Vomiting

Question 1

Probability diagnosis

Answer 1

All ages: acute GE, motion sickness, drugs, various infections

Neonates: feeding problems

Children: viral infections/fever, otitis media, UTI

Adults: gastritis, alcohol intoxication, pregnancy, migraine

Question 2

Serious disorders not to be missed

Answer 2

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, cerebellar
• haemorrhage, PICA infarction

Acute appendicitis

Acute pancreatitis

Acute myocardial infarction (e.g. painless)

Question 3

Pitfalls (mainly adults)

Answer 3

• 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

Question 4

Masquerades checklist

Answer 4

Depression (possible)

Diabetes (ketoacidosis)

Drugs (multiple)

Anaemia (possible)

Thyroid and other endocrine disorders (Addison disease)

UTI esp. pyelonephritis

Question 5

Is the patient trying to tell me something?

Answer 5

Possibly: extreme stress and anxiety (e.g. panic attacks).

Consider bulimia (self-induced vomiting) and functional (psychogenic).

Question 6

Key history

Answer 6

Nausea and vomiting have a wide range of potential causes emanating from every body system.

drug intake

possible psychogenic factors including self-induced emesis,

weight loss

other GIT symptoms or symptoms suggestive of systemic disease.

Question 7

Key examination

Answer 7

If fever, search fo sources of infections (e.g. middle ear, urinary tract and meninges)

A careful abd exam 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 pt’s condition including the level of hydration

Question 8

Key investigations

Answer 8

Look for the cause and also consider biochemical abnormalities resulting from fluid and electrolyte loss.

• pregnancy test
• urine analysis and MC
• stool MC
• endoscopy
• drug toxicity studies
• blood glucose
• radiology of GIT.

Question 9

Diagnostic tips

Answer 9

The common cause of acute nausea and vomiting in most age groups is gastroenteritis.

Drug ingestion is a common cause, so check for prescribed drugs and illicit street drugs such as heroin and ecstasy.