NAUSEA AND VOMITING

NAUSEA AND VOMITING: Excerpt from Differential Diagnosis in Primary Care

These two should be considered together, because nausea is just a forme fruste of vomiting. This symptom lends itself well to anatomic analysis, particularly by the target method illustrated on page 324. The focus should be on the gastrointestinal (GI) tract. Starting from the top and working to the bottom, and at the same time cross-indexing this with etiologies (Table 46), one can review the most important causes of vomiting.

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NAUSEA AND VOMITING

	V	I	N	D
	Vascular	Inflammatory	Neoplasm	Degenerative and
				Deficiency
Pharynx		Tonsillitis Diphtheria		Plummer–Vinson syndrome
Esophagus	Aortic aneurysm	Esophagitis Chagas disease	Carcinoma
Stomach		Gastritis Ulcers	Carcinoma	Pernicious anemia
Duodenum		Ulcers Duodenitis Strongyloides
Jejunum and Ileum	Mesenteric thrombosis	Tinea solium and other parasites (e.g., Salmonella, Shigella)	Carcinoid Sarcoma	Pellagra Malabsorption syndrome
Appendix		Appendicitis	Carcinoid
Colon	Mesenteric thrombosis	Amebic colitis Staphylococcal colitis	Carcinoma
Gallbladder		Cholecystitis	Cholangioma
Pancreas		Pancreatitis	Pancreatic cyst and carcinoma
Kidneys	Renal artery thrombosis	Pyelonephritis	Carcinoma with obstruction
Pelvic Organs	Torsion of ovary or cyst	Pelvic inflammatory disease	Ectopic pregnancy
Blood		Chronic anemia	Leukemia Multiple myeloma	Iron deficiency anemia

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NAUSEA AND VOMITING

I	C	A	T	E
Intoxication	Congenital and	Autoimmune	Trauma	Endocrine
	Collagen	Allergic
		Vincent angina	Foreign body
Lye stricture	Achalasia scleroderma		Foreign body
Aspirin Reserpine	Pyloric stenosis Cascade stomach			Gastrinoma Hyperparathyroidism
				Gastrinoma
Botulism	Whipple disease Meckel diverticulum	Regional enteritis	Ruptured viscus	Vasoactive intestinal peptide syndrome
			Rupture Fecalith
	Malrotation Diverticulum	Ulcerative colitis Granulomatous colitis	Ruptured viscus
			Stone
	Mucoviscidosis
Drug neuropathy	Polycystic kidney	Glomerulonephritis	Rupture Stone Obstruction
			Induced abortion
Uremia

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In the nasopharynx, one encounters tonsillitis and foreign bodies. In the esophagus, achalasia, reflux esophagitis, and carcinoma are important, although they are more likely to produce dysphagia . In the stomach, gastritis, gastric ulcers, and gastric carcinoma are important causes of vomiting. A polyp, carcinoma, or ulcer at the pylorus is most likely to produce vomiting because of gastric outlet obstruction. In children, one must not forget pyloric stenosis. In the duodenum, one must consider not only ulcers and duodenitis but also the afferent loop obstructions that occur after Billroth II surgery and the “dumping syndrome” in Billroth I and II surgery. Bile gastritis is also a cause. Intestinal obstruction from a variety of causes (e.g., volvulus, intussusception, malrotation, bezoar, carcinoma, and regional ileitis) must be considered in the jejunum and ileum. Parasites such as Strongyloides, Ascaris, and Taenia solium must also be considered in this part of the GI tract. An obstructed Meckel diverticulum or appendix may present with vomiting. In the large bowel, ulcerative colitis, amebiasis, and neoplasms should be considered. Mesenteric thrombosis can cause vomiting regardless of which portion of the intestine it involves. Acute viral or bacterial enteritis is associated with nausea and vomiting, but almost invariably there is diarrhea in botulism, salmonellosis, and shigellosis. In the next circle in the target one encounters cholecystitis and cholelithiasis, pancreatitis, gastrinomas, pancreatic cysts, peritonitis, and myocardial infarction. In the next circle are the kidneys (e.g., renal stones), the thyroid, the pelvic organs (e.g., ectopic pregnancy), and the lungs (pneumonia with gastric dilatation). The next circle contains the vestibular apparatus (Ménière disease), the brain (e.g., tumor), and the testicles (e.g., torsion and orchitis). The target method has served us well, but a biochemical evaluation of vomiting should also be done because many foreign substances or natural body substances occurring in high or low concentrations in the blood may affect the vomiting centers or cause a paralytic ileus. Thus uremia, increased ammonia and nitrogen breakdown products in hepatic disease, and hypokalemia and hyperkalemia may cause vomiting. Alterations in sodium, chloride, and CO₂ may also cause vomiting. More important is hypercalcemia due to hyperparathyroidism or other causes.

In summary, vomiting is best analyzed anatomically. Physiologically, the symptoms of vomiting should suggest obstruction, either functional or mechanical. When all studies are normal, consider a neuropsychiatric disorder.

Approach to the Diagnosis

The association of other symptoms and signs is essential in pinpointing the diagnosis of vomiting. For example, vomiting with tinnitus and vertigo suggests Ménière disease, whereas vomiting with hematemesis suggests gastritis, esophageal varices, and gastric ulcers. The laboratory workup should include a flat plate of the abdomen, upper GI series, esophagram, cholecystogram, gastric analysis, serum electrolytes, and amylase and lipase levels. Stools for occult blood, ova, and parasites are usually indicated. Gastroscopy and esophagoscopy are often indicated in the acute case, but an exploratory laparotomy should not be delayed if the patient’s condition is deteriorating and pancreatitis has been excluded.

Other Useful Tests

1. CBC (anemia, infection)
2. Chemistry panel (liver disease, uremia)
3. Serial echocardiograms (ECGs) and cardiac enzymes (myocardial infarction)
4. Pregnancy test (ectopic pregnancy)
5. Arterial blood gases (pulmonary embolism)
6. Lung scan (pulmonary embolism)
7. Gallbladder sonogram (gallstones)
8. Small-bowel series (neoplasm, diverticulum, regional enteritis)
9. CT scan of the abdomen (neoplasm, abscess)
10. Laparoscopy (neoplasm of pancreas or liver)
11. Angiogram (mesenteric thrombosis)

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NECK MASS

	V	I	N	D
	Vascular	Inflammatory	Neoplasm	Degenerative
Skin		Subcutaneous emphysema	Lipoma Angioma Carcinoma
Thyroid		Cyst (colloid type) Thyroiditis	Adenoma Carcinoma	Endemic goiter
Lymph Nodes		Tuberculosis Actinomycosis Lymphadenitis	Hodgkin lymphoma Metastatic carcinoma
Trachea		Bronchial cleft cyst
Esophagus			Carcinoma of esophagus
Jugular Veins	Thrombosis Varicocele Obstruction		Hemangioma
Carotid Arteries	Aneurysms			Atherosclerotic disease
Brachial Plexus			Neurofibroma
Cervical Spine		Tuberculosis	Multiple myeloma Metastatic carcinoma
Muscles of Neck		Myositis	Rhabdomyosarcoma

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NECK MASS

I	C	A	T	E
Intoxication	Congenital	Allergic and	Trauma	Endocrine
		Autoimmune
	Cystic hygroma	Angioneurotic edema	Contusion Fractured rib
				Graves disease Thyroid carcinoma
		Sarcoidosis
	Diverticulum of esophagus		Surgical esophageal bypass
			Hemorrhage
			Contusion
	Cervical rib		Fracture Sprain Contusion
	Scalenus anticus

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Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 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: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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