A Synopsis or AFPs "Evaluation of Nausea and Vomiting in Adults: A Case-Based Approach"

Evaluation of Nausea and Vomiting in Adults: A Case-Based Approach
WILLIAM D. ANDERSON, III, MD, and SCOTT M. STRAYER, MD, MPH, University of South Carolina School of Medicine, Columbia, South Carolina
Am Fam Physician. 2013 Sep 15;88(6):371-379.
http://www.aafp.org/afp/2013/0915/p371.pdf

     Nausea and vomiting is a very common symptom with a wide differential. The clinical presentation can  hint towards the diagnosis. The differential is extremely large, but the most common cause is viral, norovirus in adults.  If the presentation is acute, then it may suggest cholecystitis, gastroenteritis, medication side effects, or pancreatitis. A viral gastroenteritis may also be associated with diarrhea, headaches and myalgia. Bilious vomiting may be due to a small bowel obstruction. Feculent or foul smelling vomit may be due to an intestinal obstruction. A gastric outlet obstruction may have non-bilious vomiting of partially digest food. It can also be due to achalasia, esophageal stricture, or a diverticulum. Projectile vomiting may be due to an intracranial disorder. It is important to assess the patient's' vital signs and hydration status to quantify the severity of the illness.
    When evaluating nausea and vomiting, the illness can be divided by length of symptoms into acute (less than a week) and chronic (more than a month). If there is an obvious cause (based on history and physical), then it should be treated. If it is not obvious, then it must be determined if the patient has any of the alarm signs, which include;
age above 55 years,
unintentional weight loss,
progressive dysphagia,
persistent vomiting,
GI bleeding,
family history of GI cancer,
altered mental status,
abdominal pain,
feculent vomiting,
hematochezia,
melena, and
focal neurological deficit.
If any of these warning signs are present, then a battery of labs need to be ordered, including UA, pregnancy test, CBC, CMP, lipase, TSH, stool studies, abdominal imaging, EGD, and possibly a head CT (if an intracranial issue is suspected). If there are no alarm signs and the symptoms are acute, then the clinician will give supportive care and provide reassurance and education. If the symptoms are chronic, then the clinician may consider a gastric emptying study if gastroparesis is suspected. Psychiatric causes can also be considered.
    Imagining is very helpful in the evaluation of nausea and vomiting. X rays are good for bowel obstruction and kidney stones. CT can also find stones and obstruction, as well as infectious inflammation, such a appendicitis and cholecystitis. A patient with appendicitis may also need a ultrasound. Patients with cholecystitis may need a HIDA scan if the gallbladder cannot be visualized with ultrasound. Patients suspected of H. pylori can get a urea breath test and an serum immunoglobulin G level. The labs ordered for pancreatitis are amylase (>300 U/L), lipase (>135 ukat/L), and alanine transaminase.
    Migraines are a common cause of nausea and vomiting. The patient should have a headache with at least four of the following characteristics; pulsatile, unilateral, disabling, lasting 4-72 hours, and nausea and vomiting.  These patients may also need a head CT to rule out intracranial pathology.
     The mainstay of management is supportive treatment, such as avoiding triggers, rehydration, and antiemetics. Patients with BPPV may benefit from meclizine. Those with gastroenteritis can use ondansetron or promethazine. GERD patients can have H2 blockers or PPIs. Erythromycin and metoclopramide can help patients with gastroparesis. Management of migraines can be done with NSAIDs, metoclopramide, and prochlorperazine. Motion sickness can be prevented with antihistamines and scopolamine. Symptoms associated with pregnancy can be treated with doxylamine, ginger and B6.