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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Lawrence R. Schiller, MD, FACG
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
ACG/LGS Regional Postgraduate Course - New Orleans, LA Copyright 2015 American College of Gastroenterology
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Lawrence R. Schiller, MD, FACG
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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Lawrence R. Schiller, MD, FACG
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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Lawrence R. Schiller, MD, FACG
Normal functions of the stomach
Processing
Normal functions of the stomach
Emptying
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Lawrence R. Schiller, MD, FACG
Normal functions of the stomach
InterdigestiveInterdigestiveEmptying
Gastroparesis
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Lawrence R. Schiller, MD, FACG
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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Lawrence R. Schiller, MD, FACG
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.
ACG/LGS Regional Postgraduate Course - New Orleans, LA Copyright 2015 American College of Gastroenterology
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Lawrence R. Schiller, MD, FACG
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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Lawrence R. Schiller, MD, FACG
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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Lawrence R. Schiller, MD, FACG
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.
ACG/LGS Regional Postgraduate Course - New Orleans, LA Copyright 2015 American College of Gastroenterology
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Lawrence R. Schiller, MD, FACG
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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Lawrence R. Schiller, MD, FACG
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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Lawrence R. Schiller, MD, FACG
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?
??ACG/LGS Regional Postgraduate Course - New Orleans, LA Copyright 2015 American College of Gastroenterology
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Lawrence R. Schiller, MD, FACG
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)
ACG/LGS Regional Postgraduate Course - New Orleans, LA Copyright 2015 American College of Gastroenterology
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Lawrence R. Schiller, MD, FACG
Educational Resources
• 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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Lawrence R. Schiller, MD, FACG
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
• 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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Lawrence R. Schiller, MD, FACG
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
ACG/LGS Regional Postgraduate Course - New Orleans, LA Copyright 2015 American College of Gastroenterology
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Lawrence R. Schiller, MD, FACG
Educational Resources
• 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
ACG/LGS Regional Postgraduate Course - New Orleans, LA Copyright 2015 American College of Gastroenterology
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Lawrence R. Schiller, MD, FACG
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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Lawrence R. Schiller, MD, FACG
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 alonenausea alone
• Scopolamine patches or antihistamines (meclizine, dimenhydrinate) helpful
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Lawrence R. Schiller, MD, FACG
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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