Evaluation of Nausea and Vomiting



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Am Fam Physician. 2007 Jul 1;76(1):76-84.

A comprehensive history and physical examination can often reveal the cause of nausea and vomiting, making further evaluation unnecessary. Acute symptoms generally are the result of infectious, inflammatory, or iatrogenic causes. Most infections are self-limiting and require minimal intervention; iatrogenic causes can be resolved by removing the offending agent. Chronic symptoms are usually a pathologic response to any of a variety of conditions. Gastrointestinal etiologies include obstruction, functional disorders, and organic diseases. Central nervous system etiologies are primarily related to conditions that increase intracranial pressure, and typically cause other neurologic signs. Pregnancy is the most common endocrinologic cause of nausea and must be considered in any woman of childbearing age. Numerous metabolic abnormalities and psychiatric diagnoses also may cause nausea and vomiting. Evaluation should first focus on detecting any emergencies or complications that require hospitalization. Attention should then turn to identifying the underlying cause and providing specific therapies. When the cause cannot be determined, empiric therapy with an antiemetic is appropriate. Initial diagnostic testing should generally be limited to basic laboratory tests and plain radiography. Further testing, such as upper endoscopy or computed tomography of the abdomen, should be determined by clinical suspicion based on a complete history and physical examination.

Nausea is the unpleasant, painless sensation that one may potentially vomit. Vomiting is an organized, autonomic response that ultimately results in the forceful expulsion of gastric contents through the mouth. Vomiting is intended to protect a person from harmful ingested substances. However, chronic nausea and vomiting are typically a pathologic response to any of a variety of conditions.1

Nausea and vomiting significantly affect quality of life. In a study of 17 gastrointestinal conditions in the United States, it was estimated that the cost of acute gastrointestinal infections exceeds $3.4 billion annually.2,3 When other causes of nausea and vomiting are taken into account, the associated medical costs and loss of worker productivity are considerable.

This article reviews common and significant causes of nausea and vomiting, offers an approach to evaluation, and provides a brief overview of treatment options.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical Recommendation Evidence Rating References

Most causes of acute nausea and vomiting can be determined from the history and physical examination.

C

2

Initial evaluation should focus on signs or symptoms that indicate urgent treatment, surgical intervention, or hospitalization.

C

2

Diagnostic testing for nausea and vomiting should be targeted at finding the etiology suggested by a thorough history and physical examination.

C

15, 1719

Fluid imbalances, electrolyte abnormalities, and nutritional deficiencies should be corrected.

C

2

Treatment should be directed at the underlying etiology of the nausea and vomiting. If no etiology is found, the patient should be treated symptomatically with antiemetic and prokinetic therapy, and other etiologies of chronic unexplained nausea and vomiting (e.g., psychogenic, bulimic, rumination, functional) should be considered.

B

2023


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 14 or http://www.aafp.org/afpsort.xml.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical Recommendation Evidence Rating References

Most causes of acute nausea and vomiting can be determined from the history and physical examination.

C

2

Initial evaluation should focus on signs or symptoms that indicate urgent treatment, surgical intervention, or hospitalization.

C

2

Diagnostic testing for nausea and vomiting should be targeted at finding the etiology suggested by a thorough history and physical examination.

C

15, 1719

Fluid imbalances, electrolyte abnormalities, and nutritional deficiencies should be corrected.

C

2

Treatment should be directed at the underlying etiology of the nausea and vomiting. If no etiology is found, the patient should be treated symptomatically with antiemetic and prokinetic therapy, and other etiologies of chronic unexplained nausea and vomiting (e.g., psychogenic, bulimic, rumination, functional) should be considered.

B

2023


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 14 or http://www.aafp.org/afpsort.xml.

Causes

The etiologies of nausea and vomiting include iatrogenic, toxic, or infectious causes; gastrointestinal disorders; and central nervous system or psychiatric conditions. A differential diagnosis for nausea and vomiting is provided in Table 1,2,410 and each category is discussed in the following.

Table 1

Differential Diagnosis of Nausea and Vomiting

Central nervous system

Closed head injury 4

Increased intracranial pressure

Cerebrovascular accident (infarction/hemorrhage)

