Red flag symptoms - Vomiting in adults

A focused history and clinical examination should identify the cause, says Dr Harry Brown.

A peptic ulcer (pictured above) can cause vomiting (Photograph: SPL)
A peptic ulcer (pictured above) can cause vomiting (Photograph: SPL)

Vomiting is defined as the forceful oral expulsion of gastric contents which is aided by the contraction of the abdominal and chest wall muscles, and is often associated with nausea and retching.

Regurgitation is different from vomiting as it is the reflux of gastric contents, which is effortless.

A focused history taking and clinical examination should help to quickly narrow down the list of potential diagnoses for vomiting.

History and examination
Check for associated diarrhoea, which may suggest gastroenteritis. Establish if the vomiting is acute or chronic, intermittent or constant, and clarify medication use and other illnesses.

If inspection of the vomit reveals undigested foodstuffs, this could suggest achalasia; while if there is a delay in vomiting after eating and there is evidence of partially digested foodstuffs, it could suggest a gastric outlet obstruction or even gastroparesis.

Obstruction of the gut at any point may result in vomiting, which can also result from an acute abdomen.

Consider a neurological cause if there are signs or symptoms of, for example, meningism or a suggestion of migraine; on examination, look for localising neurological signs. Dizziness or tinnitus could suggest an inner ear problem.

When examining the abdomen, look for signs of peritonism or abdominal distension. Also ask the patient about their bowel habits.

Assessing mental state will help to reveal a psychogenic cause, and in all women of childbearing age consider the possibility of pregnancy.

Physical examination will be guided by the history and if appropriate a haematological and biochemical profile may be requested. This may help to evaluate hydration and assess any electrolyte disturbance, as well as establish the presence or absence of anaemia.

In the case of suspected dehydration or bowel obstruction, admission to hospital may be required. Radiological imaging of an appropriate anatomical site or endoscopy may also be required, but many diagnoses can be suspected from the history and physical examination.

Potential complications
Complications include hypokalaemia, dehydration, aspiration and a Mallory-Weiss tear. Many cases of vomiting seen in primary care settle by themselves. However, severe cases may need treatment of an underlying condition and an antiemetic or IV fluids.

Possible causes
  • Biliary colic.
  • Pancreatic disease.
  • Peptic ulcer.
  • Food poisoning.
  • Bowel obstruction.
  • Excess alcohol or drug ingestion.
  • Gastroparesis.
  • Increased intracranial pressure.
  • Labyrinthine pathology.
  • Bulimia nervosa.
  • Dr Brown is a GP in Leeds

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