Rosen & Barkin's 5-Minute Emergency Medicine Consult (777 page)

• Vital signs/lab or physical exam findings suggestive of moderate to severe dehydration
  
• Inability to tolerate PO fluids
  

• Stable vital signs
  
• Cessation of vomiting and pain control
  
• Able to tolerate PO fluids and keep self hydrated
  

• GI consult for further outpatient workup when symptom free
  
• Consider additional referral to specialist managing this syndrome
  

• Prophylaxis:
  
  • Identification and avoidance of triggers:
    
    • Emotional stress, poor sleep, fasting, illness, marijuana, specific foods (chocolate, cheeses, etc.)
      
  • Management of coexisting conditions:
    
    • Migraine headaches, psychiatric disorders, chronic narcotic, and marijuana use
      
  • Medications (outpatient-in active research):
    
    • Tricyclic antidepressants (amitriptyline)
      
    • Propranolol
      
    • Coenzyme Q-10
      
    • Antihistamines
      
    • Antianxiety medications
      

• Obtain good history about prior cyclic episodes and similarities to prior episodes
  
• Manage active coexisting conditions if applicable
  
• Exclude other disorders with similar presentations of nausea/vomiting/abdominal pain
  

• Abell TL, Adams KA, Boles RG, et al. Cyclic vomiting syndrome in adults.
  Neurogastroenterol Motil.
  2008;20:269–284.
  
• Fleisher DR, Gornowicz B, Adam K, et al. Cyclic Vomiting Syndrome in 41 adults: The illness, the patients, and problems of management.
  BMC Med.
  2005;3:20.
  
• Hejazi RA, McCallum RW. Review article: Cyclic vomiting syndrome in adults – rediscovering and redefining an old entity.
  Aliment Pharmacol Ther.
  2011;34:263–273.
  
• Venkatesan T, Prieto T, Barboi A, et al. Autonomic nerve function in adults with cyclic vomiting syndrome: A prospective study.
  Neurogastroenterol Motil.
  2010;22:1303–1307.
  
• Venkatesan T, Tarbell S, Adams K, et al. A survey of emergency department use in patients with cyclic vomiting syndrome.
  BMC Emerg Med.
  2010;10:4.
  

CODES

• 346.20 Variants of migraine, not elsewhere classified, without mention of intractable migraine without mention of status migrainosus
  
• 346.21 Variants of migraine, not elsewhere classified, with intractable migraine, so stated, without mention of status migrainosus
  
• 536.2 Persistent vomiting
  

BASICS

• Forceful, coordinated act of expelling gastric contents through the mouth; characterized by nausea, retching, and emesis; no gastric contents are expelled during retching.
  
• Emesis results from sustained contraction of abdominal muscles and diaphragm; at the same time, the pylorus and antrum contract.
  

Mechanism:

• GI/mechanical: Gastroesophageal reflux (GER), meconium ileus, necrotizing enterocolitis, hypertrophic pyloric stenosis, intussusception, malrotation with midgut volvulus, Hirschsprung disease, congenital obstructions (atresias, stenoses, and webs), hernia, foreign body/bezoar, pancreatitis, appendicitis, paralytic ileus
  
• Metabolic/endocrine: Inborn errors of metabolism (amino acidurias, fatty acid oxidation disorders, urea cycle defects), uremia, diabetic ketoacidosis, congenital adrenal hyperplasia, kernicterus
  
• Neurologic: CNS bleeding (often due to trauma), tumor, hydrocephalus
  
• Infectious: Otitis media, UTI, pneumonia, sepsis, gastroenteritis, meningitis/encephalitis
  
• Feeding problems: Chalasia, improper technique (overfeeding, improper position), milk allergy
  
• Other: Toxicologic, nonaccidental trauma, pregnancy
  

DIAGNOSIS

• General:
  
  • Appearance variable depending on the underlying cause
    
  • Signs of dehydration, including tachycardia, tachypnea, pallor, decreased perfusion, and shock
    
  • Altered mental status may occur secondary to shock, hypoglycemia, or extra-abdominal conditions (sepsis, inborn error of metabolism, increased intracranial pressure, toxicologic poisoning).
    
• Vomiting characteristics:
  
  • Assess color, composition, onset, progression, and relationship to intake and position.
    
  • Nonbilious emesis is caused by a lesion proximal to the pylorus.
    
  • Bilious (green) emesis indicates obstruction below the duodenal ampulla of Vater; in infants, bilious emesis is associated with a more serious underlying condition (malrotation, volvulus, intussusception, bowel obstruction); may also be due to adynamic ileus or sepsis.
    
