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🤢 Vomiting
Is there abdominal pain, and what is in the vomit? Vomiting WITHOUT pain points away from the abdomen — think head, drugs, and metabolic.
| Bowel obstruction Must exclude | Vomiting with distension, absolute constipation and colicky pain. Faeculent vomit means distal and late. Previous surgery, a hernia, or known malignancy.Drip and suck — NG tube, fluids, catheter — then CT. Surgical review the same day. |
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| Raised intracranial pressure / mass Must exclude | Vomiting with NO abdominal pain, in the context that matters: headache worse on waking, lying flat, coughing or straining, new focal neurology, a falling conscious level, papilloedema, or known malignancy or immunosuppression.Vomiting without abdominal pain gets a neurological examination. Image before any lumbar puncture. |
| DKA Must exclude | Vomiting, abdominal pain, Kussmaul breathing and ketotic breath. The abdominal pain of DKA is routinely investigated as a surgical abdomen.Glucose, ketones and a gas in every vomiting diabetic. Fluids and fixed-rate insulin. |
| Perforated viscus Must exclude | Sudden severe pain then vomiting, with a rigid silent abdomen. NSAIDs, steroids, known ulcer disease.Erect CXR or CT. Surgeons now — do not wait for the vomiting to settle. |
| Addisonian crisis Must exclude | Vomiting with hypotension, hyponatraemia, hyperkalaemia and hypoglycaemia. Long-term steroids stopped, missed, or not doubled during an illness — and vomiting means the oral dose is not being absorbed anyway.Hydrocortisone 100mg IV. In KNOWN adrenal insufficiency, or clinically significant adrenal suppression, a patient who cannot retain or absorb their oral steroid is an emergency in its own right. |
| Ascending cholangitis Must exclude | Charcot's triad — fever, jaundice, right upper quadrant pain — with vomiting. Add confusion and hypotension and it is Reynolds' pentad.Cultures, antibiotics, and urgent biliary decompression. Antibiotics alone do not treat an obstructed system. |
| Acute pancreatitis Time-sensitive | Severe epigastric pain boring through to the back, with persistent vomiting. Gallstones and alcohol are most of it.Lipase or amylase, and a severity score at 48 hours. Aggressive fluids. |
| Drug toxicity or withdrawal Time-sensitive | Opioids, chemotherapy, antibiotics, digoxin, lithium, colchicine — and alcohol withdrawal. Digoxin toxicity brings visual disturbance and bradycardia; lithium brings tremor and ataxia.Read the chart for what is new AND what is at a new dose. Levels for digoxin and lithium. |
| Hypercalcaemia Time-sensitive | Nausea and vomiting with constipation, polyuria, thirst and confusion. Malignancy and hyperparathyroidism account for most of it.Corrected calcium — the uncorrected value misleads when the albumin is low. Fluids first, then bisphosphonate. |
| Gastroenteritis Common | Vomiting then diarrhoea, often with others affected. Vomiting that starts AFTER the diarrhoea, or lasts beyond 48 hours, is worth a second look.Rehydration. Stool sample if bloody, if travel-related, or if it does not settle. |
| Hyperemesis gravidarum Time-sensitive | Persistent vomiting in early pregnancy with weight loss, ketonuria and electrolyte disturbance. Not the same thing as morning sickness.A pregnancy test in every woman of childbearing age who is vomiting. Thiamine before glucose-containing fluids. |
| Constipation / faecal loading Common | Vomiting is a late feature of severe loading, especially in the frail or on opioids. Overflow diarrhoea can coexist and confuse it.PR examination and an abdominal X-ray if uncertain. A common and reversible cause of vomiting in an inpatient. |
| Post-operative nausea and vomiting Common | Within 24 hours of an anaesthetic, in a patient who is otherwise well with a soft abdomen and passing flatus. Female sex, non-smoker, previous PONV and opioids all raise the risk.Antiemetic by mechanism, not by habit. But a soft abdomen today does not exclude an obstruction tomorrow — re-examine. |
| Labyrinthitis / vestibular Common | Vomiting with true rotational vertigo, worse on head movement, often with nystagmus. Central causes bring other neurology.HINTS examination if acute and persistent. A first episode of severe vertigo in an older patient is a posterior stroke until excluded. |
| Inferior MI Consider | Nausea, vomiting and sweating with little or no chest pain, particularly in diabetics, women and the elderly.An ECG is cheap. Unexplained vomiting with sweating earns one. |
15 differentials · 9 open a full pathway in the app.