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Basic concepts Functional gastroduodenal disorders / Nausea and vomiting disorders

Nausea and vomiting disorders

A new category, cyclical vomiting in adults, was added based on expert opinion and a better appreciation, and included in the Rome III criteria, as those patients with stereotypical attacks of cyclical vomiting differ from those with functional vomiting(1)

There is an extensive differential diagnosis concerning recurrent nausea and vomiting. Many drugs, - including cannabinoid use - may cause nausea and vomiting. In patients with recurrent unexplained vomiting, rumination and eating disorders need to be excluded, as well as it is particularly important to exclude intestinal obstruction, gastroparesis, intestinal pseudo-obstruction and metabolic and central nervous system disease (e.g., brainstem lesions on magnetic resonance imaging)(1).

Upper endoscopy, small bowel x-ray enterography or computed tomography can be performed to exclude gastroduodenal disease and small bowel obstruction. Biochemical testing is also essential to exclude electrolyte abnormalities and metabolic diseases. If all the tests are normal, it is reasonable to consider other diagnostic tests as gastric-emptying evaluation or gastrointestinal manometry. Gastric dysrrhythmias may be present in some patients with unexplained nausea and vomiting with normal gastric emptying, but the use of electrogastrography is not widely accepted in the scientific community(1).

The treatment of chronic idiopathic nausea is not defined. It includes antinauseants as prochlorperazine, diphenhydrinate, and cyclizine promethazine; 5-hydroxytryptamine antagonists ondansetron and alosetron also have been used. Low-dose tricyclic antidepressant therapy may be helpful anecdotally(1).

Patients with cyclical vomiting syndrome may even require hospital admission and supportive care during severe bouts. Empiric treatments of antimigraine could be useful when there is a family history of migraine headaches(1).

In functional vomiting, management of nutritional status and psychosocial support is important. The role of dietary and pharmacological therapy, both frequently used, has not been specifically tested. There is also no evidence that medications are particularly useful in this group. Antiemetic drugs can be tried but are often of little value. Data are lacking on the value of behavioural or psychotherapy(1).

Nausea is a subjective symptom that can be defined as an unpleasant sensation of the imminent need to vomit, which is typically experienced in the epigastrium or throat. Vomiting refers to the forceful oral expulsion of gastric or intestinal content associated with contraction of the abdominal and chest wall muscles. Both symptoms can be present as a result of an organic underlying cause, but also as functional disorders(1).

Nausea and vomiting functional disorders comprises(1):
· Chronic idiopathic nausea: frequent bothersome nausea without vomiting.
· Functional vomiting: recurrent vomiting in the absence of self-induced vomiting, or underlying eating disorders, metabolic disorders, drug intake, or psychiatric or central nervous system disorders.
· Cyclic vomiting syndrome: stereotypical episodes of vomiting with vomiting-free intervals.

Rome III diagnostic Criteria* for Chronic Idiopathic Nausea

Must include all of the following:
1. Bothersome nausea, occurring at least several times per week
2. Not usually associated with vomiting
3. Absence of abnormalities at upper endoscopy or metabolic disease that explains the nausea

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis

Rome III diagnostic Criteria* for Functional Vomiting(1):

Must include all of the following:
1. One or more episodes of vomiting per week on average.
2. Absence of criteria for an eating disorder, rumination, or major psychiatric disease according to DSM-IV.
3. Absence of self-induced vomiting and chronic cannabinoid use and absence of abnormalities in the central nervous system or metabolic diseases to explain the recurrent vomiting.

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis

Rome III diagnostic Criteria* for Cyclic Vomiting Syndrome

Must include all of the following:
1. Stereotypical episodes of vomiting regarding onset (acute) and duration (less than 1 week)
2. Three or more discrete episodes in the prior year
3. Absence of nausea and vomiting between episodes

Supportive criterion: History or family history of migraine headaches.

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis

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