GIT GUT - Vomiting

Question 1

Differential diagnoses of Vomiting

Answer 1

Hyperkalemia- ACF on CRF*

Probability diagnosis

All ages: acute gastroenteritis, motion sickness, drugs, various infections
Neonates: feeding problems
Children: viral infections/fever, otitis media, UTI
Adults: gastritis, alcohol intoxication, pregnancy, migraine

Serious disorders not to be missed  
Bowel obstruction:
•oesophageal atresia (neonates)
•pyloric obstruction <3 months
•intestinal malrotation
•intussusception 
•malignancy (e.g. oesophagus, stomach)Infection:
•botulinum poisoning
•septicaemia
•meningitis/encephalitis
•infective endocarditis
•others (e.g. acute viral hepatitis)
Malignancy
Intracranial disorders: malignancy, cerebellarhaemorrhage, PICA infarction 
Acute appendicitis
Acute pancreatitis
Acute myocardial infarction (e.g. painless

Pitfalls (mainly adults)
Pregnancy (early)
Organ failure: liver, kidney (uraemia), heart, respiratory
Labyrinthine disorders: Meniere syndrome, labyrinthitis
Poisoning: food, chemicals
Gut motility disorders: achalasia
Paralytic ileus
Substance abuse (e.g. opioids, ecstasy)Radiation therapy
Hypercalcaemia
Functional obstruction: diabetic gastroparesis, idiopathic gastroparesis

Masquerades checklist 
Depression (possible)
Diabetes (ketoacidosis)
Drugs (multiple)
Anaemia (possible) 
Thyroid and other endocrine disorders (Addison disease)
UTI esp. pyelonephritis

Is the patient trying to tell me something?
Possibly: extreme stress and anxiety (e.g. panic attacks). Consider bulimia (self-induced vomiting) and functional (psychogenic).

Question 2

Vomiting - Key History

Answer 2

Key history

Nausea and vomiting have a wide range of potential causes emanating from every body system. A careful history is essential with an emphasis on drug intake, possible psychogenic factors including self-induced emesis, weight loss, other GIT symptoms or symptoms suggestive of systemic disease.

Question 3

Vomiting - Key Physical examination

Answer 3

Key examination

• If fever is present possible sources of infections (e.g. middle ear, urinary tract and meninges) should be checked
• A careful abdominal examination is appropriate in most instances, searching for scars indicative of previous surgery
• Consider a neurological examination
• Be mindful of the possibility of pregnancy
• Always assess the patient’s condition including the level of hydration

Question 4

Vomiting - Key Investigation

Answer 4

Key investigations

Look for the cause and also consider biochemical abnormalities resulting from fluid and electrolyte loss. Consider:
•pregnancy test
•urine analysis and MC
•stool MC
•endoscopy
•drug toxicity studies
•blood glucose
•radiology of GIT

Question 5

Vomiting - Diagnostic Tips

Answer 5

Diagnostic tips

The common cause of acute nausea and vomiting in most age groups is gastroenteritis.
•Drug ingestion is a common cause of nausea and vomiting so check for prescribed drugs and illicit street drugs such as heroin and ecstasy.