Evaluation of nausea and vomiting, adults

The causes of nausea and vomiting are extensive and can be summarized in the following broad categories.

Gastrointestinal mucosal inflammation

Mucosal irritation of the esophagus, stomach, or duodenum; ranges from gastritis to frank ulceration.
Causes include peptic ulcer disease, esophagitis, radiation, and gastritis.[3]

Gastrointestinal infections

Cardiac

Causes include acute coronary syndrome and postural orthostatic tachycardia syndrome.

Central nervous system (CNS) disorders

Includes migraine, CNS infections such as meningitis and brain abscess, tumors such as an astrocytic tumor, complex partial seizures, vestibular nerve lesions ranging from motion sickness to an acoustic neuroma, stroke, and Parkinson disease.

Metabolic and endocrine disorders

Type 1 and type 2 diabetes, hypercalcemia, hypothyroidism, and hyperthyroidism are associated with nausea, vomiting, and gastroparesis.[4][5][6][7]
Adrenal insufficiency is a medical emergency with nausea, vomiting, volume depletion, and low sodium.

Mechanical gastrointestinal obstruction or manipulation

Includes luminal obstructions from the pylorus through to the colon and obstruction of the cystic duct, common bile duct, or pancreatic duct.

May be due to adhesions, strictures, stones, or tumors.
Postvagotomy or after resection of any major region of the stomach (e.g., fundus, antrum). Chronic nausea and gastroparesis may follow fundoplication.

Gastrointestinal pseudo-obstructions

Patients have gastroparesis and dilated small bowel or colon; some patients also have GERD due to a delay in gastric emptying and more retained gastric juices available as refluxate. In addition, with small bowel obstruction due to mechanical causes or in pseudo-obstruction, small bowel liquids move backward into the stomach and then into the esophagus, inducing GERD.
Neuromuscular dysfunction of the entire gastrointestinal tract may be present.
Symptoms suggesting mechanical obstruction of the gastrointestinal tract may be attributable to dilation of the stomach, duodenum, small bowel, or colon.
Associated with severe abnormalities in the smooth muscle, intrinsic or extrinsic nervous system, or interstitial cells of the gastrointestinal tract.
Degenerative disorders of the enteric nerves, smooth muscles, or interstitial cells of Cajal may be primary mechanisms.

Gastric neuromuscular disorders

Range from gastric dysrhythmias to frank gastroparesis.[8][9]
Gastric dysrhythmias are common in patients with gastric neuromuscular disorders; many of them will have documented gastroparesis.
Some patients have abnormalities of gastric relaxation or visceral hypersensitivity.
Other patients have circulating antibodies against gastrointestinal nerves and/or muscle.[10]

Peritoneal irritation

Unusual cause, but can result from an intra-abdominal abscess, chronic bacterial or fungal peritoneal infection, or carcinoma.

Malignancy

Infiltrating cancer of the stomach may present with nausea, vomiting, and gastroparesis.
Ovarian cancers, renal cell carcinoma, and small cell cancers of the lungs with paraneoplastic syndromes are associated with gastroparesis.

Eating disorders

Common symptom associated with the psychological disturbance of bulimia nervosa, but may also be part of the binge eating/purging subtype of anorexia nervosa.
Gastroparesis in patients with eating disorders such as anorexia nervosa, bulimia nervosa, or psychogenic vomiting is likely due to undernutrition.[7]

Ischemic gastroparesis

Gastroparesis can be caused by chronic mesenteric ischemia, which occurs when 2 of 3 mesenteric arteries are occluded, usually by atherosclerotic plaques.[11][12]
Presents with very little pain.

Pregnancy

In the first trimester of pregnancy 80% of pregnant women have nausea and vomiting.[13]
In hyperemesis gravidarum the nausea and vomiting is unremitting. Volume depletion, and lightheadedness or syncope, may occur.
Hyperemesis gravidarum may be associated with measurable autonomic and enteric dysfunction.[14]

Toxic

Almost all medications induce dose-dependent nausea and vomiting.
Nonsteroidal anti-inflammatory drugs are the most common. Others include: antidepressants, opioids, antiarrhythmics, hormones such as estrogen and progesterone, chemotherapy, theophylline, and digoxin.[1][3][15] Specific drugs that are associated with a high incidence of nausea include lubiprostone, metformin, and exenatide.
Chronic symptoms may develop in some patients after exposure to antibiotics or anesthetic agents.
Cannabinoid hyperemesis has been described mainly in younger adults who are chronic users.[16] In one case series, all patients were younger than 50 years of age. Most had used cannabis for more than 2 years and at a frequency of more than once per week.[17] Abdominal pain, as well as nausea/vomiting, is common. Patients report relief with hot showers or baths (suggesting autonomic nervous system arousal).[17][18]

Renal

Idiopathic nausea and vomiting

Diagnosis of exclusion.
Patients have other symptoms such as vague epigastric discomfort, early satiety, and prolonged fullness.
Termed "functional" dyspepsia or postprandial distress syndrome because many patients have no objective test findings.[19]

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Etiology