acute renal failure.

Gastritis.Nausea is common with gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Vomiting of mucus or blood, epigastric pain, belching, fever, and malaise may also occur.

Gastroenteritis.Usually viral, gastroenteritis causes nausea, vomiting, diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, abdominal pain and tenderness, and possible dehydration and electrolyte imbalances may also develop.

Heart failure.Heart failure may produce nausea and vomiting, particularly with right-sided heart failure. Associated findings include tachycardia, a ventricular gallop, profound fatigue, dyspnea, crackles, peripheral edema, jugular vein distention, ascites, nocturia, and diastolic hypertension.

Hepatitis.Nausea is an insidious early symptom of viral hepatitis. Vomiting, fatigue, myalgia and arthralgia, headache, anorexia, photophobia, pharyngitis, cough, and fever also occur early in the preicteric phase.

Hyperemesis gravidarum.Unremitting nausea and vomiting that persist beyond the first trimester are characteristic of hyperemesis gravidarum. Vomitus ranges from undigested food, mucus, and bile early in the disorder to a coffee-ground appearance in later stages. Associated findings include weight loss, signs of dehydration, headache, and delirium.

Intestinal obstruction.Nausea commonly occurs, especially with high small-intestinal obstruction. Vomiting may be bilious or fecal; abdominal pain is usually episodic and colicky, but can become severe and steady with strangulation. Constipation occurs early in large-intestinal obstruction and later in small-intestinal obstruction; obstipation may signal complete obstruction. Bowel sounds are typically hyperactive in partial obstruction and hypoactive or absent in complete obstruction. Abdominal distention and tenderness occur, possibly with visible peristaltic waves and a palpable abdominal mass.

Labyrinthitis.Nausea and vomiting commonly occur with labyrinthitis. More significant findings include severe vertigo, progressive hearing loss, nystagmus, tinnitus and, possibly, otorrhea.

Listeriosis.Signs and symptoms of listeriosis include nausea, vomiting, diarrhea, fever, myalgia, and abdominal pain. If listerosis spreads to the nervous system and causes meningitis, signs and symptoms include fever, headache, nuchal rigidity, and a change in the level of consciousness (LOC).

Ménière's disease.Ménière's disease causes sudden, brief, recurrent attacks of nausea, vomiting, vertigo, tinnitus, diaphoresis, and nystagmus. It also causes hearing loss and ear fullness.

Mesenteric venous thrombosis.An insidious or acute onset of nausea, vomiting, and abdominal pain occurs with mesenteric venous thrombosis, along with diarrhea or constipation, abdominal distention, hematemesis, and melena.

Metabolic acidosis.Metabolic acidosis may produce nausea and vomiting, anorexia, diarrhea, Kussmaul's respirations, and decreased LOC.

Migraine headache.Nausea and vomiting may occur in the prodromal stage of a migraine headache, along with photophobia, light flashes, increased sensitivity to noise, light-headedness and, possibly, partial vision loss and paresthesia of the lips, face, and hands.

Motion sickness.With motion sickness, nausea and vomiting are brought on by motion or rhythmic movement. Headache, dizziness, fatigue, diaphoresis, hypersalivation, and dyspnea may also occur.

Myocardial infarction (MI).Nausea and vomiting may occur with an MI, but the cardinal symptom is severe substernal chest pain that may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, altered blood pressure, and arrhythmias also occur.

Norovirus infection.Acute gastroenteritis from noroviruses commonly causes infected individuals to experience nausea. Common accompanying symptoms include vomiting, diarrhea, and abdominal pain or cramping. Less commonly, individuals may develop low-grade fever, headache, chills, muscle aches, and generalized tiredness.

Pancreatitis (acute).Nausea, usually followed by vomiting, is an early symptom of pancreatitis. Other common findings include steady, severe pain in the epigastrium or left upper quadrant that may radiate to the back; abdominal tenderness and rigidity; anorexia; diminished bowel sounds; and fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.

Peptic ulcer.With peptic ulcer, nausea and vomiting may follow attacks of sharp or gnawing, burning epigastric pain. Attacks typically occur when the stomach is empty or after the ingestion of alcohol, caffeine, or aspirin; they're relieved by eating food or taking an antacid or antisecretory. Hematemesis or melena may also occur.

Peritonitis.With peritonitis, nausea and vomiting usually accompany acute abdominal pain localized to the area of inflammation. Other findings include a high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness (including rebound tenderness); positive obturator sign and obturator weakness; pale, cold skin; diaphoresis; hypotension; shallow respirations; and hiccups.

