Approach to vomiting (chronic): Clinical sciences

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Introduction 0:00–0:33

Vomiting refers to the forceful expulsion of the stomach contents caused by humoral stimulation of the chemoreceptor trigger zone or neural stimulation of the emetic center.
If it persists for four weeks or more, that's chronic vomiting based on the presence of abdominal symptoms, causes of chronic vomiting can be categorized into abdominal and nonabdominal ones.
If a patient presents with chronic vomiting, first, perform an ABCD E assessment to determine if they are unstable or stable.

Unstable Patient 0:33–1:15

If unstable, stabilize the airway breathing and circulation. Next, obtain IV access and administer IV fluids.
Put your patient on continuous vital sign monitoring including heart rate, BP and pulse oximetry and if needed, provide supplemental oxygen.
Also keep in mind that unstable patients might have electrolyte abnormalities, acid base disturbances or signs of severe dehydration.
Let's move on to stable patients. Your first step is to obtain a focused history and physical examination and order labs including A CMP.

Stable Patient 1:15–1:25

Your patient will report persistent vomiting for more than four weeks. Usually associated with nausea and changes in bowel habits.

Abdominal causes1:25–2:39

Physical exam might reveal abdominal tenderness and distension as well as poor skin turgor and dry mucous membranes. Labs might show electrolyte disturbances like hypokalemia or hyponatremia, elevated bicarbonate level and renal insufficiency.
With these findings. Think about abdominal causes of chronic vomiting.
Here's a clinical pearl, pregnancy is a can't miss cause of nausea and vomiting. If your patient is a biological female of childbearing age, order a urine pregnancy test, vomiting in pregnancy can range from mild to severe disease and hyperemesis, gravidarum which may even require hospitalization.
Other causes of chronic vomiting include medications like opioids, antibiotics, chemotherapeutic agents and substances like alcohol and cannabis, which can cause cannabinoid hyperemesis syndrome.
Ok. The first abdominal cause is peptic ulcer disease or pu.

Peptic Ulcer Disease2:39–3:19

These patients typically report epigastric pain that worsens after eating early satiety and sometimes hematemesis or Melana physical exam might reveal epigastric tenderness and pallor at this point.
Consider P UD and obtain a CBC and an esophagogastroduodenoscopy or EGD if the CBC reveals anemia and the EGD shows a gastric or duodenal ulcer diagnosed P UD.
Next up is inflammatory bowel disease or IBD. If your patient reports crampy, abdominal pain, diarrhea, and possibly hematochezia.

Inflammatory Bowel Disease 3:19–4:06

And the exam reveals diffuse abdominal tenderness. Consider IBD then obtain a CBC and colonoscopy.
CBC often shows anemia. While colonoscopy will reveal either signs of ulcerative colitis such as continuous mucosal inflammation or Crohn's disease like transmural skip lesions.
You might also note histologic granulomas if you see these findings diagnose IBD. Keep in mind that vomiting in IBD can be a sign of obstruction.
On that note, let's talk about mechanical obstruction. These patients generally report crampy, abdominal pain that is worse after eating early satiety and in some cases, constipation or intractable obstipation which is caused by prolonged retention of hard dry feces that can even block the passage of gas exam.

Mechanical Obstruction 4:06–5:23

Findings include abdominal tenderness and distension and possibly a palpable mass. With these findings consider mechanical obstruction and order a CT of the abdomen if you see signs of obstruction, such as a mass bowel wall thickening as well as distention with an air fluid level, proximal to the obstruction, diagnose mechanical gastrointestinal obstruction.
Here's a clinical pearl. Even though you've diagnosed an obstruction as a cause of chronic vomiting.
In some cases, you'll need additional tests to reach your final diagnosis. For example, if colon cancer is suspected additional steps like a CT scan of the chest tumor markers and colonoscopy with biopsy should be completed.
Next, let's talk about chronic pancreatitis. Patients typically report upper abdominal pain that can range from constant and dull to acute and stabbing that sometimes radiates to the back and is relieved by leaning forward.

Chronic Pancreatitis 5:23–6:26

They might also report fatty stools that are difficult to flush. Abdominal bloating and unexplained weight loss exam will reveal epigastric tenderness at this point.
Consider chronic pancreatitis and order labs including lipase and fecal elastase and CT of the abdomen. Lipase is elevated in many cases but not always.
While fecal elastase is decreased. Indicating pancreatic secretory insufficiency.
CT will reveal chains of lakes sign which are dilated pancreatic ducts and extensive parenchymal calcifications. With these findings diagnosed chronic pancreatitis.
Let's move on to GERD and gastritis. These patients typically report heartburn, acid regurgitation and a sour or bitter taste in their mouth.

