• Clinical science
  • Physician

Nausea and vomiting

Summary

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

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:
    • Conduct a detailed patient history and clinical examination.
    • Consider further diagnostic testing.
  • 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

  • Abdominal
  • Neurologic
  • Pulmonary/cardiovascular
    • Dyspnea
    • Chest tightness
    • Feeling of impending doom

Immediately life-threatening causes

Diagnostics

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
HEENT
  • N/a
Cardiopulmonary
  • ECG
  • TTE
  • X-ray chest (upright)
Abdominal/pelvic
  • X-ray abdomen (upright and supine)
  • X-ray chest (upright)
  • Ultrasound abdomen (complete)
  • Duplex ultrasound of the pelvis ()/scrotum ()
  • Transvaginal ultrasound
  • CT abdomen and pelvis with IV contrast
  • CT abdomen and pelvis with IV and oral contrast
  • MRI abdomen and pelvis
  • Upper gastrointestinal endoscopy
Neurologic/psychiatric
Endocrine/metabolic
  • 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]
  • Heavy, dull, pressure/squeezing sensation
  • Substernal pain with radiation to left shoulder
  • Nausea, vomiting
  • Diaphoresis, anxiety
  • Dizziness, lightheadedness, syncope
  • Pain may improve with nitroglycerin.
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

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last updated 02/03/2020
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