Preeclampsia.Nausea and vomiting commonly occur with preeclampsia along with rapid weight gain, epigastric pain, oliguria, a severe frontal headache, hyperreflexia, and blurred or double vision. The classic diagnostic triad of signs include hypertension, proteinuria, and edema.

Q fever.Signs and symptoms of Q fever include nausea, vomiting, diarrhea, fever, chills, severe headache, malaise, and chest pain. In severe cases, the patient may develop hepatitis or pneumonia.

Rhabdomyolysis.Signs and symptoms of rhabdomyolysis include nausea, vomiting, muscle weakness or pain, fever, malaise, and dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidneys'attempt to filter myoglobin from the bloodstream.

Typhus.With typhus, an abrupt onset of nausea, vomiting, fever, and chills follows the initial symptoms of headache, myalgia, arthralgia, and malaise.

Other causes

Drugs.Common nausea-producing drugs include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, cardiac glycosides, theophylline (overdose), and nonsteroidal anti-inflammatory drugs.

Radiation and surgery.Radiation therapy can cause nausea and vomiting. Postoperative nausea and vomiting are common, especially after abdominal surgery.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Vomiting: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Adrenal insufficiency.Common GI findings with adrenal insufficiency include vomiting, nausea, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze skin; orthostatic hypotension; and weak, irregular pulse.

Anthrax (GI).Initial signs and symptoms after eating contaminated meat from an animal infected with anthrax include vomiting, loss of appetite, nausea, and fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis.Vomiting and nausea may follow or accompany abdominal pain from appendicitis. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe, stabbing pain in the right lower quadrant. The patient generally has a positive McBurney's sign—severe pain and tenderness on palpation about 29 (5 cm) from the right anterior superior spine of the ilium, on a line between that spine and the umbilicus. Associated findings usually include abdominal rigidity and tenderness, anorexia, constipation or diarrhea, cutaneous hyperalgesia, fever, tachycardia, and malaise.

Cholecystitis (acute).With cholecystitis, nausea and mild vomiting commonly follow severe right-upper-quadrant pain that may radiate to the back or shoulders. Associated findings include abdominal tenderness and, possibly, rigidity and distention, fever, and diaphoresis.

Cholelithiasis.With cholelithiasis, nauseaand vomiting accompany severe, unlocalized right-upper-quadrant or epigastric pain after ingestion of fatty foods. Other findings include abdominal tenderness and guarding, flatulence, belching, epigastric burning, pyrosis, tachycardia, and restlessness.

Cholera.Signs and symptoms of cholera include vomiting and abrupt watery diarrhea. Severe water and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Cirrhosis.Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, aching abdominal pain, and constipation or diarrhea. Later findings include jaundice, hepatomegaly, and abdominal distention.

Electrolyte imbalances.Such electrolyte disturbances as hyponatremia, hypernatremia, hypokalemia, and hypercalcemia frequently cause nausea and vomiting. Other effects include arrhythmias, tremors, seizures, anorexia, malaise, and weakness.

Escherichia coli O157:H7. The signs and symptoms of E.coli include vomiting, watery or bloody diarrhea, nausea, fever, and abdominal cramps. In children younger than age 5 and the elderly, hemolytic uremic syndrome may develop in which the red blood cells are destroyed, which may ultimately lead to acute renal failure.

Food poisoning.Vomiting is a common finding of food poisoning, caused by preformed toxins produced by bacteria typically found in foods, such as Bacillus cereus, Clostridium, and Staphylococcus. Diarrhea and fever also usually occur.

Gastric cancer.This rare cancer may produce mild nausea, vomiting (possibly of mucus or blood), anorexia, upper abdominal discomfort, and chronic dyspepsia. Fatigue, weight loss, melena, and altered bowel habits are also common.

Gastritis.Nausea and vomiting of mucus or blood are common with gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Epigastric pain, belching, and fever may occur.

Gastroenteritis.Gastroenteritis causes nausea, vomiting (commonly of undigested food), diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, and abdominal pain and tenderness may also occur.

Heart failure.Nausea and vomiting may occur heart failure, especially with right-sided heart failure. Associated findings include tachycardia, ventricular gallop, fatigue, dyspnea, crackles, peripheral edema, and jugular vein distention.

Hepatitis.Vomiting commonly follows nausea as an early sign of viral hepatitis. Other early findings include fatigue, myalgia, arthralgia, headache, photophobia, anorexia, pharyngitis, cough, and fever.

Hyperemesis gravidarum.Unremitting nausea and vomiting that last beyond the first trimester characterize this disorder of pregnancy. Vomitus contains undigested food, mucus, and small amounts of bile early in the disorder; later, it has a coffee-ground appearance. Associated findings include weight loss, headache, delirium, and electrolyte imbalance. Thyroid dysfunction may be associated with this condition.

