Initial Workup for Chronic Nausea
The initial workup for chronic nausea should include basic laboratory tests (complete blood count, comprehensive metabolic panel, thyroid function), upper endoscopy, and targeted investigations based on associated symptoms to rule out common causes before considering functional disorders. 1
Basic Diagnostic Approach
Begin with a thorough history focusing on timing of symptoms, relationship to meals, associated symptoms, medication use, and potential triggers 2, 3
Basic laboratory workup should include:
One-time esophagogastroduodenoscopy (EGD) or upper gastrointestinal imaging to exclude obstructive lesions 1
- Avoid repeated endoscopies unless clinically indicated
- Note that findings like mild gastritis or esophagitis shortly after vomiting episodes may be consequences rather than causes 1
Specific Evaluations Based on Clinical Presentation
- For suspected gastroparesis: gastric emptying study (avoid if patient uses cannabis or opiates as these can affect results) 1
- For neurological symptoms: brain imaging and neurological consultation 1
- For suspected metabolic disorders: consider testing for Addison's disease, hepatic porphyria 1
- For medication-related nausea: check blood levels of medications when applicable (e.g., digoxin, phenytoin, tricyclic antidepressants) 1
- For suspected cannabis hyperemesis syndrome: detailed cannabis use history (frequency, duration, and relationship to symptom onset) 1
Evaluating for Common Comorbidities
- Assess for anxiety and mood disorders which frequently coexist with chronic nausea 1
- Screen for migraine history, as cyclic vomiting syndrome and migraine share pathophysiological mechanisms 1
- Evaluate for autonomic dysfunction, including postural orthostatic tachycardia syndrome (POTS) 1
Important Considerations
- Gastric emptying studies should not be ordered routinely as they have limited utility in many cases of chronic nausea 1
- Cannabis use patterns must be carefully documented - chronic heavy use (>4 times weekly for >1 year) preceding symptom onset suggests cannabis hyperemesis syndrome 1
- Avoid stigmatizing patients who use cannabis, as use may be an attempt at symptom management rather than the cause 1
- For patients with episodic vomiting patterns, document frequency, duration, and severity to distinguish between mild and moderate-severe forms 1
Red Flags Requiring Urgent Evaluation
- Significant weight loss
- Progressive symptoms
- Focal neurological findings
- Signs of dehydration or electrolyte abnormalities 2, 3
- Persistent vomiting with abdominal pain 3
By following this systematic approach, clinicians can efficiently evaluate chronic nausea while avoiding unnecessary testing, leading to appropriate diagnosis and management strategies.