Approach to vomiting (acute): Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:41

Vomiting refers to the forceful expulsion of the stomach contents, which usually occurs after mechanical or chemical stimulation of emetic receptors in the brain.
Life-threatening causes of acute vomiting lasting less than 4 weeks include surgical emergencies and medical conditions associated with an acute abdomen, severe gastrointestinal hemorrhage, or increased intracranial pressure, or ICP.
Less critical causes include gastrointestinal and non-gastrointestinal intra-abdominal conditions as well as various extra-abdominal systemic and physiological conditions.

Unstable Patient0:41–1:29

Alright, if a patient presents with acute vomiting, first perform an ABCDE assessment to determine if they are stable or unstable.
If unstable, stabilize the airway, breathing, and circulation. Then, obtain IV access, start IV fluid resuscitation, and continuously monitor vital signs.
If your patient is actively vomiting, keep them NPO, and consider NG tube placement to decompress the bowel and prevent aspiration.
Finally, consider elevating the head of the bed. After initiating acute management, obtain a focused history and physical exam, and order labs, including a CBC, CMP, and serum lactate level.
Let’s start by discussing surgical emergencies. Here, patients typically present with severe abdominal pain, and some may have bilious emesis or evidence of gastrointestinal bleeding, such as coffee-ground emesis, hematemesis, melena, or hematochezia.

Surgical emergency1:29–3:15

Physical exam might reveal altered mental status and signs of shock, such as tachycardia and hypotension. Patients with an acute surgical abdomen typically have severe generalized abdominal tenderness with distension, rebound, and guarding.
Labs often show leukocytosis, electrolyte abnormalities, and elevated serum lactate levels. These findings should immediately make you consider an acute abdomen, abdominal sepsis, or gastrointestinal hemorrhage.
These are surgical emergencies requiring urgent operative intervention, so promptly get an abdominal X-ray. You can also consider a CT scan of the abdomen and pelvis, if X-ray findings are nonspecific, and if your patient is not actively decompensating.
X-ray may demonstrate red-flag findings like pneumoperitoneum, indicating perforation; or a severely dilated bowel with air-fluid levels; indicating obstruction.
If you get a CT scan, it may reveal additional red flag findings, like bowel dilation with a transition point; a whirl sign, which represents twisting of the mesentery or volvulus; pneumatosis intestinalis or pneumoperitoneum, a sign of perforation; bowel thickening with fat stranding, which suggests inflammation; or mesenteric ischemia.
Any one of these imaging findings indicates a surgical emergency. Now let’s talk about increased intracranial pressure, another life-threatening cause of vomiting.

Medical emergency3:15–4:15

In this case, the patient might present after a severe headache, head trauma, or a seizure. On physical exam, you’ll often see altered mental status and the Cushing triad, which consists of bradycardia, systolic hypertension with a widened pulse pressure, and irregular respirations.
Depending on the underlying cause, you might also observe nuchal rigidity, anisocoria, paralysis or paresthesia, or a cranial nerve deficit.
In this case, immediately consider increased intracranial pressure, and get a head CT scan to find the underlying cause.
Findings typically demonstrate evidence of intracranial pathology, such as hemorrhage, hydrocephalus, cerebral edema, brain herniation, or a mass.
If you see any of these, that’s a medical emergency. Now that we have discussed unstable patients, let’s take a look at stable ones.

Stable Patient4:15–4:44

First, perform a focused history and physical exam. History typically reveals abdominal pain, nausea, and vomiting; occasionally with fever, malaise, or changes in bowel habits.
On exam, you'll often notice abdominal tenderness and distention. With these findings, consider intra-abdominal causes of vomiting.

