Nausea and Vomiting

Question 1

Where is the vomiting centre in the brain?

Answer 1

medulla oblangata

Question 2

What can the vomiting centre be activated by?

Answer 2

1. Vestibular system
2. Central Nervous system (CNS)
3. Chemoreceptor trigger zone (CTZ)
4. Cranial Nerves IX and X

Question 3

What are the conditions with nausea and vomiting that come from the vestibular system?

Answer 3

1. BPPV
2. Labyrinthitis
3. Motion sickness
4. Ménieres disease

Question 4

What are the conditions with nausea and vomiting that come from the chemoreceptor trigger zone (CTZ)?

Answer 4

1. Medications
2. Alcohol
3. Hormones
4. electrolytes
5. Toxins

Question 5

What are the conditions with nausea and vomiting that come from the CNS?

Answer 5

1. Pain
2. Anxiety
3. Raised ICP
4. Meningitis
5. Encephalitis

Question 6

What are the conditions with nausea and vomiting that come from the cranial nerves IX and X?

Answer 6

1. GI obstruction
2. GI infection
3. Inflammation of diaphragm
4. Inflammation of liver, pancreas, gallbladder, peritoneum

Question 7

What receptors does the CTZ use?

Answer 7

dopamine receptors

Question 8

What receptors does the VS use?

Answer 8

histamine and acetylcholine receptors

Question 9

What receptors does the cranial nerves IX and X use?

Answer 9

serotonin and acetylcholine receptors

Question 10

What questions are key to ask about the details of the vomit?

Answer 10

1. Contents
2. Timing
3. Assoicated with eating

Question 11

What would undigested vomit suggest?

Answer 11

oesophageal disorder e.g. achalasia, pharyngeal pouch

Question 12

What would partially digested vomit suggest?

Answer 12

gastric outlet obstruction, gastroparesis (delayed stomach emptying e.g. in DM)

Question 13

What would bile (green) vomit suggest?

Answer 13

small bowel obstruction (distal to ampulla of Vater)

Question 14

What would feaculent vomit suggest?

Answer 14

distal intestinal or colonic obstruction

Question 15

What would blood/coffee ground vomit suggest?

Answer 15

haematemesis

Question 16

What would a large volume of vomit suggest?

Answer 16

less likely to be functional

Question 17

What would early morning vomit suggest?

Answer 17

• pregnancy

- raised ICP

Question 18

What would a longer time course of nausea and vomiting suggest?

Answer 18

makes acute pathologies e.g. bowel obstruction less likely

Question 19

What would vomiting within 1hr of eating suggest?

Answer 19

upper GI proximal to gastric outlet - if so ask about PUD as can cause scarring and pyloric stenosis

Question 20

What would vomiting long after eating suggest?

Answer 20

obstruction low GI tract - small bowel

Question 21

What would long early sateity, postprandial bloating and abdominal discomfort suggest?

Answer 21

1. gastroparesis

2. outlet obstruction

Question 22

How do you ask about details of pain?

Answer 22

socrates

Question 23

What would RUQ pain with nausea and vomiting suggest?

Answer 23

hepatobiliary cause

Question 24

What would epigastric pain with nausea and vomiting suggest?

Answer 24

pancreatic or gastroduodenal cause

Question 25

What would relief of pain after vomiting suggest?

Answer 25

obstruction

Question 26

What other symptoms should you ask about with nausea and vomiting?

Answer 26

1. Fever 2. Headache, visual disturbance 3. Vertigo, difficulty standing

Question 27

What would a fever with nausea and vomiting suggest?

Answer 27

1. gastroenteritis 2. appendicitis 3. cholecystitis 4. cholangitis 5. pancreatitis 6. hepatitis 7. UTI 8. meningoencephalitis

Question 28

What would headache, visual disturbance, any other neurological symptoms with nausea and vomiting suggest?

Answer 28

1. Raised ICP 2. meningitis 3. encenphalitis 4. migraine

Question 29

What would vertigo/difficulty walking or standing due to it with nausea and vomiting suggest?

Answer 29

1. Labyrinthitis 2. Menieres disease 3. BPPV

Question 30

What bowel movement (flatus and feaces) questions would you ask with nausea and vomiting

Answer 30

1. Delay/absolute constipation | 2. Diarrhoea

Question 31

What would long delay with nausea and vomiting suggest?

Answer 31

bowel obstruction

Question 32

What would constipation with nausea and vomiting suggest?

Answer 32

eating less, vomiting

Question 33

What would absolute constipation with nausea and vomiting suggest?

Answer 33

bowel obstruction

Question 34

What would diarrhoea and vomiting suggest?

Answer 34

infectious gastroenteritis

Question 35

What could close contacts also suffering nausea and vomiting suggest?

Answer 35

1. rotavirus 2. adenovirus 3. norovirus

Question 36

What could living in close quarters with nausea and vomiting suggest?

Answer 36

common outbreak of GI pathogens

Question 37

What would recent foreign travel with nausea and vomiting suggest?

Answer 37

1. different hygeine standards 2. local pathogens risk of GI infections

Question 38

What would unusual food with nausea and vomiting suggest?

Answer 38

exposure to infectious GI pathogen

Question 39

What medications can cause nausea and vomiting?

Answer 39

1. opiate 2. chemo 3. anticonvulsants 4. antibitoics

Question 40

What industrial chemicals can cause vomiting?

Answer 40

- arsenic | - organophosphate fertilizer

Question 41

What else do you check in SHx with nausea and vomiting?

Answer 41

Alcohol? Ilicit drugs?

Question 42

What PMHx is important to ask with nausea and vomiting?

Answer 42

previous abdominal surgery predisposes to adhesion between peritoneum and bowel which can cause bowel obstruction

Question 43

What would an acute onset (<1month) of nausea and vomiting with abdominal pain with fever suggest?

Answer 43

1. Gastroenternritis 2. Food poising 3. Appendicitis 4. Mesenteric adenitis 5. Cholecystitis 6. Pancreatitis

Question 44

What would an acute onset (<1month) of nausea and vomiting with abdominal pain without fever suggest?

Answer 44

1. SBO 2. DKA 3. Drug side effect/OD 4. Toxins (lead) 5. LBO 6. Mesenteric ischaemia 7. MI 8. Due to pain e.g. kidney stone, testicular torsion

Question 45

What would an acute onset (<1month) of nausea and vomiting with headache suggest?

Answer 45

1. Meningitis 2. Raised ICP (SOL, hydrocephalus) 3. Migraine

Question 46

What would an acute onset (<1month) of nausea and vomiting with vertigo suggest?

Answer 46

1. Labyrinthitis 2. Menieres 3. BPPV 4. Motion sickness 5. Acoustic Neuroma

Question 47

What would an acute onset (<1month) of nausea and vomiting shortly after food suggest?

Answer 47

gastric outlet obstruction

Question 48

What would an acute onset (<1month) of nausea and vomiting with no major other symptoms?

Answer 48

1. Drugs side effect 2. Psychogenic 3. Hyperthryoid 4. Renal failure + uraemia 5. Cyclic vomiting syndrome