GERD/Gastritis 6:26–7:14

Atypical symptoms include cough and hoarseness. The exam is often normal but may reveal epigastric tenderness, dental erosions and halitosis as well as wheezing, which is an atypical finding at this point.
Consider GERD and gastritis which are often diagnosed clinically. But when associated with chronic vomiting, you can obtain an EGD if the EGD reveals inflammation at the gastroesophageal junction and possibly inflammation in the stomach as well.
That's GERD or gastritis. Next up is gastroparesis.
Your patient will report upper abdominal pain worse after eating early satiety and postprandial fullness. They may also have a history of diabetes, mellitus or neurologic disease.

Gastroparesis 7:14–8:05

The exam will often reveal epigastric distension and tenderness at this point. Consider gastroparesis.
So next review the C MP and obtain a gastric emptying study and an EGD C MP might reveal elevated glucose if diabetes is present.
While the gastric emptying study will reveal delayed emptying of the stomach contents. And EGD will show retained food in the stomach.
Despite overnight fasting with these findings, diagnose gastroparesis moving on. Let's talk about irritable bowel syndrome or IBS.

IBS 8:05–9:04

Your patient will report bowel habit changes for at least six months, either diarrhea, constipation or both as well as abdominal discomfort that's typically relieved with defecation in some cases, the patient could report abdominal bloating or they might have a history of depression, anxiety, fibromyalgia, trauma, or recent infectious gastroenteritis on exam.
You might notice abdominal tenderness or fine hemorrhoids or anal fissures on the rectal exam. With these findings consider IBS and evaluate Rome four criteria.
If the diagnosis isn't clear, you can also obtain a colonoscopy egd or both. If your patient meets Rome four criteria and if endoscopy is normal, that's IBS.
Now, let's go back to the initial assessment and talk about patients without predominantly abdominal symptoms. In this case, consider nonabdominal causes of chronic vomiting including increased intracranial pressure, migraine vestibular disease, adrenal insufficiency and renal failure.

Non-abdominal causes 9:04–9:27

First, let's discuss increased intracranial pressure which might occur due to infection, a mass hemorrhage or hydrocephalus.

Increased Intracranial pressure 9:27–10:06

Patients typically report headaches while the exam might reveal mental status changes and focal neurologic deficits such as cranial nerve palsy or unilateral weakness at this point, consider increased intracranial pressure and obtain a ct or MRI of the brain.
If imaging reveals a mass hemorrhage or hydrocephalus diagnose increased intracranial pressure. Next, let's consider migraine which leads to vomiting due to hypersensitivity of the nervous system.

Migraine 10:06–10:43

These patients present with unilateral headache, photophobia and some describe an aura. Their physical exam could reveal neurologic deficits such as hemiparesis or aphasia at this point.
Consider migraine which is usually a clinical diagnosis, but you might also need to get an MRI of the brain to rule out other conditions.
If there's no evidence of organic disease, diagnose migraine. All right, let's consider a vestibular cause like benign positional vertigo or Meniere disease.

Vestibular causes 10:43–11:20

If history reveals episodic dizziness or vertigo, often associated with hearing loss or tinnitus. An exam shows nystagmus and possibly a positive dix Hallpike maneuver.
Consider vestibular causes of chronic vomiting. This is usually a clinical diagnosis, but once again, you might need a brain MRI to rule out other conditions if there is no evidence of organic disease, diagnose vestibular disease.
Moving on. Let's take a look at adrenal insufficiency, also known as Addison disease.

Adrenal Insufficiency/Addison’s Disease 11:20–12:06

These patients typically report fatigue and unintentional weight loss, sometimes associated with abdominal pain, myalgias and arthralgias.
Physical exam usually reveals orthostatic hypotension and possibly hyperpigmented skin at this point, consider adrenal insufficiency.
So, review their C MP and obtain a morning cortisol level if their C MP reveals electrolyte disturbances like hyponatremia and hyperkalemia and their morning cortisol level is decreased.
That's adrenal insufficiency. Finally, let's consider renal failure.

Renal failure 12:06–13:08

History might reveal fatigue, anorexia and muscle cramps while the exam often shows hypertension and peripheral edema in this case, consider renal failure and review the CMP which will reveal elevated bun and creatinine and perhaps electrolyte disturbances such as hyperkalaemia.
If you see this, think about renal failure. Here's a clinical pearl cyclic vomiting syndrome is a cause of chronic vomiting characterized by severe episodic nausea and vomiting.
Physical exam might reveal abdominal tenderness but is otherwise unremarkable while an extensive diagnostic workup is typically negative cyclic vomiting syndrome has no known organic cause.
But potential triggers include stress, migraines and certain foods such as chocolate and caffeine. All right, as a quick recap causes of chronic vomiting can be categorized based on the presence of associated abdominal symptoms.

Review 13:08–13:52

Abdominal causes include peptic ulcer disease, inflammatory bowel disease, mechanical obstruction, chronic pancreatitis, gastroesophageal reflux disease, or gastritis, gastroparesis and irritable bowel syndrome.
On the other hand, nonabdominal causes include neurologic causes such as increased intracranial pressure, migraine and vestibular causes as well as endocrine or metabolic conditions like adrenal insufficiency and renal