Treatment of Yellowish Vomit
The treatment of yellowish vomit (bile-stained emesis) requires immediate assessment for bowel obstruction or other surgical emergencies, followed by targeted antiemetic therapy with ondansetron as first-line, fluid resuscitation, and treatment of the underlying cause.
Immediate Assessment and Red Flags
Yellowish or greenish vomit indicates bile presence, which is a red flag requiring urgent evaluation. Bilious vomiting mandates immediate assessment for bowel obstruction, malrotation with volvulus (especially in infants), or other surgical emergencies. 1, 2
Key red flags requiring immediate intervention include:
- Bilious or bloody vomiting 1, 2
- Altered mental status or severe dehydration 1
- Signs of gastrointestinal obstruction (abdominal distension, absent bowel sounds) 2
- Unstable vital signs or acidotic breathing 2
If bilious vomiting is present, stop all oral intake immediately and insert a nasogastric tube for gastric decompression while arranging urgent surgical consultation and abdominal imaging. 1
Fluid and Electrolyte Management
For patients who can tolerate oral intake, provide small, frequent sips of electrolyte-rich fluids (sports drinks). 3 However, most patients with bilious vomiting will require IV therapy.
Initiate IV fluid resuscitation with balanced crystalloid solutions (lactated Ringer's or normal saline) using a 500-1000 mL bolus followed by maintenance rate for moderate-to-severe dehydration. 3 Add dextrose-containing fluids if prolonged fasting or hypoglycemia is a concern. 3
Pharmacologic Antiemetic Therapy
Ondansetron (5-HT3 antagonist) is the preferred first-line antiemetic for acute vomiting. 3 Dosing:
- Adults: 4-8 mg IV/IM or sublingual tablet 3
- Children: 0.15 mg/kg IV (maximum 4 mg) or 0.2 mg/kg oral 1
The sublingual formulation may improve absorption in actively vomiting patients. 3
For refractory vomiting or ondansetron failure, use alternative dopamine antagonists: 3
- Promethazine 12.5-25 mg IV/IM/rectal 3
- Prochlorperazine 10 mg IV/IM or 25 mg rectal suppository 3
- Metoclopramide 10 mg IV/IM 3
For severe refractory cases, consider combination therapy with a benzodiazepine (lorazepam 0.5-1 mg IV) plus haloperidol 0.5-2 mg IV, monitoring for QT prolongation. 3
Diagnostic Evaluation
The history should focus on:
- Timing and color of vomitus (yellow/green indicates bile) 2
- Associated abdominal pain, distension, or obstipation 2
- Recent medication changes or toxic exposures 4, 5
- Neurologic symptoms (headache, altered mental status) 6
Physical examination must include vital signs, hydration status, careful abdominal examination including hernial orifices and genitalia, and fundoscopic examination. 2
Order abdominal X-ray immediately if signs of obstruction are present (distension, high-pitched bowel sounds, or obstipation). 2 Consider abdominal CT if X-ray is inconclusive but clinical suspicion remains high. 6
Basic laboratory testing should include:
- Complete blood count and comprehensive metabolic panel 6
- Urinalysis and pregnancy test (if applicable) 6
- Amylase/lipase if pancreatitis suspected 6
Common Pitfalls
Do not provide antiemetics prophylactically before determining the cause, as suppressing vomiting may mask a surgical emergency or delay diagnosis. 2 The exception is chemotherapy-induced or radiation-induced nausea where prophylaxis is standard. 7
Avoid using antiemetics as mere symptomatic treatment without identifying the underlying cause, as this may delay specific diagnosis and therapy. 2
In children with bilious vomiting, malrotation with volvulus is a surgical emergency requiring immediate intervention—do not delay with prolonged medical management. 1