One-liner#

Evaluate nausea and vomiting to identify serious causes (obstruction, increased ICP, metabolic emergencies) while efficiently managing the common causes (viral gastroenteritis, medication-induced, pregnancy, vestibular) in the outpatient setting.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Bilious (green) or feculent vomiting (bowel obstruction)
• Hematemesis or coffee-ground emesis (upper GI bleed)
• Severe dehydration: hypotension, tachycardia, oliguria, altered mental status
• Signs of increased intracranial pressure: severe headache, papilledema, focal neurologic deficits, altered consciousness
• Severe abdominal pain with peritoneal signs
• Diabetic with vomiting + hyperglycemia (DKA)
• Pregnancy + intractable vomiting with ketonuria (hyperemesis gravidarum)
• Recent head trauma
• Suspected toxic ingestion
• Chest pain with vomiting (consider ACS, especially in women/diabetics)

Key history#

Timing and pattern:

• Acute (<1 week) vs chronic (>4 weeks)
• Timing relative to meals: during/immediately after (psychogenic, rumination), 1–2 hours after (gastroparesis, obstruction), unrelated to meals (CNS, metabolic, vestibular)
• Morning predominance: pregnancy, increased ICP, uremia, alcohol
• Projectile: pyloric obstruction, increased ICP

Character of vomitus:

• Undigested food: esophageal obstruction, achalasia, Zenker’s diverticulum
• Partially digested food: gastroparesis, gastric outlet obstruction
• Bilious (green/yellow): obstruction distal to ampulla
• Feculent: distal small bowel or colonic obstruction
• Blood/coffee grounds: upper GI bleed

Associated symptoms:

• Abdominal pain: location and character guide differential
• Diarrhea: gastroenteritis, food poisoning
• Vertigo/dizziness: vestibular causes
• Headache: migraine, increased ICP
• Fever: infection
• Weight loss: malignancy, gastroparesis, eating disorder
• Early satiety: gastroparesis, gastric outlet obstruction

Key questions:

• Last menstrual period (pregnancy test in ALL reproductive-age women)
• New medications or recent changes
• Alcohol use (acute intoxication, withdrawal, alcoholic gastritis, pancreatitis)
• Sick contacts, recent travel, suspect food
• Diabetes (gastroparesis, DKA)
• Prior abdominal surgery (adhesive obstruction)
• Psychiatric history (eating disorders, cyclic vomiting syndrome, cannabinoid hyperemesis)
• Cannabis use (cannabinoid hyperemesis syndrome increasingly common)

Focused exam#

• Vitals: orthostatic BP/HR (dehydration), fever (infection)
• General: hydration status (mucous membranes, skin turgor, capillary refill), nutritional status
• HEENT: papilledema (increased ICP), nystagmus (vestibular), dental erosions (chronic vomiting/bulimia)
• Neck: thyromegaly, lymphadenopathy
• Cardiac: arrhythmia (electrolyte abnormalities)
• Abdominal: distension, bowel sounds (high-pitched = obstruction; absent = ileus), tenderness, succussion splash (gastroparesis, obstruction)
• Neurologic: mental status, focal deficits, gait (cerebellar)
• Skin: jaundice (hepatobiliary), rash (viral)

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

In-office (stable patients):

• Urine pregnancy test: ALL reproductive-age women
• Point-of-care glucose: diabetics, altered mental status
• Urinalysis: ketones (starvation, DKA), infection

Labs to consider:

• BMP: dehydration, electrolyte abnormalities (hypokalemia, hypochloremia from vomiting), renal function
• CBC: infection, anemia
• LFTs, lipase: hepatobiliary or pancreatic cause
• TSH: hyper/hypothyroidism
• Magnesium: if severe/prolonged vomiting

Imaging:

• Abdominal X-ray: if obstruction suspected (limited sensitivity)
• CT abdomen: obstruction, pancreatitis, mass
• Upper GI series or EGD: if structural cause suspected
• Gastric emptying study: if gastroparesis suspected (4-hour scintigraphy)
• Head CT/MRI: if CNS cause suspected

When NOT to do extensive workup:

• Classic viral gastroenteritis with sick contacts, improving
• Clear medication-induced with temporal relationship
• Early pregnancy with mild symptoms
• Known migraineur with typical pattern

Initial management#

• Assess hydration: If severely dehydrated or unable to tolerate PO → ED for IV fluids
• Oral rehydration: Small frequent sips; electrolyte solutions; avoid large volumes
• Dietary: Clear liquids → bland diet as tolerated; avoid fatty, spicy foods
• Antiemetics: Based on suspected cause and patient factors (see table)
• Address underlying cause: Stop offending medication; treat infection; manage gastroparesis

Management by diagnosis#

Acute gastroenteritis#

Education:

• Usually viral; resolves in 1–3 days
• Focus on hydration—small frequent sips
• Contagious; hand hygiene important

Treatment:

Follow-up: Return if not improving in 48–72 hours, bloody stool, high fever, or unable to keep fluids down.

Medication-induced nausea#

Education:

• Many medications cause nausea, especially when starting
• Often improves after 1–2 weeks as body adjusts
• Taking with food may help (unless contraindicated)

Treatment:

• Take medication with food if appropriate
• Consider dose reduction or alternative medication
• Short-term antiemetic while adjusting

Common culprits and alternatives:

Follow-up: 1–2 weeks to reassess; consider alternative if not tolerating.