GI Causes/Infectious gastroenteritis4:44–5:38

Let’s start by assessing for an underlying gastrointestinal condition. First up is infectious gastroenteritis.
Your patient will likely report sick contacts or exposure to raw, undercooked, or spoiled food; and they'll often develop diarrhea later in the illness.
On exam, you might notice signs of dehydration, like decreased skin turgor and dry mucous membranes, along with mild abdominal tenderness.
Here, consider infectious gastroenteritis, which you can usually diagnose from clinical findings alone. However, if you need to determine disease severity, consider ordering labs, including CBC and CMP, which might show mild leukocytosis and electrolyte abnormalities such as hyper- or hyponatremia.
These findings further support the diagnosis of infectious gastroenteritis. Let’s move on to acute appendicitis.

Appendicitis5:38–6:45

Affected patients typically report periumbilical pain that localizes to the right lower quadrant, in combination with anorexia, nausea, and vomiting.
On exam, you'll usually find tenderness at McBurney point, or even a positive Rovsing, psoas, or obturator sign. With this clinical presentation, consider acute appendicitis.
Next, order labs, including a CBC, CMP and serum lactate level. Additionally, obtain an abdominal ultrasound, or consider a CT scan of the abdomen and pelvis.
Keep in mind that ultrasound is preferred over CT scan, since it can avoid excessive radiation exposure. The CBC classically demonstrates leukocytosis; and on ultrasound, you'll usually see a dilated appendix with wall thickening.
If you order a CT scan, it will reveal an inflamed appendix with periappendiceal inflammatory changes, like fat stranding.
These findings confirm acute appendicitis. Now let’s switch gears and discuss gastritis.

Gastritis6:45–7:14

Patients often report upper abdominal pain, early satiety, and occasionally, frequent NSAID use; while the exam typically reveals epigastric tenderness.
With these findings, consider gastritis, and order a CBC and an EGD. In most cases, labs are unremarkable, but EGD will reveal gastric mucosal inflammation, erythema, and erosions; confirming the diagnosis of gastritis.

Cholecystitis7:14–8:08

Let’s turn our attention to acute cholecystitis. These patients usually have a sudden onset of intense right upper abdominal pain that may radiate to the shoulder.
The exam commonly reveals fever, with right upper quadrant tenderness and a positive Murphy sign, which is the abrupt cessation of breathing during subcostal palpation of the gallbladder.
You may also find jaundice. In this case, consider acute cholecystitis, and order a CBC and LFTs as well as an abdominal ultrasound.
Labs commonly reveal leukocytosis and elevated serum bilirubin levels. Ultrasound typically demonstrates calculi in the gallbladder or biliary tree, as well as gallbladder wall thickening and pericholecystic fluid, which confirms acute cholecystitis.

Pancreatitis8:08–9:19

Moving on to acute pancreatitis. In addition to nausea and vomiting, these patients often report epigastric abdominal pain radiating to the back.
Past medical history is often significant for cholelithiasis or alcohol overuse. On physical examination, palpation typically elicits epigastric tenderness.
This clinical picture should make you consider acute pancreatitis, so next, order labs, including CBC, CMP, LFTs and amylase, lipase, and serum lactate levels.
Also, obtain imaging, such as an abdominal ultrasound or CT scan of the abdomen and pelvis. Labs may reveal leukocytosis with elevated LFTs and markedly elevated lipase and amylase levels.
In severe cases, serum lactate levels could also be elevated. On ultrasound, you might see cholelithiasis and peripancreatic edema.
CT scan typically demonstrates pancreatic inflammation and parenchymal enlargement with peripancreatic edema and fat stranding.
These findings confirm acute pancreatitis. Now let’s look at small bowel obstruction, our last gastrointestinal cause of acute vomiting.

SBO9:19–10:11

These patients often report diffuse abdominal pain with nausea and vomiting, and most have a history of previous abdominal surgery.
The exam typically reveals abdominal distention with diffuse tenderness to palpation. With this presentation, consider small bowel obstruction, and order a CBC, CMP, and serum lactate levels; as well as a CT scan of the abdomen and pelvis.
Labs often reveal leukocytosis, while the CT scan typically demonstrates dilated small bowel loops with air-fluid levels, often with a transition point between the proximal, dilated bowel and the distal, decompressed bowel.
These findings are highly suggestive of small bowel obstruction. Now, let’s switch our focus to non-gastrointestinal causes of acute vomiting.

