• Clinical science
  • Clinician

Nausea and vomiting


Nausea refers to an unpleasant sensation that is often localized to the abdomen and typically interpreted as an urge to vomit. Vomiting is the forceful oral expulsion of gastric contents. Common causes of nausea and/or vomiting include gastrointestinal pathologies, early pregnancy, and adverse effects of medications. However, nausea and vomiting may be caused by pathology in any organ system, including the CNS, endocrine, and vestibular systems, as well as be a manifesting symptom of a functional disorder. Patients presenting with acute onset of recurrent vomiting should be evaluated for signs of dehydration and electrolyte and acid-base disorders, which should be corrected at the earliest opportunity. A thorough history and physical examination should be performed to narrow down the differential diagnoses and guide further diagnostic workup and treatment. Accompanying symptoms (e.g., fever, abdominal pain, headache) may provide clues as to the underlying disorder. Nausea and vomiting in children are not addressed here.


Approach to management [1][2]

  • ABCDE survey
  • Establish IV access.
  • Perform screening examination and targeted diagnostics to rule out life-threatening causes (see below).
  • Once life-threatening causes have been ruled out:
  • Identify and treat hypovolemia (see fluid resuscitation).
  • Identify and treat electrolyte imbalance (see electrolyte repletion).
  • Identify and treat acid-base disorders.
  • Identify and treat the underlying cause.
  • Minimize or discontinue any contributing medications.
  • Administer antiemetic therapy.
  • Consider NPO diet.

Red flags for nausea and vomiting

Immediately life-threatening causes


The diagnostic workup should be guided by the pretest probability of the possible diagnoses. The following list includes some commonly used diagnostic tools that can help to diagnose or rule out possible etiologies in a patient with nausea and vomiting.

Laboratory studies

Routine [1] [2]

In patients with severe and sustained vomiting

Further diagnostic testing to consider based on localization of symptoms [1][2]

Laboratory studies Imaging and other interventions
  • N/a
  • N/a

In patients with suspected gastroenteritis without signs of sepsis, it may not be necessary to do any diagnostic testing.

Life-threatening causes of nausea and vomiting

Clinical features Diagnostic findings Acute management
Acute coronary syndrome [3][4]
Acute pancreatitis [5][6][7]
  • Severe epigastric pain that radiates to the back
  • Nausea, vomiting
  • Epigastric tenderness, guarding, rigidity
  • Upper abdominal pain
  • Hypoactive bowel sounds
  • History of gallstones or alcohol use
Mechanical bowel obstruction [8][9][10][11]
  • Colicky abdominal pain
  • Obstipation/bloating
  • Progressive nausea and vomiting (late finding)
  • Diffuse abdominal distention, tympanic abdomen, collapsed rectum on DRE
  • Tinkling bowel sounds
  • History of abdominal surgery
  • X-ray abdomen
    • Dilated bowel loops proximal to the obstruction
    • Rectal air shadow absent
    • Multiple air-fluid levels
  • CT abdomen with IV and oral contrast
    • Similar findings as on x-ray
    • Transition point at site of obstruction
DKA [12][13]
  • Polyuria, polydipsia
  • Nausea and vomiting
  • Signs of volume depletion
  • Altered mental status, coma
Meningitis [14][15][16]
Hyperemesis gravidarum [17][18][1][19]
  • Ketonuria
  • Electrolyte and acid-base abnormalities

Other causes of nausea and vomiting

Clinical features Diagnostic findings Acute management
Postoperative nausea and vomiting (PONV) [20][21]
  • Nausea and/or vomiting within the first 24–48 hours of surgery
  • Clinical diagnosis

Chemotherapy-induced nausea and vomiting (CINV) [22][23][24][22][25][26]

  • Clinical diagnosis

Uncomplicated first-trimester nausea and vomiting [17][18][1][19][27]

Infectious gastroenteritis [28][29][30][31][32]

  • Clinical diagnosis
  • Stool analysis: fecal leukocytes

Migraine [33]

  • Clinical diagnosis [33]
  • Neuroimaging: typically normal findings [34][35]

Medications are a common cause of nausea and vomiting. Consider replacing the medication with a suitable alternative or decreasing the dose and then slowly up titrating it to minimize this adverse effect.