Pregnancy-related nausea (morning sickness)#

Education:

• Affects 70–80% of pregnancies; usually resolves by 12–16 weeks
• Not harmful to baby; may actually be associated with lower miscarriage risk
• Severe cases (hyperemesis gravidarum) need closer monitoring

Treatment:

Non-pharmacologic (first-line):

• Small, frequent meals; avoid empty stomach
• Avoid triggers (strong smells, fatty/spicy foods)
• Ginger (250 mg QID or ginger tea)
• Acupressure wristbands (P6 point)

Pharmacologic:

Follow-up: 1–2 weeks; if weight loss >5%, ketonuria, or unable to tolerate PO → consider IV hydration or hospitalization.

Gastroparesis#

Education:

• Stomach empties too slowly; often related to diabetes or idiopathic
• Dietary changes are as important as medications
• Chronic condition; goal is symptom management

Treatment:

Dietary modifications (essential):

• Small, frequent meals (5–6/day)
• Low-fat, low-fiber diet (fat and fiber delay emptying)
• Avoid carbonated beverages
• Stay upright after meals; walk after eating
• Liquid calories if solid food not tolerated

Pharmacologic:

Follow-up: GI referral for refractory cases; consider gastric electrical stimulation or pyloric interventions. Optimize diabetes control if diabetic gastroparesis.

Cannabinoid hyperemesis syndrome (CHS)#

Education:

• Caused by chronic, heavy cannabis use (paradoxically, despite cannabis being antiemetic)
• Only treatment is complete cannabis cessation
• Symptoms resolve within days to weeks of stopping; will recur if cannabis resumed
• Hot showers provide temporary relief but are not treatment

Treatment:

• Cannabis cessation (essential—symptoms will not resolve otherwise)
• Supportive care during acute episodes
• Topical capsaicin cream (0.075%) to abdomen—activates same receptors as hot water

Follow-up: 1–2 weeks to confirm cessation and symptom resolution. Counsel on addiction resources if needed.

Cyclic vomiting syndrome (CVS)#

Education:

• Episodic, stereotyped episodes of severe nausea/vomiting with symptom-free intervals
• Related to migraines; often triggered by stress, sleep deprivation, menstruation
• Prophylactic treatment can reduce frequency and severity

Treatment:

Acute episode:

• Dark, quiet room; IV fluids if needed (often requires ED)
• Ondansetron, lorazepam, or sumatriptan (if migraine-associated)

Prophylaxis:

Follow-up: GI referral recommended; 4–6 weeks after starting prophylaxis to assess response.

Follow-up#

• Gastroenteritis: Return if not improving in 48–72 hours or worsening
• Medication-induced: 1–2 weeks to reassess tolerance
• Pregnancy: 1–2 weeks; sooner if weight loss or unable to tolerate fluids
• Gastroparesis: 2–4 weeks after starting treatment; GI referral for refractory cases
• CHS: 1–2 weeks to confirm cannabis cessation and symptom resolution

Return precautions (all patients):

• Unable to keep any fluids down for >24 hours
• Blood in vomit
• Severe abdominal pain
• Fever >101°F (38.3°C)
• Signs of dehydration: dizziness, dark urine, no urination for 8+ hours
• Confusion or altered mental status

Patient instructions#

• Take small sips of clear fluids frequently rather than large amounts at once.
• Avoid solid food until nausea improves, then start with bland foods (crackers, toast, rice).
• Avoid fatty, spicy, or strong-smelling foods.
• If you’re taking a new medication that’s causing nausea, try taking it with food unless told otherwise.
• Rest in a comfortable position; avoid lying flat right after eating.
• Call the office or go to the ER if you can’t keep fluids down, see blood in your vomit, have severe pain, or feel very weak or dizzy.

Smartphrase snippets#

.NVACUTE Acute nausea/vomiting, likely [viral gastroenteritis/medication-induced]. No red flags (no hematemesis, bilious vomiting, severe dehydration, or neurologic symptoms). Plan: supportive care with oral rehydration, antiemetics PRN. Discussed return precautions including inability to keep fluids down, blood in vomit, or worsening symptoms.

.NVPREGNANCY Nausea/vomiting in early pregnancy (morning sickness). No signs of hyperemesis gravidarum (no significant weight loss, ketonuria, or severe dehydration). Plan: dietary modifications, ginger, pyridoxine. Discussed when to seek care if symptoms worsen.

.GASTROPARESIS Chronic nausea with early satiety and postprandial fullness consistent with gastroparesis. [Diabetes history/idiopathic]. Plan: dietary modifications (small frequent low-fat low-fiber meals), prokinetic trial. GI referral for gastric emptying study and further management.

Related pages#

• GERD (problem) — GERD commonly causes nausea
• Dyspepsia/GERD (complaint) — dyspepsia evaluation
• Abdominal Pain (Acute) (complaint) — if pain accompanies nausea
• Diarrhea (Acute) (complaint) — gastroenteritis with diarrhea
• Type 2 Diabetes (problem) — diabetic gastroparesis
• Generalized Anxiety Disorder (problem) — anxiety commonly causes nausea