Table 31

Investigation and management of vomiting

InvestigationsPotential resultsClinical management plan
Actions from history, medication and dietary assessment
History findingsSymptoms of heartburn/acid reflux:
  1. Trial of proton pump inhibitor±trial of antiemetic.

  2. Reassess after 2–4 weeks as clinically indicated.

If within 2 weeks after surgeryDiscuss with the surgical team within 24 hours.
Chemotherapy relatedContact team to change antiemetics urgently.
Persistent vomitingThis is an emergency. Contact the on-call medical team.
Nutritional compromiseRefer for dietetic advice.
First line
FundoscopyRaised ICPThis is an emergency. Discuss immediately with the supervising clinician.
Routine and additional blood testsMetabolic abnormalityDiscuss immediately with the supervising clinician.
Liver/biliary abnormalityDiscuss with the supervising clinician within 24 hours.
Suggestive of infectionTreat with antibiotics within level of confidence or discuss with a microbiologist/supervising clinician.
Urine analysisMetabolic abnormality, eg, glucosuria, ketonuriaDiscuss immediately with the supervising clinician.
InfectionTreat with antibiotics within level of confidence or discuss with a microbiologist/supervising clinician within 24 hours.
AXR (if with pain)Small bowel obstructionThis is an emergency. Discuss immediately with a GI surgeon and arrange urgent CT scan.
Faecal loadingSee management of constipation (p. 26).
Second line
OGD and SI aspirate (p. 25)Upper GI inflammation/ulcerationSee management of acid or bile related inflammation (p. 25).
Assess Helicobacter pylori and treat if positive.
Discuss with the supervising clinician the need for future repeat endoscopy.
Gastric dysmotilityConsider prokinetic (p. 26).
Pyloric strictureConsider dilatation (p. 25) with careful biopsy only after agreement from the appropriate MDT.
SIBOManagement of SIBO (p. 27).
Glucose hydrogen methane breath testSIBOManagement of SIBO (p. 27).
US liver and pancreasBiliary/hepatic/pancreatic aetiologySee jaundice (p. 18).
(head/chest/ abdomen/ pelvis)
Malignancy/tumour recurrence/lymphadenopathyDiscuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks.
Consider also
  1. Internal hernia (if Roux-en-Y)

  2. Jejunal tube complication, eg, volvulus (if still in situ)

  3. Pancreatitis

These are emergencies. Refer to the upper GI surgical team.
Mesenteric ischaemiaThis is an emergency. Discuss with the on-call surgical team immediately.
AscitesDiscuss with the supervising clinician and the oncology team within 24 hours.
Third line
If normal investigations/no response to intervention
  1. Consider contributing psychological factors.

  2. Consider referral for psychological support if there is a possible underlying eating disorder.

  3. Consider a routine referral to gastroenterology for further management.

  • AXR, abdominal X-ray; CT, computerised tomography; GI, gastrointestinal; ICP, intracranial pressure; MDT, multidisciplinary team; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); PET, positron emission tomography; SI, small intestine; SIBO, small intestinal bacterial overgrowth; US, ultrasound.