Differential Diagnosis and Treatment of Adult Nausea and Vomiting

Immediate Life-Threatening Causes

The American College of Cardiology recommends immediately evaluating for cardiac ischemia with an ECG, particularly in patients with concurrent left-sided pain, as nausea and vomiting frequently accompany acute coronary syndrome, especially in women 1
Esophageal perforation and aortic dissection are emergent causes requiring urgent evaluation, characterized by severe pain with dysphagia and severe chest/back pain, respectively 1
Bowel obstruction is a life-threatening cause that requires urgent evaluation, characterized by abdominal distension and absent bowel sounds 2
Increased intracranial pressure is a life-threatening cause that requires urgent evaluation, characterized by headache, altered mental status, and focal neurologic deficits 3

The National Comprehensive Cancer Network recommends hospitalization for acute nausea and vomiting with suspected surgical causes, such as peritoneal signs or obstruction 4

Gastroparesis, gastric outlet obstruction, and cyclic vomiting syndrome are gastrointestinal causes of chronic nausea and vomiting, which require comprehensive evaluation 1, 2, 4
Medication-related causes, such as opioids, chemotherapy agents, antibiotics, NSAIDs, and selective serotonin reuptake inhibitors, are common reversible causes of chronic nausea and vomiting 3, 5, 6
Uremia, hypercalcemia, adrenal insufficiency, and thyroid disorders are metabolic and endocrine causes of chronic nausea and vomiting 3
Increased intracranial pressure, vestibular disorders, and migraine headaches are neurologic causes of chronic nausea and vomiting 3

The American College of Clinical Pharmacology recommends using dopamine receptor antagonists, such as metoclopramide and prochlorperazine, as first-line treatment for non-chemotherapy-related acute symptoms 3
The National Comprehensive Cancer Network recommends using a combination of NK1 receptor antagonist, 5-HT3 receptor antagonist, and dexamethasone as prophylaxis for chemotherapy-induced nausea 6, 7
Olanzapine is recommended as an add-on therapy for breakthrough symptoms despite optimal prophylaxis 5, 7

The National Comprehensive Cancer Network recommends performing endoscopic or fluoroscopic evaluation in patients with known malignancy and symptoms of gastric outlet obstruction 2, 4
Endoscopic stent placement is preferred for patients with shorter life expectancy, while gastrojejunostomy is preferred for patients with longer prognosis 2, 4