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Hyperemesis

Specialties > Obstetrics

Differential Diagnosis Schema 🧠

Pregnancy-Related Causes

  • Hyperemesis Gravidarum: Severe nausea and vomiting during pregnancy, typically starting in the first trimester and leading to dehydration, electrolyte imbalance, and weight loss.
  • Multiple Pregnancy: Increased levels of hCG and estrogen can exacerbate symptoms of nausea and vomiting.
  • Molar Pregnancy: Abnormal proliferation of trophoblastic tissue with high hCG levels, leading to severe nausea and vomiting.
  • Normal Pregnancy: Mild to moderate nausea and vomiting (morning sickness) is common, but should not cause severe dehydration or weight loss.

Gastrointestinal Causes

  • Gastroenteritis: Inflammation of the stomach and intestines, typically presenting with nausea, vomiting, diarrhea, and abdominal pain.
  • Peptic Ulcer Disease: Can present with nausea and vomiting, particularly with complications like pyloric stenosis.
  • Cholecystitis: Inflammation of the gallbladder, often associated with nausea, vomiting, and right upper quadrant pain.
  • Pancreatitis: Acute inflammation of the pancreas, presenting with severe epigastric pain radiating to the back, nausea, and vomiting.
  • Gastroesophageal Reflux Disease (GERD): Can cause nausea and vomiting, especially in the morning or after meals.
  • Bowel Obstruction: Presents with nausea, vomiting, abdominal distension, and absence of bowel movements.
  • Hepatitis: Inflammation of the liver, often presenting with nausea, vomiting, jaundice, and right upper quadrant tenderness.
  • Gastroparesis: Delayed gastric emptying, often associated with diabetes, presenting with nausea, vomiting, and early satiety.

Neurological and Endocrine Causes

  • Migraine: Can present with severe nausea and vomiting, often associated with photophobia and phonophobia.
  • Increased Intracranial Pressure: Causes include tumors, hydrocephalus, or pseudotumor cerebri; presents with headache, nausea, vomiting, and visual disturbances.
  • Vestibular Disorders: Such as labyrinthitis or Meniere’s disease, can cause vertigo, nausea, and vomiting.
  • Diabetic Ketoacidosis (DKA): Can present with nausea, vomiting, abdominal pain, and a characteristic fruity breath odor.
  • Addison’s Disease: Adrenal insufficiency can lead to nausea, vomiting, abdominal pain, weight loss, and hyperpigmentation.
  • Hyperthyroidism: Overactivity of the thyroid gland can cause nausea, vomiting, weight loss, and tremors.
  • Adrenal Crisis: Acute adrenal insufficiency, often triggered by stress, presenting with severe vomiting, hypotension, and shock.

Other Causes

  • Psychogenic Vomiting: Often associated with eating disorders, anxiety, or depression, presenting with persistent vomiting without an organic cause.
  • Medications: Certain drugs (e.g., chemotherapy, opioids, antibiotics) can cause nausea and vomiting as side effects.
  • Substance Abuse: Alcohol, cannabis, and other substances can lead to vomiting, either acutely or chronically.
  • Motion Sickness: Nausea and vomiting triggered by motion, due to a mismatch between visual and vestibular inputs.
  • Toxic Ingestion: Ingestion of toxins, such as heavy metals or certain plants, can lead to severe nausea and vomiting.
  • Cyclic Vomiting Syndrome: Characterized by recurrent episodes of severe vomiting with no apparent cause, often linked to migraines.
  • Postoperative Nausea and Vomiting (PONV): A common complication following anesthesia and surgery.
  • Chronic Renal Failure: Uremia associated with renal failure can cause nausea and vomiting.
  • Acute Myocardial Infarction: Particularly in inferior wall MI, nausea and vomiting may be prominent symptoms.
  • Hypercalcemia: Elevated calcium levels can cause nausea, vomiting, constipation, and abdominal pain.

Key Points in History 🥼

Symptom History

  • Onset and Duration: Acute onset suggests gastroenteritis or toxin ingestion, while chronic symptoms may suggest conditions like GERD, gastroparesis, or pregnancy-related hyperemesis.
  • Associated Symptoms: Abdominal pain, fever, diarrhea, weight loss, and headache can help narrow down the differential diagnosis.
  • Pregnancy: Always consider pregnancy in women of childbearing age presenting with nausea and vomiting; hyperemesis gravidarum typically presents in the first trimester.
  • Medication History: Review for any new medications or changes in dosage that might contribute to symptoms.
  • Dietary and Social History: Recent dietary changes, alcohol use, and substance abuse history can provide important clues.
  • Travel History: Recent travel to areas with endemic infections like malaria or hepatitis could be relevant.
  • Previous Medical History: Including any history of gastrointestinal disorders, endocrine disorders, or previous episodes of similar symptoms.
  • Psychosocial History: Consider stress, anxiety, or psychiatric conditions as contributing factors.
  • Family History: Relevant for hereditary conditions like cyclic vomiting syndrome or metabolic disorders.
  • Exposure History: Consider environmental or occupational exposure to toxins or infectious agents.
  • Hydration Status: Assess for signs of dehydration, including dry mucous membranes, decreased skin turgor, and tachycardia.
  • Severity and Impact: Assess the impact of symptoms on daily activities, weight loss, and the need for hospital admission.
  • Triggers and Relieving Factors: Identify any known triggers (e.g., certain foods, stress) and what provides relief (e.g., antiemetics).
  • Nausea and Vomiting Characteristics: The presence of bile, blood, or undigested food in vomit can provide diagnostic clues.
  • Gastrointestinal Symptoms: Explore symptoms such as heartburn, regurgitation, or a history of peptic ulcer disease.
  • Neurological Symptoms: Consider headache, dizziness, or visual disturbances that could suggest a neurological cause.

