2. Anorexia, nausea, vomiting Flashcards
2 general mechanisms for nausea and vomting
neurological
peripheral
neurological cause for nausea and vomiting
Stimulation of the area postrema, which ‘senses’ noxious chemical agents (e.g., poisons, chemotherapy agents, digoxin) and subsequently stimulates the vagal nuclei, which evokes nausea and co-ordinates the emesis reflex.
Diseases of the central nervous system (CNS) such as infections or brain tumours stimulate CNS structures and elicit nausea and vomiting, ultimately through vagal pathways.
peripheral causes for nausea and vomtiing
Diseases and disorders that originate in peripheral organ systems, such as the gastrointestinal tract, stimulate vagal or spinal afferent nerves that connect with the vagal sensory (tractus solitarius) and vagal efferent motor nuclei. Ultimately, cortical centres where nausea is perceived and the efferent pathways that mediate vomiting are stimulated.
Tumours, infections, and drugs in the periphery may cause local dysfunction in a variety of organ systems that is sensed as nausea that, when severe, evokes vomiting.
gastritis Hx
use of non-steroidal anti-inflammatory drugs; burning epigastric pain often relieved by food; may be aggravated by recent stress or anxiety
gastritis O/E
tenderness to palpation in the epigastrium or normal examination
gastritis Ix
upper gastrointestinal endoscopy:
gastritis; antral mucosal biopsies may reveal H pylori infection, which requires antibiotic therapy; may confirm aetiology such as eosinophilic gastritis
Helicobacter pylori antibody:
positive
GORD Hx
typical: heartburn and regurgitation; atypical: minimal epigastric burning or regurgitation; nausea predominates; morning nausea common
GORD O/E
tenderness in the epigastrium on palpation or normal examination
GORD Ix
upper gastrointestinal endoscopy:
may be normal or reveal oesophageal inflammation ranging from erythema to frank ulceration (not required for diagnosis)
24-hour oesophageal pH study:
confirms acid reflux if endoscopy normal
diagnosis of GORD made based on
history, endoscopy, or 24 hour pH study
peptic ulcer disease Hx
use of non-steroidal anti-inflammatory drugs; burning epigastric pain often relieved by food
peptic ulcer disease O/E
tenderness to palpation in the epigastrium or normal examination
peptic ulcer disease Ix
Helicobacter pylori antibody:
positive
upper gastrointestinal endoscopy:
reveals gastritis, gastric ulcer, duodenal ulcer, or duodenitis; antral mucosal biopsies reveal H pylori infection, which requires antibiotic therapy
acute gastroenteritis Hx
diarrhoea; abdominal pain; low-grade fever in viral disease; high-grade fever with toxicity in bacterial aetiology
acute gastroenteritis O/E
diffuse abdominal tenderness to palpation; signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension)
acute gastroenteritis labs
serum electrolytes:
low sodium and potassium
stool culture:
may identify microbial agent; usually unrevealing (most cases are viral in origin)
food poisoning Hx
diarrhoea, abdominal pain; symptoms develop within 24 hours of a meal; symptoms may improve or persist for weeks leading to chronic disease
food poisoning O/E
epigastric tenderness; lower abdominal tenderness to palpation; signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension)
food poisoning labs
serum electrolytes:
low sodium and potassium
stool culture:
may reveal Campylobacter, Salmonella, Shigella
migraine Hx
recurrent nausea and/or vomiting in the presence of headache and disturbed vision
migraine O/E
no neurological findings but abdomen may be tender due to vomiting/retching
migraine Ix
no initial test:
clinical diagnosis
CT head:
may exclude alternate diagnosis
MRI head:
may exclude alternate diagnosis
benign paroxysmal positional vertigo Hx
brief, sudden, episodic vertigo
normal neurological exam
benign paroxysmal positional vertigo Ix
Dix-Hallpike manoeuvre:
positive
stroke Hx
transient nausea, loss of vision, instability, dizziness
focal neurological deficits
Stroke Ix
CT head:
oedema or infarct in brainq
hypercalcaemia Hx
alterations of mental status, abdominal pain, constipation, muscle pains, polyuria, headache
hypercalaemia Ix
calcium:
elevated; >2.63 mmol/L (>10.5 mg/dL)
parathyroid hormone:
suppressed (non-hyperparathyroid diagnoses such as malignancy) or elevated (hyperparathyroidism)
hypothyroidism Hx
fatigue; cold intolerance; dyspepsia
hair loss; dry skin; delayed reflexes; goitre
hypothyroidism Ix
thyroid-stimulating hormone:
elevated in primary hypothyroidismMore
T4 (serum free thyroxine):
low or normalMore
T4 in hypothyroidism
Low free T4 with an elevated thyroid-stimulating hormone is diagnostic of primary hypothyroidism. However, free T4 may be normal in subclinical hypothyroidism, despite a mildly elevated thyroid-stimulating hormone.
