The Challenges of Chronic Nausea and Vomiting and Normal Gastric Emptying

Abstract

Chronic nausea and vomiting are perhaps the most challenging problems we face as gastroenterologists. Despite all that we see and do in the practice of medicine, having a patient vomiting in your examination room challenges the stomach and wits of even the most patient and humanistic physician. Chronic nausea and vomiting are problems that are messy, difficult to discuss, diagnose, and manage. The astute clinician can understand that not all chronic nausea and vomiting is gastroparesis, bulimia nervosa, obstruction, hormonal dysfunction, or increased intracranial pressure — some nausea and vomiting is chronic, severe, and simply unexplainable. While the Rome Committee in their third iteration has provided some rudimentary groundwork for classifying patients with “functional vomiting” and “chronic idiopathic nausea,” very little has been heard from these diagnostic entities since they left Rome. 1 Chronic nausea and vomiting have enormous financial and emotional impacts on our patients. This is a poorly understood problem. Gastric scintigraphy is a difficult test to perform correctly and can be very timeconsuming and has problems with false negatives even in the best hands. 2 Some recent data have come to light suggesting that some patients with normal emptying of solids may suffer from abnormal emptying of liquids. 3 Whether or not this is causative of their symptoms is not clear. The current measurement of gastric emptying may only detect a certain subset of patients in whom mechanical emptying of solids is the primary pathology, rather than other patients who may suffer from neuronal, subtle hormonal, or vascular pathology causing their nausea and vomiting. 4,5 In this issue, Pasricha and colleagues 6 attempt to shed light on some of these problems and lay some foundation for future studies. While they make clear that they’re not attempting to describe a new disease, their findings are quite interesting. Like every good study, this one has its own set of shortcomings. Nevertheless this may be the largest group of patients with chronic unexplained nausea and vomiting and normal gastric emptying in the literature. One of the more interesting findings was the fact that the Rome III criteria fail to adequately capture these patients as a standalone diagnosis — the Rome III criteria only successfully identifying about 13% of patients with a discrete diagnosis. This represents an excellent opportunity for the Rome committee to improve the criteria for both “functional vomiting” and “chronic idiopathic nausea.” Because very little published data are available on any of these syndromes, the opportunity to refine the criteria based on this large group shouldn’t be overlooked.