Clinical Approach to the GI Patient: Nausea and Vomiting

Question 1

what is rumination?

Answer 1

refers to the regurgitation, rechewing, and reswallowing food from the stomach

Question 2

what are 6 intraperitoneal causes of nausea and vomiting?

Answer 2

small bowel obstruction, enteric infections, inflammatory diseases, gastroparesis, gastroesophageal reflux, biliary colic

Question 3

what are 4 extraperitoneal causes of nausea and vomiting?

Answer 3

MI, labyrinth disease, intracerebral disorders, psychiatric illness

Question 4

what things outside of the GI system could be associated with nausea and vomiting?

Answer 4

vertigo and tinnitus, Meniere’s disease, inner ear infection (labyrinthitis); headache

Question 5

what does a plain film abdominal x-ray show when evaluating nausea/vomiting?

Answer 5

intestinal obstruction or perforation

Question 6

what does a plain film chest xray show when evaluating nausea/vomiting?

Answer 6

pneumomediastinum

Question 7

what are gastric emptying scans used to diagnosed?

Answer 7

gastroparesis

Question 8

what are 5 complications associated with nausea and vomiting?

Answer 8

rupture of the esophagus (boerhaave syndrome), hematemesis from a mucosal tear (mallory-weiss tear), dehydration, malnutrition, dental caries, and erosions, metabolic alkalosis and hypokalemia, aspiration pneumonitis

Question 9

what is the etiology of small bowel obstructions?

Answer 9

it is commonly caused by adhesions (mechanical obstruction); multiple abdominal surgeries, diverticulitis, Crohn disease

Question 10

what might the history/presentation look like in someone with a small bowel obstruction?

Answer 10

nausea and vomiting (can be feculent); obstipation (no BM or flatus); intermittent, crampy, periumbilical pain

Question 11

what might the physical exam look like in a patient with. a small bowel obstruction?

Answer 11

abdominal pain and distention, decreased or absent bowel sounds sounding like high pitched tinkling bowel sounds

Question 12

how do you diagnose a small bowel obstruction?

Answer 12

plain abdominal radiography (KUB X-ray/ abdominal serious x-ray) or CT scan

Question 13

what might the radiographs show in a patient with a small bowel obstruction?

Answer 13

dilated loops of small bowel and air fluid levels

Question 14

what is the treatment/management for small bowel obstruction?

Answer 14

nasogastric tube (NGT) to suction, supportive, and sometimes surgery if NGT isn’t helpful

Question 15

what are some possible etiologies of gastroparesis?

Answer 15

endocrine disorders: DM or hypothyroidism; postsurgical complications (gastric bypass); neurologic conditions (multiple sclerosis); medications

Question 16

how can a diabetic patient prevent getting gastroparesis?

Answer 16

controlling blood glucose prior to gastroparesis can help to prevent it

Question 17

how does gastroparesis present?

Answer 17

intermittent, waxing and waning symptoms, chronic or intermittent symptoms of postprandial fullness; nausea and vomiting (1-3 hours after meals)

Question 18

what might the physical exam look like in a patient with gastroparesis?

Answer 18

abdominal distention and decreased bowel sounds

Question 19

how do you diagnose gastroparesis?

Answer 19

gastric emptying study (scintigraphy)–> low-fat solid meal is the optimal means for assessing gastric emptying (eggs commonly used)

Question 20

what results from the gastric emptying study show gastroparesis?

Answer 20

gastric retention of 60% after 2 hours or more than 10% after 4 hours is abnormal

Question 21

what is the treatment/management for gastroparesis?

Answer 21

supportive; medications to enhance gastric emptying (metoclopramide and erythromycin)

Question 22

what are the adverse effects associated with metoclopramide?

Answer 22

risk of tardive dyskinesia, which is involuntary unintentional uncontrollable movements

Question 23

what is the last resort for treatment of gastroparesis?

Answer 23

gastric electrical stimulation with internally implanted neurostimulators

Question 24

what are some possible etiologies of extraperitoneal DDx that cause nausea and vomiting?

Answer 24

labyrinthine disease, intracerebral disorders, psychiatric, and medications

Question 25

what is labyrinthine disease?

Answer 25

inner ear or cranial nerve VIII dysfunction/pathology; meniere disease

Question 26

what are some intracerebral disorders that could cause nausea and vomiting?

Answer 26

mass? subarachnoid hemorrhage= “worst headache of my life”/ thunderclap

Question 27

how would you diagnose nausea and vomiting caused by an intracerebral disorder?

Answer 27

get a CT head (eventually MRI, but CT head without contrast is done first, as it is fast and contrast left out of orders as it would hide blood if hemorrhagic stroke)