Can nausea be a symptom of pulmonary embolism (PE)?

Nausea as a Symptom of Pulmonary Embolism

Yes, nausea can be a symptom of pulmonary embolism (PE), though it is not among the most common presenting symptoms. While dyspnea, chest pain, syncope, and hemoptysis are more typical presentations, nausea can occur as part of the clinical picture, particularly in certain types of PE presentations.

Common Symptoms of PE

According to the 2019 European Society of Cardiology (ESC) guidelines, the most frequently reported symptoms of PE include:

• Dyspnea (may be acute and severe in central PE; mild or transient in peripheral PE)
• Chest pain (often pleuritic due to distal emboli causing pulmonary infarction)
• Pre-syncope or syncope
• Hemoptysis 1

Nausea in PE: Clinical Evidence

Nausea can present as part of the PE symptom complex in several scenarios:

1. As an isolated or predominant symptom:

   • Case evidence shows that PE can present primarily with nausea and vomiting, as documented in a 14-year-old oncology patient whose main complaints were persistent nausea and vomiting exacerbated by exertion 2

2. In association with abdominal symptoms:

   • PE can masquerade as acute abdominal pain with accompanying nausea and vomiting, as reported in a 47-year-old woman who presented with right upper quadrant pain, nausea, and vomiting without respiratory complaints 3

3. In severe PE presentations:

   • Nausea may occur in patients with central or extensive PE with severely reduced hemodynamic reserve 1

Pathophysiological Mechanisms

Several mechanisms may explain the presence of nausea in PE:

• Hemodynamic disturbances leading to low cardiac output and systemic hypoperfusion
• Vagal stimulation from right ventricular strain
• Hypoxemia affecting the chemoreceptor trigger zone
• Referred pain from pleural irritation affecting the diaphragm

Clinical Implications

The presence of nausea in a patient with risk factors for venous thromboembolism (VTE) should not exclude PE from the differential diagnosis. In fact:

• Atypical presentations including gastrointestinal symptoms may lead to diagnostic delays
• A high index of suspicion is needed, especially in patients with risk factors for VTE
• The combination of nausea with exertional symptoms (worsening with activity) should raise suspicion for PE 2

Diagnostic Approach

When evaluating patients with nausea who may have PE:

• Consider PE in the differential diagnosis, especially when nausea is accompanied by dyspnea or when it worsens with exertion
• Evaluate for other more common PE symptoms
• Assess for PE risk factors
• Apply appropriate clinical prediction rules (Wells or Geneva score)
• Proceed with D-dimer testing and/or appropriate imaging based on clinical probability

Conclusion

While nausea is not among the classic symptoms of PE listed in major guidelines, case evidence clearly demonstrates that it can be part of the clinical presentation. Clinicians should maintain awareness of this association, particularly when nausea occurs in patients with risk factors for VTE or when accompanied by other suspicious symptoms.