  • Bloody emesis (hematemesis) involves a lesion proximal to the ligament of Treitz; bright red bloody emesis has little or no contact with gastric juices due to an active bleeding site at or above cardia.
    
  • “Coffee-grounds” emesis results from reduction of heme by gastric secretions.
    
  • Feculent odor suggests lower obstruction or peritonitis.
    
  • Undigested food in emesis suggests an esophageal lesion or one at or above the cardia.
    
  • GER: Begins shortly after birth, remains relatively constant, usually with normal weight gain.
    
  • Hypertrophic pyloric stenosis: Begins insidiously at 2–6 wk of age and progresses, becoming increasingly forceful (projectile) after feedings.
    
  • Obstruction and/or ischemic bowel (malrotation with midgut volvulus, intussusception, necrotizing enterocolitis): Sudden onset associated with rapid progression to appearing ill out of proportion to the duration of illness; abdomen distended and tender.
    
• Abdominal:
  
  • Distention suggests obstruction.
    
  • Peritoneal signs suggest inflammation and possible perforation.
    
• Complications:
  
  • Aspiration
    
  • Mallory–Weiss tear
    
  • Boerhaave syndrome
    

• Constitutional:
  
  • Fever
    
• Vomiting characteristics:
  
  • Timing, duration
    
  • Bilious?
    
  • Bloody?
    
• Associated symptoms:
  
  • Diarrhea
    
  • Anorexia
    
  • Abdominal pain
    
  • Dysuria
    
  • Inguinal swelling
    
• PMHx:
  
  • History of similar
    
  • Past surgical history
    

• General:
  
  • General appearance, vital signs, hydration status
    
• Cardiovascular:
  
  • Quality heart tones
    
  • Pulses, perfusion
    
• Abdominal:
  
  • Tenderness, distention, mass
    
  • Bowel sounds
    
• Genitourinary:
  
  • Scrotal swelling, tenderness, mass
    
• Rectal:
  
  • Presence of blood, mass, tenderness
    

Exclude life-threatening causes of vomiting.

• As indicated by history and physical exam and consideration of differential:
  
  • Metabolic assessment (glucose, electrolytes)
    
  • Infection assessment (CBC, culture—urine)
    
  • Pregnancy tests for females of childbearing age
    

• As indicated by differential considerations
  
• Abdominal radiographs (flat plate, upright, and decubitus) helpful for evaluation of obstruction or perforation
  
• Pelvic and abdominal US for evaluation of hypertrophic pyloric stenosis, intussusception, appendicitis as well as pelvic or scrotal pathology
  
• Abdominal CT scan helpful for evaluation of appendicitis, mass/tumor often requiring contrast
  

Nasogastric tube:

• Location, character, and severity of gastric bleeding
  

• Neonate/infant:
  
  • GI/mechanical: GER, meconium ileus, necrotizing enterocolitis, hypertrophic pyloric stenosis, intussusception, malrotation with midgut volvulus, Hirschsprung disease, congenital obstructions (atresias, duplications, imperforate anus. stenoses, and webs), hernia, foreign body/bezoar, paralytic ileus
    
  • Metabolic/endocrine: Inborn errors of metabolism (amino acidurias, fatty acid oxidation disorders, urea cycle defects), uremia, congenital adrenal hyperplasia, kernicterus
    
  • Neurologic: CNS bleeding (often due to trauma), tumor, hydrocephalus
    
  • Infectious: Otitis media, UTI, pneumonia, sepsis, pertussis, meningitis/encephalitis
    
  • Feeding problems: Chalasia, improper technique (overfeeding, improper position), milk allergy
    
  • Other: Toxicologic, nonaccidental trauma
    
• Child/adolescent:
  
  • GI: Gastroenteritis, obstruction (hernia, adhesions, intussusception, foreign body, bezoar), pancreatitis, appendicitis, peptic ulcer, peritonitis, paralytic ileus, trauma (duodenal hematoma)
    
  • Metabolic/endocrine: Diabetic ketoacidosis, uremia, adrenal insufficiency
    
  • Infectious: Gastroenteritis, UTI, sinusitis, upper respiratory infection, sepsis, meningitis, encephalitis, pneumonia, hepatitis
    
  • Neurologic: CNS mass/tumor, CNS bleeding (often due to trauma), cerebral edema, concussion, migraine
    
  • Other: Toxicologic, (nonaccidental) trauma, pregnancy, bulimia
    

TREATMENT