Hydrocephalus

Mass lesion

Meningitis/encephalitis/abscess

Pseudotumor cerebri

Migraine

Seizure disorders2

Vestibular

Labyrinthitis

Ménière's disease

Motion sickness

Gastrointestinal

Functional disorders

Chronic intestinal pseudo-obstruction

Gastroparesis

Irritable bowel syndrome

Nonulcer dyspepsia

Obstruction

Adhesions

Esophageal disorders/achalasia

Intussusception

Malignancy

Pyloric stenosis

Strangulated hernia

Volvulus

Organic disorders

Appendicitis

Cholecystitis/cholangitis

Hepatitis

Inflammatory bowel disease

Mesenteric ischemia

Pancreatitis

Peptic ulcer disease

Peritonitis

Infectious

Acute otitis media

Bacteria

Bacterial toxins

Food-borne toxins

Pneumonia5

Spontaneous bacterial peritonitis

Urinary tract infection/pyelonephritis

Viruses

Adenovirus

Norwalk

Rotavirus

Medications/Toxins

Medications

Antiarrhythmics

Antibiotics

Anticonvulsants

Chemotherapeutics

Digoxin

Ethanol overdose

Hormonal preparations

Illicit substances

Nonsteroidal anti-inflammatory drugs

Opiates

Overdoses/withdrawal6

Radiation therapy

Toxins

Arsenic 7

Organophosphates/pesticides8

Ricin9

Metabolic

Adrenal disorders

Diabetic ketoacidosis

Paraneoplastic syndromes

Parathyroid disorders

Pregnancy

Thyroid disorders

Uremia

Miscellaneous

Acute glaucoma5

Acute myocardial infarction

Nephrolithiasis10

Pain

Psychiatric disorders

Anorexia nervosa

Anxiety

Bulimia nervosa

Conversion disorder

Depression

Psychogenic/emotional


Information from references 2 and 4 through 10.

Table 1   Differential Diagnosis of Nausea and Vomiting

View Table

Table 1

Differential Diagnosis of Nausea and Vomiting

Central nervous system

Closed head injury 4

Increased intracranial pressure

Cerebrovascular accident (infarction/hemorrhage)

Hydrocephalus

Mass lesion

Meningitis/encephalitis/abscess

Pseudotumor cerebri

Migraine

Seizure disorders2

Vestibular

Labyrinthitis

Ménière's disease

Motion sickness

Gastrointestinal

Functional disorders

Chronic intestinal pseudo-obstruction

Gastroparesis

Irritable bowel syndrome

Nonulcer dyspepsia

Obstruction

Adhesions

Esophageal disorders/achalasia

Intussusception

Malignancy

Pyloric stenosis

Strangulated hernia

Volvulus

Organic disorders

Appendicitis

Cholecystitis/cholangitis

Hepatitis

Inflammatory bowel disease

Mesenteric ischemia

Pancreatitis

Peptic ulcer disease

Peritonitis

Infectious

Acute otitis media

Bacteria

Bacterial toxins

Food-borne toxins

Pneumonia5

Spontaneous bacterial peritonitis

Urinary tract infection/pyelonephritis

Viruses

Adenovirus

Norwalk

Rotavirus

Medications/Toxins

Medications

Antiarrhythmics

Antibiotics

Anticonvulsants

Chemotherapeutics

Digoxin

Ethanol overdose

Hormonal preparations

Illicit substances

Nonsteroidal anti-inflammatory drugs

Opiates

Overdoses/withdrawal6

Radiation therapy

Toxins

Arsenic 7

Organophosphates/pesticides8

Ricin9

Metabolic

Adrenal disorders

Diabetic ketoacidosis

Paraneoplastic syndromes

Parathyroid disorders

Pregnancy

Thyroid disorders

Uremia

Miscellaneous

Acute glaucoma5

Acute myocardial infarction

Nephrolithiasis10

Pain

Psychiatric disorders

Anorexia nervosa

Anxiety

Bulimia nervosa

Conversion disorder

Depression

Psychogenic/emotional


Information from references 2 and 4 through 10.

IATROGENIC, TOXIC, AND INFECTIOUS

Almost any medication can cause nausea and vomiting. Chemotherapeutic agents are the most well-known; however, many commonly prescribed medications can cause these symptoms. Medications typically cause nausea and vomiting early in their course, although the onset of symptoms may be insidious. Overdoses of alcohol, illicit substances, and other toxins may also cause acute symptoms.6,7,9

Infectious etiologies typically result in an acute onset of symptoms. Viral gastroenteritis is particularly common; however, bacteria or their toxins may also be the cause. Infectious and toxic causes of nausea and vomiting are usually self-limiting. Nausea and vomiting caused by ingestion of a toxin such as the enterotoxin in staphylococcal food poisoning or the toxin produced by Bacillus cereus typically occur one to six hours after ingestion and last only 24 to 48 hours.

GASTROINTESTINAL DISORDERS

Many gastrointestinal disorders cause nausea and vomiting. Acute symptoms are typically the result of an inflammatory process (e.g., appendicitis, cholecystitis, pancreatitis). Obstructions may result in acute or chronic symptoms. Gastric outlet obstructions tend to cause intermittent symptoms, whereas intestinal obstructions typically cause acute symptoms and severe pain.

Motility disorders such as gastroparesis typically produce an insidious onset of symptoms resulting from an inability to move food through the gastrointestinal tract. Patients with disorders such as dyspepsia, gastro-esophageal ref lux disease (GERD), peptic ulcer disease (PUD), or irritable bowel syndrome (IBS) may have nausea and vomiting, but these are rarely the primary symptoms.

