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Bilious vomiting

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Warning Tmi to follow.


64 y/o wm reasonably healthy non-smoking, with recurrent cough for last 6 mos, treated emperically with non sedating antihistamines, and, when severe, with abx, with resolution of sx.. Presented to ED after 12 hours of continuous gagging, and retching. Unable keep anything down.



Slight catarrhal rhinorrhea but vomiting is definitely not pos-tussive: occurs spontaneously and without warning, is prolonged and protracted.

No abdominal pain.

No food in antecedent 15 hours, no suspicious fod.

No diarrhea.

Good BMs.


Bad headache bitemporaland lateral forehead, felt to be due to the combination of sustained straining at retching and intermittent coughing spasms, which improved with hydration and pain Meds. NO meningigmus.


General body aches.


CBC, Cmp , UA, EKG, troponins, EKG all okay. BNP nl


Sed rate 93mmhr


CXR consolidate RML pna with pleural effusion and Fluffy RLL infiltrate


CTA chest ( to better image RML density... Not looking for PE) showed no PE, but 4x5 cm homogenously dense mass in RML to pleura, "favor infection", and repeat scan 4-6 weeks advised.


ECHOcardiogram normal. Ef 60%


PPD neg. INFA/B neg


Vomiting required IV serial phenergan and 16 mg zofran to control.


IV abx ( a whole different story) started, and most nonposttussive nausea improved within 24 hours.


Pt is me.


Question I have is..


What caused the nausea and vomiting?


Via what/which pathway?


I know that babies / infants will present with vomiting as a symptom a lobar pna ... But I never really considered the pathway.


The working assumption is I have a RML syndrome, and will complete tx for atypical pna, and probably undergo bronch in 4-6 weeks.

Other than the cough .. Never had systemic sx ( weight loss, hemoptysis, fever, chills, etc).. So " endotoxin reaction" and " transient bacteremia" as a trigger of my vomiting doesn't seem to fit.


Any of you ID guys or experienced clinical PAs got any ideas ; just what causes non tussive vomiting as a sx in pna?

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  • 2 weeks later...

I think it's the other way around -- I would worry more about a GI issue (esophageal stenosis, GERD, cancer?? eek!!) causing aspiration PNA.


have you been able to eat at all? dysphagia? weight loss?


are you a drinker? drinking EtOH before bed can also cause an aspiration PNA.


bilious...obstruction - stone/pancreatic irritation? any jaundice?


get an UGI to start, RC!


...and keep us posted

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