13. Nausea and Vomiting

Question 1

What are the 4 main input systems that can activate the vomiting centre?

Answer 1

Vestibular system
CNS
Chemoreceptor trigger zone
Cranial nerves IX + X

Question 2

What broad questions should you ask about in the presenting complaint in someone who has been vomiting?

Answer 2

details of the cotnent
timing + duration
association with eating

Question 3

What does undigested vomit suggest?

Answer 3

Oesophageal disorders: achalasia, pharyngeal pouch

Question 4

What does partially digested vomit suggest?

Answer 4

Gastric outlet obstruction

Gastroparesis

Question 5

What does faeculent vomit suggest?

Answer 5

Distal intestinal or colonic obstruction

Question 6

What does vomiting within an hour of eating suggest?

Answer 6

Obstruction high in the GI tract

Question 7

What does vomiting a few hours after eating?

Answer 7

Obstruction lower in the GI tract

Question 8

What other symptoms should you ask about in someone who has presented with vomiting?

Answer 8

Fever
Headache, visual disturbance, other neuro symptoms
Vertigo

Question 9

What questions should you ask about in the social history in someone who presents with vomiting?

Answer 9

Any close contacts suffering from nausea + vomiting?
Living in close quarters?
Recent foreign travel?
Unusual meals recently?

Question 10

What is the immediate management for small bowel obstruction?

Answer 10

Nil by mouth
‘Drip + suck’ IV fluid + aspiration of gastric contents by nasogastric tube
Analgesia
Antiemetics

Question 11

List 4 vertigo/ vestibular system related causes of nausea and vomiting

Answer 11

BPPV
Labyrinthitis
Motion sickness
Menieres disease

Question 12

List 5 chemical/ CTZ related causes of nausea and vomiting

Answer 12

Medication
Alcohol
Hormones
Electrolytes
Toxins

Question 13

List 5 CNS related causes of nausea and vomiting

Answer 13

Pain
Anxiety
Raised ICP
Meningitis
Encephalitis

Question 14

List 4 abdo + heart (CN9+10) related causes of nausea and vomiting

Answer 14

GI obstruction
GI infection
Inflammation of diaphragm
Inflammation of liver, pancreas, gallbladder, peritoneum

Question 15

What does bile/ green vomit suggest?

Answer 15

Small bowel obstruction (distal to ampulla of vater)

Question 16

What is early morning sickness associated with?

Answer 16

Pregnancy

Raised ICP

Question 17

What condition is suggested by a motionless patient with a rigid abdomen and absent bowel sounds?

Answer 17

Peritonitis

Question 18

What condition is suggested by bilious/ faeculent vomiting, distended abdome, absolute constipation and abdominal pain?

Answer 18

Bowel obstruction

Question 19

What condition is suggested by early morning vomiting, headache worse when lying down and 6th nerve palsy?

Answer 19

Raised ICP

Question 20

What may absence of bowel sounds or high pitched tinkling sounds suggest?

Answer 20

Absence: Ileus
Tinkling: Mechanical obstruction

Question 21

What causes transaminitis (raised ALT + AST)?

Answer 21

Hepatitis

Question 22

What is a postoperative adhesion caused by? What may this result in?

Answer 22

Postsurgical inflammatory response leads to formation of fibrous adhesions between the bowel + parietal peritoneum
Bowel obstruction if loop of bowel gets twisted around adhesion