Differential diagnosis

Infectious causes of nausea and vomiting

Noninfectious causes of nausea and vomiting

  • 1. Quigley EMM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology. 2001; 120(1): pp. 263–286. doi: 10.1053/gast.2001.20516.
  • 2. Anderson W, Strayer S,. Evaluation of Nausea and Vomiting in Adults: A Case-Based Approach. Am Fam Physician. 2013. url: https://www.aafp.org/afp/2013/0915/p371.html.
  • 3. O’Gara PT, Kushner FG, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation. 2013; 127(4). doi: 10.1161/cir.0b013e3182742cf6.
  • 4. E. A. Amsterdam, N. K. Wenger, R. G. Brindis, D. E. Casey Jr., T. G. Ganiats, D. R. Holmes Jr., A. S. Jaffe, H. Jneid, R. F. Kelly, M. C. Kontos, G. N. Levine, P. R. Liebson, D. Mukherjee, E. D. Peterson, M. S. Sabatine, R. W. Smalling, S. J. Zieman. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. Journal of the American College of Cardiology. 2014. doi: 10.1016/j.jacc.2014.09.017.
  • 5. Crockett et al. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018; 154(4): pp. 1096–1101. doi: 10.1053/j.gastro.2018.01.032.
  • 6. D Jeffrey. Acute Pancreatitis. AAFP. 2014. url: https://www.aafp.org/afp/2014/1101/p632.html.
  • 7. Vege SS, DiMagno MJ, Forsmark CE, Martel M, Barkun AN. Initial Medical Treatment of Acute Pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology. 2018; 154(4): pp. 1103–1139. doi: 10.1053/j.gastro.2018.01.031.
  • 8. Scheirey CD, Fowler KJ, et al. American College of Radiology ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain. https://acsearch.acr.org/docs/69467/Narrative/. Updated January 1, 2018. Accessed March 30, 2018.
  • 9. Katz SD, Baker EM, et al. American College of Radiology ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction. https://acsearch.acr.org/docs/69476/Narrative/. Updated January 1, 2013. Accessed June 3, 2019.
  • 10. Jackson PG, Raiji MT. Evaluation and Management of Intestinal Obstruction. American Family Physician. 2011; 83(2): pp. 159–165. pmid: 21243991.
  • 11. Griffiths S, Glancy DG. Intestinal obstruction. Surgery. ; 35(3): p. 3. doi: 10.1016/j.mpsur.2016.12.005.
  • 12. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care. 2009; 32(7): pp. 1335–1343. doi: 10.2337/dc09-9032.
  • 13. Westerberg D. Diabetic Ketoacidosis: Evaluation and Treatment. Am Fam Physician. 2013. url: https://www.aafp.org/afp/2013/0301/p337.html#afp20130301p337-b19.
  • 14. Bamberger DM. Diagnosis, initial management, and prevention of meningitis. Am Fam Physician. 2010; 82(12): pp. 1491–8. pmid: 21166369.
  • 15. Seehusen DA, Reeves MM, Fomin DA. Cerebrospinal fluid analysis. Am Fam Physician. 2003; 68(6): pp. 1103–1108. pmid: 14524396.
  • 16. Mount HR, Boyle SD. Aseptic and Bacterial Meningitis: Evaluation, Treatment, and Prevention. Am Fam Physician. 2017; 96(5): pp. 314–322. pmid: 28925647.
  • 17. Wegrzyniak LJ, Repke JT, Ural SH. Treatment of hyperemesis gravidarum. Reviews in obstetrics & gynecology. 2012; 5(2): pp. 78–84. pmid: 22866186.
  • 18. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 189: Nausea And Vomiting Of Pregnancy. Obstet Gynecol. 2018; 131(1): pp. e15–e30. doi: 10.1097/AOG.0000000000002456.
  • 19. Quinlan JD, Hill DA. Nausea and vomiting of pregnancy. Am Fam Physician. 2003; 68(1): pp. 121–128. url: https://www.aafp.org/afp/2003/0701/p121.html.
  • 20. Gan TJ, Diemunsch P, Habib AS, et al. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2014; 118(1): pp. 85–113. doi: 10.1213/ANE.0000000000000002.
  • 21. Pierre S, Whelan R. Nausea and vomiting after surgery. Continuing Education in Anaesthesia Critical Care & Pain. 2013; 13(1): pp. 28–32. doi: 10.1093/bjaceaccp/mks046.
  • 22. Ettinger D, Beger M, Aston J, et al. NCCN clinical Practice Guidelines in Oncology: Antiemesis, Version 1.2019. https://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf. Updated February 28, 2019. Accessed September 16, 2019.
  • 23. Brafford MV, Glode A. Olanzapine: an antiemetic option for chemotherapy-induced nausea and vomiting. Journal of the advanced practitioner in oncology. 2014; 5(1): pp. 24–9. pmid: 25032030.
  • 24. Rapoport BL. Delayed Chemotherapy-Induced Nausea and Vomiting: Pathogenesis, Incidence, and Current Management. Frontiers in Pharmacology. 2017; 08. doi: 10.3389/fphar.2017.00019.
  • 25. Rao KV, Faso A. Chemotherapy-induced nausea and vomiting: optimizing prevention and management. American health & drug benefits. 2012; 5(4): pp. 232–40. pmid: 24991322.
