NAUSEA AND VOMITING

NAUSEA AND VOMITING: Excerpt from Algorithmic Diagnosis of Symptoms and Signs

Ask the Following Questions:

1. Is there a history of alcohol or drug ingestion? Alcohol and many drugs such as digitalis, aspirin, nonsteroidal anti-inflammatory agents, antihypertensives, and antibiotics may cause gastric irritation or gastritis.
2. Is there fever? Fever may point to a localized abdominal condition such as acute cholecystitis or acute appendicitis, as well as a systemic condition such as tuberculosis, brucellosis, yellow fever, and other febrile illnesses.
3. Is there abdominal pain? Abdominal pain suggests the possibility of acute cholecystitis, acute appendicitis, pyelonephritis, pancreatitis, renal calculus, and peritonitis.
4. Is there an abdominal mass? The presence of an abdominal mass suggests pyloric or intestinal obstruction, a pancreatic neoplasm, acute cholecystitis, Crohn's disease, perinephric abscess, diverticulitis, and other abscesses and neoplasms.
5. Is there vertigo? The clinician should remember that inner ear diseases such as Ménière's disease and labyrinthitis may be associated with vomiting, and sometimes the patient does not mention vertigo.
6. Is there headache? Migraine, concussion, cerebral tumors or other space-occupying lesions, meningitis, and subarachnoid hemorrhage are associated with headaches, nausea, and vomiting.

DIAGNOSTIC WORKUP

The basic workup includes a CBC, sedimentation rate, urinalysis, urine drug screen, chemistry panel and electrolytes, serum amylase, arterial blood gases, stools for occult blood, chest x-ray, EKG, and flat plate of the abdomen. Acute onset of nausea and vomiting with ataxia requires an immediate CT scan of the brain to rule out a cerebellar hemorrhage. A pregnancy test should be routine in women of child-bearing age. If there is fever, febrile agglutinins and a heterophile antibody titer should be done. If there is an abdominal mass, a gallbladder ultrasound and intravenous pyelogram may need to be done. Isotope scanning with iminodiacetic acid derivatives is extremely useful to detect acute cholecystitis. If there is chronic vomiting and abdominal pain, the diagnosis can often be made with an upper GI series, small bowel series, or barium enema.

When there is persistent vomiting with abdominal pain, an exploratory laparotomy may need to be considered. The presence of an abdominal mass or suspected pancreatic or biliary disease merits consideration of a CT scan. However, before ordering expensive diagnostic tests, a general surgeon or gastroenterologist ought to be consulted. Laparoscopy, gastroscopy, esophagoscopy, duodenoscopy, and colonoscopy all need to be considered in the workup. Gastroparesis and intestinal pseudo-obstruction can be ruled out by radioisotope studies and manometry of the stomach and small intestine. Angiography is useful to diagnose mesenteric artery ischemia.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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