Vomiting

Probability diagnosis

All ages: acute gastroenteritis, motion sickness, drugs, various infections

Neonates: feeding problems

Children: viral infections/fever, otitis media, UTI

Adults: gastritis, alcohol intoxication, pregnancy, migraine

Serious disorders not to be missed

Bowel obstruction:

• oesophageal atresia (neonates)

• pyloric obstruction <3 months

• intestinal malrotation

• intussusception

• malignancy (e.g. oesophagus, stomach)

Infection:

• botulinum poisoning

• septicaemia

• meningitis/encephalitis

• infective endocarditis

• others (e.g. acute viral hepatitis)

Malignancy

Intracranial disorders: malignancy, cerebellar

haemorrhage, PICA infarction

Acute appendicitis

Acute pancreatitis

Acute myocardial infarction (e.g. painless)

Pitfalls (mainly adults)

Pregnancy (early)

Organ failure: liver, kidney (uraemia), heart, respiratory

Labyrinthine disorders: Meniere syndrome, labyrinthitis

Poisoning: food, chemicals

Gut motility disorders: achalasia

Paralytic ileus

Substance abuse (e.g. opioids, ecstasy)

Radiation therapy

Hypercalcaemia

Functional obstruction: diabetic gastroparesis, idiopathic gastroparesis

Masquerades checklist

Depression (possible)

Diabetes (ketoacidosis)

Drugs (multiple)

Anaemia (possible)

Thyroid and other endocrine disorders (Addison disease)

UTI esp. pyelonephritis

Is the patient trying to tell me something?

Possibly: extreme stress and anxiety (e.g. panic attacks). Consider bulimia (self-induced vomiting) and functional (psychogenic).

Key history

Nausea and vomiting have a wide range of potential causes emanating from every body system. A careful history is essential with an emphasis on drug intake, possible psychogenic factors including self-induced emesis, weight loss, other GIT symptoms or symptoms suggestive of systemic disease.

Key examination

• If fever is present possible sources of infections (e.g. middle ear, urinary tract and meninges) should be checked

• A careful abdominal examination is appropriate in most instances, searching for scars indicative of previous surgery

• Consider a neurological examination

• Be mindful of the possibility of pregnancy

• Always assess the patient’s condition including the level of hydration

Key investigations

Look for the cause and also consider biochemical abnormalities resulting from fluid and electrolyte loss. Consider:

• pregnancy test

• urine analysis and MC

• stool MC

• endoscopy

• drug toxicity studies

• blood glucose

• radiology of GIT.

Diagnostic tips

The common cause of acute nausea and vomiting in most age groups is gastroenteritis.

• Drug ingestion is a common cause of nausea and vomiting so check for prescribed drugs and illicit street drugs such as heroin and ecstasy.