Evaluation of Nausea and Vomiting in Adults: A Case-Based Approach

 

This is a corrected version of the article that appeared in print.

Am Fam Physician. 2013 Sep 15;88(6):371-379.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/health-tools/search-by-symptom/nausea-vomiting.html.

Author disclosure: No relevant financial affiliations.

In the absence of acute abdominal pain, significant headache, or recent initiation of certain medications, acute nausea and vomiting is usually the result of self-limited gastrointestinal infections. Nausea and vomiting is also a common adverse effect of radiation therapy, chemotherapy, and surgical anesthesia. Other potential diagnoses include endocrine conditions (including pregnancy), central nervous system disorders, psychiatric causes, toxin exposure, metabolic abnormalities, and obstructive or functional gastrointestinal causes. The likely cause of acute nausea and vomiting can usually be determined by history and physical examination. Alarm signs such as dehydration, acidosis caused by an underlying metabolic disorder, or an acute abdomen warrant additional evaluation. Based on the suspected diagnosis, basic laboratory testing may include urinalysis, urine pregnancy testing, complete blood count, comprehensive metabolic panel, amylase and lipase levels, thyroid-stimulating hormone level, and stool studies with cultures. Imaging studies include abdominal radiography, ultrasonography, and computed tomography. Computed tomography of the head should be performed if an acute intracranial process is suspected. Chronic nausea and vomiting is defined by symptoms that persist for at least one month. Patients with risk factors for gastric malignancies or alarm symptoms should be evaluated with esophagogastroduodenoscopy. If gastroparesis is suspected, a gastric emptying study is recommended. In addition to functional causes, it is also important to consider psychiatric causes when evaluating patients with chronic nausea and vomiting.

Nausea and vomiting is a common presenting symptom in primary care. Diagnostic and management strategies vary depending on the duration of symptoms. This article addresses acute and chronic nausea and vomiting, with illustrative cases.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Findings from the history and physical examination should guide diagnostic testing in patients with nausea and vomiting.

C

18

Acute nausea and vomiting in the absence of alarm symptoms (e.g., altered mental status, abdominal pain, hematochezia, melena, focal neurologic deficit) may initially be treated supportively.

C

31

Ginger is effective at relieving nausea in pregnant women.

A

36, 37


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, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Findings from the history and physical examination should guide diagnostic testing in patients with nausea and vomiting.

C

18

Acute nausea and vomiting in the absence of alarm symptoms (e.g., altered mental status, abdominal pain, hematochezia, melena, focal neurologic deficit) may initially be treated supportively.

C

31

Ginger is effective at relieving nausea in pregnant women.

A

36, 37


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, go to http://www.aafp.org/afpsort.

Acute Nausea and Vomiting

ILLUSTRATIVE CASE

A 49-year-old woman with type 2 diabetes mellitus presents with a three-day history of acute-onset nausea and intermittent vomiting. She rapidly becomes nauseous when eating solid food. She does not have fever, chills, abdominal pain, diarrhea, hematochezia, melena, or constipation. Over-the-counter antacids have been ineffective. Blood glucose measurements taken at home have been less than 180 mg per dL (10.0 mmol per L).

PRESENTATION

The duration of nausea and vomiting, associated symptoms, and alleviating and exacerbating factors can help determine the likely cause (Table 1).14 [ corrected] Physicians should ask about exposure to toxins; suspect food; sick contacts; and recent radiation therapy, surgery, or chemotherapy. The absence of significant abdominal pain, headaches, and other alarm signs or symptoms can narrow the differential diagnosis.

View/Print Table

Table 1.

Presentations of Nausea and Vomiting That Suggest Specific Diagnoses

Clinical presentationSuggested diagnosesSuggested tests

Acute onset

Cholecystitis, gastroenteritis, medication-related effect, pancreatitis

Cholecystitis: right upper-quadrant ultrasonography1

Pancreatitis: amylase and lipase levels, ultrasonography to assess for gallstones, contrast-enhanced abdominal computed tomography in patients with severe illness2

Associated with diarrhea, headache, and myalgias

Viral gastroenteritis

None

Bilious vomiting

Small bowel obstruction

Abdominal radiography or computed tomography4

Continuous vomiting

Conversion disorders

Electrolyte levels

Delayed vomiting (more than one hour after meals)

Gastric outlet obstruction, gastroparesis

Obstruction: abdominal radiography4

Gastroparesis: gastric emptying study3

Feculent or foul odor to vomitus

Intestinal obstruction

Abdominal radiography4

Habitual postprandial, irregular vomiting

Major depression

Patient Health Questionnaire-9, Beck Depression Inventory

Insidious onset

Gastroesophageal reflux, gastroparesis, medication-related effect, metabolic disorders, pregnancy

Gastroesophageal reflux: esophagogastroduodenoscopy if patient has warning signs or does not improve with empiric therapy

Gastroparesis: gastric emptying study3

Metabolic disorders: pulse oximetry, arterial blood gases, serum chemistries, chest radiography

Pregnancy: pregnancy test in women of childbearing age, with pelvic ultrasonography if ectopic pregnancy is suspected

Patient report of previous organic or functional gastrointestinal illness

Chronic psychogenic vomiting

Electrolyte levels, further evaluation if organic cause is suspected

Projectile vomiting, may not be preceded by nausea

Intracranial disorders, increased intracranial pressure (also associated with normal emesis)

Brain computed tomography

Regurgitation of undigested food

Achalasia, esophageal stricture, Zenker diverticulum

Esophagogastroduodenoscopy, upper gastrointestinal barium study

Vomiting before breakfast

Alcohol ingestion, increased intracranial pressure, pregnancy, uremia

Increased intracranial pressure: brain computed tomography

Pregnancy: pregnancy test in women of childbearing age, with pelvic ultrasonography if ectopic pregnancy is suspected

Uremia: renal function testing, electrolyte levels

Vomiting during or soon after meals

Anorexia, bulimia

Electrolyte levels

Vomiting partly digested food or chyme several hours after meals

Gastric outlet obstruction (no bile), gastroparesis

Obstruction: abdominal radiography4


Information from references 1 through 4.