gastric outlet obstruction Hx
history of peptic ulcer disease; vomitus is yellow gastric juice or may contain blood; upper abdominal pain is prominent
gastric outlet obstruction O/E
epigastric tenderness and/or distension; a rigid abdomen with rebound tenderness suggests concurrent bowel perforation and acute peritonitis
gastric outlet obstruction Ix
upper gastrointestinal series:
gastric distension
upper gastrointestinal endoscopy:
reveals the site and cause of obstruction (strictures and cancers can be biopsied)
CT abdomen:
reveals the site of obstruction or free air under the diaphragm indicating perforation
small bowel obstruction Ix
bilious vomiting; peri-umbilical location of pain
small bowel obstruction O/E
peri-umbilical tenderness; abdominal distension; bowel sounds high pitched or absent; rigid abdomen with rebound tenderness suggests concurrent bowel perforation and acute peritonitis
small bowel obstruction Ix
acute abdominal x rays:
air fluid levels in small bowelMore
CT abdomen:
reveals site of obstruction or free air under the diaphragm indicating perforation
colonic obstruction Hx
lower abdominal pain with or without distension; faeculent vomitus
colonic obstruction O/E
tenderness and/or distension in lower abdomen; bowel sounds may be absent; a rigid abdomen with rebound tenderness suggests concurrent bowel perforation and acute peritonitis
colonic obstruction Ix
acute abdominal series:
distended colon proximal to site of obstruction; air fluid levels in small bowel
CT abdomen:
reveals site of colonic obstruction; free air under the diaphragm indicating perforation
colonoscopy:
may reveal mucosal lesion that may narrow the bowel lumen
choledocholithiasis Hx
right upper quadrant (RUQ) or epigastric pain, postprandial symptoms
RUQ tenderness; may have jaundice
choledocolithiasis Ix
abdominal ultrasound:
stones in gallbladder or bile duct`
cholecystitis Hx
history of prior biliary colic; right upper quadrant (RUQ) pain; may have fever or referred right shoulder pain
cholecystitis O/E
may have positive Murphy sign (right subcostal tenderness, worse after deep inspiration); may have tender RUQ mass; possible jaundice
cholecystitis Ix
CBC:
elevated WBC count
LFTs:
cholestatic pattern
ultrasound RUQ:
may show thickened gallbladder wall with calculi or pericholecystic fluid collection
post-GI surgery Hx
previous surgery (fundoplication, oesophagectomy, gastrojejunostomy [Bilroth I or II], or bariatric operation); epigastric discomfort; bloating; regurgitation after oesophagectomy with early satiety
post Gi surgery O/E
epigastric tenderness; tender scars, positive Carnett’s sign (occurs when a combination of pressure on the scar and flexion of the head clearly exacerbates the patient’s typical pain)
post Gi surgery Ix
upper endoscopy:
mechanical obstruction at site of surgery, mucosal abnormalities, or normal
gastric emptying study:
gastroparesis or normal
electrogastrogram:
gastric dysrhythmia or normal
severe constipation Hx
constipation; altered bowel habits; abdominal pain; pain on defecation
tender abdomen; palpable abdominal mass
severe constipation Ix
acute abdominal series:
dilated loops of bowel; faecal loading in right colon
IBS Hx
altered bowel habits (alternating constipation and diarrhoea), bloating, abdominal pain and distension, stress-related symptoms
IBS O/E
normal in most patients; abdominal tenderness in some cases
IBS Ix
no initial test:
diagnosis of exclusion
acute abdominal series:
dilated loops of bowel
colonoscopy:
may demonstrate alternate diagnosis such as inflammatory bowel disease or neoplasm
cyclic vomiting syndrome Hx
onset in childhood; migraine common; symptom-free weeks
normal
cyclic vomiting syndrome Ix
solid-phase gastric emptying study:
>50% retained at 2 hours; >10% retained at 4 hours
electrogastrogram:
