Vomiting History

Aka: Vomiting History, Nausea History

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II. History: Associated Factors

  1. Weight Loss
    1. Malignancy
    2. Gastric outlet obstruction
    3. Peptic Ulcer Disease
  2. Adequate nutrition despite prolonged course
    1. Psychogenic Vomiting
  3. Diarrhea
    1. Diarrhea that follows Vomiting is consistent with Gastroenteritis
      1. Viral Gastroenteritis (viral prodrome, contagious contacts)
      2. Foodborne Illness
    2. Vomiting that follows Diarrhea is consistent with enteritis (or Urinary Tract Infection in girls, women)
  4. Fever with Emesis
    1. Acute Gastroenteritis (most common cause)
    2. Cholecystitis
    3. Appendicitis
    4. Hepatitis
  5. Headache
    1. Exertional Headache with valsava or associated with stiff neck or focal neurologic deficit
      1. Increased Intracranial Pressure
    2. Unilateral, pulsatile, light sensitive under 72 hours
      1. Migraine Headache
  6. Early satiety and postprandial bloating
    1. Gastroparesis
  7. Repetitive Migraine Headaches
    1. Cyclic Vomiting Syndrome

III. History: Onset

  1. Abrupt Onset
    1. Gastroenteritis or Food Poisoning
    2. Pancreatitis
    3. Cholecystitis
    4. Medication Induced Vomiting or Illicit Drugs
  2. Insidious Onset
    1. Gastroesophageal Reflux
    2. Gastroparesis
    3. Medication Induced Vomiting
    4. Metabolic Disorders
    5. Pregnancy

IV. History: Associated Pain

  1. Right upper quadrant pain
    1. Cholecystitis or other biliary tract disease
  2. Epigastric Pain
    1. Pancreatitis
    2. Peptic Ulcer Disease
  3. Severe pain
    1. Cholecystitis or other biliary tract disease
    2. Pancreatitis
    3. Peritonitis
    4. Appendicitis
    5. Small Bowel Obstruction (pain precedes Vomiting)
  4. Vomiting is Palliative of Pain
    1. Vomiting relieves Peptic Ulcer Disease pain
    2. Vomiting does not relieve pain of:
      1. Pancreatitis
      2. Cholecystitis
  5. Vomiting follows Abdominal Pain
    1. Appendicitis (99% Test Sensitivity, 64% Test Specificity)

V. History: Timing

  1. Vomiting prior to eating breakfast
    1. Alcoholism
    2. Uremia
    3. Chronic Obstructive Lung Disease
    4. Psychogenic Vomiting
    5. Increased Intracranial Pressure
    6. Vomiting in Pregnancy (Morning Sickness)
      1. Vomiting occurs throughout day in pregnancy
  2. During or immediately after eating
    1. Psychogenic Vomiting (most common)
    2. Peptic Ulcer Disease
    3. Pyloric Stenosis
    4. Eating Disorder (e.g. Anorexia Nervosa or Bulimia)
  3. One to four hours after a meal
    1. Gastric outlet obstruction
    2. Peptic Ulcer Disease
    3. Malignancy
    4. Gastroparesis
  4. Continuous Vomiting
    1. Conversion Disorder
  5. Intermittent sporadic Vomiting
    1. Major Depression
  6. Associated with new medication or dosage change
    1. See Medication Induced Vomiting

VI. History: Characteritics of Emesis

  1. Putrid or fecal odor (Stercoraceous Vomiting)
    1. Vomiting of fecal material
    2. Causes
      1. Intestinal Obstruction
      2. Gastrocolic fistula
      3. Gastric outlet obstruction (Bacterial overgrowth)
  2. Regurgitation of undigested food
    1. Achalasia
    2. Esophageal Stricture
    3. Zenker's Diverticulum
  3. Large residues of gastric contents and particles (partly digested food or chyme)
    1. Large volumes (>1.5 L/24h) suggests organic cause
    2. Gastroparesis
      1. Emesis delayed 1 hour or more after eating
    3. Gastric Outlet Obstruction
      1. Emesis delayed as much as 12 hours after eating
      2. Partially digested food without bile present
  4. Hematemesis (Coffee-ground Emesis or black Emesis)
    1. Suggests Gastrointestinal Bleeding
    2. Upper Respiratory tract can also be bleeding source
  5. Bilious Emesis suggests Small Bowel Obstruction
    1. Emesis stained green with bile
    2. Confirms patency of gastric outlet
  6. Projectile Vomiting (with or without Nausea)
    1. Increased Intracranial Pressure

VII. References

  1. Degowin (1987) Diagnostic Exam, Macmillan, p. 526-7
  2. Feldman (1998) Sleisenger Gastrointestinal, p. 117-126
  3. Friedman (1991) Medical Diagnosis, Little Brown, p. 174
  4. Heilenbach in Marx (2002) Rosen's Emergency Med, p. 178
  5. Anderson (2013) Am Fam Physician 88(6): 371-9 [PubMed]
  6. Quigley (2001) Gastroenterology 120(1):263-86 [PubMed]
  7. Scorza (2007) Am Fam Physician 76:76-84 [PubMed]

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