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So ... what bought you here today > 13. Nausea and Vomiting > Flashcards

13. Nausea and Vomiting Flashcards

1
Q

Where is the vomiting centre located?

A

Medulla oblongata

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2
Q

What are the two main types of receptors found within the vomiting centre?

A

Histamine receptors

Acetylcholine receptors

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3
Q

What are the four main inputs to the vomiting centre? List 4 mechanisms

A

Vestibular system
CNS
Chemoreceptor Trigger Zone (CTZ)
Cranial Nerves IX & X

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4
Q

List some causes of nausea and vomiting caused by the vestibular system (vertigo)

A

BPPV
Meniere’s disease
Labyrinthitis
Motion sickness

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5
Q

List some of the causes of nausea and vomiting caused by the CNS (brain problems)

A

Pain
Anxiety
Raised ICP
Meningitis/Encephalitis

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6
Q

List some of the causes of nausea and vomiting caused by the CTZ (chemicals in the blood)

A 
Alcohol
Drugs 
Toxins
Electrolytes 
Hormones
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7
Q

List some of the causes of nausea and vomiting caused by CN IX & X (abdomen and heart problems)

A

GI obstruction
GI infection
Inflammation of the diaphragm
Infection/Inflammation of organs (e.g. hepatitis, pancreatitis)

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8
Q

List some key features of the history of presenting complain that you should ask about.

A

Contents
Timing
Association with eating
Pain

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9
Q

Describe different types of vomit and how they relate to their aetiology.

A

Undigested – the food hasn’t reached the stomach, probably an oesophageal problem
Partially digested – gastric outlet obstruction, gastroparesis
Bile – SBO distal to ampulla of Vater
Faeculent – distal intestinal or colonic obstruction
Blood/coffee-ground – haematemesis causes

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10
Q

Which causes of nausea and vomiting are associated with early-morning vomiting?

A

Raised ICP

Pregnancy

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11
Q

Explain how the association between the nausea/vomiting and eating helps narrow down the differential diagnosis.

A

Within 1 hr of eating = high GI obstruction (proximal to gastric outlet)
Longer, post-prandial delay = lower GI obstruction
Early satiety, post-prandial bloating and abdominal discomfort = gastroparesis or outlet obstruction

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12
Q

List some important associated symptoms to ask about.

A

Fever
Headache, visual disturbance, focal neurological deficits
Vertigo

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13
Q

Explain how asking about the patient’s bowel movements can help narrow the differential diagnosis.

A

Absolute constipation – bowel obstruction

Diarrhoea – suggests gastroenteritis

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14
Q

List some risk factors for infectious diarrhoea.

A

Close contacts with similar symptoms
Living in close quarters
Unusual meals
Recent travel

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15
Q

List some drugs/toxins that are associated with causing nausea and vomiting.

A

Medications (e.g. opiates, chemotherapy)
Industrial chemicals (e.g. arsenic, organophosphates)
Alcohol and drugs

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16
Q

Why is it important to enquire about previous abdominal surgery?

A

Previous abdominal surgery increases the risk of forming adhesions, which can lead to bowel obstruction

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17
Q

How can the causes of chronic nausea and vomiting be subdivided?

A

Weight loss

  • Upper GI obstruction (e.g. cancer)
  • Functional dysphagia (e.g. achalasia)
  • Coeliac disease

No weight loss

  • Oesophagitis
  • Pharyngeal pouch
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18
Q

List some causes of nausea and vomiting that are associated with abdominal pain

A

With fever: infection (e.g. gastroenteritis), inflammation (e.g. appendicitis, cholecystitis)
Without fever: DKA, SBO, drug side-effects, toxins

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19
Q

List some causes of nausea and vomiting that are associated with headache

A

Meningitis
Raised ICP
Migraine

20
Q

List some causes of nausea and vomiting that are associated with vertigo

A

Labyrinthitis
Meniere’s disease
BPPV
Motion sickness

21
Q

List some causes of nausea and vomiting that are associated with onset shortly after eating food

A

Gastric outlet obstruction

22
Q

List some other causes of nausea and vomiting

A

Drug side-effect
Psychogenic
Hyperthyroid
Renal failure + uraemia

23
Q

List some particularly worrying signs that are associated with nausea and vomiting.