tachygastria, bradygastria, or mixed dysrhythmia
endoscopy:
normal
gastric dysrhythmias Hx
nausea, early satiety, fullness worse after meals
normal
gastric dysrhythmias Ix
electrogastrogram:
tachygastria, bradygastria, or mixed dysrhythmias
endoscopy:
normal (excludes mucosal disease)
gastric emptying study:
normal (excludes gastroparesis)
gastroparesis Hx
nausea, early satiety, fullness, and vomiting of undigested food; all symptoms are worse after ingestion of meals; history of diabetes or Parkinson’s disease
gastroparesis O/E
succussion “splash” rarely detected; weight loss, orthostatic hypotension
gastroperesis Ix
solid-phase gastric emptying study:
>50% retained at 2 hours; >10% retained at 4 hours
non-digestible capsule test:
diagnosis is confirmed if capsule not emptied within 5 hours after it is ingested
electrogastrogram:
tachygastria, bradygastria, or mixed dysrhythmia
endoscopy:
no evidence of mucosal inflammation
bacterial peritonitis Hx
abdominal pain; nausea or vomiting ranges from mild to severe; fever low grade to severe; recent abdominal surgery
rigid abdomen with rebound tenderness
bacterial peritonitis Ix
acute abdominal series:
air under diaphragm indicates perforation
CT abdomen:
air under diaphragm, ascites; thickened bowel wall, intra-abdominal fluid or masses
anorexia nervosa Hx
abnormalities in body image, depression, amenorrhoea, or psychosocial dysfunction
anorexia nervosa O/E
cachexia; signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension), signs of malnutrition (loss of subcutaneous fat, apathy and lethargy, pallor, depigmentation, enlarged abdomen, winged scapula, flaky skin, bipedal oedema)
anorexia nervosa Ix
solid-phase gastric emptying study:
gastroparesis
electrogastrogram:
tachygastria, bradygastria, mixed dysrhythmia
bulimia nervosa Hx
abnormalities in body image, depression, other psychosocial dysfunction
bulimia nervosa O/E
normal examination; possible signs of volume depletion (altered mental status, poor skin turgor, dry mucous membranes, sunken eyes, irritability, and hypotension) and malnutrition (loss of subcutaneous fat, apathy and lethargy, pallor, depigmentation, enlarged abdomen, winged scapula, flaky skin, bipedal oedema); may have teeth enamel erosion from repeated vomiting
bulimia nervosa Ix
solid-phase gastric emptying study:
normal
electrogastrogram:
normal
drug induced Hx
symptoms not related to eating or bowel movements; onset days to weeks after starting the medicine; symptoms recur 3 to 4 days after re-initiation of medicine (e.g., chemotherapy agents); causative medications include non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, anti-arrhythmics, opioids, chemotherapy, oestrogen/progesterone, theophylline, digoxin, lubiprostone, metformin, exenatide
epigastric tenderness may be present with NSAIDs
nephrolithiasis Hx
flank pain, may radiate to groin; dysuria
costovertebral angle tenderness
nephrolithiasis Ix
urinalysis:
microscopic or gross haematuria
noncontrast CT abdomen:
size and location of stones
uraemia Hx
existing renal disease or diabetes; fatigue, anorexia, weight loss; severe cases may have muscle cramps, pruritus, mental and visual disturbances; increased thirst
uraemia O/E
oedema; sallow skin; pallor; occult gastrointestinal bleed; hypertension
uraemia Ix
24-hour urine creatinine clearance:
<10 to 20 mL/minute
renal profile:
hyperkalaemia; acidosis; hypocalcaemia; hyperphosphataemia
ultrasound kidneys:
large kidneys in hydronephrosis, obstructions; small kidneys in chronic irreversible damage
CT abdomen:
size and morphology of the kidneys, lymph nodes
idiopathic functional dyspepsia/post prandial distress syndrome
vague epigastric discomfort, early satiety, and prolonged fullness
no initial test:
diagnosis of exclusion
upper gastrointestinal endoscopy:
excludes structural lesions or inflammation
