Approach to vomitting Flashcards
What are the differential diagnosis of vomiting + diarrhoea?
infection
What are the differential diagnosis of vomiting + constipation?
Intestinal obstruction
Functional
- Parkinson disease
- diabetes
- recent surgery
- intra- abdominal inflammation
Small bowel IO
- intraluminal: gallstones, bezoar, foreignn body
- luminal: strictures (IBD)
- extraluminal: adhesions, abdo tumour, hernias
What are the differential diagnosis of vomiting alone?
GI causes
- appendicitis
- diverticulitis
- PUD
- gastritis
HPB causes
- hepatitis
- cholecystitis
- choledocholithiasis
- cholangitis
- pancreatitis
Non GI causes
- psych: bulimia, anorexia
- pregnancy
- anaemia/ hypotension
- AMI
- infection/ sepsis
- iatrogenic e.g. chemotherapy, opiates, NSAIDs, anticholinergic agents, recreation drugs .e.g marijuana
- metabolic: DM (gastroparesis, DKA), thyroid disorders, adrenal insufficiency, uraemia
- increased ICP/ meningitis
- vertigo/ migraine
What is the ddx of acute nausea & vomiting?
Usually transient medical condition
- infectious cause e.g. viral gastroenteritis
- self limiting somatic disorder e.g. msk trauma
- medication side effect
May herald an emergency
- GI: peritoneal (IO/ perforation, peritonitis, cholecystitis, pancreatitis)
- Non GI: AMI, cerebral oedema, dka
What does insidious nausea onset suggest?
- Gastroparesis
- Medication side effect
- Metabolic disorders
- Pregnancy
- GERD
What does partially digested food few hours post-meal suggest?
gastric outlet obstruction, gastroparesis
What does bilious vomitus suggest?
small bowel obstruction
What does feculent vomiting suggest?
intestinal obstruction
What does nausea and vomiting ~1h post-meal suggest?
Gastric outlet obstruction, gastroparesis
What does nausea and vomiting during/ soon after meal suggest?
Anorexia nervosa/ bulimia
What does episodic severe unrelenting vomiting suggest?
cyclic vomiting syndrome, cannabinoid hyperemesis
What does early AM vomiting before breakfast suggest?
Pregnancy, uraemia, alcohol, increased ICP
What does projectile vomiting w/o nausea suggest?
IMPT in adults, think about increased ICP
What are the associated symptoms of vomiting to ask for in the history?
- Early satiety, post prandial fullness/ bloating –> Gastroparesis
- Abdominal pain –> Biliary, pancreatic disorder
- Prominent severe colicky pain (may improve after vomiting –> small bowel obstruction
- Weight loss –> Malignancy, gastric outlet obstruction, gastroparesis
- CNS symptoms (headache, vertigo, focal neurological deficits) –> central cause
What would you examine for in a patient who has vomited?
Signs of dehydration
Cachexia
Postural bp
- with hr increase: significant dehydration
- without hr increase: autonomic neuropathy
Peripheries
- dental enamel
- fingernails
- raynaud’s phenomenon
- telangiectasia
- peripheral neuropathy
abdo exam
- jaundice
- abdominal mass
- abdominal tenderness
- lymphadenopathy
- hyperactive/ absent bowel sounds
- succussion splash
neurological exam
- cranial nerves
- papilledema
- gait/ long tract signs
endocrine system: systemic features of thyrotoxicosis, addison’s disease
