Chronic nausea and vomiting in patients with normal gastric emptying is a significant medical problem that is indistinguishable from gastroparesis and might be a separate clinical entity, according to a study by Pankaj Pasricha et al in the July issue of Clinical Gastroenterology and Hepatology.
Chronic nausea and vomiting in patients that do not have any obvious structural abnormalities is a difficult problem for physicians and patients alike. When the nausea and vomiting are associated with a delay in gastric emptying, the syndrome is called gastroparesis. However, some patients have no demonstrable abnormalities in gastric emptying, and are a challenge to diagnose and manage.
To study this disorder, Pasricha et al. collected and analyzed data from 425 patients with chronic nausea and vomiting; 319 (75%) had delayed emptying, defined by the results of a standardized, low-fat meal, and 106 had normal gastric emptying.
Pasricha et al. found that patients with symptoms of chronic nausea and vomiting, but normal gastric emptying, were indistinguishable from patients with classical gastroparesis by most demographic and clinical criteria. Symptom severity indexes were similar between groups for nausea, retching, vomiting, stomach fullness, inability to complete a meal, feeling excessively full after meals, loss of appetite, bloating, and a visibly larger stomach. There were no differences in health care utilization, quality of life indexes, depression, or trait anxiety scores.
Importantly, patients with the syndrome were not adequately captured by the stand-alone criteria for the Rome III diagnoses of chronic idiopathic nausea and functional vomiting. In an accompanying editorial, Nathaniel Winstead states that the Rome Committee should improve the criteria for functional vomiting and chronic idiopathic nausea.
The pathogenesis of nausea and vomiting in these patients is unexplained—it is not clear whether this is a distinct syndrome, a heterogenous collection of unidentified etiologies, or a type of gastroparesis that changes over time.
Pasricha et al. propose that these patients might have abnormalities in gastric function that are more subtle than those found in classical gastroparesis. Techniques used to measure solid gastric emptying might not capture the entire spectrum of gastric dysfunctions—the authors point out that nearly a third of patients believed to have normal solid gastric emptying have delayed liquid gastric emptying. Aberrant afferent signaling via the vagal of splanchnic nerves, or changes in hormone levels, might also account for the symptoms.
Pasricha et al. did associate a history of binge drinking with chronic unexplained nausea and vomiting with normal gastric emptying. Winstead suggested that ethanol might be toxic to the enteric nervous system in some individuals.
Winstead states that one of the most interesting features of the study was the stability of the disorder—after nearly 1 year, very few patients had a change in diagnosis. He states that we must determine whether this is a primary disorder, a highly selected group of very ill patients with severe functional dyspepsia, or a collection of different problems leading to a final common pathway of chronic unexplainable nausea.
Read the article online.
Pasricha PJ, Colvin R, Yates K, et al. Characteristics of patients with chronic unexplained nausea and vomiting and normal gastric emptying. Clin Gastroenterol and Hepatol 2011;9:567–576.
Read the accompanying editorial.
Winstead N. The challenges of chronic nausea and vomiting and normal gastric emptying. Clin Gastroenterol and Hepatol 2011;9:534–535.