Nausea and Vomiting
Nausea and Vomiting: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Eric M. Walsh
Approach
Nausea and vomiting are common presenting complaints in office practice. An effective diagnostic approach will consider causes both within the gastrointestinal (GI) system, and systemic causes (1–3), as well as paying special attention to the presence or absence of coexisting abdominal pain.
A. Causes originating in the GI system
1. In the newborn and infant, causes of nausea and vomiting include reflux, pyloric stenosis, meconium ileus, and congenital malformations (e.g., malrotation of the bowel).
2. In children, consider esophageal reflux, gastritis, peptic ulcer, Crohn’s disease, food intolerance or allergy, intussusception, Reye’s syndrome, and anatomic disorders (e.g., ileal band).
3. In adults, the differential diagnosis includes reflux esophagitis (4), gastritis, peptic ulcer, achalsia, malignancy, Crohn’s disease, gall bladder disease, liver disease, and pancreatic disease.
4. GI infections occur in all age groups and include bacterial causes (Staphylococcus aureus, Bacillus cereus, Escherichia coli, and Campylobacter, Helicobacter, Salmonella, Shigella, Vibrio organisms), viral causes (especially Norwalk agent and rotovirus), and parasitic agents such as Giardia organisms.
B. Systemic causes of nausea and vomiting include medications, especially narcotics, oral contraceptives, digoxin, theophylline, nonsteriodal antiinflammatory drugs, erythromycin, steroids, and iron. Remember, the Physician’s Desk Reference lists nausea as a potential side effect for many, if not most drugs. Also consider renal disease, electrolyte abnormalities or Addison’s disease, pregnancy, central nervous system problems (migraine, bleed, tumor, head trauma, meningitis), and toxins (especially lead, other heavy metals, cholinesterase inhibitors, and methemoglobin formers). Psychiatric problems such as anorexia or bulemia, obsessive compulsive disorder with trichotillomania and bezoar formation, and psychogenic polydypsia can also cause nausea and vomiting (5). Also on the differential diagnosis for infants and children are inborn errors of metabolism, congenital heart disease, and common pediatric infections.
Infections that can cause nausea and vomiting in all age groups include pneumonia, pyelonephritis, pelvic inflammatory disease, and sepsis. Also consider alcohol or drug withdrawal, radiotherapy, chemotherapy, malignancy, thyrotoxicosis, and cardiac causes (e.g., ischemia or congestive heart failure).
History.
As is usually the case in clinical practice, most diagnoses will be made by history and confirmed by physical examination and laboratory studies. Key points in the history include the following:
A. Are the symptoms acute, chronic, or recurrent?
B. If vomiting is the predominant feature, consider GI infection, reflux, gastritis, or ulcer.
C. Nausea as the predominant feature often results from systemic problems.
D. Is there a history of travel, drinking unsafe water, or eating unusual or uncooked food?
E. Is there a history of fevers or chills (Chapter 2.6.)?
F. Are general systemic symptoms or signs such as edema, discolored urine or jaundice, fatigue, weight loss or anorexia, headache, or blurred vision present?
G. Are psychiatric symptoms present?
H. Is the patient taking any medications?
I. Is diarrhea present?
J. Is there abdominal pain? The presence of abdominal pain raises some important and potentially serious possibilities:
1. Common problems presenting with abdominal pain and vomiting include cholecystitis, appendicitis, gastritis or ulcer, hepatitis, small bowel obstruction, inferior myocardial infarction or ischemia, renal colic, peritonitis, pancreatitis, food poisoning, and complications of pregnancy.
2. Uncommon problems presenting with abdominal pain and vomiting include diabetic ketoacidosis, drug withdrawal, uremia, and vasculitis or abdominal migraine.
3. Rare problems presenting with abdominal pain and vomiting include porphyria, lead intoxication, adrenal insufficiency, hyperlipidemia, abdominal epilepsy, glaucoma, hypercalcemia, and acute hemolysis.
Physical examination.
A directed physical examination is dictated by the findings on history, but the following are areas of key importance:
A. Vital signs. Focus on presence of fever, pulse, and blood pressure to assess hydration, and respiratory rate to look for acidosis-related hyperventilation.
B. Skin, eyes, mucous membranes. Look for dehydration and signs of jaundice.
C. Signs of systemic infection. Pay special attention to examining the lung and the costovertebral angle for tenderness.
D. A detailed abdominal examination should include inspection, auscultation, palpation, percussion, areas of tenderness, rebound, guarding, hepatomegaly, Murphy’s sign, stool for occult blood, and bimanual pelvic examination.
Testing.
Most cases of nausea and vomiting seen in a generalist’s office will not require laboratory testing. If the diagnosis is still unclear after history and physical examination, the laboratory workup can be classified into primary, secondary, and tertiary on the basis of their utility and ability to detect disease with an urgent need for diagnosis.
A. Primary tests include electrolytes, glucose, renal and liver function tests, amylase, urinalysis, stool for white blood cells, pregnancy test, and plain films of the abdomen or abdominal ultrasound if pain is a prominent feature of the presentation.
B. Secondary tests include abdominal ultrasound if not already done, upper GI series or upper endoscopy, stool culture, thyroid-stimulating hormone, electrocardiogram, and chest x-ray study.
C. Tertiary tests include lower endoscopy, computed tomography or magnetic resonance imaging studies, urine toxicology, urine porphyrins, and, in many instances, specialty consultation.
Diagnostic assessment
The diagnostic assessment of nausea and vomiting will benefit from a structured approach that includes the following:
A. A differential diagnosis based on age and reproductive status.
B. Attention to GI versus systemic causes of nausea and vomiting.
C. Special attention to the potentially more urgent nature of cases of nausea and vomiting that are often accompanied by abdominal pain (Chapter 9.1).
References
1. Avner JR. Vomiting. In: Schwartz MW, ed. Pediatric primary care—a problem oriented approach, 3rd ed. Chicago: Yearbook Medical Publishers, 1997:397–406.
2. Sorgel KH, Greenberger NJ. Nausea and vomiting in the diabetic patient. Hosp Pract (Off Ed) 1998;33:14–16.
3. Bouchier IAD. Nausea, vomiting. In: Bouchier IAD, Ellis H, Flemming P, eds. Index of differential diagnosis, 13th ed. Oxford: Butterworth Heinman Publishers, 1996:
446,710–713.
4. Brzana RJ, Koch KL. Gastroesophageal reflux disease presenting with intractable nausea. Ann Intern Med 1997;126:704–707.
5. Withers GD, Silburn SR, Forbes DA. Precipitants and aetiology of cyclic vomiting syndrome. Acta Pediatr 1998;87:272–277.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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