ch i n & v itichronic nausea &...

Lawrence R. Schiller, MD, FACG

Ch i N & V itiChronic Nausea & Vomiting

Lawrence R. Schiller, MD, FACGDigestive Health Associates of Texas

Baylor University Medical Center

Dallas, Texas

Nausea & Vomiting

• Common symptomsQ it t bli t ti t & f ili• Quite troubling to patients & families

• May have a variety of causes– Mechanical obstruction: GOO & SBO– Inflammatory/painful diseases: e.g.,

pancreatitis, biliary tract disease, hepatitis– Ingestion of poisons & toxins, drug toxicity– Functional disorders: gastroparesis, pseudo-

obstruction, others

ACG/LGS Regional Postgraduate Course - New Orleans, LA Copyright 2015 American College of Gastroenterology

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Case #1

• JM, 42-year-old man with diabetes mellitus f 20 hi f l i t iti &for 20 years; chief complaint: vomiting & weight loss

• Diabetes poorly controlled, blood sugars often >250 mg% despite insulin therapy

• Has disabling peripheral neuropathy for• Has disabling peripheral neuropathy for three years treated with gabapentin (600 mg TID)

Case #1

• Has had problems with vomiting for last 6 th i t d ith 40 lb i ht lmonths associated with 40 lb. weight loss

• Vomits each morning: contents include remnants of food from previous dinner

• Nausea through the day reduces appetite

Also complains of epigastric fullness and• Also complains of epigastric fullness and some pain

• Has occasional diarrhea


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Case #1• Physical examination

– Normal vital signs thin: ht 66 in wt 125 lbsNormal vital signs, thin: ht. 66 in., wt. 125 lbs.

– Pupils unreactive to light, but do accommodate, absent knee jerks

– Abdomen & balance of exam: unremarkable, no succussion splash

Endoscop• Endoscopy– Distal esophageal erythema, hiatal hernia

– Old food and bile in stomach (after 12 h fast)

– No pyloric obstruction

Case #1

• What is your differential diagnosis?

• What further evaluation or management would you recommend?

??ACG/LGS Regional Postgraduate Course - New Orleans, LA Copyright 2015 American College of Gastroenterology

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Gastroparesis• Relatively rare condition: incidence, 6.2 per

100,000; prevalence, 23.7 per 100,0001

• Symptomatic reduction in gastric emptying

• Common symptoms– Nausea, vomiting

– Dyspepsia, indigestion

– Weight loss

– Early satiety, bloating

– Abdominal pain1Jung H-K et al. Gastroenterology 2009;136:1225-33

Normal functions of the stomach

Storage


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Processing


Emptying


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InterdigestiveInterdigestiveEmptying

Gastroparesis


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Gastroparesis

• Common causes– Idiopathic

– Diabetes mellitus

– Post-vagotomy

– Parkinson’s disease

– Vascular diseaseVascular disease

– Pseudo-obstruction

Hasler WL. Nat Rev Gastroenterol Hepatol 2011;8:438-53.

Causes of Gastroparesis

6% Idiopathic

8%

5%

4% 35% Diabetic

Postsurgical

Parkinson's

29%13%Vascular Disease

Pseudoobstruction

MiscellaneousSoykan I et al. Dig Dis Sci 1998;43:2398-404.


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Idiopathic Gastroparesis

• Most common type in most series

• May be related to previous infection– “Reprogramming” of enteric nervous system

– Degeneration of enteric nervous system

• May be related to “auto-immunity”Degeneration of enteric ner o s s stem– Degeneration of enteric nervous system

– Fibrosis of muscle

• Symptoms may resolve with time

Cherian D, Parkman HP. Neurogastroenterol Motil 2012;24:217-22,e103.

Diabetic Gastroparesis

• Diabetes is most common known cause of t igastroparesis

• Most often occurs with longstanding insulin-dependent diabetes

• Diabetic neuropathy coexists in mostVagal autonomic neuropathy– Vagal autonomic neuropathy

• Hyperglycemia will slow emptying by itself

• Gastroparesis may upset diabetic control

Choung RS et al. Am J Gastroenterol 2012;107:82-8.


