Nausea & Vomiting

Nausea & Vomiting: Excerpt from In a Page: Signs and Symptoms

Vomiting is an involuntary forceful extrusion of stomach contents. It is a mediated by a complex reflex that is located in the vomiting center of the medulla oblongata. Reflex vomiting results when afferent fibers of the inner ear, meninges, or gastrointestinal tract fire; central vomiting results from direct stimulation of the vomiting center. Vomiting of blood (hematemesis) requires immediate workup and possible resuscitation and identification of the source of bleeding (see “GI Bleeding—Hematemesis” entry)

Differential Diagnosis

• Central nausea/vomiting
  –Pregnancy (hyperemesis gravidarum)
  –Uremia
  –Hypercalcemia
  –Drugs (e.g., chemotherapy agents)
  –Carbon monoxide poisoning

• Gastrointestinal disease
  –Infection (e.g., gastroenteritis, appendicitis, cholecystitis)
  –Obstruction (e.g., pyloric stenosis, small bowel obstruction, large bowel obstruction, gastroparesis, Ogilvie's syndrome)
  –Inflammation (e.g., pancreatitis, peptic ulcer disease)
  –Food poisoning
• Toxic ingestions
  –Syrup of ipecac
  –Alcohol
  –Salicylates: Result in tachypnea, tinnitus,
• and metabolic acidosis/respiratory alkalosis
  –Iron: Causes profound gastritis
  –Arsenic
• Middle ear disease (e.g., Ménie're's disease, labyrinthitis, benign positional vertigo)
• Post-tussive emesis (especially in children)
• Motion sickness
• CNS disease
  –Increased intracranial pressure due to brain tumor, CNS infection (e.g., meningitis, abscess), head trauma, hydrocephalus, subarachnoid hemorrhage, vestibular neuritis, or intracerebral hemorrhage
  –Migraine headache
• Acute myocardial infarction (especially inferior MI)
• Ovarian torsion
• Testicular torsion
• Malingering: Relatively common, but should be a diagnosis of exclusion until more serious causes are excluded
• Intussusception: Classically causes colicky abdominal pain, vomiting, and currant jelly stools
• Pyelonephritis or other abdominal process

Workup and Diagnosis

• Complete history and physical examination is the most useful diagnostic aid
  –Neurologic examination looking for clues to CNS lesions
  –Ear examination to evaluate for middle ear disease
  –Ophthalmologic examination to evaluate for nystagmus in labyrinthitis or benign positional vertigo
  –Abdominal examination including stool guaiac to evaluate for GI pathology
• Labs may include CBC, electrolytes, liver function tests, amylase, lipase, urinalysis, calcium, magnesium, salicylate level, hepatitis serologies, toxicology screen, and CSF analysis (for meningitis or bleeding)
• ECG and cardiac enzymes may be indicated to evaluate for cardiac ischemia
• Abdominal CT scan with oral and IV contrast if history and physical examination suggest abdominal pathology
• Plain KUB X-rays may be indicated to evaluate for bowel obstruction or perforation
• Abdomen/pelvic ultrasound is especially helpful in cases of lower abdominal pain in female patients or in suspected gallbladder disease
• Endoscopy is indicated for suspected peptic ulcer disease
• Head CT with and without contrast if CNS lesion is suspected

Treatment

• Fluid resuscitation is a mainstay of therapy, because vomiting may cause significant dehydration
• Antiemetics (e.g., metoclopramide, ondansetron, prochlorperazine) may be administered to control symptoms
• Treat reversible causes as necessary (e.g., uremia, hypercalcemia, CNS infections, toxic exposures)
• Treatment of underlying etiologies generally eliminates vomiting
• Inner ear causes of vomiting may respond to treatment with anticholinergics (e.g., meclizine)
• Endoscopy/colonoscopy may be used diagnostically and therapeutically in cases of peptic ulcer disease or large bowel obstruction

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Hyperemesis Gravidarum

• Back to disease: Hyperemesis Gravidarum: Introduction
• Next Book Extract About Hyperemesis Gravidarum: Vomiting (In A Page: Pediatric Signs and Symptoms)
• More Book Extracts: All Online Books for Hyperemesis Gravidarum

More Medical Textbooks Online about Hyperemesis Gravidarum

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

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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