Table 31

Investigation and management of vomiting

Investigations	Potential results	Clinical management plan
Actions from history, medication and dietary assessment
History findings	Symptoms of heartburn/acid reflux:	Trial of proton pump inhibitor±trial of antiemetic. Reassess after 2–4 weeks as clinically indicated.
	If within 2 weeks after surgery	Discuss with the surgical team within 24 hours.
	Chemotherapy related	Contact team to change antiemetics urgently.
	Persistent vomiting	This is an emergency. Contact the on-call medical team.
	Nutritional compromise	Refer for dietetic advice.
First line
Fundoscopy	Raised ICP	This is an emergency. Discuss immediately with the supervising clinician.
Routine and additional blood tests	Metabolic abnormality	Discuss immediately with the supervising clinician.
	Liver/biliary abnormality	Discuss with the supervising clinician within 24 hours.
	Suggestive of infection	Treat with antibiotics within level of confidence or discuss with a microbiologist/supervising clinician.
Urine analysis	Metabolic abnormality, eg, glucosuria, ketonuria	Discuss immediately with the supervising clinician.
	Infection	Treat with antibiotics within level of confidence or discuss with a microbiologist/supervising clinician within 24 hours.
AXR (if with pain)	Small bowel obstruction	This is an emergency. Discuss immediately with a GI surgeon and arrange urgent CT scan.
	Faecal loading	See management of constipation (p. 26).
Second line
OGD and SI aspirate (p. 25)	Upper GI inflammation/ulceration	See 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 dysmotility	Consider prokinetic (p. 26).
	Pyloric stricture	Consider dilatation (p. 25) with careful biopsy only after agreement from the appropriate MDT.
	SIBO	Management of SIBO (p. 27).
Glucose hydrogen methane breath test	SIBO	Management of SIBO (p. 27).
US liver and pancreas	Biliary/hepatic/pancreatic aetiology	See jaundice (p. 18).
CT/MRI/PET (head/chest/ abdomen/ pelvis)	Malignancy/tumour recurrence/lymphadenopathy	Discuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks.
	Consider also Internal hernia (if Roux-en-Y) Jejunal tube complication, eg, volvulus (if still in situ) Pancreatitis	These are emergencies. Refer to the upper GI surgical team.
	Mesenteric ischaemia	This is an emergency. Discuss with the on-call surgical team immediately.
	Ascites	Discuss with the supervising clinician and the oncology team within 24 hours.
Third line
If normal investigations/no response to intervention		Consider contributing psychological factors. Consider referral for psychological support if there is a possible underlying eating disorder. 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.