Vomiting

Seite 1

Vomiting

Establishes onset and number of times vomited and the contents of the vomitus

Enquires whether there was any bile or blood in the vomit

Enquires about the severity of the vomiting and whether the patient has taken any medication to alleviate the symptoms

Associated symptoms ->

Abdominal pain

Change in bowel habit

Blood passage per rectum

Fainting episodes

Retching

Did anything cause the vomiting to start? Food eaten? Foreign travel

Enquires about previous similar episodes and how they were resolved

Systemic features ->

Pregnancy

Weight change

Fever

Rigors

Appetite

Urinary symptoms

Night sweats

Diagnosis of small bowel obstruction->

Differentials are adhesions, hernia

(in rare cases the cause for obstruction may be secondary to a tumour, which could be adenocarcinoma, lymphoma or GI stromal tumour)

Last two days awful crampy pain in the centre of your stomach

Initially thought trapped wind

Pain gradually worsening and is now generalised across the whole of your abdomen. Can't pinpoint one specific place

Felt nauseous overnight, little sleep

This morning vomiting a large amount of greenish foul tasting liquid

No food in the vomitus as little appetite

Since morning vomited at least 6 times

Now nothing left to vomit up so been retching

Past day or two haven't opened up bowels

Still passing gas

Abdomen distended despite not eating much for past 2 days

Had been feeling bloated before started vomiting

Smoker

Investigations- (Rectal examination) (FBC, U+Es, LFTs, CRP, group and save, maybe CEA tumour marker) (ABG check for lactate, base excess which if raised could signify bowel ischaemia) (AXR, erect CXR to look for obstructed bowel loops and perforation) (CT scan given differential of a tumour causing the obstruction)

Management- admit the patient and keep them nil by mouth. Insert a NG tube and catheter and ensure hourly fluid monitoring with 4 hourly aspiration of the NG tube. Start IV fluids and give antiemetics (cyclizine, metaclopromide) and analgesia NSAIDS ( ibuprofen, diclofenac, paracetamol).

Diagnosis of a Variceal Bleed ->

Differentials are Mallory-Weiss Tear and Upper GI Cancer

60 year old

Woke up feeling unwell

As got up to go to toilet suddenly felt urge to vomit

Noticed large amounts of fresh blood in toilet bowel (more than 2 cupfuls)

After vomiting blood felt extremely faint and dizzy

Couldn't stand up properly without needing to lie down on toilet floor

Dialed 999

Vomited up blood before, last episode 2 weeks ago after having a lot to drink. Not as much that time and did not feel faint

Stools darker than normal

Bad diet

Has Hepatitis B and C

Has Alcoholic Liver Disease

Have dilated cardiomyopathy- never followed that up

Heavy drinker

Heavy Smoker

Been to rehab

Used to inject heroin

Investigations -> FBC< U+Es, LFT, CRP, coagulation profile, group and save and crossmatch 4 units blood

Managemhhhhhhhhhb bs access, start IV fluids and resuscitate the patient, call on call gastroenterologist as will require an emergency upper GI endoscopy

Diagnosis of Mallory-Weiss Tear ->

Differentials are gastritis, variceal bleed, reflux disease

22 year old

Had a lot to drink

Vomiting and retching up everything you have drunk all night

Vomited twice in the nightclub and then three times on way home at 4am

Vomited 6 times overnight and noticed there were streaks of bright red blood in vomit the last few occasions

Mild dull ache in abdomen and feels like acid reflux

Investigations (FBC, U+Es, LFTs, coagulation profile, group and save) (CXR look for mediastinal air)

Management -> IV antiemetics and PPI (omeprazole), call on call gastroenterologist as will require an emergency upper GI endoscopy