Urgent considerations

See Differentials for more details

Severe abdominal pain

  • Cramping epigastric or right upper quadrant pain followed by nausea and vomiting may reflect gastric outlet obstruction, or acute or chronic cholecystitis.

  • A rigid abdomen associated with severe pain suggests an acute abdomen due to bowel perforation, or acute peritonitis due to peritoneal inflammation or malignancy. Rebound tenderness and guarding may be present in bowel perforation.

  • Patients should be referred to the emergency department for assessment of vital signs, routine laboratory studies, and urgent computed tomography (CT) of the abdomen.

  • Patients with diabetic ketoacidosis may present with nausea, vomiting, and abdominal pain.[21][22]​ These patients require urgent assessment and management, often with senior or critical care support.[8]

Acute neurological events

  • Symptoms of severe headache that may be associated with a rash or neck stiffness are suggestive of infections of the central nervous system, such as a brain abscess or meningitis. The headache is most often accompanied with photophobia and precedes nausea and vomiting. Patients with acute onset of severe headache, with or without fever, should be referred to the emergency department for a CT head and possible lumbar puncture if meningitis is suspected.

    Diagnostic lumbar puncture in adults: animated demonstration
    Diagnostic lumbar puncture in adults: animated demonstration

    How to perform a diagnostic lumbar puncture in adults. Includes a discussion of patient positioning, choice of needle, and measurement of opening and closing pressure.

  • Older patients presenting with acute-onset focal neurological deficit should be urgently evaluated for a possible stroke. The goals of the initial evaluation are to identify the stroke syndrome, ensure medical stability, perform an abbreviated neurological examination, and rapidly transport the patient to head CT or magnetic resonance imaging (MRI) scan. The need for thrombolysis should be determined following scanning.

Older patients with atherosclerotic disease: gastrointestinal vascular considerations

  • Ischaemic gastroparesis can present with nausea, vomiting, and mild abdominal discomfort (and not necessarily excruciating abdominal pain) and should be considered in older patients with coronary artery disease or other known atherosclerotic diseases. Patients may have an abdominal bruit.

  • These patients need urgent magnetic resonance angiography to determine the presence of coeliac or superior mesenteric artery stenosis that may explain mesenteric ischaemia.

Cardiac considerations

  • Nausea and vomiting may accompany, or be a presenting symptom of, an acute coronary syndrome (ACS). Any suspicion of cardiac disease (e.g., acute onset chest pain radiating to the left arm, neck, or jaw) should prompt immediate evaluation. ACS includes ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA). These terms are used as a framework for guiding management.

    • Patients with STEMI should be considered for immediate reperfusion therapy by thrombolytic agents or percutaneous coronary intervention.

    • Patients with NSTEMI have elevated cardiac enzymes without ST segment elevation on ECG. Patients with NSTEMI may be managed medically or require reperfusion depending on clinical status, presence of risk factors, and response to initial treatment.[29]

    • Patients with normal cardiac enzymes but abnormal ECG findings have UA. Patients with UA have a significantly lower risk of death compared with patients with NSTEMI and get less benefit from an aggressive pharmacological and invasive approach.[30]​ Acute management depends on the patient’s clinical presentation and a risk assessment.

Shock, volume depletion, or life-threatening illness

  • A high index of suspicion should exist for patients with acute or chronic adrenal insufficiency. Patients may already be on chronic corticosteroid therapy. Patients may present in shock with hyponatraemia, hyperkalaemia, and hypoglycaemia.

  • Suspect diabetic ketoacidosis if nausea and/or vomiting is present in a patient with known diabetes, and in any patient presenting with nausea and/or vomiting with increased thirst, polyuria, recent unexplained weight loss, or excessive tiredness.[8]​

Anorexia or weight loss

  • Anorexia may be a symptom of extensive liver metastases associated with nausea. Ovarian cancer should be considered in middle-aged women who report vague abdominal discomfort, loss of appetite, and early satiety.[31][32]​​ Renal carcinomas are also nauseogenic, and small cell cancers of the lungs are associated with paraneoplastic syndromes. Infiltrating adenocarcinomas of the stomach may result in linitis plastica (morphological variant of diffuse or infiltrating stomach cancer) and symptoms of early satiety, fullness, nausea, and vomiting.

  • Bulimia nervosa and anorexia nervosa (binge eating/purging sub-type) present with nausea, anorexia, and weight loss associated with marked psychological disturbance and require a complete psychiatric evaluation. These patients also have disordered gastrointestinal physiology.[33]

  • Patients with anorexia and weight loss need a CT abdominal scan with attention to specific abdominal organs depending on localising symptoms.

Presence of occult or frank blood in stools

  • May indicate peptic ulcer disease or gastrointestinal malignancies.

  • These patients need upper endoscopy, colonoscopy, and possible capsule endoscopy or double-balloon enteroscopy to determine the cause.

Consideration of pregnancy

  • The possibility of pregnancy should be considered in all women of child-bearing age presenting with nausea and vomiting.

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