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Postvagotomy Gastroparesis

• Altered proximal gastric accommodation• Altered proximal gastric accommodation

• Impaired antral peristalsis with truncal vagotomy

• Planned vagotomy usually associated with drainage procedured a age p ocedu e

• Inadvertent vagotomy may occur with antireflux surgery and other procedures

Park MI, Camilleri M. Am J Gastroenterol 2006;101:1129-39.

Evaluation of Gastroparesis

Histor• History

• Physical Examination

• Diagnostic testing– Endoscopy

Radiography– Radiography

– Gastric emptying testing

– Electrogastrography

– Telemetry capsule


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History

• Assess symptoms, impact on patient

• Consider gastrointestinal disorders, outlet obstruction

• Look for systemic illnesses– Metabolic diseases

Central nervous system problems– Central nervous system problems

• Review medications

• Explore diet modifications

Physical Examination

• Nutritional status– Weight loss

– Cachexia

• Succussion splash

• Evidence of neuropathy, systemic disease


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Diagnostic Testing

• Endoscopy

• Radiography– Exclude gastric outlet obstruction

– Exclude small bowel obstruction

– Look for other conditions

Diagnostic Testing

• Gastric emptying testing– Saline load test

– Radio-opaque markers

– Scintigraphy: 4 hour study more reproducible• Standardized international protocol1

• Less overall gamma camera time

• Better correlates with symptoms2

1Tougas G, et al. Am J Gastroenterol 2000;95:1456-62.2Pathikonda M, et al. J Clin Gastroenterol 2012;46:209-15.


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Diagnostic Testing

• Electrogastrography1

• Telemetry pill2

– Sensitivity: 0.65

– Specificity: 0.87

1Simonian HP, et al. Am J Gastroenterol 2004;99:478-85.2Kuo B, et al. Aliment Pharmacol Ther 2008;27:186-96.

Therapy

• Diet modifications

• Drugs• Drugs– Antemetics

– Prokinetic drugs

• Enteral/parenteral feeding

• Surgery• Surgery– Gastrostomy, jejunostomy

– Gastric electrical stimulator

– Gastrectomy


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Educational Resources

• For patients– ACG

• www.patients.gi.org/topics/gastroparesis

– NIH• www.digestive.niddk.nih.gov/diseases/pubs/gastrop

aresis/

• For doctors– ACG

• http://gi.org/guideline/management-of-gastroparesis/

Case #2

• 24-year-old man with vomiting for 6 years

• Episodes of severe nausea, epigastric abdominal pain, vomiting every 2-3 weeks

• Rapidly becomes dehydrated, goes to ER

• Treated with IV fluid, antemetics and narcotics; symptoms resolve in 24 48 hnarcotics; symptoms resolve in 24-48 h

• Extensive work ups on two occasions were negative (endoscopy, CT scan, UGI/SBFT)


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Case #2

• Well between episodes

• No weight loss

• No alcohol use, occasional marijuana

• No help with metoclopramide, promethazine, ondansetron

• Physical examination in office: normal

• 4-h gastric emptying scan shows 4% retention at 4 hours

Case #2




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Cyclic Vomiting Syndrome

• First described in children; now recognized i d ltin adults

• Stereotypical episodes occur with little prodrome; characteristic time course

• Pain may be quite prominent

Nothing is wrong with the gut• Nothing is wrong with the gut

• ?migraine equivalent

• Often history of marijuana abuseHejazi RA, McCallum RW. Aliment Pharmacol Ther 2011;34:263-73.

Cyclic Vomiting Syndrome

• Acute treatment– Sedation is key to acute management

(lorazepam, haloperidol on scheduled basis)

– Minimize or avoid narcotics

– Tryptans, antemetics may be helpful

• ProphylaxisProphylaxis– Amitriptyline in substantial dose (>100 mg)

– ?other migraine prophylaxis

• Abortive therapy (sedation at onset)


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• For patients– NIH

• www.digestive.niddk.nih.gov/ddiseases/pubs/cvs

– Cyclic Vomiting Syndrome Association• www.cvsaonline.org

• For doctors– CVSA

• http://www.cvsa.org.uk/downloads/Fleisherguidlines.pdf

Case #3

• 28-year-old woman with vomiting for 5 yr.

