Acute onset vomitingClinical evaluation

Dr Manoj K Ghoda M.D., M.R.C.P

Consultant Gastroenterologist

82/ M

Admitted for persistent vomiting for about a week.

•Initially food, but then small amount of liquid with greenish tinge•Mild colicky pain +•Mild abdominal distention +

•PH/o femoral hernia

Acute vomiting:

Of recent onset. A week to 10 days is usually acceptable

Acute recurrent vomiting may confuse the issue

Good history, I suggest taken first hand, is crucial to the optimum approach

•Circumstances of onset•Associated symptoms like anorexia, diarrhea, malaise, fever, headache, vertigo•Nature of vomiting•Colour and contents of vomitus•Associated abdominal pain•Associated abdominal distention•Presence or absence of obstipation

Circumstances of onset and Associated symptoms

•Acute nausea and vomiting without any warning signs suggests infectious or iatrogenic etiologies.

•Food ingestions, contact with ill persons, and the presence of coexisting viral symptoms suggest an infectious etiology.

•Recent consumption of drugs may be pointing towards drug induced gastritis or central effect or hepatotoxicity.

• Altered level of consciousness, headache, or neurological deficit favours neurological cause.

•Vertigo, deafness, tinnitus or ear discharge points towards ear pathology

Infectious etiologies ………..

•Viral gastroenteritis is particularly common; however, bacteria or their toxins may also be the cause.

•Typically result in an acute onset of symptoms.

•Infectious and toxic causes of nausea and vomiting are usually self-limiting.

•Nausea and vomiting caused by ingestion of a toxin such as the enterotoxin in staphylococcal food poisoning or the toxin produced by Bacillus cereus typically occur one to six hours after ingestion and last only 24 to 48 hours.

Nature of vomiting

Projectile vomiting suggests intestinal obstruction

•Circumstances of onset•Associated symptoms like diarrhea, malaise, fever•Nature of vomiting•Colour and contents of vomitus•Associated abdominal pain•Associated abdominal distention•Presence or absence of obstipation

Acute vomiting…….

Colour:

•Bilious•White or yellow• Red, Black or coffee ground

•Circumstances of onset•Associated symptoms like diarrhea, malaise, fever•Nature of vomiting•Colour and contents of vomitus•Associated abdominal pain•Associated abdominal distention•Presence or absence of obstipation

Bilious vomiting

is always organicPain could give clue…….

In wavesConstant pain

Localized painPoorly localized or diffuse pain

With abdominal distentionGola formation

Without abdominal distention

With obstipationWith diarrhea

White/ yellow vomiting

• Gastritis/Gastroenteritis

• Any condition with severe abdominal pain

• Secondary Vomiting as in hepatitis, DKA, meningitis, increased intracranial pressure,

Hepatitis : Malaise, fever, anorexia, RUQ pain and yellowish discolouration

DKA: Usually h/o diabetes, fever, dehydration, smell of ketones

Red, Black or coffee ground vomiting

GI bleed

CLINICAL EXAMINATION

•Look for “toxic look”, jaundice, lymphadenopathy.

•Look for of dehydration by evaluating skin turgor and mucous membranes, and observing for hypotension or orthostatic changes.

•Look for abdominal distention and “Gola” formation. Look for the scars in lower abdomen. Inspect hernial sites

•Assess level of consciousness

•Evaluate for signs of depression or anxiety, which may suggest psychiatric etiologies.

Looking for Abdominal pain and guarding or rigidity

Right upper quadrant Biliary tract disease, cholecystitis

Epigastric Pancreatic disease, peptic ulcer disease

Diffuse or periumbilical Small bowel obstruction, mesenteric ischemia

RIF Acute appendicitis

Warning signals which must not be ignored

•Chest pain, •Severe abdominal pain, localized tenderness•Central nervous system symptoms, •Fever, •History of immunosuppression, •Hypotension, •Severe dehydration, or •Older age.

Investigations:

Depends upon initial impression:

•A typical Gastritis, viral gastroenteritis, food poisoning may not need any investigations.

•With severe pain and/or distention/ bilious vomiting:•Amylase/Lipase•Abdominal x-ray standing•CECT abdomen (upper) /USG upper abdomen•Diagnostic laparoscopy

White/yellow vomiting and no abdominal pain:

Bilirubin/ SGPT

Blood sugar +/- KetonesUrea/ creatinine

UGI endoscopy

CNS: LP/ FundusCT/ MRI brain

Red/Coffee ground/ black vomiting:

UGI endoscopy

Basic Principles and cautions:

Make sure you have NOT focused only on vomiting and overlooked underlying serious pathology.

•Not overlooked intestinal obstruction•Not overlooked mesenteric ischemia•Not overlooked Boerhaave’s syndrome•Not overlooked hepatic failure•Not overlooked DKA or renal failure•Not over looked serious intracranial pathology

Basic steps for assessing acute onset vomiting of GI origin

With prodromal symptomsWith diarrhea INFECTIVEFollowing eating dubious quality food Toxins

With moderate to severe pain and +/- distention Acute abdomen

Bilious Mechanical or

functional obstruction

Basic Principles of management:

•Identify and correct underlying cause•Antiemetic and IV fluids if prolonged vomiting•Ryle’s tube if small bowel obstruction

Take home message

•Most of the causes of acute vomiting are easy to diagnose clinically with good history and physical examination only

•Presence of abdominal pain and distention always need proper follow up

•Causes other than GI tract must be kept in mind

•And don’t forget pregnancy in child bearing aged women