Management of Yellow Emesis
Yellow emesis requires immediate assessment for bile-stained vomiting suggesting intestinal obstruction or upper GI pathology, followed by aggressive antiemetic therapy with ondansetron as first-line treatment, IV hydration, and electrolyte correction. 1, 2
Immediate Clinical Assessment
Determine the underlying cause and severity:
- Yellow emesis typically indicates bile-stained vomitus, which may suggest duodenal reflux, intestinal obstruction, or prolonged vomiting with gastric emptying 1
- Evaluate hemodynamic stability immediately by checking pulse, blood pressure, and signs of shock 1
- Rule out upper GI bleeding (altered blood mixed with gastric contents can appear purple rather than classic coffee-ground, and bile can mask blood) 1
- Assess for red flags: severe abdominal pain, peritoneal signs, neurologic symptoms, or signs of dehydration 1, 3
Check for non-GI causes:
- Brain metastases 4
- Electrolyte abnormalities (particularly hyponatremia, which can present with vomiting and abdominal pain) 4, 3
- Medication effects or coagulopathy 1
- Pregnancy (hyperemesis gravidarum can cause persistent vomiting with bile) 5, 6
Pharmacologic Management
First-line antiemetic therapy:
- Administer ondansetron as the primary antiemetic agent due to superior efficacy and safety profile 1, 7, 2, 6
- Ondansetron 8 mg IV/PO is effective for most causes of vomiting 7, 2
- Use scheduled dosing (every 8 hours) rather than PRN administration for better symptom control 4, 1
- The oral route may not be feasible due to ongoing vomiting; use IV or rectal routes as needed 4, 1
Second-line options if ondansetron fails:
- Add a dopamine antagonist (metoclopramide 10 mg IV over 3 minutes to minimize extrapyramidal effects, or prochlorperazine) from a different drug class 4, 6
- Consider adding dexamethasone if severe or refractory 4
- Lorazepam or alprazolam may be added for anxiolytic effects 4
Important caveat: Metoclopramide should be administered as slow IV bolus over at least 3 minutes to minimize extrapyramidal side effects, and patients must be monitored for akathisia up to 48 hours post-administration 2, 6
Supportive Care
Hydration and electrolyte management:
- Initiate aggressive IV fluid resuscitation with normal saline (0.9% NaCl) for volume depletion 1, 6
- Check and correct electrolyte abnormalities immediately, particularly potassium, sodium, and magnesium 4, 1, 5
- Add potassium chloride to IV fluids guided by daily electrolyte monitoring 6
Nutritional considerations:
- Administer thiamine supplementation (100 mg PO three times daily or IV Pabrinex) before any dextrose administration to prevent Wernicke's encephalopathy, especially if reduced dietary intake or prolonged vomiting 5, 6
Diagnostic Workup
Document and investigate the source:
- Photograph the emesis to differentiate true bile from food coloring and guide management 1
- Obtain basic labs: complete metabolic panel, liver function tests, complete blood count 1, 5
- Consider esophagogastroduodenoscopy (EGD) if upper GI pathology suspected or if occult blood positive 1
- Abdominal imaging (CT or plain radiograph) if obstruction or other structural pathology suspected 1, 3
Common Pitfalls to Avoid
- Do not delay treatment while awaiting diagnostic workup - begin antiemetics and hydration immediately 1, 2
- Do not use PRN dosing for persistent vomiting - scheduled around-the-clock administration is more effective 4, 1
- Do not forget thiamine supplementation - critical before giving dextrose-containing fluids in malnourished or prolonged vomiting patients 5, 6
- Do not overlook electrolyte abnormalities - hyponatremia can present with vomiting and abdominal pain, creating a vicious cycle 3
- Do not assume ketonuria indicates dehydration severity - it is not a reliable indicator 6
Reassessment Strategy
If vomiting persists despite initial therapy: