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Cause

Suggestive Findings*

Diagnostic Approach

Gastrointestinal disorders

Adynamic ileus

Abdominal distention

Increased risk after surgery or with severe illness or an electrolyte abnormality

Clinical evaluation

Radiograph or CT

Bowel obstruction

Obstipation, distention, tympany

Often bilious vomiting, abdominal surgical scars, or hernia

Flat and upright abdominal radiographs

Gastroenteritis

Vomiting, diarrhea

Benign abdominal examination

Clinical evaluation

Gastroparesis

Vomiting of partially digested food a few hours after ingestion

Often in diabetics with elevated blood glucose or after abdominal surgery

Flat and upright abdominal radiographs

Sometimes gastric emptying scan

Hepatitis

Mild to moderate nausea for many days, sometimes vomiting

Jaundice, anorexia, malaise

Sometimes slight tenderness over the liver

Serum aminotransferases, bilirubin, viral hepatitis titers

Perforated viscus or other acute abdomen (eg, appendicitis, cholecystitis, pancreatitis)

Significant abdominal pain

Usually peritoneal signs

See Acute Abdominal Pain

Toxic ingestion (numerous)

Usually apparent based on history

Varies with substance

Central nervous system (CNS) disorders

Brain tumor

Dizziness and/or headache

Sometimes mental status change and/or focal neurologic deficits

Head CT or MRI

Cannabis use (cannabinoid hyperemesis syndrome)

Persistent nausea, vomiting, and dyspepsia

Usually requires chronic use of cannabis

Relief with hot bath or marijuana cessation

Clinical evaluation

Urine drug screen

Closed head injury

Apparent based on history

Head CT

CNS hemorrhage

Sudden-onset headache, mental status change

Often meningeal signs

Head CT

Lumbar puncture if CT is normal

CNS infection

Gradual-onset headache

Often meningeal signs, mental status change

Sometimes petechial rash* due to meningococcemia

Head CT

Lumbar puncture

Increased intracranial pressure (eg, caused by hematoma or mass)

Headache, mental status change

Sometimes focal neurologic deficits

Head CT

Labyrinthitis

Vertigo, nystagmus, symptoms worsened by motion

Sometimes tinnitus

See Dizziness and Vertigo

Migraine

Headache sometimes preceded or accompanied by a neurologic aura or photophobia

Often a history of recurrent similar attacks

In patients with known migraine, possible development of other CNS disorders

Clinical evaluation

Head CT and lumbar puncture considered if evaluation is unclear

Motion sickness

Apparent based on history

Clinical evaluation

Psychogenic disorders (eg, anorexia nervosa, bulimia nervosa)

Occurring with stress

Eating food is considered repulsive

Clinical evaluation

Systemic conditions

Advanced cancer (independent of chemotherapy or bowel obstruction)

Apparent based on history

Clinical evaluation

Diabetic ketoacidosis

Polyuria, polydipsia

Often significant dehydration

With or without history of diabetes

Serum glucose, electrolytes, ketones

Medication or illicit drug adverse effect or toxicity

Apparent based on history

Varies with substance

Liver failure or renal failure

Often apparent based on history

Asterixis

Often jaundice in advanced liver disease, uremic odor in renal failure

Laboratory tests of liver and renal function

Blood ammonia level

Pregnancy

Often occurring in morning or triggered by food

Benign examination (possibly dehydration)

Pregnancy test

Radiation exposure

Apparent based on history

Clinical evaluation

Severe pain (eg, due to a kidney stone)

Varies with cause

Clinical evaluation

* Sometimes forceful vomiting (caused by any disorder or condition) causes petechiae on the upper torso and face, which may resemble those of meningococcemia. Patients with meningococcemia are usually very ill, whereas those with petechiae caused by vomiting often appear otherwise quite well.

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