Background

  • Past Medical History: Relevant history includes previous episodes of hyperemesis, gastrointestinal disorders, metabolic conditions, or chronic illnesses.
  • Surgical History: Previous surgeries, particularly gastrointestinal surgeries, may contribute to symptoms (e.g., bowel obstruction).
  • Drug History: Comprehensive review of current medications, particularly those known to cause nausea and vomiting.
  • Family History: Inquire about familial conditions that could present with hyperemesis, such as cyclic vomiting syndrome.
  • Social History: Include alcohol use, substance abuse, occupational exposures, and stress levels.
  • Dietary Habits: Recent changes in diet, fasting, or consumption of triggering foods.
  • Travel History: Consider exposure to infectious agents in endemic areas.
  • Allergies: Review any known allergies, particularly to medications or foods.
  • Psychiatric History: Consider underlying psychiatric conditions that may manifest with somatic symptoms.
  • Reproductive History: Important in women of childbearing age to assess for current or recent pregnancy, previous pregnancies, and any complications.
  • Immunization History: Consider relevance in cases of infectious causes, such as hepatitis or tuberculosis.
  • Hydration and Nutritional Status: Review for signs of malnutrition or dehydration.
  • Previous Investigations: Any previous endoscopies, imaging, or laboratory tests that could provide insight.
  • Family Planning: In women, discuss future pregnancy plans, as this may impact management in cases like hyperemesis gravidarum.
  • Lifestyle Factors: Consider the impact of lifestyle choices on symptoms, including work stress, sleep patterns, and exercise.
  • Comorbid Conditions: Review of other chronic conditions, such as diabetes, hypertension, or renal disease, which may complicate management.
  • Functional Impact: Assess the impact of symptoms on daily functioning, including work, family life, and mental health.

Possible Investigations 🌡️

Initial Laboratory Tests

  • Full Blood Count (FBC): To assess for anemia, infection, or hemoconcentration due to dehydration.
  • Electrolyte Panel: Important to assess for electrolyte imbalances, particularly hypokalemia, hyponatremia, and metabolic alkalosis.
  • Liver Function Tests (LFTs): To assess for hepatic involvement or dehydration.
  • Renal Function Tests: Assess for renal impairment, particularly in cases of severe dehydration or chronic kidney disease.
  • Serum Glucose: Important in ruling out diabetic ketoacidosis as a cause of nausea and vomiting.
  • Thyroid Function Tests: To assess for hyperthyroidism as a potential cause of vomiting.
  • Urinalysis: To assess for ketonuria, which is indicative of dehydration or starvation.
  • Arterial Blood Gas (ABG): To assess for acid-base disturbances in severe cases.
  • Pregnancy Test: Mandatory in women of childbearing age to rule out or confirm pregnancy-related causes.
  • Serum Amylase/Lipase: To rule out pancreatitis in cases of epigastric pain.
  • Infection Markers (CRP, ESR): To assess for underlying infection or inflammation.
  • Coagulation Profile: May be relevant in assessing the risk of bleeding or in cases of liver dysfunction.
  • Blood Cultures: If sepsis is suspected, particularly in febrile patients.
  • Toxicology Screen: To assess for substance use or overdose.
  • Cortisol Levels: To assess for adrenal insufficiency, particularly in patients with hypotension or electrolyte abnormalities.
  • Vitamin and Nutrient Levels: In chronic cases, assess for deficiencies in vitamins (e.g., B12, folate) and electrolytes.
  • Hepatitis Serology: Consider in cases with liver involvement or risk factors for viral hepatitis.
  • Urine Drug Screen: In cases where substance abuse is suspected.
  • Serum Calcium: To assess for hypercalcemia as a potential cause of nausea and vomiting.

Imaging and Further Tests

  • Abdominal Ultrasound: Useful for assessing for gallstones, pancreatitis, or hepatic abnormalities.
  • Upper Gastrointestinal Endoscopy: Consider if there is suspicion of peptic ulcer disease, esophagitis, or malignancy.
  • CT Abdomen/Pelvis: Indicated if there is suspicion of bowel obstruction, abdominal mass, or other intra-abdominal pathology.
  • MRI Brain: Consider if there is suspicion of increased intracranial pressure or central causes of nausea and vomiting.
  • Electrocardiogram (ECG): To rule out cardiac causes of nausea and vomiting, particularly in older patients.
  • Barium Swallow or Upper GI Series: May be indicated in cases of suspected esophageal or gastric motility disorders.
  • CXR (Chest X-ray): To assess for lower lobe pneumonia or other thoracic causes of nausea.
  • H. Pylori Testing: In cases of suspected peptic ulcer disease.
  • Thyroid Ultrasound: If there is suspicion of thyroid pathology contributing to symptoms.
  • Endocrine Testing: Cortisol, ACTH, and aldosterone levels may be indicated in suspected adrenal or pituitary dysfunction.
  • EEG: In cases of suspected neurological causes, particularly if there are associated seizures or altered consciousness.
  • Laparoscopy: May be considered in cases of unexplained abdominal pain with persistent vomiting.
  • Holter Monitoring: If cardiac arrhythmias are suspected in relation to symptoms.
  • ENT Referral: For suspected ENT causes like vestibular disorders or postnasal drip contributing to symptoms.
  • Psychiatric Evaluation: In cases where psychogenic vomiting or eating disorders are suspected.
  • Nutritional Assessment: In chronic cases, assess for malnutrition and the need for nutritional support.
  • Serum Ketones: To assess for ketoacidosis, particularly in diabetic patients.
  • Cervical Spine Imaging: Consider in cases of suspected cervical spine pathology contributing to nausea and vomiting.

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Obstetrics