Table 1.

Presentations of Nausea and Vomiting That Suggest Specific Diagnoses

Clinical presentationSuggested diagnosesSuggested tests

Acute onset

Cholecystitis, gastroenteritis, medication-related effect, pancreatitis

Cholecystitis: right upper-quadrant ultrasonography1

Pancreatitis: amylase and lipase levels, ultrasonography to assess for gallstones, contrast-enhanced abdominal computed tomography in patients with severe illness2

Associated with diarrhea, headache, and myalgias

Viral gastroenteritis

None

Bilious vomiting

Small bowel obstruction

Abdominal radiography or computed tomography4

Continuous vomiting

Conversion disorders

Electrolyte levels

Delayed vomiting (more than one hour after meals)

Gastric outlet obstruction, gastroparesis

Obstruction: abdominal radiography4

Gastroparesis: gastric emptying study3

Feculent or foul odor to vomitus

Intestinal obstruction

Abdominal radiography4

Habitual postprandial, irregular vomiting

Major depression

Patient Health Questionnaire-9, Beck Depression Inventory

Insidious onset

Gastroesophageal reflux, gastroparesis, medication-related effect, metabolic disorders, pregnancy

Gastroesophageal reflux: esophagogastroduodenoscopy if patient has warning signs or does not improve with empiric therapy

Gastroparesis: gastric emptying study3

Metabolic disorders: pulse oximetry, arterial blood gases, serum chemistries, chest radiography

Pregnancy: pregnancy test in women of childbearing age, with pelvic ultrasonography if ectopic pregnancy is suspected

Patient report of previous organic or functional gastrointestinal illness

Chronic psychogenic vomiting

Electrolyte levels, further evaluation if organic cause is suspected

Projectile vomiting, may not be preceded by nausea

Intracranial disorders, increased intracranial pressure (also associated with normal emesis)

Brain computed tomography

Regurgitation of undigested food

Achalasia, esophageal stricture, Zenker diverticulum

Esophagogastroduodenoscopy, upper gastrointestinal barium study

Vomiting before breakfast

Alcohol ingestion, increased intracranial pressure, pregnancy, uremia

Increased intracranial pressure: brain computed tomography

Pregnancy: pregnancy test in women of childbearing age, with pelvic ultrasonography if ectopic pregnancy is suspected

Uremia: renal function testing, electrolyte levels

Vomiting during or soon after meals

Anorexia, bulimia

Electrolyte levels

Vomiting partly digested food or chyme several hours after meals

Gastric outlet obstruction (no bile), gastroparesis

Obstruction: abdominal radiography4


Information from references 1 through 4.

Assessment of the patient's hydration status and vital signs can help determine the severity of the illness and whether outpatient therapy is appropriate. The physical examination should evaluate for acute abdominal or intracranial processes and other causes (Table 2).516 [ corrected] If musculoskeletal pain is suspected, an increase in abdominal pain with tensing of abdominal muscles (i.e., Carnett sign) suggests that the abdominal wall is the source.17 The absence of severe abdominal pain and hematochezia excludes gastrointestinal malignancy (negative predictive value = 99%) and gastrointestinal ulcers (negative predictive value = 97%).8 Conversely, abdominal pain relieved by vomiting suggests bowel obstruction (specificity = 94%).15

View/Print Table

Table 2.

Diagnostic Accuracy of Clinical Findings Associated with Nausea and Vomiting in Adults

Clinical findingsDiagnosisStatistical associations

Abdominal pain before vomiting5,6

Appendicitis

99% sensitivity, 64% specificity

LR+ = 2.7, LR– = 0.02

PPV = 47.4%, NPV = 99.3% (based on pretest probability of 25%)

Abdominal pain with nausea7

Acute cholecystitis

77% sensitivity, 36% specificity

LR+ = 1.2, LR– = 0.6

PPV = 12%, NPV = 93% (based on pretest probability of 10%)

Abdominal pain with nausea or vomiting5,6

Appendicitis

58% sensitivity, 37% specificity for nausea

51% sensitivity, 45% specificity for vomiting

LR+ = 0.9, LR– = 1.1

PPV = 24%, NPV = 73% (based on pretest probability of 25%)

Abdominal pain with vomiting7

Acute cholecystitis

71% sensitivity, 53% specificity

LR+ = 1.5, LR– = 0.6

PPV = 14.3%, NPV = 94.2% (based on pretest probability of 10%)

Alarm signs when evaluating dyspepsia (e.g., anemia, black or bloody stools, dysphagia, jaundice, weight loss)8

Cancer

PPV = 3% (if at least one symptom), NPV = 99%

Ulcer

PPV = 10% (if at least one symptom), NPV = 97%

Dyspepsia with vomiting9

Peptic ulcer disease

33% sensitivity, 75% specificity

LR+ = 1.3, LR– = 0.9

PPV = 31%, NPV = 77% (based on pretest probability of 25%)

Dyspepsia with water brash (i.e., regurgitation of sour or tasteless fluid)9

Peptic ulcer disease

42% sensitivity, 77% specificity

LR+ = 1.8, LR– = 0.8

PPV = 38%, NPV = 80% (based on pretest probability of 25%)