Increased intracranial pressure.Projectile vomiting that isn't preceded by nausea is a sign of increased intracranial pressure. The patient may exhibit a decreased level of consciousness (LOC) and Cushing's triad (bradycardia, hypertension, and respiratory pattern changes). He may also have headache, widened pulse pressure, impaired motor movement, vision disturbances, pupillary changes, and papilledema.

Intestinal obstruction.Nausea and vomiting (bilious or fecal) are common with intestinal obstruction, especially of the upper small intestine. Abdominal pain is usually episodic and colicky but can become severe and steady. Constipation occurs early in large intestinal obstruction and late in small intestinal obstruction. Obstipation, however, may signal complete obstruction. In partial obstruction, bowel sounds are typically high pitched and hyperactive; in complete obstruction, bowel sounds are typically hypoactive or absent. Abdominal distention and tenderness also occur, possibly with visible peristaltic waves and a palpable abdominal mass.

Labyrinthitis.Nauseaand vomiting commonly occur with labyrinthitis. Other findings include severe vertigo, progressive hearing loss, nystagmus, and possibly otorrhea.

Listeriosis.After the ingestion offood contaminated with the bacterium Listeria monocytogenes, vomiting, fever, myalgias, abdominal pain, nausea, and diarrhea occur. If the infection spreads to the nervous system, meningitis may develop. Signs and symptoms may include fever, headache, nuchal rigidity, and change in LOC. The food-borne illness primarily affects pregnant women, neonates, and those with weakened immune systems.

Mesenteric venous thrombosis.Insidious or acute onset of nausea, vomiting, and abdominal pain occurs with mesenteric venous thrombosis. Other findings include diarrhea or constipation, abdominal distention, hematemesis, and melena.

Migraine headache.Nausea and vomiting are prodromal signs of a migraine headache, along with such accompanying symptoms as fatigue, photophobia, light flashes, increased noise sensitivity, and possibly partial vision loss and paresthesia.

Motion sickness.With motion sickness, nausea and vomiting may be accompanied by headache, vertigo, dizziness, fatigue, diaphoresis, and dyspnea.

Norovirus infection.Violent vomiting may occur frequently and without warning with norovirus infection. Additional symptoms include nausea, diarrhea, and abdominal pain or cramping.

Pancreatitis (acute).Vomiting, usually preceded by nausea, is an early sign of pancreatitis. Associated findings include steady, severe epigastric or left-upper-quadrant pain that may radiate to the back, abdominal tenderness and rigidity, anorexia, hypoactive bowel sounds, vomiting, and fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.

Peritonitis.With peritonitis, nausea and vomiting usually accompany acute abdominal pain in the area of inflammation. Other findings include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness; weakness; pale, cold skin; diaphoresis; hypotension; signs of dehydration; and shallow respirations.

Preeclampsia.Nausea and vomiting are common with preeclampsia. Rapid weight gain, epigastric pain, generalized edema, elevated blood pressure, oliguria, proteinuria, severe frontal headache, and blurred or double vision also occur.

Q fever.Signs and symptoms of Q fever include vomiting, fever, chills, severe headache, malaise, chest pain, nausea, and diarrhea. Fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Renal and urologic disorders.Cystitis, pyelonephritis, calculi, and other disorders of this system can cause vomiting. Accompanying findings reflect the specific disorder. Persistent nausea and vomiting are typical findings in patients with acute or worsening chronic renal failure.

Rhabdomyolysis.Signs and symptoms of rhabdomyolisis include vomiting, muscle weakness or pain, fever, nausea, malaise, and dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidney's attempt to filter the myoglobin from the bloodstream.

Typhus.Initial symptoms of typhus include headache, myalgia, arthralgia, and malaise, followed by an abrupt onset of vomiting, nausea, chills, and fever. A maculopapular rash may be present in some cases.

Other causes

Drugs.Drugs that commonly cause vomiting include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium, chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, and overdoses of cardiac glycosides and theophylline. Syrup of ipecac is used to treat overdoses by inducing vomiting.

Radiation and surgery.Radiation therapy may cause nausea and vomiting if it disrupts the gastric mucosa. Postoperative nausea and vomiting are common, especially after abdominal surgery.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Vomiting - Case 3-1: 7-Week-Old Boy: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Vomiting - Case 3-2: 9-Month-Old Girl: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Vomiting - Case 3-6: 10-Month-Old Girl: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

 » Next page: Risk Factors for Cyclic vomiting syndrome

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