  • 26. Hawkins R, Grunberg S. Chemotherapy-Induced Nausea and Vomiting: Challenges and Opportunities for Improved Patient Outcomes. Clin J Oncol Nurs. 2009; 13(1): pp. 54–64. doi: 10.1188/09.cjon.54-64.
  • 27. Herell EH. Nausea and Vomiting of Pregnancy. Am Fam Physician. . url: https://www.aafp.org/afp/2014/0615/p965.html.
  • 28. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017; 65(12): pp. e45–e80. doi: 10.1093/cid/cix669.
  • 29. Zollner-Schwetz I, Krause R. Therapy of acute gastroenteritis: role of antibiotics. Clinical Microbiology and Infection. 2015; 21(8): pp. 744–749. doi: 10.1016/j.cmi.2015.03.002.
  • 30. Barr W, Smith A. Acute Diarrhea in Adults. Am Fam Physician. 2014. url: https://www.aafp.org/afp/2014/0201/p180.html#afp20140201p180-f1.
  • 31. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018; 66(7): pp. e1–e48. doi: 10.1093/cid/cix1085.
  • 32. Switaj T, Winter K, Christensen S. Diagnosis and Management of Foodborne Illness. Am Fam Physician. . url: https://www.aafp.org/afp/2015/0901/p358.html.
  • 33. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018; 38(1): pp. 1–211. doi: 10.1177/0333102417738202.
  • 34. Silberstein SD. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000; 55(6): pp. 754–762. doi: 10.1212/wnl.55.6.754.
  • 35. Holle D, Obermann M. The role of neuroimaging in the diagnosis of headache disorders. Therapeutic Advances in Neurological Disorders. 2013; 6(6): pp. 369–374. doi: 10.1177/1756285613489765.
  • Abell TL, Adams KA, Boles RG, et al. Cyclic vomiting syndrome in adults. Neurogastroenterology & Motility. 2008; 20(4): pp. 269–284. doi: 10.1111/j.1365-2982.2008.01113.x.
  • Sharkey KA, Wiley JW. The Role of the Endocannabinoid System in the Brain–Gut Axis. Gastroenterology. 2016; 151(2): pp. 252–266. doi: 10.1053/j.gastro.2016.04.015.
  • Darmani NA. Mechanisms of Broad-Spectrum Antiemetic Efficacy of Cannabinoids against Chemotherapy-Induced Acute and Delayed Vomiting. Pharmaceuticals. 2010; 3(9): pp. 2930–2955. doi: 10.3390/ph3092930.
  • Tan L, Liu J, Liu X, et al. Clinical research of Olanzapine for prevention of chemotherapy-induced nausea and vomiting. Journal of Experimental & Clinical Cancer Research. 2009; 28(1): p. 131. doi: 10.1186/1756-9966-28-131.
  • Perwitasari DA, Gelderblom H, Atthobari J, et al. Anti-emetic drugs in oncology: pharmacology and individualization by pharmacogenetics. International Journal of Clinical Pharmacy. 2011; 33(1): pp. 33–43. doi: 10.1007/s11096-010-9454-1.
  • Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol. 2016; 111(5): pp. 602–622. doi: 10.1038/ajg.2016.126.
  • Bányai K, Estes MK, Martella V, Parashar UD. Viral gastroenteritis. The Lancet. 2018; 392(10142): pp. 175–186. doi: 10.1016/s0140-6736(18)31128-0.
  • Ryan JL. Treatment of Chemotherapy-Induced Nausea in Cancer Patients. European oncology. 2010; 6(2): pp. 14–16. pmid: 21984886.
  • Einhorn LH, Grunberg SM, Rapoport B, Rittenberg C, Feyer P. Antiemetic therapy for multiple-day chemotherapy and additional topics consisting of rescue antiemetics and high-dose chemotherapy with stem cell transplant: review and consensus statement. Supportive Care in Cancer. 2010; 19(S1): pp. 1–4. doi: 10.1007/s00520-010-0920-z.
  • Kamen C, Tejani MA, Chandwani K, et al. Anticipatory nausea and vomiting due to chemotherapy. Eur J Pharmacol. 2014; 722: pp. 172–179. doi: 10.1016/j.ejphar.2013.09.071.
  • Navari RM. Treatment of Breakthrough and Refractory Chemotherapy-Induced Nausea and Vomiting. BioMed Research International. 2014; 2015: pp. 1–6. doi: 10.1155/2015/595894.
  • Roila F, Molassiotis A, Herrstedt J, et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Annals of Oncology. 2016; 27(suppl_5): pp. v119–v133. doi: 10.1093/annonc/mdw270.
  • Flake Z, Linn B, Hornecker J. Practical Selection of Antiemetics in the Ambulatory Setting. Am Fam Physician. 2015. url: https://www.aafp.org/afp/2015/0301/p293.html.
  • Boyce TG. Gastroenteritis. https://www.merckmanuals.com/professional/gastrointestinal-disorders/gastroenteritis/gastroenteritis#. Updated June 1, 2019. Accessed November 1, 2019.
  • James E. Tisdale. Drug-induced Diseases: Prevention, Detection, and Management. American society of health-system phramacists: p. 834.
last updated 06/11/2020
{{uncollapseSections(['ab1QH20', 'Yb1nH20', '1b12s20', 'Vb1Gs20', 'Wb1Ps20', 'I11YRf0'])}}