Common Causes of Nausea and Vomiting and Treatment Reviewed
CME/CE
News Author: Emma Hitt, PhD
CME Author: Hien T. Nghiem, MD
Release Date: July 12, 2007; Valid for credit through July 12, 2008
July 12, 2007 — In a review article in the July 1 issue of American Family
Physician, Keith Scorza, MD, and colleagues from the Dewitt Army
Community Hospital in Fort Belvoir, Virginia, describe an approach to
evaluating common causes of nausea and vomiting and briefly review treatment
options.
According to the authors, the significant causes of nausea and vomiting include
iatrogenic causes, toxicity, infectious causes, gastrointestinal disorders, and
central nervous system or psychiatric conditions.
Among iatrogenic causes, chemotherapeutic agents are the most well known.
Infectious and toxic causes are usually self-limiting and include viral
gastroenteritis as well as bacteria and their toxins. Gastrointestinal disorders are
often caused by an inflammatory process, such as appendicitis, cholecystitis, or
pancreatitis, or may be caused by obstruction or motility problems. Central
nervous system or psychiatric causes include increases in intracranial pressure,
migraine, and emotional or physical stressors.
"Pregnancy is the most common endocrinologic cause of nausea and vomiting
and must be considered in any woman of childbearing age," the authors point
out.
The authors review the 3-step process for evaluating nausea and vomiting
recommended by the American Gastroenterological Association. The 3
recommended steps are as follows:
Recognize and correct symptoms, such as dehydration or electrolyte abnormalities.
Try to identify the underlying cause and provide specific therapy.
Use empiric therapy if no cause can be identified.
"Diagnostic tests should be ordered only when based on clinical suspicion," the authors
suggest. "Most of the time, a history and physical examination can identify the cause. If all
organic, gastrointestinal, and central causes of nausea and vomiting have been explored,
psychogenic vomiting should be considered," they add. A detailed algorithm for the
evaluation of nausea and vomiting adapted from an American Gastroenterological
Association medical position statement on nausea and vomiting is provided in the article.
With respect to treatment, the primary goal is "a careful assessment of fluid and electrolyte
status with appropriate replacement," Dr. Scorza and colleagues suggest. A low-fat or liquid
diet may be prescribed. Targeted therapy should be given when a specific cause is identified,
but empiric therapy should be administered in the event that the cause remains unknown. "It is
reasonable to begin with a trial of a phenothiazine, such as prochlorperazine."
Therapies for known etiologies of nausea and vomiting include the following:
ondansetron/dexamethasone for acute chemotherapy-induced nausea and vomiting and
metoclopramide/dexamethasone for delayed chemotherapy-induced nausea and vomiting;
tricyclic antidepressants for adults with cyclic vomiting syndrome;
supportive treatment and possible gastric pacing for gastroparesis; and
droperidol/dexamethasone or ondansetron for postoperative nausea and vomiting.
During pregnancy, prochlorperazine, chlorpromazine, metoclopramide, and
methylprednisolone are recommended for hyperemesis gravidarum; meclizine, promethazine,
electrolyte replacement, and thiamine supplementation are recommended for morning
sickness.
Am Fam Physician. 2007;76:76-84.
Clinical Context
Nausea and vomiting are common ailments had by many individuals. Nausea is defined as the
unpleasant, painless sensation that one may potentially vomit. Vomiting involves the forceful
expulsion of stomach contents through involuntary muscular contractions. The causes of
nausea and vomiting include iatrogenic, toxic, infectious causes; gastrointestinal disorders;
and central nervous system or psychiatric conditions. Most infections are self-limiting. Most
medications can cause nausea and vomiting; iatrogenic causes are resolved by removing the
offending agent. Gastrointestinal etiologies include obstruction, functional disorders, and
organic diseases. Central nervous system etiologies are related to conditions that increase
intracranial pressure and cause other neurologic signs. Psychiatric diagnoses such as anorexia
nervosa, bulimia nervosa, depression, and anxiety should be considered.
This article reviews the common and significant causes of nausea and vomiting, offers an
approach to evaluation, and provides a brief overview of treatment options.
Study Highlights
The American Gastroenterological Association suggests a 3-step approach to the initial
evaluation of nausea and vomiting.
The first step is to recognize and correct any consequences of the symptoms, such as
dehydration and electrolyte abnormalities.
The second step is to try to identify the underlying cause and provide specific therapies:
The cause of most acute nausea and vomiting can be determined from the history and
physical examination; diagnostic tests should be ordered based on clinical suspicion.
Symptom duration should be determined because the differential diagnoses for acute
symptoms and chronic symptoms differ.
The physical examination should focus on signs of dehydration, evaluation of skin turgor
and mucous membranes, and observation for hypotension or orthostatic changes. Abdominal
and neurologic examinations should also be performed.
The presence of abdominal pain usually suggests an organic cause; the location, severity,
and timing of pain may indicate a specific etiology.
Warning signs such as chest pain, severe abdominal pain, central nervous system symptoms,
and fever; a history of immunosuppression, hypotension, or severe dehydration; or older age
should prompt immediate evaluation.
There are no diagnostic tests specific to determining the etiologies of nausea and vomiting;
tests should be directed based on history and physical examination.
A pregnancy test should be performed in any woman of childbearing age and is needed
before radiography.
Proximal mucosal lesions and obstructions may be detected by
esophagogastroduodenoscopy or upper gastrointestinal radiography; computed tomography
may soon be the method of choice for detecting intestinal obstructions.
If no diagnosis is determined after initial evaluation, gastric motility studies (eg, gastric
emptying scintigraphy, cutaneous electrogastrography, and antroduodenal manometry) may
be considered.
The third step, if no etiology can be determined, is to use empiric therapy and treat
symptoms.
Medications that may be beneficial include phenothiazines (eg, prochlorperazine),
prokinetic agents (eg, metoclopramide), and serotonin antagonists (eg, ondansetron).
Trials determining the specific effectiveness of medication for nausea and vomiting are
limited; therefore, a trial of any medication may be reasonable on an individual basis.
Pearls for Practice
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
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The American Gastroenterological Association suggests a 3-step approach to the initial
evaluation of nausea and vomiting: recognizing and correcting any consequences of the
symptoms, trying to identify the underlying cause and providing specific therapies, and using
empiric therapy and treating symptoms.