Nausea Vomiting

Gastroenterology
Approach to the patient with

nausea and vomiting
With Kelley Chuang, M.D.
Led Joestar, pifeli2160@zevars.com

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Learning Objectives
In this lecture, you will learn how to

 define dyspepsia and functional
dyspepsia.
 identify alarm features of dyspepsia.
 describe a general approach to evaluating
a patient with nausea and vomiting.

Dyspepsia
What is dyspepsia?

Dyspepsia
Dyspepsia is a constellation of symptoms

including epigastric pain/burning, abdominal
bloating, nausea, and vomiting.

53-year-old Woman with Epigastric Pain Test case
A 53-year-old woman is seen in clinic for 8 months of epigastric Chronic abdominal

pain. Her pain is intermittent, described as a sense of discomfort, nausea,
abdominal bloating/discomfort. Symptoms tend to occur after vomiting, and weight loss
meals. She has nausea, occasional vomiting, and has lost 5 kg
in the last year. Her mother had a history of stomach cancer.
Family history of upper GI
Vitals are normal. On exam, she has mild tenderness in the malignancy
epigastric region but no palpable mass. Labs show a Hgb of
11.5 g/dL.
What is the best next step in management?

Dyspepsia
2 of3
however this is a diagnosis of exclusion. Make sure to rule out the
other causes below.
Causes of dyspepsia
GERD Gastric cancer Biliary disease Medications
(NSAIDs, ASA)
Peptic ulcer disease Gastroparesis Pancreatitis Alcohol
H. pylori infection Celiac disease Pancreatic cancer Metabolic disorders
Esophageal cancer Carbohydrate Ischemic bowel Pregnancy
malabsorption

Alarm Features of Dyspepsia
Onset after age 50
Anemia
Dysphagia or odynophagia
Unintentional weight loss If any of these

are present,
Family or personal history of upper GI malignancy refer for
endoscopy!
Personal history of PUD
Prior gastric surgery

Functional Dyspepsia
Symptoms must be present for past 3 months

with onset at least 6 months prior.
Diagnosis of exclusion must have 1 or more of the following:
Postprandial fullness Epigastric pain
Early satiety Epigastric burning
No structural disease to explain symptoms.

Functional Dyspepsia
Unknown mechanism, but suspected contributions from:

• Abnormal upper GI motor activity
• Psychological factors
• Genetic factors
• Disruption in brain-gut interactions
• Disruption in gut microbiome

Management of Functional Dyspepsia
If no alarm features are present, basic management includes:

1. Testing and treating for Helicobacter pylori infection
2. Initiate PPI therapy
3. Diet and lifestyle modification (avoiding foods that

trigger symptoms)

53-year-old Woman with Epigastric Pain Test case

meals. She has nausea, occasional vomiting, and has lost 5 kg  dyspepsia with alarm
in the last year. Her mother had a history of stomach cancer. features
Vitals are normal. On exam, she has mild tenderness in the Family history of upper GI
epigastric region but no palpable mass. Labs show a Hgb of malignancy
11.5 g/dL.

53-year-old Woman with Epigastric Pain Answer
Test case

meals. She has nausea, occasional vomiting, and has lost 5 kg  dyspepsia with alarm
in the last year. Her mother had a history of stomach cancer. features
Vitals are normal. On exam, she has mild tenderness in the Family history of upper GI
epigastric region but no palpable mass. Labs show a Hgb of malignancy
11.5 g/dL.
Answer: Multiple alarm symptoms endoscopy

65-year-old Man with Frequent Nausea and Vomiting Test case
A 65-year-old man is seen in clinic for a 2-week history of Dyspepsia with vomiting
frequent nausea and vomiting. He vomits about 30 minutes immediately after meals
after eating meals and notes frequent stomach gurgling and
bloating between meals. He has a history of uncontrolled type Uncontrolled diabetes and
2 diabetes mellitus and had a cholecystectomy 10 years ago. history of abdominal
He has lost 2 kg (4.4 lb) in the and history of abdominal last surgery
month, but denies dysphagia, odynophagia, or abdominal pain.
Succussion
Vitals are normal. On exam, when auscultating the stomach, he indicates presence of gas
has an audible splashing sound when he is rocked side to side. and food in the stomach
What is the most likely diagnosis?

How Do You Know it's not a Small Bowel Obstruction?
In a patient with nausea and vomiting, make

sure to rule out SBO! Ask about abdominal
pain, constipation, obstipation, and history of
abdominal surgeries.

