Evaluation of nausea and vomiting, adults

Severe abdominal pain

• Cramping epigastric or right upper quadrant pain followed by nausea and vomiting may reflect gastric outlet obstruction, or acute or chronic cholecystitis.

• A rigid abdomen associated with severe pain suggests an acute abdomen due to bowel perforation, or acute peritonitis due to peritoneal inflammation or malignancies. Rebound tenderness and guarding may be present in bowel perforation.

• Patients should be referred to the emergency department for assessment of vital signs, routine laboratory studies, and urgent computed tomography (CT) of the abdomen.

Acute neurologic events

• Symptoms of severe headache that may be associated with a rash or neck stiffness are suggestive of migraine headaches or infections of the central nervous system, such as a brain abscess or meningitis. The headache is most often accompanied with photophobia and precedes nausea and vomiting. Patients with acute onset of severe headache, with or without fever, should be referred to the emergency department for a CT head and possible lumbar puncture if meningitis is suspected.

  ---

  

  Diagnostic lumbar puncture in adults: animated demonstration

  How to perform a diagnostic lumbar puncture in adults. Includes a discussion of patient positioning, choice of needle, and measurement of opening and closing pressure.

  ---

• Older patients presenting with acute-onset focal neurologic deficit should be urgently evaluated for a possible stroke. The goals of the initial evaluation are to identify the stroke syndrome, ensure medical stability, perform an abbreviated neurologic exam, and rapidly transport the patient to head CT or magnetic resonance imaging (MRI) scan. The need to perform thrombolysis should be determined following scanning.

Older patients with atherosclerotic disease: gastrointestinal vascular considerations

• Ischemic gastroparesis can present with nausea, vomiting, and mild abdominal discomfort (but not necessarily excruciating abdominal pain) and should be considered in older patients with coronary artery disease or other known atherosclerotic diseases. Patients may have an abdominal bruit.

• These patients need urgent magnetic resonance angiography to determine the presence of celiac or superior mesenteric artery stenosis that may explain mesenteric ischemia.

Cardiac considerations

• Nausea and vomiting may accompany, or be a presenting symptom of, an acute coronary syndrome (ACS). Any suspicion of cardiac disease (e.g., acute onset chest pain radiating to the left arm, neck, or jaw) should prompt immediate evaluation. ACS includes ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA). These terms are used as a framework for guiding management.

• Patients with STEMI should be considered for immediate reperfusion therapy by thrombolytic agents or percutaneous coronary intervention. Patients with NSTEMI have elevated cardiac enzymes without ST segment elevation on ECG. Patients with normal cardiac enzymes but abnormal ECG findings have UA. Patients with NSTEMI or UA do not benefit from immediate reperfusion.

Shock, volume depletion, or life-threatening illness

• A high index of suspicion should exist for patients with acute or chronic adrenal insufficiency. Patients may already be on chronic corticosteroid therapy. Patients may present in shock with hyponatremia, hyperkalemia, and hypoglycemia.

Anorexia or weight loss

• Anorexia may be a symptom of extensive liver metastases associated with nausea. Ovarian cancers should be considered in middle-aged women who report vague abdominal discomfort, loss of appetite, and early satiety.[26]Ebell MH, Culp MB, Radke TJ. A systematic review of symptoms for the diagnosis of ovarian cancer. Am J Prev Med. 2016 Mar;50(3):384-94. http://www.ncbi.nlm.nih.gov/pubmed/26541098?tool=bestpractice.com [27]Bankhead CR, Collins C, Stokes-Lampard H, et al. Identifying symptoms of ovarian cancer: a qualitative and quantitative study. BJOG. 2008 Jul;115(8):1008-14. https://www.doi.org/10.1111/j.1471-0528.2008.01772.x http://www.ncbi.nlm.nih.gov/pubmed/18651882?tool=bestpractice.com ​​​ Renal carcinomas are also nauseogenic, and small cell cancers of the lungs are associated with paraneoplastic syndromes. Infiltrating adenocarcinomas of the stomach may result in linitis plastica (morphologic variant of diffuse or infiltrating stomach cancer) and symptoms of early satiety, fullness, nausea, and vomiting.

• Bulimia nervosa and anorexia nervosa (binge eating/purging subtype) present with nausea, anorexia, and weight loss associated with marked psychological disturbance and require a complete psychiatric evaluation. These patients also have disordered gastrointestinal physiology.[28]Abell TL, Malagelada JR, Lucas AR, et al. Gastric electromechanical and neurohormonal function in anorexia nervosa. Gastroenterology. 1987 Nov;93(5):958-65. https://www.doi.org/10.1016/0016-5085(87)90557-9 http://www.ncbi.nlm.nih.gov/pubmed/3653645?tool=bestpractice.com

• Patients with anorexia and weight loss need a CT abdomen with attention to specific abdominal organs depending on localizing symptoms.

Presence of occult or frank blood in stools

• May indicate peptic ulcer disease or gastrointestinal malignancies.

• These patients need upper endoscopy, colonoscopy, and possible capsule endoscopy or double-balloon enteroscopy to determine the cause.

Consideration of pregnancy

• The possibility of pregnancy should be considered in all women of child-bearing age presenting with nausea and vomiting.