A 
Peritonitis (guarding, motionless, rigid abdomen, absent bowel sounds)
Signs of bowel obstruction
High fever (infection)
Signs of raised ICP 
Signs of MI 
Signs of meningitis 
Reduced consciousness 
Haematemesis
24
Q

List some signs of meningitis.

A

Photophobia
Neck stiffness
Headache
Kernig’s sign (when the hip is flexed, there is resistance against knee extension)
Brudzinski’s sign (flexion of the neck causes flexion of the hip)

25
Q

List some key features of inspection when performing an abdominal examination on a patient presenting with nausea and vomiting.

A 
Hydration status (vomiting can lead to dehydration)
Abdominal distension 
Scars 
Hernias 
Jaundice
26
Q

List two important signs that may be picked up on auscultation of the abdomen.

A

Absent bowel sounds -> ileus

Tinkling bowel sounds -> obstruction

27
Q

List some blood tests that would be undertaken in a patient presenting with nausea and vomiting and explain why they would be performed.

A

FBC and CRP – high WCC and CRP in infection
U&Es – vomiting can cause derangement of electrolyte levels
LFTs – check for hepatobiliary cause of nausea/vomiting
VBG – check lactate and pH to get an idea of how sick the patient is
Amylase – rule out pancreatitis
Group and save

28
Q

List two forms of imaging that may be useful in patients with nausea and vomiting.

A

AXR

Erect CXR

29
Q

How are the small and large bowel differentiated on an AXR?

A

Small bowel – valvulae conniventes, 3 cm diameter

Large bowel – haustra, 6 cm diameter

30
Q

Which test is important to consider in young female patients presenting with nausea and vomiting?

A

Pregnancy test

31
Q

Outline the management of a patient with acute abdomen.

A

Nil-by-mouth
Drip and suck
Analgesia
Anti-emetics

32
Q

Which anti-emetic must you take caution with when using in a patient with acute abdomen?

A

Metoclopramide – it has a prokinetic effect on the GI tract

33
Q

Which form of imaging is useful in a patient with suspected bowel obstruction?

A

CT scan – allows localisation of the obstruction and identification of a cause

34
Q

Under what circumstances is surgery indicated in patients with bowel obstruction?

A

Signs of strangulation or peritonism
After 48 hrs if it hasn’t resolved
No history of previous abdominal surgery – this suggests that there may be a more sinister cause (not adhesions)

35
Q

Describe the typical presentation of gastroenteritis.

A

Nausea, vomiting, diarrhoea, fever and abdominal pain

Last a matter of days and resolves by itself

36
Q

What does ketonuria in a patient without diabetes suggest?

A

Starvation

37
Q

How can food poisoning be differentiated from gastroenteritis?

A

Food poisoning is caused by bacterial toxins

Symptoms don’t tend to persist longer than 24 hrs

38
Q

Describe the typical presentation of DKA.

A 
Drowsy
Polyuria/Polydipsia
Abdominal pain
Nausea and vomiting 
If severe: Kussmaul breathing, reduced consciousness
39
Q

Outline the management of DKA.

A

IV fluids to rehydrate
IV insulin (sliding scale)
Monitor capillary ketones and serum K+ concentration
Switch to subcutaneous insulin once pH and capillary ketones have normalised

40
Q

When does morning sickness typically affect pregnant women?

A

First trimester

41
Q

Outline the management of morning sickness.

A

Advise dietary changes (e.g. avoiding spicy food)
Anti-emetics (e.g. promethazine)
Electrolyte replacement
Thiamine supplementation

42
Q

What term is used to describe severe morning sickness?

A

Hyperemesis gravidarum

43
Q

List some strong anti-emetics that may be used in such cases of severe morning sickness.

A

Prochlorperazine
Chlorpromazine
Ondansteron
Metoclopramide

44
Q

Describe the distinguishing clinical features of raised ICP.

A

Early morning nausea and vomiting

Headaches worse when lying down

45
Q

Which cranial nerve palsy is most commonly involved in raised ICP and why?

A

CN VI – it has the longest intracranial course

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