Non-GI causes10:11–10:20

First up are urologic conditions. Here, the history typically reveals abdominal or flank pain.

Urologic conditions10:20–11:35

Some patients also report dysuria; with increased urinary frequency, hesitancy, or urgency; which suggests urinary tract infection, or UTI; while others may report hematuria, which suggests nephrolithiasis.
On exam, you'll often detect flank or suprapubic tenderness. With these findings, consider urologic causes, like UTI or nephrolithiasis.
To differentiate between them, order labs, including a CBC, CMP, and UA; and if you suspect nephrolithiasis, also order a CT scan of the abdomen and pelvis.
Labs may demonstrate leukocytosis, and in some cases, elevated serum creatinine. The urinalysis may reveal positive nitrites, leukocyte esterase, white blood cells, and bacteria, which suggests a UTI; or it may reveal blood, which suggests nephrolithiasis.
CT scan may demonstrate a ureteral calculus, possibly with hydronephrosis, to confirm nephrolithiasis. Any of these findings indicate a urologic condition as a cause of vomiting.
Switching gears, let’s discuss obstetric and gynecologic conditions. Affected patients are biologically female individuals who may present with lower abdominal or pelvic pain, reduced appetite, and in some cases, menstrual cycle changes or amenorrhea.

Obstetric & gynecological conditions11:35–12:55

Exam might reveal lower pelvic or abdominal tenderness or fullness. This clinical picture should make you consider obstetric or gynecologic causes of vomiting.
To evaluate further, obtain a CBC, CMP, beta hCG, and UA; along with a pelvic ultrasound. You can also consider ordering a CT scan of the abdomen and pelvis but be sure to rule out pregnancy with a beta hCG first!
Labs might reveal leukocytosis, and possibly a positive hCG test, confirming pregnancy. Urinalysis will demonstrate no evidence of infection or nephrolithiasis, like nitrites, leukocyte esterase, or blood.
An ultrasound may confirm an intrauterine or ectopic pregnancy; or it might show free fluid in the pelvis, or an ovarian cyst or torsion.
If you obtain a CT scan, it may also demonstrate an ovarian cyst or ovarian torsion. Any of these findings indicate an obstetric or gynecologic condition causing vomiting.
Now let’s go back once more to the focused history and physical. If your patient reports no pain or mild abdominal pain; without fever or changes in bowel habits; and the exam reveals no abdominal distension; consider an alternative diagnosis.

Alternative diagnoses12:55–13:51

Other serious causes of acute vomiting include cardiac conditions like acute coronary syndrome, angina, or myocardial infarction; and metabolic disorders like uremia or diabetic ketoacidosis.
Acute vomiting can also be caused by medications such as chemotherapy or recreational substances. Additionally, vomiting is a manifestation of some non-life-threatening CNS conditions, like vertigo, epilepsy, or migraines.
Finally, once you rule out medical and surgical etiologies, consider the possibility of psychiatric conditions such as bulimia nervosa.

Review13:51–14:51

Alright, as a quick recap… Acute vomiting in an unstable patient can indicate a surgical emergency such as bowel perforation, bowel obstruction, and mesenteric ischemia; or a medical emergency caused by increased intracranial pressure.
In stable patients, gastrointestinal causes of vomiting include infectious gastroenteritis, acute appendicitis, gastritis, acute cholecystitis or pancreatitis, and small bowel obstruction.
Non-gastrointestinal causes of vomiting include urologic conditions, such as UTI or nephrolithiasis; and obstetric or gynecologic conditions such as intrauterine or ectopic pregnancy, ovarian cysts, and ovarian torsion.
Finally, extra-abdominal etiologies include cardiac conditions, metabolic disorders, medications and recreational substances, non-life-threatening CNS conditions,
Approach to vomiting (acute): Video, Steps, Uses | Osmosis