Exclusion criteria in women of childbearing age: no pain migration, bilateral tenderness, absence of nausea and vomiting10

Appendicitis

99% sensitivity, 33.9% specificity

LR+ = 1.5, LR– = 0.03

Global impressions of gastroenterologist11

Esophagitis

62% sensitivity, 81% specificity

Ulcer

55% sensitivity, 84% specificity

LR+ = 3.4, LR– = 0.5

Global impressions of primary care physician11

Esophagitis

62% sensitivity, 71% specificity

Ulcer

61% sensitivity, 73% specificity

LR+ = 2.3, LR– = 0.5

Headache aggravated by exertion or Valsalva maneuver12

Intracranial pathology

LR+ = 2.3

Headache, cluster-type12

Intracranial pathology

LR+ = 11

Headache, undefined12

Intracranial pathology

LR+ = 3.8

Headache with abnormal neurologic findings12

Intracranial pathology

LR+ = 5.3

Headache with at least four of the following: pulsatile quality, duration of four to 72 hours, unilateral location, nausea or vomiting, disabling intensity12

Migraine

LR+ = 24

Headache with aura12

Intracranial pathology

LR+ = 3.2

Headache with vomiting12

Intracranial pathology

LR+ = 1.8

Nausea13

Celiac disease

20% sensitivity, 74% specificity

LR+ = 0.8, LR– = 1.1

PPV = 1.5%, NPV = 97.8% (based on pretest probability of 2%)

Nonspecific abdominal pain with nausea14

Diagnosis requiring urgent intervention

80% sensitivity, 36% specificity

LR+ = 1.3, LR– = 0.6

PPV = 41.2%, NPV = 76.8% (based on pretest probability of 35%)

Nonspecific abdominal pain with vomiting14

Diagnosis requiring urgent intervention

43% sensitivity, 68% specificity

LR+ = 1.3, LR– = 0.8

PPV = 41.2%, NPV = 68.9% (based on pretest probability of 35%)

Relief of abdominal pain by vomiting15

Bowel obstruction

27% sensitivity, 94% specificity

LR+ = 4.5, LR– = 0.8

Vomiting16

Abnormal radiography findings (e.g., bowel obstruction, kidney stones, gallstones)

LR+ = 1.8

PPV = 17% (based on pretest probability of 10%)


LR+ = positive likelihood ratio; LR– = negative likelihood ratio; NPV = negative predictive value; PPV = positive predictive value.

Information from references 5 through 16.

Table 2.

Diagnostic Accuracy of Clinical Findings Associated with Nausea and Vomiting in Adults

Clinical findingsDiagnosisStatistical associations

Abdominal pain before vomiting5,6

Appendicitis

99% sensitivity, 64% specificity

LR+ = 2.7, LR– = 0.02

PPV = 47.4%, NPV = 99.3% (based on pretest probability of 25%)

Abdominal pain with nausea7

Acute cholecystitis

77% sensitivity, 36% specificity

LR+ = 1.2, LR– = 0.6

PPV = 12%, NPV = 93% (based on pretest probability of 10%)

Abdominal pain with nausea or vomiting5,6

Appendicitis

58% sensitivity, 37% specificity for nausea

51% sensitivity, 45% specificity for vomiting

LR+ = 0.9, LR– = 1.1

PPV = 24%, NPV = 73% (based on pretest probability of 25%)

Abdominal pain with vomiting7

Acute cholecystitis

71% sensitivity, 53% specificity

LR+ = 1.5, LR– = 0.6

PPV = 14.3%, NPV = 94.2% (based on pretest probability of 10%)

Alarm signs when evaluating dyspepsia (e.g., anemia, black or bloody stools, dysphagia, jaundice, weight loss)8

Cancer

PPV = 3% (if at least one symptom), NPV = 99%

Ulcer

PPV = 10% (if at least one symptom), NPV = 97%

Dyspepsia with vomiting9

Peptic ulcer disease

33% sensitivity, 75% specificity

LR+ = 1.3, LR– = 0.9

PPV = 31%, NPV = 77% (based on pretest probability of 25%)

Dyspepsia with water brash (i.e., regurgitation of sour or tasteless fluid)9

Peptic ulcer disease

42% sensitivity, 77% specificity

LR+ = 1.8, LR– = 0.8

PPV = 38%, NPV = 80% (based on pretest probability of 25%)

Exclusion criteria in women of childbearing age: no pain migration, bilateral tenderness, absence of nausea and vomiting10

Appendicitis

99% sensitivity, 33.9% specificity

LR+ = 1.5, LR– = 0.03

Global impressions of gastroenterologist11

Esophagitis

62% sensitivity, 81% specificity

Ulcer

55% sensitivity, 84% specificity

LR+ = 3.4, LR– = 0.5

Global impressions of primary care physician11

Esophagitis

62% sensitivity, 71% specificity

Ulcer

61% sensitivity, 73% specificity

LR+ = 2.3, LR– = 0.5

Headache aggravated by exertion or Valsalva maneuver12

Intracranial pathology

LR+ = 2.3

Headache, cluster-type12

Intracranial pathology

LR+ = 11

Headache, undefined12

Intracranial pathology

LR+ = 3.8

Headache with abnormal neurologic findings12

Intracranial pathology

LR+ = 5.3

Headache with at least four of the following: pulsatile quality, duration of four to 72 hours, unilateral location, nausea or vomiting, disabling intensity12

Migraine

LR+ = 24

Headache with aura12

Intracranial pathology

LR+ = 3.2

Headache with vomiting12

Intracranial pathology

LR+ = 1.8

Nausea13

Celiac disease

20% sensitivity, 74% specificity

LR+ = 0.8, LR– = 1.1

PPV = 1.5%, NPV = 97.8% (based on pretest probability of 2%)

