Nausea & Vomiting

One of the hardest complaints of all to deal with.  Whereas prominent diarrhea invariably comes from the bowel, the etiology of nausea / vomiting can lie anywhere in the body.  Try this for a smattering of possibilities (in random order):

• Brain Infections / Increased Intracranial Pressure / Migraine
• Narrow-Angle Glaucoma
• Otitis Media / Pneumonia / Pyelonephritis / Sepsis
• Abdominal Disease (from GERD to Peritonitis)
• Renal Failure / Liver Failure / Diabetes (severe)
• Metabolic Derangements (Hypo- / Hyper- Na⁺, Ca⁺⁺, Etc.⁺⁺⁺)
• New Medication / Poisoning
• Bulemia
• Pregnancy

Don’t go working up Adrenal Insufficiency right off the bat.  Rather, let’s try to devise a manageable strategy to approach Nausea / Vomiting (“N/V” from now on).

STOP a moment.  Since N/V are so non-specific, if there are any other localizing symptoms, use them to structure your approach.  The rest of this discussion presumes there’s no prominent cough, earache, headache, focal pain, etc.  Maybe malaise or fatigue, but nothing more helpful.

Define chronology & duration.  Let’s think in terms of:

• Acute: <1 month
• Chronic:  >1 mo.  Rarely serious.
• Recurrent: Significant periods of well-being interspersed between episodes.  Elicit this history, and you can be even more reassured, because whatever it is wasn’t that bad before.

We mostly deal with Acute N/V.

First  —  Look for Dehydration.  Main clues:

• Vital Signs.  Tachycardia comes before Hypotension.  Orthostatic changes occur first.  If symptoms suggest a possible fluid deficit, check Postural Vital Signs  [click for insight].
• Low Urine Output.  Ask how often they’re voiding.  Check a urine for Specific Gravity; above 1.030 is concerning.
• FORGET about “skin turgor.”  Only useful in babies, and even they would have to be real dehydrated for it to show.  Adults with “poor skin turgor” probably just have baseline flabby skin (unless it’s cholera).

Dehydrated patients can appear toxic, making us worry about a serious underlying etiology.  Rehydrate with Normal Saline.  If you’re not worried about precipitating heart failure, run the solution fast — 2-3 liters in 1-2 hours.  They should feel fine; if not, they need lots of same-day tests best done in an E.D.

Let’s assume there’s no dehydration.  Let’s also assume that a basic history & physical don’t reveal telltale findings like new medication, alcohol, jaundice, a bright red TM, etc.  Onward to Diagnosis:

**  Diarrhea —  if this is prominent, we’ll Dx Gastroenteritis

**  Fever  —  think of Pneumonia or Pyelonephritis.  Seek other acute Infections.

**  Abdominal Pain  —  could an Intra-Abdominal Catastrophe be brewing?

• If Pain began before Vomiting, worry about Appendicitis, Cholecystitis, Pancreatitis, Diverticulitis, etceteritis.  See our postings on “Abdominal Pain” to guide the differential.
• If Vomiting began first, don’t worry as much.  Vomiting itself can cause pain.

**  Bloody Emesis  —  something bad in the stomach (worse if esophageal).  Call 911, start an IV.  BUT…

• “Blood” means at least a handful’s worth.  Specks of blood don’t count.
• “Coffee-Ground” emesis is old blood.  If completely stable, can Tx for Peptic Ulcer (high-dose PPI) as long as daily follow-up is possible & patient understands to call 911 if bright red blood recusr.  Draw a CBC.  Arrange elective endoscopy later.
• For nausea without vomiting, inquire about Melena.  Deal with it as for coffee-ground emesis.  Don’t be fooled by black stools due to Pepto-Bismol^®, or multivitamins with Iron.

So let’s assume these above factors are NOT present, and that the patient doesn’t look toxic.  Also, assume our exam is unrevealing and benign (no board-like abdomen).  The discussion below follows my general thought process as I’m face-to-face with patients who present with new-onset N/V.

DAY #1 of Symptoms  —  Acute Gastroenteritis (AGE).  Call it Staphylococcal, actually due to a toxin, secreted by bugs that grew in mayonnaise or similar media, dropped off by a food handler (also occurs from precooked/prepackaged meats).  If others from house / party are also ill, the Dx is clinched.  Incubation period would be up to 8 hours.

Treatment?  Well, vomiting itself works well, clears the toxins.  Anti-emetics might relieve symptoms, might prolong them.

DAY #2  —  Staph will be getting better by now.  Norovirus or Rotavirus Gastroenteritis are certainly possibilities, and may start with vomiting alone (no diarrhea yet).  I’m cautious about diagnosing AGE in the absence of diarrhea, but it’s possible up to 48 hrs. of viral illness.

DAY #3 Onward  —  I’d never diagnose AGE after 48 hours of N/V and no diarrhea.  Now’s the time for some sort of basic work-up:

• Urine Pregnancy Test
• CBC
• Urinalysis
• Chemistry Panel
• Lipase (if any upper abdominal Sx)

The above tests will suggest or diagnose many common causes:

Of course, you can also order this work-up on Day #1 or #2 of symptoms, depending on how the patient looks.  I’d be more aggressive in the elderly, debilitated, or compromised hosts.  And it may be hard to tell someone who pays for a visit with 2 days of N/V, “come back tomorrow if you’re not better & there’s still no diarrhea, & we’ll do some tests.”

Never forget the most important Question to ask all patients all the time, which invariably defines the extent of work-up:

• “Is the [whatever complaint] getting better, getting worse, or staying the same?”

While the above tests are pending, I give a high-dose Proton Pump Inhibitor B.I.D.  That’s because Dyspepsia and Peptic Ulcer Disease are common conditions which might cause N/V without pain or tenderness.  I prefer this to anti-emetics, because the latter don’t truly treat anything.

I have the patient return in a week, always making sure I have a contact telephone number lest there be a critical result.  And of course, I tell them to return earlier if symptoms get worse.  If symptoms had been going on and stable for 2 weeks when first seen, I’d tell them to return in 2 weeks.

By a week, PPIs will have begun to work.  If there’s been absolutely not the slightest alleviation of symptoms within a week, discontinue the med.  If symptoms have begun to improve, don’t take yourself too seriously; maybe whatever syndrome it was resolved on its own.  At any rate, decrease the dose to a more conventional one for 1-2 months, or change to an H-2 blocker (famotidine et al.) & follow.

More importantly, at follow-up you can reweigh the patient.  Objective weight loss warrants continued investigation — upper endoscopy with or without abdominal CT.

When N/V qualify as chronic, after a month, with negative initial work-up, no weight loss, and no response to PPIs, it’s invariably functional.  Seek symptoms of depression, treat if suggestive.  Look for stigmata of bulimia: erosion of tooth enamel, parotid enlargement, or calluses on the back of the hand.  Addison’s would be highly unusual (check for orthostatic hypotension).

It’s OK to refer to GI for confirmation.  Treatment is difficult, since anti-emetics and especially metoclopromide can cause extrapyramidal symptoms or permanent tardive dyskinesia with ongoing use.

Finally, for an obscure syndrome, one small series described chronic marijuana abuse as a cause of persistent vomiting; compulsive bathing / repetitive showering was an associated symptom which could serve as a key clue.  So never forget to ask patients how many showers they take each day.  [joke]

Next time: travel on through to the distal lumen.