A 60-year-old male presents to your ED complaining of nausea and vomiting. Two hours ago he had the onset of epigastric abdominal pain. About 1 hour ago he started having intense nausea and multiple episodes of bilious emesis. He denies any history of coronary artery disease or NSAID use. His ECG done at the time of presentation is normal. What is the most likely cause of his emesis?
Achalasia
+Gastric outlet obstruction
+Large bowel obstruction
+Myocardial infarction
+Small bowel obstruction
Pain preceding nausea and vomiting is associated with an obstructive process. The content of the emesis is helpful in determining if an obstruction is present. Bilious emesis is associated with small bowel obstruction. Esophageal disorders such as Achalasia result in regurgitation of swallowed food particles. Gastric outlet obstruction results in emesis composed of food particles, but devoid of bile. Large bowel obstruction is associated with emesis of feculent material. While it is important to consider acute coronary syndrome in elderly patients with epigastric abdominal pain, a normal ECG and the presence of bile in the emesis point to small bowel obstruction as the most likely cause.