How should I manage an adult with acute vomiting and neutrophilia?

Management of Acute Vomiting with Neutrophilia in Adults

In an adult presenting with acute vomiting and elevated neutrophils, prioritize immediate assessment for life-threatening causes (intestinal obstruction, appendicitis, pancreatitis, sepsis), ensure adequate hydration, and use ondansetron for symptomatic relief once serious pathology is excluded. 1

Initial Assessment and Red Flag Identification

The combination of vomiting and neutrophilia suggests an acute inflammatory or infectious process requiring urgent evaluation. Immediately assess for alarm features that indicate surgical emergencies or severe systemic illness: [1, 1

• Bilious or bloody vomiting - suggests intestinal obstruction or upper GI bleeding 1
• Severe abdominal pain with peritoneal signs - consider appendicitis, perforation, or pancreatitis 1
• Altered mental status or toxic appearance - indicates sepsis, metabolic derangement, or CNS pathology 1
• Severe dehydration with hypotension - requires immediate IV resuscitation 1
• Fever with neutrophilia - strongly suggests infectious or inflammatory etiology 1

Understanding the Neutrophilia

Neutrophilia in the context of acute vomiting typically indicates: [1, 1

• Acute bacterial infection (appendicitis, cholecystitis, pyelonephritis, pneumonia) 1
• Inflammatory conditions (pancreatitis, inflammatory bowel disease flare) [1, 1
• Stress response to severe illness or dehydration 2
• Neutropenic enterocolitis if the patient is immunocompromised (though this presents with neutropenia initially) 1

The presence of neutrophils in tissue (cryptitis, crypt abscesses) on biopsy indicates active inflammatory bowel disease, but peripheral blood neutrophilia alone is nonspecific. [1, 1

Diagnostic Approach

History Focus

Obtain specific details about: [3, 4

• Timing and character of vomiting - projectile, bilious, bloody, or coffee-ground appearance 1
• Associated symptoms - fever, diarrhea (especially bloody), abdominal pain location and severity [1, 1
• Recent exposures - food intake, medications (especially chemotherapy, immunosuppressants), travel 1
• Immunosuppression status - cancer treatment, IBD medications, HIV [1, 1
• Past medical history - IBD, prior abdominal surgeries, diabetes 1

Physical Examination Priorities

Focus on identifying surgical abdomen and dehydration: 1

• Hydration status - mucous membranes, skin turgor, orthostatic vital signs 1
• Abdominal examination - peritoneal signs, distension, bowel sounds, masses 1
• Systemic signs - fever, tachycardia, hypotension suggesting sepsis 1

Laboratory and Imaging

For patients with neutrophilia and vomiting, obtain: [1, 1

• Complete blood count with differential - confirm neutrophilia, assess for left shift 1
• Comprehensive metabolic panel - electrolytes, renal function, glucose, liver enzymes 1
• Lipase if upper abdominal pain present 4
• Urinalysis and culture - exclude pyelonephritis 4
• Abdominal imaging (CT or ultrasound) - indicated for severe pain, peritoneal signs, or suspected obstruction 5
• Stool studies if diarrhea present - culture, C. difficile toxin, fecal leukocytes 1

In immunocompromised patients with neutrophilia and GI symptoms, consider early endoscopy with biopsies to exclude CMV colitis or other opportunistic infections. 1

Management Strategy

Immediate Interventions

1. Fluid and Electrolyte Resuscitation 1

• Oral rehydration solution for mild-moderate dehydration without alarm features 1
• Intravenous crystalloids for severe dehydration, hypotension, or inability to tolerate oral intake [1, 1
• Monitor and correct electrolyte abnormalities, particularly hypokalemia and metabolic alkalosis from vomiting 1

2. Bowel Rest and Decompression 5

• NPO status with nasogastric tube placement if bilious vomiting or suspected obstruction 5
• Early refeeding once obstruction excluded and vomiting controlled - improves outcomes and reduces intestinal permeability 1

3. Antiemetic Therapy [1, 6

• Ondansetron is the preferred antiemetic: 4-8 mg IV/PO for adults, can repeat every 8 hours [1, 6
• Ondansetron reduces vomiting and facilitates oral rehydration without significant adverse effects [1, 6
• Avoid antiemetics until adequate hydration is achieved - they are adjunctive, not primary therapy 1
• Do not use antimotility agents (loperamide) in the setting of fever, bloody diarrhea, or suspected inflammatory/infectious diarrhea due to risk of toxic megacolon 1

Infection-Specific Management

If infectious gastroenteritis suspected (most common cause): 1

• Supportive care with hydration is primary treatment for most viral and bacterial causes 1
• Empirical antibiotics NOT routinely indicated unless severe illness, immunocompromised host, or specific pathogens identified [1, 7
• Consider antibiotics for suspected bacterial causes with systemic toxicity (Salmonella, Shigella, Campylobacter in severe cases) 1

If neutropenic fever develops (temperature ≥38.3°C or ≥38.0°C for 1 hour): 7

• Initiate broad-spectrum empirical antibiotics within 2 hours - this is a medical emergency 7
• Do NOT wait for culture results in neutropenic patients with fever 7

Immunocompromised Patient Considerations

For patients on immunosuppressive therapy (IBD medications, chemotherapy): [1, [1, 7

• Screen for CMV infection if severe colitis symptoms - requires endoscopy with biopsies for immunohistochemistry 1
• Test for C. difficile (including toxin-negative strains) - 10% are PCR-positive but toxin-negative 1
• Consider empirical ganciclovir if CMV suspected in severely ill immunosuppressed patient while awaiting confirmatory testing 1
• Avoid colonoscopy if neutropenic enterocolitis suspected - use flexible sigmoidoscopy or CT imaging instead 1

Food Protein-Induced Enterocolitis Syndrome (FPIES)

While FPIES typically affects infants, recognize the acute presentation: 1

• Repetitive projectile vomiting 1-4 hours after food exposure with lethargy and pallor 1
• Neutrophilia and thrombocytosis are characteristic laboratory findings 1
• Treatment is supportive with IV hydration and strict avoidance of trigger food 1
• This diagnosis is unlikely in adults but consider in young adults with recurrent episodes after specific food exposures 1

Common Pitfalls to Avoid

• Do not dismiss bilious vomiting - always indicates obstruction until proven otherwise [1, 5
• Do not give antimotility agents when inflammatory or infectious diarrhea is suspected - risk of toxic megacolon 1
• Do not delay antibiotics in neutropenic patients who develop fever - mortality increases significantly with delayed treatment 7
• Do not perform colonoscopy in suspected neutropenic enterocolitis - high perforation risk 1
• Do not attribute all vomiting to gastroenteritis in immunocompromised patients - opportunistic infections (CMV, fungal) require specific treatment 1
• Do not use antiemetics as substitute for hydration - fluid resuscitation is the primary intervention 1

When to Escalate Care

Admit to hospital if: [1, 7

• Severe dehydration requiring IV fluids [1, 1
• Suspected surgical abdomen or intestinal obstruction 5
• Immunocompromised with fever and neutrophilia 7
• Inability to tolerate oral intake despite antiemetics 1
• Hemodynamic instability or altered mental status 1

Surgical consultation indicated for: 5

• Peritoneal signs on examination 5
• Bilious vomiting with imaging suggesting obstruction 5
• Suspected appendicitis, cholecystitis, or perforation 5