CENTRAL NERVOUS SYSTEM AND PSYCHIATRIC CONDITIONS

Any condition that increases intracranial pressure (e.g., mass, infarct, infection) can result in vomiting with or without nausea. Patients with central nervous system pathology usually present with additional neurologic signs such as cranial nerve dysfunction or long-tract signs. Conditions that affect the labyrinthus (e.g., infections, Ménière's disease, tumors) may cause nausea and vomiting and are often associated with vertigo. Migraine headaches classically cause nausea and vomiting.

Patients may also experience symptoms in response to emotional or physical stressors. Psychiatric diagnoses such as anorexia nervosa, bulimia nervosa, depression, and anxiety should be considered.

OTHER CONDITIONS

Pregnancy is the most common endocrinologic cause of nausea and vomiting and must be considered in any woman of childbearing age. Metabolic etiologies such as acidosis, uremia, hyperthyroidism, adrenal disorders, and parathyroid disorders also can be the cause.

Rare conditions may be considered if the history and physical examination do not support a common diagnosis. Cyclic vomiting syndrome is a poorly understood phenomenon that causes periods of nausea and vomiting alternating with asymptomatic periods. Symptoms are often associated with migraine headaches, motion sickness, or atopy. Cyclic vomiting predominantly affects children; however, it has been described in adults. Cyclic vomiting syndrome is a diagnosis of exclusion.

Evaluation

The American Gastroenterological Association suggests a three-step approach to the initial evaluation of nausea and vomiting.2 First, attempt to recognize and correct any consequences of the symptoms, such as dehydration or electrolyte abnormalities. Second, try to identify the underlying cause and provide specific therapies. Third, if no etiology can be determined, use empiric therapy to treat symptoms. An algorithm for the evaluation of nausea and vomiting is provided in Figure 1.1,11

Evaluation of Nausea and Vomiting

Figure 1.

Algorithm for the evaluation of nausea and vomiting. (N&V = nausea and vomiting; CT = computed tomography; MRI = magnetic resonance imaging; T4 = thyroxine; EGD = esophagogastroduodenoscopy; GERD = gastroesophageal reflux disease.)

Adapted with permission from American Gastroenterological Association. American Gastroenterological Association medical position statement: nausea and vomiting. Gastroenterology 2001;120:262, with additional information from reference 1.

View Large

Evaluation of Nausea and Vomiting


Figure 1.

Algorithm for the evaluation of nausea and vomiting. (N&V = nausea and vomiting; CT = computed tomography; MRI = magnetic resonance imaging; T4 = thyroxine; EGD = esophagogastroduodenoscopy; GERD = gastroesophageal reflux disease.)

Adapted with permission from American Gastroenterological Association. American Gastroenterological Association medical position statement: nausea and vomiting. Gastroenterology 2001;120:262, with additional information from reference 1.

Evaluation of Nausea and Vomiting


Figure 1.

Algorithm for the evaluation of nausea and vomiting. (N&V = nausea and vomiting; CT = computed tomography; MRI = magnetic resonance imaging; T4 = thyroxine; EGD = esophagogastroduodenoscopy; GERD = gastroesophageal reflux disease.)

Adapted with permission from American Gastroenterological Association. American Gastroenterological Association medical position statement: nausea and vomiting. Gastroenterology 2001;120:262, with additional information from reference 1.

Because of the broad range of possible etiologies, an ordered approach to evaluation is essential. The etiology of most acute nausea and vomiting can be determined from the history and physical examination; diagnostic tests should be ordered only when based on clinical suspicion. During initial consultation, the physician must rule out emergencies or any need for hospitalization. Warning signs such as chest pain, severe abdominal pain, central nervous system symptoms, fever, a history of immunosuppression, hypotension, severe dehydration, or older age should prompt immediate evaluation.

HISTORY

A clear definition of the patient's symptoms must be determined, with vomiting distinguished from regurgitation and rumination. Vomiting involves the forceful expulsion of stomach contents through involuntary muscular contractions. In regurgitation, food is returned to the mouth without forceful contractions, and in rumination food is returned to the mouth through voluntary contractions.

A detailed history of symptoms can provide clues to a diagnosis (Table 21,2,1113). Symptom duration should be determined because the differential diagnoses differ significantly for acute symptoms (i.e., persisting one month or less) and chronic symptoms (i.e., persisting for longer than one month).2  Abrupt onset of nausea and vomiting is suggestive of cholecystitis, food poisoning, gastroenteritis, pancreatitis, or drug-related etiologies. If a patient has pain, obstructive etiologies must be considered. The insidious onset of acute or chronic symptoms is suggestive of diagnoses such as GERD, gastroparesis, medication, metabolic disorders, or pregnancy. Symptom timing also is important (e.g., occurrence before, during, or after eating; continuous, irregular, or predictable), and the quality and quantity of vomited matter may also suggest specific etiologies (Table 21,2,1113).12