Nonspecific abdominal pain with nausea14

Diagnosis requiring urgent intervention

80% sensitivity, 36% specificity

LR+ = 1.3, LR– = 0.6

PPV = 41.2%, NPV = 76.8% (based on pretest probability of 35%)

Nonspecific abdominal pain with vomiting14

Diagnosis requiring urgent intervention

43% sensitivity, 68% specificity

LR+ = 1.3, LR– = 0.8

PPV = 41.2%, NPV = 68.9% (based on pretest probability of 35%)

Relief of abdominal pain by vomiting15

Bowel obstruction

27% sensitivity, 94% specificity

LR+ = 4.5, LR– = 0.8

Vomiting16

Abnormal radiography findings (e.g., bowel obstruction, kidney stones, gallstones)

LR+ = 1.8

PPV = 17% (based on pretest probability of 10%)


LR+ = positive likelihood ratio; LR– = negative likelihood ratio; NPV = negative predictive value; PPV = positive predictive value.

Information from references 5 through 16.

Table 3 lists common and uncommon causes of acute nausea and vomiting.18 Self-limited viral gastroenteritis is the most common cause.19 Approximately 179 million episodes of acute gastroenteritis occur each year in the United States and result in roughly 600,000 hospitalizations. Although this illness typically resolves in three to five days, it results in significant time lost from work and accounts for an estimated $1 billion per year in direct and indirect costs.20 Only 20% of acute gastroenteritis cases are attributed to a specific etiology.2123 Viruses are the most common cause; norovirus is the most common in adults.

View/Print Table

Table 3.

Differential Diagnosis of Nausea and Vomiting in Adults

Central nervous system

Common

Benign positional vertigo

Migraine

Motion sickness

Uncommon

Cerebrovascular event

Closed head injury

Hydrocephalus

Mass lesion

Meniere disease

Meningitis

Pseudotumor cerebri

Seizure disorder

Gastrointestinal

Common

Appendicitis

Cholecystitis

Cholelithiasis

Gastritis

Gastroesophageal reflux disease

Gastroparesis

Irritable bowel syndrome

Peptic ulcer disease

Uncommon

Adhesions

Esophageal motility disorders

Incarcerated hernia

Intestinal obstruction

Mesenteric ischemia

Pancreatitis

Peritonitis

Infections

Common

Bacterial gastroenteritis

Foodborne illness

Pyelonephritis

Viral gastroenteritis

Uncommon

Brain abscess

Encephalitis

Meningitis

Pneumonia

Metabolic

Common

Diabetic ketoacidosis

Pregnancy

Uremia

Uncommon

Adrenal disorders

Parathyroid disorders

Thyroid disorders

Medications and toxins

Antiarrhythmics, antibiotics, anticonvulsants, arsenic, chemotherapeutics, digoxin, estrogens, ethanol overdose, nonsteroidal anti-inflammatory drugs, opiates, organophosphates and pesticides, overdoses and withdrawal, radiation therapy or exposure, ricin

Other

Acute glaucoma, acute myocardial infarction, nephrolithiasis, pain, psychiatric disorder


Information from reference 18.

Table 3.

Differential Diagnosis of Nausea and Vomiting in Adults

Central nervous system

Common

Benign positional vertigo

Migraine

Motion sickness

Uncommon

Cerebrovascular event

Closed head injury

Hydrocephalus

Mass lesion

Meniere disease

Meningitis

Pseudotumor cerebri

Seizure disorder

Gastrointestinal

Common

Appendicitis

Cholecystitis

Cholelithiasis

Gastritis

Gastroesophageal reflux disease

Gastroparesis

Irritable bowel syndrome

Peptic ulcer disease

Uncommon

Adhesions

Esophageal motility disorders

Incarcerated hernia

Intestinal obstruction

Mesenteric ischemia

Pancreatitis

Peritonitis

Infections

Common

Bacterial gastroenteritis

Foodborne illness

Pyelonephritis

Viral gastroenteritis

Uncommon

Brain abscess

Encephalitis

Meningitis

Pneumonia

Metabolic

Common

Diabetic ketoacidosis

Pregnancy

Uremia

Uncommon

Adrenal disorders

Parathyroid disorders

Thyroid disorders

Medications and toxins

Antiarrhythmics, antibiotics, anticonvulsants, arsenic, chemotherapeutics, digoxin, estrogens, ethanol overdose, nonsteroidal anti-inflammatory drugs, opiates, organophosphates and pesticides, overdoses and withdrawal, radiation therapy or exposure, ricin

Other

Acute glaucoma, acute myocardial infarction, nephrolithiasis, pain, psychiatric disorder


Information from reference 18.

DIAGNOSTIC STRATEGY

Figure 1 outlines a suggested approach to the evaluation of nausea and vomiting in adults. Most conditions can be diagnosed by findings from the history and physical examination. Diagnostic testing may be warranted in patients with signs of significant dehydration (e.g., decreased urine output, skin tenting, dry mucous membranes), signs of acidosis caused by diabetic ketoacidosis or another underlying disorder (e.g., markedly increased respiratory rate, fruity odor to breath, altered mental status), severe abdominal pain or distension, hematochezia, jaundice, melena, severe headache, urinary tract infection symptoms, abdominal pain relieved by vomiting, hematemesis, or feculent vomiting.18  If any of these signs or symptoms are present, initial evaluation and testing can be guided by the suggested diagnoses in Table 1.14

View/Print Figure

Evaluation of Nausea and Vomiting

Figure 1.

Suggested algorithm for evaluating nausea and vomiting in adults.