Gastroparesis
• Slow or delayed clearance of gastric contents
Clinical features:
• Early satiety
• Postprandial fullness
• Nausea and vomiting
• Abdominal pain or bloating
• Weight loss

Gastroparesis
• Easily confused for peptic ulcer disease (PUD), gastric or small bowel obstruction,
functional dyspepsia, gastric cancer, H. pylori infection, and biliary disease
• Diagnosis: endoscopy to rule out mechanical obstruction, gastric emptying test

Gastroparesis Management
• Treat dehydration or electrolyte disturbances
• Dietary modification
• Small, frequent meals
• Avoid high fiber
• Anti-emetics for symptoms (metoclopramide)

Gastric Emptying Study
A gastric emptying study involves administering barium and taking abdominal X-rays at timed
intervals after ingestion. In this example, a patient with gastroparesis has barium in the stomach
after ingestion (left), and 20 hours later still has residual barium in the stomach (right).
© Lee et al. 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4812605/figure/Fig3/, CC BY 4.0, no changes
Why Does Gastroparesis Occur?
Always look for the underlying etiology for gastroparesis!

Frequent underlying causes: diabetes, thyroid disease,
neurologic disease, prior gastric surgery, autoimmune
disorders, and post-viral syndromes.

65-year-old Man with Frequent Nausea and Vomiting Test case
bloating between meals. He has a history of uncontrolled type Uncontrolled diabetes
2 diabetes mellitus and had a cholecystectomy 10 years ago.  high risk for
He has lost 2 kg (4.4 lb) in the and history of abdominal last gastroparesis
History of abdominal
Vitals are normal. On exam, when auscultating the stomach, he surgery  SBO
has an audible splashing sound when he is rocked side to side.
Succussion
What is the most likely diagnosis? indicates presence of gas
and food in the stomach

65-year-old Man with Frequent Nausea and Vomiting Answer
Test case
bloating between meals. He has a history of uncontrolled type Uncontrolled diabetes
2 diabetes mellitus and had a cholecystectomy 10 years ago.  high risk for
He has lost 2 kg (4.4 lb) in the and history of abdominal last gastroparesis
History of abdominal
Vitals are normal. On exam, when auscultating the stomach, he surgery  SBO
has an audible splashing sound when he is rocked side to side.
Succussion
What is the most likely diagnosis? indicates presence of gas
and food in the stomach
Answer: gastroparesis due to underlying diabetes

Learning Outcomes
In this lecture, you have learned how to
 define dyspepsia and functional

dyspepsia.
 identify alarm features of dyspepsia.
 describe a general approach to evaluating

a patient with nausea and vomiting.

This document is a property of: Led Joestar
Note: This document is copyright protected. It may not be copied, reproduced, used, or
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Gastroenterology

Approach to the patient with

With Kelley Chuang, M.D.

Led Joestar, pifeli2160@zevars.com

In this lecture, you will learn how to

Led Joestar, pifeli2160@zevars.com

Led Joestar, pifeli2160@zevars.com

Dyspepsia is a constellation of symptoms

Led Joestar, pifeli2160@zevars.com

A 53-year-old woman is seen in clinic for 8 months of epigastric Chronic abdominal

What is the best next step in management?

Led Joestar, pifeli2160@zevars.com

Led Joestar, pifeli2160@zevars.com

Onset after age 50

Unintentional weight loss If any of these

Prior gastric surgery

Led Joestar, pifeli2160@zevars.com

Symptoms must be present for past 3 months

Diagnosis of exclusion must have 1 or more of the following:

Postprandial fullness Epigastric pain

Early satiety Epigastric burning

No structural disease to explain symptoms.

Led Joestar, pifeli2160@zevars.com

Unknown mechanism, but suspected contributions from:

• Disruption in brain-gut interactions

• Disruption in gut microbiome

Led Joestar, pifeli2160@zevars.com

If no alarm features are present, basic management includes:

2. Initiate PPI therapy

3. Diet and lifestyle modification (avoiding foods that

Led Joestar, pifeli2160@zevars.com

A 53-year-old woman is seen in clinic for 8 months of epigastric Chronic abdominal

What is the best next step in management?

Led Joestar, pifeli2160@zevars.com

A 53-year-old woman is seen in clinic for 8 months of epigastric Chronic abdominal

What is the best next step in management?

Answer: Multiple alarm symptoms endoscopy

Led Joestar, pifeli2160@zevars.com

What is the most likely diagnosis?

Led Joestar, pifeli2160@zevars.com

In a patient with nausea and vomiting, make

Led Joestar, pifeli2160@zevars.com

• Slow or delayed clearance of gastric contents

• Nausea and vomiting

• Abdominal pain or bloating

Led Joestar, pifeli2160@zevars.com

• Diagnosis: endoscopy to rule out mechanical obstruction, gastric emptying test

Led Joestar, pifeli2160@zevars.com

• Treat dehydration or electrolyte disturbances

• Small, frequent meals

• Avoid high fiber

• Anti-emetics for symptoms (metoclopramide)

Led Joestar, pifeli2160@zevars.com

Always look for the underlying etiology for gastroparesis!

Led Joestar, pifeli2160@zevars.com

Led Joestar, pifeli2160@zevars.com

Led Joestar, pifeli2160@zevars.com

In this lecture, you have learned how to

 define dyspepsia and functional

 identify alarm features of dyspepsia.

 describe a general approach to evaluating

Led Joestar, pifeli2160@zevars.com

Led Joestar, pifeli2160@zevars.com