Table 2

Possible Diagnoses Based on the History in Patients with Nausea and Vomiting

History Possible diagnoses

Onset of symptoms

Abrupt

Cholecystitis, food poisoning, gastroenteritis, illicit drugs, medications, pancreatitis

Insidious

Gastroesophageal reflux disease, gastroparesis, medications, metabolic disorders, pregnancy

Timing of symptoms

Before breakfast

Ethyl alcohol, increased intracranial pressure, pregnancy, uremia

During or directly after eating

Psychiatric causes

Less likely: peptic ulcer disease or pyloric stenosis

One to four hours after a meal

Gastric outlet obstructions (e.g., from peptic ulcer disease, neoplasms), gastroparesis

Continuous

Conversion disorder, depression

Irregular

Major depression

Nature of vomited matter

Undigested food

Achalasia, esophageal disorders (e.g., diverticulum, strictures)

Partially digested food

Gastric outlet obstruction, gastroparesis

Bile

Proximal small bowel obstruction

Feculent or odorous

Fistula, obstruction with bacterial degradation of contents

Large volume (> 1,500 mL per 24 hours)

Suggests organic rather than psychiatric causes

Abdominal pain

Right upper quadrant

Biliary tract disease, cholecystitis

Epigastric

Pancreatic disease, peptic ulcer disease

Severe pain

Biliary disease, pancreatic disease, peritoneal irritation, small bowel obstruction

Severe pain that precedes vomiting

Small bowel obstruction

Associated symptoms/findings

Weight loss

Malignancy (significant weight loss may also occur secondary to sitophobia in gastric outlet obstructions and peptic ulcer disease)

Diarrhea, myalgias, malaise, headache, contact with ill persons

Viral etiologies

Headache, stiff neck, vertigo, focal neurologic deficits

Central neurologic causes (e.g., encephalitis/meningitis, head injury, mass lesion or other cause of increased intracranial pressure, migraine)

Early satiety, postprandial bloating, abdominal discomfort

Gastroparesis

Repetitive migraine headaches or symptoms of irritable bowel syndrome

Cyclic vomiting syndrome


Information from references 1, 2, and 11 through 13.

Table 2   Possible Diagnoses Based on the History in Patients with Nausea and Vomiting

View Table

Table 2

Possible Diagnoses Based on the History in Patients with Nausea and Vomiting

History Possible diagnoses

Onset of symptoms

Abrupt

Cholecystitis, food poisoning, gastroenteritis, illicit drugs, medications, pancreatitis

Insidious

Gastroesophageal reflux disease, gastroparesis, medications, metabolic disorders, pregnancy

Timing of symptoms

Before breakfast

Ethyl alcohol, increased intracranial pressure, pregnancy, uremia

During or directly after eating

Psychiatric causes

Less likely: peptic ulcer disease or pyloric stenosis

One to four hours after a meal

Gastric outlet obstructions (e.g., from peptic ulcer disease, neoplasms), gastroparesis

Continuous

Conversion disorder, depression

Irregular

Major depression

Nature of vomited matter

Undigested food

Achalasia, esophageal disorders (e.g., diverticulum, strictures)

Partially digested food

Gastric outlet obstruction, gastroparesis

Bile

Proximal small bowel obstruction

Feculent or odorous

Fistula, obstruction with bacterial degradation of contents

Large volume (> 1,500 mL per 24 hours)

Suggests organic rather than psychiatric causes

Abdominal pain

Right upper quadrant

Biliary tract disease, cholecystitis

Epigastric

Pancreatic disease, peptic ulcer disease

Severe pain

Biliary disease, pancreatic disease, peritoneal irritation, small bowel obstruction

Severe pain that precedes vomiting

Small bowel obstruction

Associated symptoms/findings

Weight loss

Malignancy (significant weight loss may also occur secondary to sitophobia in gastric outlet obstructions and peptic ulcer disease)

Diarrhea, myalgias, malaise, headache, contact with ill persons

Viral etiologies

Headache, stiff neck, vertigo, focal neurologic deficits

Central neurologic causes (e.g., encephalitis/meningitis, head injury, mass lesion or other cause of increased intracranial pressure, migraine)

Early satiety, postprandial bloating, abdominal discomfort

Gastroparesis

Repetitive migraine headaches or symptoms of irritable bowel syndrome

Cyclic vomiting syndrome


Information from references 1, 2, and 11 through 13.