Evaluation of Nausea and Vomiting


Figure 1.

Suggested algorithm for evaluating nausea and vomiting in adults.

IMAGING

Abdominal radiography is helpful in detecting bowel obstructions and kidney stones.4 Computed tomography of the abdomen is useful for detecting infections (e.g., appendicitis, cholecystitis) and for additional testing for bowel obstruction and kidney stones that are not detected on radiography.24 In adults, abdominal radiography combined with clinical examination and laboratory analysis (complete blood count and basic metabolic panel) is useful for predicting the need for urgent intervention in the first 24 hours of illness (sensitivity = 56%; specificity = 81%).4 Table 4 lists the accuracy of diagnostic tests in adults with nausea and vomiting.1,2,2529 [ corrected]

View/Print Table

Table 4.

Accuracy of Diagnostic Tests in Adults with Nausea and Vomiting

Suspected diagnosisTest resultsStatistical associations

Appendicitis25

Abdominal ultrasonography

78% sensitivity, 83% specificity

LR+ =4.6, LR– = 0.3

PPV = 53%, NPV = 94% (based on pretest probability of 20%)

Multidetector abdominal and pelvic computed tomography

94% sensitivity, 95% specificity

LR+ = 19, LR– = 4.7

PPV = 82%, NPV = 98% (based on pretest probability of 20%)

Cholecystitis1

Hepatobiliary iminodiacetic acid scan (visualization of gallbladder in less than one hour indicates normal result)

LR+ = 4.2, LR– = 0.04

PPV = 64.3%, NPV = 98.3% (based on pretest probability of 30%)

Right upper-quadrant ultrasonography

LR+ = 2.6, LR– = 0.5

PPV = 52.7%, NPV = 81.8% (based on pretest probability of 30%)

Helicobacter pylori infection26

Abnormal serum immunoglobulin G level

95% sensitivity, 91% specificity

LR+ = 10.2, LR– = 0.05

PPV = 81.5%, NPV = 97.9% (based on pretest probability of 30%)

Urea breath test

100% sensitivity and specificity

LR+ = 199, LR– = 0.01

PPV = 98.8%, NPV = 99.8% (based on pretest probability of 30%)

Pancreatic cancer2

Echo-enhanced power Doppler ultrasonography

LR+ = 16, LR– = 0.1

PPV = 79.6%, NPV = 96.6% (based on pretest probability of 20%)

Pancreatitis27

Amylase > 300 U per L (5.01 μkat per L)

LR+ = 9.4, LR– = 0.2

PPV = 86.3%, NPV = 90.1% (based on pretest probability of 40%)

Isoamylase > 455 U per L

LR+ = 115, LR– = 0.08

PPV = 98.7%, NPV = 94.9% (based on pretest probability of 40%)

Lipase > 135 U per L (2.25 μkat per L)

LR+ = 5.8, LR– = 0.01

PPV = 79.5%, NPV = 99.3% (based on pretest probability of 40%)

Pancreatitis (alcohol-related)28

Lipase-to-amylase ratio > 5

LR+ = 31, LR– = 0.3

PPV = 95.4%, NPV = 83.3% (based on pretest probability of 40%)

Pancreatitis (gallstone)29

Abnormal alanine transaminase level

LR+ = 2.8, LR– = 0.4

PPV = 80.8%, NPV = 62.5% (based on pretest probability of 60%)

AST > 60 U per L (1.00 μkat per L) and AST at 48 hours > AST on admission

LR+ = 7.2, LR– = 0.2

PPV = 91.5%, NPV = 76.9% (based on pretest probability of 60%)


AST = aspartate transaminase; LR+ = positive likelihood ratio; LR– = negative likelihood ratio; NPV = negative predictive value; PPV = positive predictive value.

Information from references 1, 2, and 25 through 29.

Table 4.

Accuracy of Diagnostic Tests in Adults with Nausea and Vomiting

Suspected diagnosisTest resultsStatistical associations

Appendicitis25

Abdominal ultrasonography

78% sensitivity, 83% specificity

LR+ =4.6, LR– = 0.3

PPV = 53%, NPV = 94% (based on pretest probability of 20%)

Multidetector abdominal and pelvic computed tomography

94% sensitivity, 95% specificity

LR+ = 19, LR– = 4.7

PPV = 82%, NPV = 98% (based on pretest probability of 20%)

Cholecystitis1

Hepatobiliary iminodiacetic acid scan (visualization of gallbladder in less than one hour indicates normal result)

LR+ = 4.2, LR– = 0.04

PPV = 64.3%, NPV = 98.3% (based on pretest probability of 30%)

Right upper-quadrant ultrasonography

LR+ = 2.6, LR– = 0.5

PPV = 52.7%, NPV = 81.8% (based on pretest probability of 30%)

Helicobacter pylori infection26

Abnormal serum immunoglobulin G level

95% sensitivity, 91% specificity

LR+ = 10.2, LR– = 0.05

PPV = 81.5%, NPV = 97.9% (based on pretest probability of 30%)

Urea breath test

100% sensitivity and specificity

LR+ = 199, LR– = 0.01

PPV = 98.8%, NPV = 99.8% (based on pretest probability of 30%)

Pancreatic cancer2

Echo-enhanced power Doppler ultrasonography

LR+ = 16, LR– = 0.1

PPV = 79.6%, NPV = 96.6% (based on pretest probability of 20%)

Pancreatitis27

Amylase > 300 U per L (5.01 μkat per L)

LR+ = 9.4, LR– = 0.2

PPV = 86.3%, NPV = 90.1% (based on pretest probability of 40%)

Isoamylase > 455 U per L

LR+ = 115, LR– = 0.08

PPV = 98.7%, NPV = 94.9% (based on pretest probability of 40%)

Lipase > 135 U per L (2.25 μkat per L)

LR+ = 5.8, LR– = 0.01

PPV = 79.5%, NPV = 99.3% (based on pretest probability of 40%)

Pancreatitis (alcohol-related)28

Lipase-to-amylase ratio > 5

LR+ = 31, LR– = 0.3

PPV = 95.4%, NPV = 83.3% (based on pretest probability of 40%)

Pancreatitis (gallstone)29

Abnormal alanine transaminase level

LR+ = 2.8, LR– = 0.4

PPV = 80.8%, NPV = 62.5% (based on pretest probability of 60%)

AST > 60 U per L (1.00 μkat per L) and AST at 48 hours > AST on admission

LR+ = 7.2, LR– = 0.2

PPV = 91.5%, NPV = 76.9% (based on pretest probability of 60%)


AST = aspartate transaminase; LR+ = positive likelihood ratio; LR– = negative likelihood ratio; NPV = negative predictive value; PPV = positive predictive value.

Information from references 1, 2, and 25 through 29.

Right upper-quadrant ultrasonography is used to evaluate for gallstones. Hepatobiliary iminodiacetic acid scans can determine whether delayed gallbladder emptying is the cause of nausea and abdominal pain when initial ultrasonography is negative.

Migraine should be diagnosed in patients who have headaches with at least four of the following characteristics: pulsatile quality, duration of four to 72 hours, unilateral location, nausea or vomiting, and disabling intensity (likelihood ratio = 24).12 Cluster-type headaches, headaches with abnormal neurologic findings, undefined headaches, and headaches aggravated by exertion or the Valsalva maneuver are more likely to have associated intracranial pathology (likelihood ratio = 11, 5, 4, and 2, respectively).12 Computed tomography or magnetic resonance imaging of the brain should be ordered for patients with these symptoms, and in those with other abnormal neurologic signs or symptoms.

MANAGEMENT

For the patient described previously, the focus should be on determining the severity of illness from the history and physical examination findings. Treatment should be supportive, including limiting foods likely to trigger vomiting and providing antiemetics with an appropriate hydration strategy. Patients with mild to moderate dehydration may benefit from oral rehydration therapy (i.e., a combination of electrolytes, glucose, and water) or sports drinks.30

Commonly prescribed antiemetics include promethazine, metoclopramide (Reglan), prochlorperazine, and ondansetron (Zofran; Table 5).3135 In pregnant women, ginger (250 mg four times per day) reduces nausea and vomiting in 84% of patients compared with placebo.36,37

View/Print Table

Table 5.

Treatment of Nausea and Vomiting in Adults

CauseTreatment

Benign positional vertigo

Meclizine (Antivert)

Benign, self-limited, no alarm signs

Cola, ginger ale, mints, oral rehydration, supportive therapy, treatment of underlying cause

Gastroenteritis

Ondansetron (Zofran), promethazine

Gastroesophageal reflux disease, gastritis

Histamine H2 antagonist, proton pump inhibitor

Gastroparesis

Erythromycin, metoclopramide (Reglan)

Migraine

Metoclopramide, nonsteroidal anti-inflammatory drugs, prochlorperazine plus antihistamines (NNT = 5)32

Motion sickness

Antihistamines, scopolamine

Peptic ulcer disease

Proton pump inhibitor (NNT = 3)33

Pregnancy

Doxylamine (Unisom), ginger, vitamin B6

Renal colic

Intravenous or intramuscular nonsteroidal anti-inflammatory drugs, with or without opioids (NNT = 16)34,35


NNT = number needed to treat.

Information from references 31 through 35.

Table 5.

Treatment of Nausea and Vomiting in Adults

CauseTreatment

Benign positional vertigo

Meclizine (Antivert)

Benign, self-limited, no alarm signs

Cola, ginger ale, mints, oral rehydration, supportive therapy, treatment of underlying cause

Gastroenteritis

Ondansetron (Zofran), promethazine

Gastroesophageal reflux disease, gastritis

Histamine H2 antagonist, proton pump inhibitor

Gastroparesis

Erythromycin, metoclopramide (Reglan)

Migraine

Metoclopramide, nonsteroidal anti-inflammatory drugs, prochlorperazine plus antihistamines (NNT = 5)32

Motion sickness

Antihistamines, scopolamine

Peptic ulcer disease

Proton pump inhibitor (NNT = 3)33

Pregnancy

Doxylamine (Unisom), ginger, vitamin B6

Renal colic

Intravenous or intramuscular nonsteroidal anti-inflammatory drugs, with or without opioids (NNT = 16)34,35


NNT = number needed to treat.

Information from references 31 through 35.

Chronic Nausea and Vomiting

ILLUSTRATIVE CASE

The patient described previously returns two months later with intermittent nausea and vomiting that is much less severe than on initial presentation. Her current symptoms have lasted two days, and she has had six bouts of emesis. She has no fever, chills, or headache, but has intermittent epigastric discomfort associated with nausea and vomiting. Her symptoms are not relieved by antacids, and she has no melena or blood in her stool. She says she feels full quickly when eating and often feels bloated. She has not had contact with any sick persons or toxins, does not drink alcohol, and appears well hydrated.

BACKGROUND

Chronic nausea and vomiting is defined by symptoms that persist for at least one month. A history and physical examination can help determine the most likely cause. A food and nausea diary may help determine patterns of symptoms and triggers. Diagnostic testing, including imaging and laboratory evaluation, may be indicated based on history and physical examination findings. Esophagogastroduodenoscopy may be necessary depending on the course and the results of diagnostic testing.

