Nausea & vomiting
A classic disguise of inferior MI, heart failure congestion and takotsubo — check the heart when the abdomen is quiet.
Echo approach, step by step
Nausea and vomiting are common presenting symptoms of inferior and posterior ischaemia (vagal activation), acute heart failure with gut and liver congestion, and takotsubo syndrome [133,138].
- Regional wall motionInferior and inferolateral walls; RV involvement (RV infarction) [138].
- LV functionLVEF, filling pressure [2].
- CongestionIVC, hepatic vein Doppler, TR, RV function [3].
- TakotsuboCircumferential apical or mid-ventricular pattern [133].
- ThrombusLV thrombus or LA thrombus with AF, as sources of mesenteric embolism [140,182].
- PericardiumEffusion.
- Inferior / inferolateral wall motion
- RV involvement
- LVEF
- IVC and hepatic veins
- Thrombus
Causes & echo clues
| Cause | Echo clue | Next step |
|---|---|---|
| Inferior / posterior MI | Inferior or inferolateral RWMA; RV infarction | ECG with right-sided and posterior leads, troponin [138] |
| Acute heart failure | Low EF or high filling pressure; congestion | NT-proBNP, diuretics [12] |
| Congestive hepatopathy / gut oedema | Dilated IVC, hepatic vein systolic reversal, severe TR | LFTs, treat RV failure [4] |
| Takotsubo | Wall motion beyond one territory | Angiography [133] |
| Mesenteric embolism | LA or LV thrombus, AF, vegetations | CT angiography [136,140,182] |
| Hypertensive emergency | LVH, pulmonary oedema | BP control [26] |
Clinical pathway to the diagnosis
- ECG in every adult with unexplained vomiting and cardiovascular risk factors, including right-sided leads (V4R) if inferior ST elevation is present [138].
- Troponin, electrolytes, glucose (DKA), lipase, LFTs, digoxin levelif relevant.
- EchoWhen ECG or troponin are abnormal, with hypotension, or with signs of heart failure.
- Abdominal imagingWhen the cardiac work-up is negative.
Clinical pearls & pitfalls
PitfallInferior MI + hypotension + clear lungs + raised JVP = RV infarction. Give fluids cautiously and avoid nitrates [138].
- Vomiting-induced hypovolaemia with a hyperdynamic LV may create dynamic LVOT obstruction [13].
- Takotsubo is often triggered by physical stress (gastroenteritis, surgery) as well as emotional stress [133].
Red flags
- Diaphoresis, hypotension or bradycardia → inferior MI [138]
- Epigastric pain in diabetic, older or female patients [195]
- Right upper quadrant pain with raised JVP → congestive hepatopathy
- Digoxin therapy (toxicity)