• Daily episodes of “projectile” vomiting while eating

• Emesis consists of food that she has just eaten; “undigested”, tastes the same as when it was first swallowedwhen it was first swallowed

• Sometimes can swallow hard/reswallow without ejecting bolus from mouth, rechews food occasionally


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Case #3

• No weight loss in last 3 yearsH i d ti f d t h l• Has missed time from graduate school

• Evaluated by two gastroenterologists– Normal endoscopy– Normal gastric emptying scan– Normal UGI/SBFT x-rays– Normal esophageal motility study

• Treated with metoclopramide, tegaserod, had TPN for 2 months with no effect on sx.

Case #3




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Rumination Syndrome

• Initially described in mentally retarded hild l b d i d ltchildren; now also observed in adults

• Key clue is effortless regurgitation of food while eating; no nausea or pain

• Thought to be behavioral; nothing wrong with gutwith gut

• Episodes due to diaphragm/abdominal wall contraction and relaxation at EG junction

Tack J, et al. Aliment Pharmacol Ther 2011;33:782-8.

Rumination Syndrome

• Symptoms may be exacerbated by stress

• Exclude Zenker’s diverticulum, achalasia

• Manometry/impedance can confirm

• Treatment is supportive– Relaxation training, biofeedback

– Psychotherapy

– ? Role for SSRI drugs (e.g., mirtazapine)

– Antemetics NOT helpful


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• For patients– NIH

• http://www.nlm.nih.gov/medlineplus/ency/article/001539.htm

• For doctors– Published reviews

• Kessing BF, et al. Am J Gastroenterol. 2014;109:52-9.

• Kessing BF, et al. J Clin Gastroenterol. 2014;48:478-83.

• Gupta R, et al. Indian J Psychiatry. 2012; 54: 283–285.

• Pareek N, et al. Am J Gastroenterol. 2007;102:2832-40.

Case #4

• 25-year-old woman with 6 years of nausea

• Feels OK when she first awakes, nausea develops within minutes of getting up

• Rarely vomits, but no appetite

• Weight loss of 30 lbs. since onset of illnessillness

• Had to drop out of college due to symptoms


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Case #4

• Extensive evaluation by three t t l i t i t f illgastroenterologists since onset of illness

– Negative endoscopy

– Negative abdominal sonography

– Negative HIDA scan

– Cholecystectomy done: no improvementCholecystectomy done: no improvement

– 90-min gastric emptying scan: abnormal

• Trials of metoclopramide, tegaserod, domperidone unsuccessful

Case #4

• Some improvement of nausea with hl iprochlorperazine

• Referred for consideration of gastric electrical stimulator placement

• Physical examinationNormal general examination– Normal general examination

– Nystagmus on rightward gaze

– Rotates 90o to left while marching in place with eyes shut and ears occluded


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Case #4



??Vestibular Dysfunction

• Surprisingly common cause of chronic nausea

• May or may not have vertigo or motion sickness symptoms (but often do)

• Emptying studies may be abnormal from nausea alonenausea alone

• Scopolamine patches or antihistamines (meclizine, dimenhydrinate) helpful


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Diagnoses in 248 Patients

Diagnosis Number (%)

Chronic Vestibular Dysfunction 64 (25.8)Chronic Vestibular Dysfunction 64 (25.8)Gastroparesis 28 (11.3)Cyclic Vomiting Syndrome 22 (8.8)Rumination Syndrome 3 (1.2)GERD 5 (2.0)Post-Surgical 6 (2.4)Medication-Induced 3 (1.2)Other Miscellaneous 41 (16.5)Unspecified 76 (30.6)

Evans TH, Schiller LR. Proc (Bayl Univ Med Cent) 2012;25:214-217.

Summary

• Not everyone with functional chronic d iti h t inausea and vomiting has gastroparesis

• 4-hour gastric emptying study should be the standard test for delayed emptying

• Differential diagnosis is broad and includes both gastrointestinal and non-includes both gastrointestinal and non-gastrointestinal problems

THINK OUTSIDE THE ABDOMEN!


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