The presence of abdominal pain usually suggests an organic cause2; the location, severity, and timing of pain may indicate a specific etiology. Other associated symptoms also provide significant information. Acute nausea and vomiting without any warning signs suggests infectious or iatrogenic etiologies. A detailed medication history is essential. Food ingestions, contact with ill persons, and the presence of coexisting viral symptoms suggest an infectious etiology. A history of weight loss should raise concern for malignancy; however, significant weight loss can occur with sitophobia (fear of eating) secondary to functional disorders. Neurologic symptoms should be investigated because central nervous system etiologies of nausea and vomiting are unlikely in a patient without other neurologic symptoms.2

PHYSICAL EXAMINATION

The physical examination should focus initially on signs of dehydration, evaluating skin turgor and mucous membranes, and observing for hypotension or orthostatic changes.1,2,12 The general examination should look for jaundice, lymphadenopathy, and signs of thyrotoxicosis. Fingers should be observed for calluses on the dorsal surfaces suggesting self-induced vomiting. Other suggestive findings may include parotid gland enlargement, lanugo hair, and loss of tooth enamel; however, loss of enamel may also be a consequence of long-standing gastroesophageal reflux. The physician should evaluate for signs of depression or anxiety, which may suggest psychiatric etiologies.

The abdominal examination is extremely important. Abdominal distention with tenderness is suggestive of a bowel obstruction, although bloating may occur with gastroparesis. The physician should observe for visible peristalsis and pay close attention for abdominal or inguinal hernias and surgical scars. Auscultation may demonstrate increased bowel sounds in obstruction or decreased bowel sounds with an ileus. A succussion splash (heard at the epigastrium while rapidly palpating the epigastrium or shaking the abdomen and pelvis) suggests gastric outlet obstruction or gastroparesis. Epigastric tenderness may suggest an ulcer or pancreatitis. Pain in the right upper quadrant is more consistent with cholecystitis or biliary tract disease.

A neurologic examination is essential. Simple maneuvers can direct the physician toward or away from a central diagnosis. Orthostatic changes may be the result of persistent vomiting; however, a decrease in blood pressure without a change in heart rate may suggest an autonomic neuropathy with coexisting motility disorders. Any deficit on examination of cranial nerves or a patient's gait suggests brainstem lesions, which may result in gastroparesis. Ophthalmoscopy should be performed to evaluate for elevations in intracranial pressure, because any cause of increased intracranial pressure can stimulate brainstem emesis centers. Abnormal findings should prompt immediate neuroimaging. Finally, observation for nystagmus may suggest a disorder of the labyrinthine system.

Diagnostic Approach

There are no controlled trials to guide the diagnostic evaluation of nausea and vomiting; therefore, most recommendations are based on expert opinion.1  In most patients with a worrisome history, it is reasonable to begin with basic laboratory tests and radiographic studies to rule out serious consequences. An overview of diagnostic tests for nausea and vomiting is provided in Table 3.1,2,1419

Table 3

Diagnostic Tests and Clinical Suspicion for Patients with Nausea and Vomiting

Test Clinical suspicion

Laboratory tests

Complete blood count

Leukocytosis in an inflammatory process, microcytic anemia from a mucosal process

Electrolytes

Consequences of nausea and vomiting (e.g., acidosis, alkalosis, azotemia, hypokalemia)

Erythrocyte sedimentation rate

Inflammatory process

Pancreatic/liver enzymes

For patients with upper abdominal pain or jaundice

Pregnancy test

For any female of childbearing age

Protein/albumin

Chronic organic illness or malnutrition

Specific toxins

Ingestion or use of potentially toxic medications

Thyroid-stimulating hormone

For patients with signs of thyroid toxicity or unexplained nausea and vomiting

Radiographic testing

Supine and upright abdominal radiography

Mechanical obstruction

Further testing

Esophagogastroduodenoscopy

Mucosal lesions (ulcers), proximal mechanical obstruction

Upper gastrointestinal radiography with barium contrast media

Mucosal lesions and higher-grade obstructions; evaluates for proximal lesions

Small bowel follow-through

Mucosal lesions and higher-grade obstructions; evaluates the small bowel to the terminal ileum

Enteroclysis

Small mucosal lesions, small bowel obstructions, small bowel cancer

Computed tomography with oral and intravenous contrast media

Obstruction, optimal technique to localize other abdominal pathology

Gastric emptying scintigraphy

Gastroparesis (suggestive)

Cutaneous electrogastrography

Gastric dysrhythmias

Antroduodenal manometry

Primary or diffuse motor disorders

Abdominal ultrasonography

Right upper quadrant pain associated with gallbladder, hepatic, or pancreatic dysfunction

Magnetic resonance imaging of the brain

Intracranial mass or lesion


Information from references 1, 2, and 14 through 19.

