Nausea/Vomiting
Evaluation
General—symptoms which range from benign and self-limiting to chronic and life-threatening
Terminology (acute ≤1 month; chronic ” class=LK href=”javascript:void(0)” target=right xpath=”/CT{06b9ee1beed59419a81e5e1e1a4f60b0cc8cd1057525de73425b2b43f4df7f1bdc6682b412bce1a63e63ee47d20c9498}/ID(AB1-M10)”>>1 month)
Nausea—a vague feeling often described as “queasy” by patients.
Vomiting (emesis)—forceful retrograde release of stomach’s contents through the mouth.
Retching—repeated contractions of the diaphragm, with or without release of stomach’s contents.
Regurgitation—retrograde movement of gastric contents to the oral cavity.
Rumination—regurgitation of food contents into the oral cavity followed by rechewing.
Differential diagnosis
Medications—almost any medication can cause nausea including selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs)
Infectious agent—viral (e.g., Norwalk virus, adenovirus), bacterial (food-borne), and so on
Gastrointestinal (GI) disorders—including gastroparesis, smallbowel obstruction, mesenteric ischemia, and so on
Neurologic disorders—including increased intracranial pressure, labyrinthine disorders, migraines, and so on
Psychogenic disorders—mood disorders, eating disorders, anxiety, and so on
Medical conditions—cardiovascular (e.g., acute myocardial infarction), endocrine disorders, pregnancy, and so on
Postoperative nausea/vomiting
Chemotherapy and radiation therapy
Idiopathic causes—cyclic vomiting syndrome (“abdominal migraine”)
Brief diagnostic algorithm
Initial history
Characteristics (projectile, contents of emesis [food particles, bilious, blood], etc.)
Associated symptoms (fever, diarrhea, abdominal pain, vertigo, neurologic signs, etc.)
Physical examination
Degree of dehydration may vary
Mild—dry mucous membranes and normal vital signs
Severe—orthostatic changes in blood pressure
Clues—jaundice, abdominal distension/pain/masses, occult blood, neurologic signs, and so on
Laboratory evaluation
Complete blood counts (CBC) (infection, anemia from bleeding)
Electrolytes (metabolic disarray, uremia)
Pregnancy test (if applicable)
Further tests—thyroid-stimulating hormone (TSH) (screen for hyperthyroidism), drug screen
Additional studies
Treatment
Initial management
Identify and correct fluid and electrolyte disturbances.
If patient cannot take fluids orally, then hospitalize for IV hydration with normal saline.
If patient can take fluids orally, then administer 1 to 2 L of fluid per day divided in small amounts.
If liquids are tolerated, advance to dry foods, broth, and so on (1,500 calories/day).
Avoid creamy, milk-based liquids.
Address the underlying cause of nausea and vomiting.
While causes are being addressed, implement antiemetic therapy.
Anticholinergic agents
Used for motion sickness and taken 1 hour before travel.
Antihistamines
