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EBMG

Nausea and Vomiting

Essentials

  • The most common cause of acute nausea is an acute gastroenteritis. The patient usually has concurrent watery diarrhoea, abdominal cramps and fever. Similar illness is possibly found in close contacts of the patient.
  • Nausea may be caused by a condition needing urgent treatment: myocardial infarction, hypoglycaemia, ketoacidosis, pancreatitis, gastrointestinal obstruction, appendicitis, meningitis or other severe infection (pneumonia, sepsis), increased intracranial pressure, acute cerebrovascular disorder or intoxication.
  • Other causes of nause include e.g. epilepsy, pregnancy, radiotherapy, medications (e.g. many antimicrobials, opioids, cytostatic drugs), hepatitis (e.g. hepatitis A), thyrotoxicosis, otogenic causes and gastritis.
  • Fairly common causes of prolonged or recurrent nausea encountered in outpatient care include migraine and episodes of bulimia, stress and various mental disorders.

Diagnostic approach in nausea

Duration and severity of the symptoms

  • Do you have only the feeling of nausea or do you actually vomit?
  • Are the symptoms associated with meals?
  • Content of the vomit
  • Preceding illnesses, use of medication and alcohol
  • Pregnancy?
  • Nausea and vomiting of acute onset is typical of gastroenteritis, labyrinthic vertigo and somatic causes that should be readily identified.
  • Prolonged symptoms often suggest a metabolic cause, a chronic disease or psychogenic origin.
  • In children and in the elderly, nausea and vomiting may be the presenting symptom of many common bacterial infections (otitis media, pneumonia, urinary tract infection).

Essentials of the clinical examination

  • Fever, systemic symptoms, dehydration, involuntary weight loss, jaundice
  • Palpation of the abdomen: tenderness, palpable masses
  • Auscultation of the abdomen: high-pitched bowel sounds (bowel obstruction, ischaemia)
  • Auscultation of the heart and the lungs
  • Neurological examination (meningism, nystagmus, optic fundi, unilateral symptoms)
  • During intense nausea and vomiting, the following medication which is nephrotoxic or affects renal function must be paused: ACE inhibitors, ARBs, NSAIDs, diuretics, in a diabetic patient also metformin, SGLT2 inhibitors and because of hypoglycaemia risk sulphonylureas as well as, at discretion, GLP-1 agonists.

Diagnostic clues

  • See table T1.

Nausea and vomiting - diagnostic clues

Symptom or sign associated with nauseaMost probable diagnosesConsider in differential diagnosis
HeadacheMigraineCerebrovascular disorders, meningitis, encephalitis
Rotatory vertigoBenign positional vertigo
Vestibular neuronitis
Ménière's disease
TIA/intracerebral bleeding
Fever(Severe) infection
Sepsis
Meningitis
DiarrhoeaGastroenteritis
Food poisoning
Abdominal painPeptic ulcer
Gastritis
Pancreatitis
Myocardial infarction
Pneumonia
Chest painMyocardial infarctionOesophagitis
Pneumonia
Neurological symptoms or signsCerebrovascular disorder
Increased intracranial pressure for other reasons
Recently started or changed medicationNausea caused by a drug

Aetiological clues from patient history

  • Sudden vomiting without preceding nausea may be associated with increased intracranial pressure.
  • Dehydration and weight loss suggest an organic disease.
  • Morning nausea and vomiting are typical of early pregnancy, alcoholic gastritis, increased intracranial pressure, and uraemia.
  • Vomiting after a meal suggests pyloric obstruction (gastric or duodenal ulcer, carcinoma), hepatic or biliary problems or a psychogenic cause (bulimia).
  • Voluminous, bile-stained vomiting suggests proximal intestinal obstruction.
  • Haematemesis suggests bleeding ulcer, acute gastric mucosal damage, Mallory-Weiss ulceration, or oesophageal varices.
  • Faecal vomitus is caused by distal intestinal obstruction.
  • History of travelling. Initial symptoms of acute hepatitis often include food aversion and nausea. Nausea and vomiting may be the cardinal symptoms of giardiasis.
  • Lactose intolerance may sometimes present as nausea and vomiting without evident intestinal symptoms.
  • The patient's medication may be cause (nitrofurantoin, sulphasalazine, imidazoles, erythromycin, tetracycline, metformin, tramadol, other opioids, antidementia drugs, SSRI drugs, digoxin in toxic concentrations).
  • If the general condition remains unaffected the symptoms may be of psychogenic origin.

Investigations

  • Consider first whether a referral to a hospital is indicated Acute Abdomen in the Adult.
  • If the patient is not referred to hospital the following tests are performed according to the history and clinical signs:
    • CRP, plasma glucose, pancreatic plasma amylase concentration, ECG, and, particularly in the elderly, a urine test.
  • In prolonged symptoms (in addition to the former)
    • Basic blood count with platelet count, plasma creatinine, potassium, sodium, ALT, alkaline phosphatase, TSH, drug concentrations, e.g. serum digoxin

Further investigations

  • If intestinal obstruction Intestinal Obstruction, Paralytic Ileus and Pseudo-Obstruction is suspected (vomiting, pain, bloating, high-pitched bowel sounds), the first-line examination is abdominal CT scan. Its availability in hospital emergency departments is good (check local availability).
  • In special circumstances (e.g. recurring intestinal obstruction whose cause is known), plain radiograph of the abdomen may be considered if not transferring the patient to a hospital is preferred.

Prolonged symptoms

  • Gastroscopy
  • Abdominal ultrasonography
  • Neurological examination
  • Psychiatric assessment (eating disorders)

Drug therapy of nausea Acupuncture for Postoperative Nausea and Vomiting, Drugs for the Treatment of Nausea and Vomiting in Adults in the Emergency Department Setting

Migraine, labyrinthic, intestinal, or cerebrovascular vomiting

  • Metoclopramide
    • Dosage
      • P.o. 10 mg 3 times daily
      • As a suppository 10 mg 1-3 times daily (special permission for compassionate use may be required)
      • I.m. 5-10 mg 1-3 times daily
    • Extrapyramidal symptoms may occur as adverse effects especially in young patients.
    • The recommended maximum duration of treatment is 5 days.
  • Prochlorperazine (especially vestibular nausea)
    • Dosage: p.o. 5-10 mg 3 times daily, in migraine as a suppository if needed (special permission for compassionate use may be required) 25 mg once daily
    • The adverse effects include extrapyramidal symptoms and orthostatic hypotension especially in elderly patients.

Nausea caused by cytostatic drugs

Motion sickness

Nausea and pain associated with colic (biliary or ureteral)

  • Analgesics i.v., i.m., suppositories, or p.o.

Nausea associated with increased intracranial pressure

Nausea associated with morphine medication