Table 3   Diagnostic Tests and Clinical Suspicion for Patients with Nausea and Vomiting

View Table

Table 3

Diagnostic Tests and Clinical Suspicion for Patients with Nausea and Vomiting

Test Clinical suspicion

Laboratory tests

Complete blood count

Leukocytosis in an inflammatory process, microcytic anemia from a mucosal process

Electrolytes

Consequences of nausea and vomiting (e.g., acidosis, alkalosis, azotemia, hypokalemia)

Erythrocyte sedimentation rate

Inflammatory process

Pancreatic/liver enzymes

For patients with upper abdominal pain or jaundice

Pregnancy test

For any female of childbearing age

Protein/albumin

Chronic organic illness or malnutrition

Specific toxins

Ingestion or use of potentially toxic medications

Thyroid-stimulating hormone

For patients with signs of thyroid toxicity or unexplained nausea and vomiting

Radiographic testing

Supine and upright abdominal radiography

Mechanical obstruction

Further testing

Esophagogastroduodenoscopy

Mucosal lesions (ulcers), proximal mechanical obstruction

Upper gastrointestinal radiography with barium contrast media

Mucosal lesions and higher-grade obstructions; evaluates for proximal lesions

Small bowel follow-through

Mucosal lesions and higher-grade obstructions; evaluates the small bowel to the terminal ileum

Enteroclysis

Small mucosal lesions, small bowel obstructions, small bowel cancer

Computed tomography with oral and intravenous contrast media

Obstruction, optimal technique to localize other abdominal pathology

Gastric emptying scintigraphy

Gastroparesis (suggestive)

Cutaneous electrogastrography

Gastric dysrhythmias

Antroduodenal manometry

Primary or diffuse motor disorders

Abdominal ultrasonography

Right upper quadrant pain associated with gallbladder, hepatic, or pancreatic dysfunction

Magnetic resonance imaging of the brain

Intracranial mass or lesion


Information from references 1, 2, and 14 through 19.

LABORATORY TESTING

There are no laboratory tests specific to determining etiologies of nausea and vomiting. Tests should be directed by the history and physical examination to determine the underlying cause or to evaluate for the consequences of nausea and vomiting. In patients with unexplained symptoms, it is reasonable to perform a complete blood count and erythrocyte sedimentation rate measurement in conjunction with a complete metabolic profile. A pregnancy test should be performed in any woman of childbearing age. This may reveal the cause of symptoms and is also needed before radiography. If a patient has abdominal pain, pancreatic enzyme measurements should be performed. Additional laboratory tests and their indications are listed in Table 3.1,2,1419

RADIOGRAPHIC TESTING

Supine and upright abdominal radiography should be performed if there is any concern about a small bowel obstruction,14 although false-negative results occur in as many as 22 percent of patients with a partial obstruction.1 If results are negative but an obstruction is still suspected, further testing should be performed.

FURTHER TESTING

Proximal mucosal lesions and obstructions may be detected by esophagogastroduodenoscopy (EGD) or upper gastrointestinal radiography. EGD is the best study for detecting such lesions15; however, the use of double contrast media in radiographic studies reduces error rates and allows a less-expensive, less-invasive approach. The addition of a small bowel follow-through enables visualization of the small bowel to the terminal ilium, but it may not detect smaller mucosal lesions. This has led many to advocate the use of enteroclysis.16 Enteroclysis is extremely sensitive but requires placement of an oral/nasal tube directly into the small bowel. Computed tomography may soon become the study of choice for detecting intestinal obstructions and also allows evaluation of the surrounding abdominal structures.17,18 In patients with unexplained symptoms or with abnormal neurologic findings, magnetic resonance imaging of the brain should be considered.19

If no diagnosis is determined after initial evaluation, gastric motility studies (e.g., gastric emptying scintigraphy, cutaneous electrogastrography, antroduodenal manometry) may be considered. However, the utility of such tests is controversial, and many experts suggest a trial of antiemetic or prokinetic medications instead.1

Finally, if all organic, gastrointestinal, and central causes of nausea and vomiting have been explored, psychogenic vomiting should be considered.2

Treatment

After identification of any warning signs and appropriate emergency interventions, the primary goal of initial treatment is a careful assessment of fluid and electrolyte status with appropriate replacement. A low-fat or liquid diet may be prescribed, because lipids delay gastric emptying and liquids are more readily absorbed.

If an etiology is identified, a targeted therapy can be provided; however, delays in evaluation may require empiric treatment for patient comfort.1 It is reasonable to begin with a trial of a phenothiazine, such as prochlorperazine, because these medications are effective in a range of clinical situations. A trial of a prokinetic agent (e.g., metoclopramide [Reglan]) may then be beneficial. Serotonin antagonists (e.g., ondansetron [Zofran]) are effective and are better tolerated than phenothiazines and prokinetics, but their high cost (approximately $20 per dose, even for the recently approved generic ondansetron) makes long-term use impractical. Trials determining the specific effectiveness of medications for nausea and vomiting are limited; therefore, a trial of any medication may be reasonable on an individual basis.1  Antiemetic agents commonly used for nausea and vomiting are listed in Table 41,2,6 ; therapies for known etiologies of nausea and vomiting are listed in Table 52,2026 ; and alternative therapies are listed in Table 6.22,2729

Table 4

Select Antiemetic Agents, Common Uses, and Side Effects

Class of medication Common uses Common side effects

Anticholinergic* (scopolamine [Maldemar]

