Lawrence R. Schiller, MD, FACG. Digestive Health Associates of Texas Baylor University Medical Center Dallas, Texas.

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1 Chronic Nausea & Vomiting Lawrence R. Schiller, MD, FACG Digestive Health Associates of Texas Baylor University Medical Center Dallas, Texas Nausea & Vomiting Common symptoms Quite troubling to patients t & 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, pseudoobstruction, others 1

2 Case #1 JM, 42-year-old man with diabetes mellitus for 20 years; chief complaint: vomiting & weight loss Diabetes poorly controlled, blood sugars often >250 mg% despite insulin therapy Has disabling peripheral neuropathy for three years treated with gabapentin (600 mg TID) Case #1 Has had problems with vomiting for last 6 months 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 some pain Has occasional diarrhea 2

3 Case #1 Physical examination Normal 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 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?? 3

4 Gastroparesis Relatively rare condition: incidence, 6.2 per 100,000; prevalence, 23.7 per 100,000 1 Symptomatic reduction in gastric emptying Common symptoms Nausea, vomiting Dyspepsia, indigestion Weight loss Early satiety, bloating Abdominal pain 1 Jung H-K et al. Gastroenterology 2009;136: Normal functions of the stomach Storage 4

5 Normal functions of the stomach Processing Normal functions of the stomach Emptying 5

6 Normal functions of the stomach Interdigestive Emptying Gastroparesis 6

7 Common causes Idiopathic Diabetes mellitus Post-vagotomy Parkinson s disease Vascular disease Pseudo-obstruction Gastroparesis Hasler WL. Nat Rev Gastroenterol Hepatol 2011;8: Causes of Gastroparesis 6% 4% 5% 8% 13% Idiopathic 35% Diabetic Postsurgical Parkinson's Vascular Disease 29% Pseudoobstruction Soykan I et al. Dig Dis Sci 1998;43: Miscellaneous 7

8 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 nervous systemstem 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 gastroparesis Most often occurs with longstanding insulin-dependent diabetes Diabetic neuropathy coexists in most Vagal autonomic neuropathy Hyperglycemia will slow emptying by itself Gastroparesis may upset diabetic control Choung RS et al. Am J Gastroenterol 2012;107:

9 Postvagotomy Gastroparesis Altered proximal gastric accommodation Impaired antral peristalsis with truncal vagotomy Planned vagotomy usually associated with drainage age procedure e Inadvertent vagotomy may occur with antireflux surgery and other procedures Park MI, Camilleri M. Am J Gastroenterol 2006;101: Evaluation of Gastroparesis History Physical Examination Diagnostic testing Endoscopy Radiography Gastric emptying testing Electrogastrography Telemetry capsule 9

10 History Assess symptoms, impact on patient Consider gastrointestinal disorders, outlet obstruction Look for systemic illnesses Metabolic diseases Central nervous system problems Review medications Explore diet modifications Physical Examination Nutritional status Weight loss Cachexia Succussion splash Evidence of neuropathy, systemic disease 10

11 Endoscopy Radiography Diagnostic Testing 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 protocol 1 Less overall gamma camera time Better correlates with symptoms 2 1 Tougas G, et al. Am J Gastroenterol 2000;95: Pathikonda M, et al. J Clin Gastroenterol 2012;46:

12 Diagnostic Testing Electrogastrography 1 Telemetry pill 2 Sensitivity: 0.65 Specificity: Simonian HP, et al. Am J Gastroenterol 2004;99: Kuo B, et al. Aliment Pharmacol Ther 2008;27: Diet modifications Drugs Antemetics Prokinetic drugs Therapy Enteral/parenteral feeding Surgery Gastrostomy, jejunostomy Gastric electrical stimulator Gastrectomy 12

13 Educational Resources For patients ACG NIH aresis/ For doctors ACG 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 h Extensive work ups on two occasions were negative (endoscopy, CT scan, UGI/SBFT) 13

14 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 What is your differential diagnosis? What further evaluation or management would you recommend?? 14

15 Cyclic Vomiting Syndrome First described in children; now recognized in adults Stereotypical episodes occur with little prodrome; characteristic time course Pain may be quite prominent Nothing is wrong with the gut?migraine equivalent Often history of marijuana abuse Hejazi RA, McCallum RW. Aliment Pharmacol Ther 2011;34: 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 Prophylaxis Amitriptyline in substantial dose (>100 mg)?other migraine prophylaxis Abortive therapy (sedation at onset) 15

16 Educational Resources For patients NIH Cyclic Vomiting Syndrome Association For doctors CVSA s.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 swallowed Sometimes can swallow hard/reswallow without ejecting bolus from mouth, rechews food occasionally 16

17 Case #3 No weight loss in last 3 years 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 What is your differential diagnosis? What further evaluation or management would you recommend?? 17

18 Rumination Syndrome Initially described in mentally retarded children; 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 gut Episodes due to diaphragm/abdominal wall contraction and relaxation at EG junction Tack J, et al. Aliment Pharmacol Ther 2011;33: 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 18

19 Educational Resources For patients NIH For doctors Published reviews Kessing BF, et al. Am J Gastroenterol. 2014;109:52-9. Kessing BF, et al. J Clin Gastroenterol. 2014;48: Gupta R, et al. Indian J Psychiatry. 2012; 54: Pareek N, et al. Am J Gastroenterol. 2007;102: 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 illness Had to drop out of college due to symptoms 19

20 Case #4 Extensive evaluation by three gastroenterologists t t since onset of illness Negative endoscopy Negative abdominal sonography Negative HIDA scan Cholecystectomy done: no improvement 90-min gastric emptying scan: abnormal Trials of metoclopramide, tegaserod, domperidone unsuccessful Case #4 Some improvement of nausea with prochlorperazine Referred for consideration of gastric electrical stimulator placement Physical examination Normal general examination Nystagmus on rightward gaze Rotates 90 o to left while marching in place with eyes shut and ears occluded 20

21 Case #4 What is your differential diagnosis? What further evaluation or management would you recommend?? 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 alone Scopolamine patches or antihistamines (meclizine, dimenhydrinate) helpful 21

22 Diagnoses in 248 Patients Diagnosis Number (%) 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: Summary Not everyone with functional chronic nausea 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 nongastrointestinal problems THINK OUTSIDE THE ABDOMEN! 22

GASTROPARESIS. C. Prakash Gyawali, MD Professor of Medicine Washington University in St. Louis

GASTROPARESIS. C. Prakash Gyawali, MD Professor of Medicine Washington University in St. Louis GASTROPARESIS C. Prakash Gyawali, MD Professor of Medicine Washington University in St. Louis Symptom Definitions Nausea: a subjective feeling of wanting to vomit Vomiting: forceful expulsion of gastroduodenal