שלשול או הקאות ממושכים

Both vomiting and diarrhoea are often self-limiting and have a benign cause and prognosis. However, it is essential to make a thorough assessment to ensure there is not a more serious aetiology requiring prompt intervention. The arbitrary use of symptomatic treatments without a clear diagnosis is inappropriate. Continued vomiting and diarrhoea require reassessment and reconsideration of the previously assumed diagnosis.

הקאה¹

There are separate articles on Nausea and Vomiting in Palliative Care, Persistent Nausea or Vomiting, Nausea and Vomiting in Pregnancy (Hyperemesis Gravidarum) ו דיספפסיה.

There is no consistent definition for persistent vomiting; it may be described in number of episodes per day, or number of days or weeks on which vomiting has occurred.²

Clinical assessment

• The main priorities on assessment include the presence and degree of dehydration (especially in infants, young children and the elderly) and the underlying cause, particularly any possibility of a serious underlying cause requiring urgent admission or referral.

• Associated headache may occur with migraine but meningitis, subarachnoid haemorrhage and raised intracranial pressure also need to be considered.

• Abnormal clinical signs in the abdomen may include localised pain, tenderness and guarding (eg, acute appendicitis, acute cholecystitis) or absent bowel sounds (acute gastrointestinal obstruction).

• Associated anorexia and weight loss indicate possible malignancy.

• Vomiting blood may indicate peptic ulcer disease, Mallory-Weiss tear, oesophageal varices, gastro-oesophageal reflux disease, or malignancy.

• Genitourinary causes should be considered - eg, testicular torsion or acute epididymitis in men, and ruptured ovarian cyst or ovarian torsion in women.

• Pregnancy in women, medication, occupation and recent travel should also be considered in the assessment of the cause for the vomiting.

אבחנה מבדלת³

There are very many causes of vomiting. Consider the possible subheadings:

• Functional.

• Gastrointestinal.

• Iatrogenic eg, chemotherapy.

• Medication.

• Metabolic.

• Miscellaneous (including pregnancy).

• Neurological.

• Psychiatric.

• Vestibular.

חקירות

• Blood tests: FBC, ESR or CRP, renal function and electrolytes, LFTs, amylase, glucose, calcium.

• Urine: urinalysis, microscopy and culture, pregnancy test.

• Further assessment for possible underlying infection may include stool cultures, blood cultures, lumbar puncture.

• Ultrasound: gallstones, liver metastases, urinary tract obstruction.

• CXR (malignancy), abdominal X-ray (gastrointestinal obstruction).

• Barium meal, small bowel enema, barium enema.

• Upper gastrointestinal endoscopy.

• CT/MRI scan: abdominal and intracranial.

סיבוכים

Severe or persistent vomiting may cause:

• התייבשות.

• Metabolic alkalaemia, hyponatraemia, and hypokalaemia.

• Haematemesis from a Mallory-Weiss tear of the oesophagus.

שלשול

There are separate articles on Childhood Diarrhoea, Chronic Diarrhoea in Adults, גסטרואנטריטיס במבוגרים וילדים גדולים, Traveller's Diarrhoea, אי שליטה בצואה ו Rectal Bleeding in Adults.

Clinical assessment ⁴

• The main principles for assessment are the same as for vomiting, ie assessment of dehydration, excluding a serious cause and making a specific diagnosis to enable specific treatment.

• It is essential to make an assessment of the degree of diarrhoea, as there is considerable variation in normal bowel habit and patient perception.

• Associated weight loss usually indicates a serious underlying cause - eg, inflammatory bowel disease or malignancy.

• עצירות with overflow should be considered, especially in the elderly.

• Recent foreign travel may be important in terms of indicating a cause for the diarrhoea.⁵

אבחנה מבדלת

There are very many. It may be useful to consider them in subgroups:⁶

• Watery שלשול - functional disorders, למשל, irritable bowel syndrome.

• Watery שלשול - secretory disorders, למשל, מרה acid malabsorption.

• Watery שלשול - osmotic disorders, למשל, carbohydrate malabsorption.

• Fatty שלשול - malabsorptive disorders, למשל, amyloidosis.

• Fatty שלשול - maldigestive disorders, למשל, pancreatic exocrine insufficiency.

• Inflammatory, למשל, inflammatory bowel disease, malignancy.

חקירות⁷

• Blood tests: FBC (raised white cell count with infection), CRP (raised in inflammation or malignancy); renal function and electrolytes, LFTs, TFTs, Coeliac serology.

• Specific investigations for rarer causes might be undertaken in secondary care and may include serum gastrin (תסמונת זולינגר-אליסון), calcitonin (medullary carcinoma of thyroid) or vasoactive intestinal polypeptide-secreting tumour (VIPoma).

• Stool: microscopy, culture and sensitivities; faecal immunochemical test (FIT) kit, faecal fats (malabsorption).

• Ultrasound/CT scan: liver metastases.

• Barium enema, small bowel enema.

• Proctoscopy, sigmoidoscopy, colonoscopy.

• Biopsy: rectal biopsy (מחלת קרוהן), in association with colonoscopy (eg, ulcerative colitis), jejunal biopsy (מחלת צליאק).

סיבוכים

Prolonged diarrhoea may cause:

• התייבשות.

• Hypokalaemia.

Vomiting and diarrhoea treatment and management

General principles of management of vomiting or diarrhoea

• Refer urgently if there is significant dehydration or a possible serious underlying cause (eg, acute admission for a patient with an בטן חריפה או serious infective cause; urgent referral for possible malignancy).

• An urgent referral for endoscopy or to a specialist with expertise in upper gastrointestinal cancer should be made for any patient of any age with dyspepsia who presents with persistent vomiting.⁸

• In patients with persistent vomiting and weight loss in the absence of dyspepsia, upper gastro-oesophageal cancer should be considered and, if appropriate, an urgent referral should be made.⁸

• An urgent referral should be made for patients aged 60 years and older, with a change in bowel habit to looser stools and/or more frequent stools persisting for six weeks or more.⁸

• אנשים עם סוכרת are at particular risk of dehydration and electrolyte imbalance, and so should have a lower threshold for hospital admission.

• Correction of fluid and electrolyte imbalance.

• Diagnosis and specific treatment of any underlying cause.

• Symptomatic treatment should only be used as part of a management plan with a definite diagnosis of the cause of the vomiting and/or diarrhoea.