Possible adjunct for cytotoxic chemotherapy, prophylaxis and treatment of motion sickness

Drowsiness, dry mouth, vision disturbances

Antihistamines (cyclizine [Marezine], diphenhydramine [Benadryl], dimenhydrinate [Dramamine], meclizine [Antivert])

Migraine, motion sickness, vertigo

Drowsiness

Benzodiazepines (alprazolam [Xanax], diazepam [Valium], lorazepam [Ativan])

Adjunct for chemotherapy-related symptoms

Sedation

Butyrophenones (droperidol [Inapsine†], haloperidol [Haldol])

Anticipatory and acute chemotherapeutic nausea and vomiting, postoperative nausea and vomiting

Agitation, restlessness, sedation

Cannabinoids (dronabinol [Marinol])

Refractory chemotherapy-related nausea and vomiting

Ataxia, dizziness, euphoria, hypotension, sedation

Corticosteroids (dexamethasone)

Adjunct for chemotherapy-related symptoms

Increased energy, insomnia, mood changes

Phenothiazines (chlorpromazine [Thorazine†], prochlorperazine, promethazine [Phenergan])

Migraine, motion sickness, postchemotherapy nausea and vomiting, postoperative nausea and vomiting, severe episodes of nausea and vomiting, vertigo

Extrapyramidal symptoms (e.g., dystonia, tardive dyskinesia), orthostatic hypotension, sedation

Serotonin 5-hydroxytryptamine antagonists‡ (dolasetron [Anzemet], odansetron [Zofran], granisetron [Kytril], palonosetron [Aloxi])

Postchemotherapy nausea and vomiting, severe nausea and vomiting

Asthenia, constipation, dizziness, mild headache

Substituted benzamides* (metoclopramide [Reglan], trimethobenzamide [Tigan])

Diabetic gastroenteropathy, gastroparesis

Extrapyramidal side effects (e.g., akathisia, dyskinesia, dystonia, oculogyric crises, opisthotonos), fatigue, hyperprolactinemia


*— Use limited by high occurrence of side effects.

†— Not available in the United States.

‡— Low incidence of side effects.

Information from references 1, 2, and 6.

Table 4   Select Antiemetic Agents, Common Uses, and Side Effects

View Table

Table 4

Select Antiemetic Agents, Common Uses, and Side Effects

Class of medication Common uses Common side effects

Anticholinergic* (scopolamine [Maldemar]

Possible adjunct for cytotoxic chemotherapy, prophylaxis and treatment of motion sickness

Drowsiness, dry mouth, vision disturbances

Antihistamines (cyclizine [Marezine], diphenhydramine [Benadryl], dimenhydrinate [Dramamine], meclizine [Antivert])

Migraine, motion sickness, vertigo

Drowsiness

Benzodiazepines (alprazolam [Xanax], diazepam [Valium], lorazepam [Ativan])

Adjunct for chemotherapy-related symptoms

Sedation

Butyrophenones (droperidol [Inapsine†], haloperidol [Haldol])

Anticipatory and acute chemotherapeutic nausea and vomiting, postoperative nausea and vomiting

Agitation, restlessness, sedation

Cannabinoids (dronabinol [Marinol])

Refractory chemotherapy-related nausea and vomiting

Ataxia, dizziness, euphoria, hypotension, sedation

Corticosteroids (dexamethasone)

Adjunct for chemotherapy-related symptoms

Increased energy, insomnia, mood changes

Phenothiazines (chlorpromazine [Thorazine†], prochlorperazine, promethazine [Phenergan])

Migraine, motion sickness, postchemotherapy nausea and vomiting, postoperative nausea and vomiting, severe episodes of nausea and vomiting, vertigo

Extrapyramidal symptoms (e.g., dystonia, tardive dyskinesia), orthostatic hypotension, sedation

Serotonin 5-hydroxytryptamine antagonists‡ (dolasetron [Anzemet], odansetron [Zofran], granisetron [Kytril], palonosetron [Aloxi])

Postchemotherapy nausea and vomiting, severe nausea and vomiting

Asthenia, constipation, dizziness, mild headache

Substituted benzamides* (metoclopramide [Reglan], trimethobenzamide [Tigan])

Diabetic gastroenteropathy, gastroparesis

Extrapyramidal side effects (e.g., akathisia, dyskinesia, dystonia, oculogyric crises, opisthotonos), fatigue, hyperprolactinemia


*— Use limited by high occurrence of side effects.

†— Not available in the United States.

‡— Low incidence of side effects.

Information from references 1, 2, and 6.

Table 5

Specific Therapies for Known Etiologies of Nausea and Vomiting

Clinical situation Common treatment

Chemotherapy- and radiation-associated nausea and vomiting

Acute: ondansetron (Zofran) 32 mg IV or 24 mg orally 30 minutes before chemotherapy and dexamethasone 4 mg

Delayed: metoclopramide (Reglan) 1 to 2 mg IV or orally every 2 to 4 hours and dexamethasone 4 mg2

Cyclic vomiting syndrome

Supportive, and possible tricyclic antidepressants for adults25,26

Gastroparesis

Supportive, and possible gastric pacing24

Postoperative nausea and vomiting

Droperidol (Inapsine*) 1.25 mg IV and dexamethasone 4 mg IV within 20 minutes of anesthesia; or ondansetron 4 mg IV during the last 20 minutes of surgery20

Pregnancy: hyperemesis gravidarum

Prochlorperazine 5 to 10 mg IM, chlorpromazine (Thorazine*) 10 to 25 mg orally, metoclopramide2 1 to 2 mg IV, and methylprednisolone (DepoMedrol)23

Pregnancy: morning sickness

Meclizine (Antivert) 25 to 50 mg orally and promethazine (Phenergan) 12.5 to 50 mg orally or IV, electrolyte replacement, thiamine supplementation21,22


IV = intravenously; IM = intramuscularly

*— Not available in the United States.

Information from references 2 and 20 through 26.

Table 5   Specific Therapies for Known Etiologies of Nausea and Vomiting

View Table

Table 5

Specific Therapies for Known Etiologies of Nausea and Vomiting

Clinical situation Common treatment

Chemotherapy- and radiation-associated nausea and vomiting

Acute: ondansetron (Zofran) 32 mg IV or 24 mg orally 30 minutes before chemotherapy and dexamethasone 4 mg

Delayed: metoclopramide (Reglan) 1 to 2 mg IV or orally every 2 to 4 hours and dexamethasone 4 mg2

Cyclic vomiting syndrome

Supportive, and possible tricyclic antidepressants for adults25,26

Gastroparesis

Supportive, and possible gastric pacing24

Postoperative nausea and vomiting

Droperidol (Inapsine*) 1.25 mg IV and dexamethasone 4 mg IV within 20 minutes of anesthesia; or ondansetron 4 mg IV during the last 20 minutes of surgery20

Pregnancy: hyperemesis gravidarum

Prochlorperazine 5 to 10 mg IM, chlorpromazine (Thorazine*) 10 to 25 mg orally, metoclopramide2 1 to 2 mg IV, and methylprednisolone (DepoMedrol)23

Pregnancy: morning sickness

Meclizine (Antivert) 25 to 50 mg orally and promethazine (Phenergan) 12.5 to 50 mg orally or IV, electrolyte replacement, thiamine supplementation21,22


IV = intravenously; IM = intramuscularly

*— Not available in the United States.

Information from references 2 and 20 through 26.

Table 6

Alternative Treatments for Nausea and Vomiting

Treatment Conditions

Acupuncture (point P6)

Chemotherapy,27 postoperative nausea and vomiting,28 early pregnancy nausea and vomiting2

Ginger 250 mg (powdered root) before meals and at bedtime

Nausea and vomiting in pregnancy29

Pyridoxine (vitamin B6)

Early pregnancy nausea and vomiting22


Information from references 22 and 27 through 29.

Table 6   Alternative Treatments for Nausea and Vomiting

View Table

Table 6

Alternative Treatments for Nausea and Vomiting

Treatment Conditions

Acupuncture (point P6)

Chemotherapy,27 postoperative nausea and vomiting,28 early pregnancy nausea and vomiting2

Ginger 250 mg (powdered root) before meals and at bedtime

Nausea and vomiting in pregnancy29

Pyridoxine (vitamin B6)

Early pregnancy nausea and vomiting22


Information from references 22 and 27 through 29.

The Authors

KEITH SCORZA, MD, MBA, is a staff family physician serving at Fort Bragg, N.C. He received his medical degree from the Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, Bethesda, Md., and completed his residency in family medicine at Dewitt Army Community Hospital, Fort Belvoir, Va.

AARON WILLIAMS, DO, is a family medicine resident at Dewitt Army Community Hospital. He received his medical degree from Midwestern University–Chicago (Ill.) College of Osteopathic Medicine.

J. DANIEL PHILLIPS, MD, is a staff family physician serving in Darmstadt, Germany. He received his medical degree from Tulane University School of Medicine, New Orleans, La., and completed his family medicine residency at Dewitt Army Community Hospital.

JOEL SHAW, MD, is a staff physician in the Family Medicine Residency Program at Dewitt Army Community Hospital and in the Primary Care Sports Medicine Fellowship at the Uniformed Services University of the Health Sciences, Bethesda, Md. He graduated from the Medical College of Ohio, Toledo, and completed a residency in family medicine at Dewitt Army Community Hospital.

Address correspondence to Keith Scorza, MD, MBA, Dewitt Army Community Hospital, 9501 Farrel Rd., Ft. Belvoir, VA 22060–5901. Reprints are not available from the authors.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.

Author disclosure: Nothing to disclose.

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