Nausea and Vomiting 2 Flashcards
What would chronic (>1month) nausea and vomiting with weight loss suggest?
- Upper GI obstruction: mechanical or functional
2. Coeliac disease
What would chronic (>1month) nausea and vomiting without weight loss suggest?
- Oesophagitis
2. Pharyngeal Pouch
What are the worrying signs and symptoms in nausea and vomiting?
- Motionless patient, rigid abdomen, absent bowel signs
- Bilious or faeculent vomiting, distended abdomen, absolute constipation, abdominal pain
- Very high fever (>38.5 degrees)
- Early morning vomiting, headache worsen when lying now, nerve VI palsy
- Central, crushing pain
- Meningism (stiff neck, photophobia, headache) conciousness
- Haematemesis
What does a motionless patient, rigid abdomen, absent bowel signs with nausea and vomiting suggest?
peritonitis (any cause)
What does bilious or faeculent vomiting, distended abdomen, absolute constipation, abdominal pain with nausea and vomiting suggest?
bowel obstruction
What does a very high fever with nausea and vomiting suggest?
infection
What would early morning vomiting, headache worsen when lying down, nerve VI palsy suggest?
raised ICP
What would central crushing pain with nausea and vomiting suggest?
MI
What would meningism (stiff neck, photophobia, headache) with nausea and vomiting suggest?
meningitis
What would reduced consciousness with nausea and vomiting suggest?
- diabetic ketoacidosis
- menigitis
- . raised ICP
What would haematemesis with nausea and vomiting suggest?
- bleeding peptic ulcer
2. oesophageal varices
What do you look for in inspection with nausea and vomiting?
- Hydration status
- Abdominal distention
- Scars
- Hernias
- Jaundice
How do you look for hydration status?
dry mucous membranes, cold peripheries, delayed cap refill time
What are causes for abdominal distention?
fetus, fat, fucking big tumour, flatus, feaces, fluid
Why do you look for scars?
previous surgery - adhesions
Why type of hernias do you look for?
irreducable ones (could contain trapped bowel and cause obstruction)
What would jaundice suggest?
hepatobiliary cause
What would a tender abdomen with nausea and vomiting suggest?
inflammation somewhere in peritoneal cavity
Why do you look for masses with nausea and vomiting?
could be cause of an obstruction
What would guarding and rigidity on palpation suggest?
peritonitis
What would absent bowel sounds suggest?
ileus (due to peritonitis)
What would high pitched or tickling bowel sounds suggest?
mechanical obstruction
What bloods do you investigate for nausea and vomiting?
- FBC and CRP
- U+Es
- VBG
- Liver enzymes
- Amylase
- Group and save
Why do you do fbc and crp?
raised CRP + WCC indicates infection or inflammation
Why do you do U+Es?
in severe vomiting electrolyte imbalance, baseline before surgery, urea may be raised due to dehydration with subsequent renal hypoperfusion
Why do you carry out a VBG?
pH and lactate, Na+ and K+ give indication how critical patient is
What would a biliary cause show up as in liver enzymes?
raised ALP and GGT
What would a raise in ALT and AST suggest
hepatitis
Why do you measure amylase?
confirm or exclude pancreatitis
Why do you carry out a group and save?
incase surgery needed
What imaging do you do in nausea and vomiting?
- Supine abdominal radiograph
2. Erect chest radiograph
Why do you do a ABX?
looking for signs of bowel obstruction (e.g. foreign body and toxic megacolon)
Why do you do a CXR?
look for air under diaphragm if bowel has perforated (sit up for 10 mins before image taken)
What other potential X-rays could you do for nausea and vomiting?
- Preg test
- Toxicology screen
- Contrast studies
- Abdominal CT
- Head CT
Why would you do a tox screen in nausea and vomiting?
for paracetemol or aspirin OD (accidental or not)
What contrast studies do you do for nausea and vomiting?
e.g. small bowel follow through, looking for obstruction if cant see from ABX
Why do you do a abdominal CT in nausea and vomiting?
intraperitoneal pathology
What do you do a head CT in nausea and vomiting?
look for intracranial pathology e.g. dilated ventricles or mass lesions (if history suggest raised ICP
What is the management of small bowel obstruction (SBO) acutely?
- ABC
- Nil by mouth
- Drip and suck
- Analgesia
- Antiemetics
What is drip and suck?
IV fluids and aspiration of GI contents via an NG tube
What analgesia can you not give for SOB?
- opiates can cause nausea and constipation
- NSAIDs are nephrotoxic so should be avoided if AKI and dehydrated
What antiemetics can you not use in SBO?
- metoclopramide is prokinetic and can make obstruction worse
- cyclizine or ondansetron better options
What is the management plan for SBO?
- Trial of conservative management
- CT scan
- Surgery if needed e.g. lapartomtomy
What is conservative management for SBO?
- Fluids
- NG aspiration
- See if obstruction resolves on itself
- Reviewed regularly to ensure not deteriorate (e.g. bowel strangulation)
Why do you do a CT scan for SBO?
- demonstrate exact level or obstruction
- establish whether closed loop obstruction, ischaemic bowel or a cause for obstruction other than adhesions (intussusception or a mass lesion)
When is surgery used in SBO?
If:
- signs of strangulation or peritonism
- after around 48hr the obstruction not resolved or
- no history of abdominal surgery, making adhesions less likely and more sinister causes more lik
