What is causing vomiting in a patient with potential gastrointestinal issues at work?

Causes of Vomiting in a Patient at Work

The most common causes of vomiting in an adult at work are acute gastrointestinal infections (gastroenteritis), food poisoning, medication side effects, stress-related conditions, and metabolic abnormalities. 1, 2, 3

Acute Causes (Symptoms <7 days)

Most Likely Etiologies

• Viral gastroenteritis is the predominant cause, often occurring in epidemics with sudden onset, mild fever, and diarrhea 4, 1, 2
• Foodborne illness should be suspected if symptoms began within hours of eating, especially if coworkers are similarly affected 2, 3
• Medication adverse effects must be considered—review any recently started medications including antibiotics, NSAIDs, or opioids 1, 2
• Stress or anxiety can trigger vomiting in the workplace setting, particularly if the patient has a history of anxiety disorders 4, 1

Red Flag Conditions Requiring Urgent Evaluation

• Severe abdominal pain suggests surgical causes like appendicitis, cholecystitis, or bowel obstruction 4, 1, 2
• Significant headache with vomiting may indicate increased intracranial pressure, meningitis, or migraine 4, 1
• Bilious (green) emesis indicates possible bowel obstruction 4
• Dehydration signs (decreased urine output, orthostatic hypotension, altered mental status) require immediate fluid resuscitation 1, 2

Chronic/Recurrent Causes (Symptoms ≥4 weeks)

Disorders of Gut-Brain Interaction

• Cyclic Vomiting Syndrome (CVS) presents with stereotypical episodes lasting <7 days, occurring ≥3 times yearly, with complete wellness between episodes 4

  • Triggered by stress (70-80% of cases), sleep deprivation, menstrual cycle, or infections 4
  • Hot water bathing behavior provides temporary relief in 48% of non-cannabis users 4
  • Associated with migraine history (20-30%), anxiety/depression (50-60%), and autonomic dysfunction 4

• Cannabinoid Hyperemesis Syndrome (CHS) should be suspected with chronic cannabis use (>1 year, ≥4 times weekly) 4

  • Mean age 30 years, 69% male, hot water bathing in 71% of cases 4
  • Requires cannabis cessation for ≥6 months to confirm diagnosis 4

Functional and Motility Disorders

• Functional dyspepsia causes chronic nausea with early satiety and epigastric discomfort 4
• Gastroparesis presents with postprandial vomiting, early satiety, and bloating—confirm with gastric emptying study 5, 2

Metabolic and Endocrine Causes

• Pregnancy must be excluded in women of childbearing age 1, 2
• Hypercalcemia, uremia, diabetic ketoacidosis, or adrenal insufficiency can cause persistent vomiting 5, 1
• Thyroid disorders (hyperthyroidism or hypothyroidism) should be evaluated with TSH 2

Infectious Considerations

• COVID-19 can present with gastrointestinal symptoms including vomiting (8-23%), nausea (15-16%), and diarrhea (10-22%) 4
• H. pylori infection may contribute to chronic dyspepsia and should be tested via stool antigen or breath test 4

Diagnostic Approach

Essential History Elements

• Timing: Acute (<7 days) versus chronic (≥4 weeks) guides differential diagnosis 1, 2
• Relationship to meals: Immediate postprandial suggests gastric outlet obstruction; delayed (>1 hour) suggests gastroparesis 2
• Associated symptoms: Diarrhea (infection), headache (migraine/CNS), abdominal pain (surgical), fever (infection) 1, 2
• Medication review: Recent additions or changes, especially opioids, antibiotics, NSAIDs 1, 2
• Substance use: Cannabis (CHS), alcohol (gastritis, pancreatitis) 4
• Triggers: Stress, specific foods, menstrual cycle, sleep deprivation 4
• Hot water bathing behavior: Suggests CVS or CHS 4

Initial Laboratory Testing (When Indicated)

• Urine pregnancy test in all women of reproductive age 2
• Complete metabolic panel to assess electrolytes, renal function, glucose, calcium 1, 2
• Complete blood count for infection or anemia 2
• Urinalysis to exclude urinary tract infection or ketones 2
• Thyroid-stimulating hormone if chronic symptoms 2
• Stool studies with cultures if diarrhea present 2

Imaging Considerations

• Abdominal radiographs for suspected obstruction or perforation 4, 2
• Abdominal ultrasound or CT if acute abdomen, persistent pain, or alarm features 2
• Head CT only if severe headache, neurologic signs, or altered mental status 2

Management Principles

Acute Vomiting Treatment

• Fluid and electrolyte replacement is the cornerstone of acute management 5, 1
• Dopamine antagonists (metoclopramide 10 mg TID, prochlorperazine 10 mg q6h) are first-line antiemetics 5
• 5-HT3 antagonists (ondansetron 8 mg q8h) added if dopamine antagonists insufficient 5, 6
• Avoid oral route if actively vomiting—use sublingual, rectal, or IV formulations 5

Chronic Vomiting Management

• Identify and treat underlying cause (H. pylori eradication, medication adjustment, stress management) 4, 5
• Prokinetic agents (metoclopramide) for gastroparesis, but monitor for tardive dyskinesia risk 5
• Tricyclic antidepressants (amitriptyline 75-100 mg at bedtime) for CVS prophylaxis 4, 5
• Cannabis cessation counseling is mandatory for CHS—only definitive treatment 4

Critical Pitfalls to Avoid

• Do not dismiss hot water bathing as malingering—it is a legitimate self-soothing behavior in CVS and CHS 4
• Do not use antiemetics in suspected mechanical bowel obstruction—may mask progressive ileus 5, 6
• Do not overlook medication adverse effects—review all medications including over-the-counter and supplements 1, 2
• Do not assume functional cause without excluding pregnancy, metabolic disorders, and structural lesions 2, 3
• Monitor for QT prolongation with ondansetron, especially in patients with electrolyte abnormalities or cardiac disease 6
• Avoid opioids for symptom control—they worsen nausea and carry addiction risk 4