DIAGNOSTIC STRATEGY

Diabetes-associated gastroparesis, gastroesophageal reflux disease, gastritis, and gastric ulcer are common causes of chronic nausea and vomiting. Initial testing should be guided by findings from the history and physical examination. Esophagogastroduodenoscopy is recommended in patients with risk factors or alarm signs (e.g., age older than 55 years, unintended weight loss, progressive dysphagia, persistent vomiting, evidence of gastrointestinal bleeding, family history of gastrointestinal cancer).38

For this patient, the chronic nature of her symptoms and the waxing and waning course suggest that the most likely cause is diabetes-associated gastroparesis. In this patient and in others with suspected gastroparesis, a gastric emptying study should be performed.3

In patients with recurrent or chronic nausea and vomiting who also have abdominal pain with no definable physiologic cause, physicians should consider major depressive disorders, schizophrenia, somatoform and somatization disorders, hypochondriasis, factitious disorder, pain disorder, and generalized anxiety disorder. The Carnett sign can also support or exclude a diagnosis of psychogenic abdominal pain (positive likelihood ratio = 2.91 [95% confidence interval, 2.71 to 3.13]; negative likelihood ratio = 0.19 [95% confidence interval, 0.11 to 0.34]).39

MANAGEMENT

A gastric emptying study can detect delayed solid and liquid emptying, which may be present in up to 55% of patients with diabetes. Enhancing glycemic control in these patients can improve symptoms. In addition, a low-fat and low-residue diet that includes small, frequent meals may reduce symptoms of gastroparesis. If possible, medications that delay gastric emptying (e.g., opioids, calcium channel blockers, anticholinergics) should be discontinued.40 Alcohol, cannabis, and nicotine also delay gastric emptying.

Impaired gastric emptying may be treated with metoclopramide or erythromycin, which result in up to 60% improvement in symptoms.3 However, symptom relief must be balanced against the risk of Parkinson-like symptoms or tardive dyskinesia with the use of metoclopramide and the risk of tachyphylaxis with the use of erythromycin, which limits its long-term effectiveness. Patients with gastroparesis and significant weight loss, recurrent dehydration, or electrolyte disturbances should be referred to a gastroenterologist for possible endoscopic therapies and nutritional supplementation.40

Gastritis is suggested by the presence of dyspepsia symptoms, including postprandial fullness, early satiety, epigastric pain, or burning. Helicobacter pylori testing should be performed,41 and, if negative, a gastric emptying study and esophagogastroduodenoscopy can be conducted, particularly if nausea and vomiting persists. Patients with dyspepsia who are not taking nonsteroidal anti-inflammatory drugs and who have negative H. pylori serology are unlikely to have a gastric ulcer.42

Data Sources: A PubMed search was completed in Clinical Queries using the key terms nausea and vomiting, diagnosis, and treatment. Also searched were Essential Evidence Plus and the Cochrane database. The search included meta-analyses, randomized controlled trials, and reviews. Search dates: March 10, 2012, and August 20, 2012.

The Authors

show all author info

WILLIAM D. ANDERSON, III, MD, is the chief medical officer and associate dean for clinical affairs, and an associate professor in the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine in Columbia....

SCOTT M. STRAYER, MD, MPH, is vice chairman and a professor in the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine.

Address correspondence to William D. Anderson, III, MD, University of South Carolina School of Medicine, 15 Medical Park, Suite 300, Columbia, SC 29203 (e-mail: william.anderson@uscmed.sc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. American College of Radiology. ACR Appropriateness Criteria: right upper quadrant pain. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightUpperQuadrantPain.pdf. Accessed May 14, 2013....

2. American College of Radiology. ACR Appropriateness Criteria: acute pancreatitis. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AcutePancreatitis.pdf. Accessed May 14, 2013.

3. Parkman HP, Hasler WL, Fisher RS; American Gastroenterological Association. American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology. 2004;127(5):1592–1622.

4. Smith JE, Hall EJ. The use of plain abdominal x rays in the emergency department. Emerg Med J. 2009;26(3):160–163.

5. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589–1594.

6. Witt K, Mäkelä M, Olsen O. Likelihood ratios to determine ‘does this patient have appendicitis?’: comment and clarification. JAMA. 1997;278(10):819–820.

7. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? [published correction appears in JAMA. 2009; 302(7):739]. JAMA. 2003;289(1):80–86.

8. Meineche-Schmidt V, Jørgensen T. ‘Alarm symptoms’ in patients with dyspepsia: a three-year prospective study from general practice. Scand J Gastroenterol. 2002;37(9):999–1007.

9. Spiegelhalter DJ, Crean GP, Holden R, Knill-Jones RP. Taking a calculated risk: predictive scoring systems in dyspepsia. Scand J Gastroenterol Suppl. 1987;128:152–160.

10. Morishita K, Gushimiyagi M, Hashiguchi M, Stein GH, Tokuda Y. Clinical prediction rule to distinguish pelvic inflammatory disease from acute appendicitis in women of childbearing age. Am J Emerg Med. 2007;25(2):152–157.

11. Value of the unaided clinical diagnosis in dyspeptic patients in primary care. Am J Gastroenterol. 2001;96(5):1417–1421.

12. Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM. Does this patient with headache have a migraine or need neuroimaging? JAMA. 2006;296(10):1274–1283.

13. Vogelsang H, Genser D, Wyatt J, et al. Screening for celiac disease: a prospective study on the value of noninvasive tests. Am J Gastroenterol. 1995;90(3):394–398.

14. Gerhardt RT, Nelson BK, Keenan S, Kernan L, MacKersie A, Lane MS. Derivation of a clinical guideline for the assessment of nonspecific abdominal pain: the Guideline for Abdominal Pain in the ED Setting (GAPEDS) Phase 1 Study. Am J Emerg Med. 2005;23(6):709–717.

15. Böhner H, Yang Q, Franke C, Verreet PR, Ohmann C. Simple data from history and physical examination help to exclude bowel obstruction and to avoid radiographic studies in patients with acute abdominal pain. Eur J Surg. 1998;164(10):777–784.

16. Eisenberg RL, Heineken P, Hedgcock MW, Federle M, Goldberg HI. Evaluation of plain abdominal radiographs in the diagnosis of abdominal pain. Ann Intern Med. 1982;97(2):257–261.

17. Suleiman S, Johnston DE. The abdominal wall: an overlooked source of pain. Am Fam Physician. 2001;64(3):431–438.

18. Quigley EM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology. 2001;120(1):263–286.

19. Scallan E, Hoekstra RM, Angulo FJ, et al. Foodborne illness acquired in the United States—major pathogens. Emerg Infect Dis. 2011;17(1):7–15.

20. Skolnik NS, Albert RH. Essential Infectious Disease Topics for Primary Care. Totowa, N.J.: Humana Press; 2008.

21. Scallan E, Griffin PM, Angulo FJ, Tauxe RV, Hoekstra RM. Foodborne illness acquired in the United States—unspecified agents. Emerg Infect Dis. 2011;17(1):16–22.

22. Jones TF, McMillian MB, Scallan E, et al. A population-based estimate of the substantial burden of diarrhoeal disease in the United States; FoodNet, 1996–2003. Epidemiol Infect. 2007;135(2):293–301.

23. Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122(5):1500–1511.

24. Jacobs JE, Birnbaum BA, Macari M, et al. Acute appendicitis: comparison of helical CT diagnosis focused technique with oral contrast material versus nonfocused technique with oral and intravenous contrast material. Radiology. 2001;220(3):683–690.

25. Rosen MP, Ding A, Blake MA, et al. ACR Appropriateness Criteria right lower quadrant pain—suspected appendicitis. J Am Coll Radiol. 2011;8(11):749–755.

26. Gatta L, Ricci C, Tampieri A, et al. Accuracy of breath tests using low doses of 13C-urea to diagnose Helicobacter pylori infection: a randomised controlled trial. Gut. 2006;55(4):457–462.

27. Lin XZ, Wang SS, Tsai YT, et al. Serum amylase, isoamylase, and lipase in the acute abdomen. Their diagnostic value for acute pancreatitis. J Clin Gastroenterol. 1989;11(1):47–52.

28. Tenner SM, Steinberg W. The admission serum lipase:amylase ratio differentiates alcoholic from nonalcoholic acute pancreatitis. Am J Gastroenterol. 1992;87(12):1755–1758.

29. Mayer AD, McMahon MJ. Biochemical identification of patients with gallstones associated with acute pancreatitis on the day of admission to hospital. Ann Surg. 1985;201(1):68–75.

30. Weinberg AD, Minaker KL; Council on Scientific Affairs; American Medical Association. Dehydration. Evaluation and management in older adults. JAMA. 1995;274(19):1552–1556.

31. Scorza K, Williams A, Phillips JD, Shaw J. Evaluation of nausea and vomiting. Am Fam Physician. 2007;76(1):76–84.

32. Kostic MA, Gutierrez FJ, Rieg TS, Moore TS, Gendron RT. A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department. Ann Emerg Med. 2010;56(1):1–6.

33. Caro JJ, Salas M, Ward A. Healing and relapse rates in gastroesophageal reflux disease treated with the newer proton-pump inhibitors lansoprazole, rabeprazole, and pantoprazole compared with omeprazole, ranitidine, and placebo: evidence from randomized clinical trials. Clin Ther. 2001;23(7):998–1017.

34. Holdgate A, Pollock T. Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic [published correction appears in BMJ. 2004;329(7473):1019]. BMJ. 2004;328(7453):1401.

35. Safdar B, Degutis LC, Landry K, Vedere SR, Moscovitz HC, D'Onofrio G. Intravenous morphine plus ketorolac is superior to either drug alone for treatment of acute renal colic. Ann Emerg Med. 2006;48(2):173–181, 181.e1.

36. Smith C, Crowther C, Willson K, Hotham N, McMillian V. A randomized controlled trial of ginger to treat nausea and vomiting in pregnancy. Obstet Gynecol. 2004;103(4):639–645.

37. Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for nausea and vomiting in pregnancy: randomized, double-masked, placebo-controlled trial. Obstet Gynecol. 2001;97(4):577–582.

38. Dickerson LM, King DE. Evaluation and management of nonulcer dyspepsia. Am Fam Physician. 2004;70(1):107–114.

39. Takada T, Ikusaka M, Ohira Y, Noda K, Tsukamoto T. Diagnostic usefulness of Carnett's test in psychogenic abdominal pain. Intern Med. 2011;50(3):213–217.

40. Fukami N, Anderson MA, Khan K, et al.; ASGE Standards of Practice Committee. The role of endoscopy in gastroduodenal obstruction and gastroparesis. Gastrointest Endosc. 2011;74(1):13–21.

41. Delaney B, Ford AC, Forman D, Moayyedi P, Qume M. Initial management strategies for dyspepsia Cochrane Database Syst Rev. 2009;(4):CD001961.

42. Fraser AG, Ali MR, McCullough S, Yeates NJ, Haystead A. Diagnostic tests for Helicobacter pylori—can they help select patients for endoscopy? N Z Med J. 1996;109(1018):95–98.


 

Copyright © 2013 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in Pubmed

MOST RECENT ISSUE


Dec 1, 2016

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article