Hello - thanks for asking your question.
Although I am an internal medicine physician, please see your primary
care physician for specific questions regarding any individual cases –
please do not use Google Answers as a substitute for medical advice.
I will be happy to answer factual medical questions.
It sounds like you are having intractable nausea. Of course, there
are many causes for this - you may want to discuss some of these with
your personal physician. Please understand that I cannot diagnose you
over the internet.
Possible causes
There are a variety of causes that can cause nausea with and without
vomiting. To list a few:
- gastroenteritis
- food poisoning
- mechanical obstruction of the stomach, small bowel, colon
- hepatobiliary disease
- pancreatic disease
- peptic disease
- eosinophilic gastroenteritis
- cancer
- gastroparesis
- CNS disease
- psychiatric disorders
- irritable bowel
I will briefly discuss some salient points about possible esoteric
diseases that may cause chronic nausea and vomiting:
GERD:
An infrequently reported symptom of GERD is nausea. A retrospective
study evaluated 10 patients with intractable nausea and GERD in the
absence of typical symptoms (1). The most notable finding was the
resolution of symptoms in all patients by various GERD related
therapies. These observations suggest that GERD should be considered
as a cause of persistent nausea, even if typical symptoms and
endoscopic findings are absent.
Eosinophilic gastroenteritis:
Benign eosinophilic infiltration of the gut is a rare disorder which
can occur anywhere from the esophagus to the colon, causing symptoms
dependent upon the area and tissue layer of bowel involved. Gastric
mucosal disease is typically associated with nausea and vomiting.
Endoscopic biopsy is needed for diagnosis. Establishing the diagnosis
is important because of the excellent response to steroid therapy.
Viral gastroparesis:
Approximately 50 percent of patients with chronic idiopathic nausea
and vomiting evaluated in referral centers have gastroparesis (2). In
one series of 143 patients with gastroparesis, 52 (36 percent) were
regarded as idiopathic, of which 12 were presumed to be "viral
gastroparesis" (3). A viral etiology was suggested in these patients
and in other series when there was an acute onset of nausea and
vomiting with other features of a viral illness (fever, myalgia,
diarrhea, fatigue, or abdominal cramping). In contrast to the
long-term nature of gastroparesis in patients without features
suggestive of a viral etiology, those with viral gastroparesis have
partial or complete resolution of symptoms over time.
Chronic idiopathic intestinal pseudo-obstruction:
Chronic intestinal pseudo-obstruction is a syndrome that suggests
mechanical bowel obstruction of the small or large bowel in the
absence of an anatomic lesion that obstructs the flow of intestinal
contents. There are four important steps in the evaluation of
patients with suspected intestinal pseudo-obstruction:
- Radiographic testing
- Assessment of nutritional status
- Confirmation of dysmotility with a transit test
- Performance of specialized tests such as manometry
Cyclic vomiting syndrome:
Cyclic vomiting syndrome is a disorder characterized by repeated
episodes of nausea and vomiting that last for hours to days separated
by symptom-free periods of variable length. In adults, the disorder
has been described as consisting of episodes of nausea and vomiting
lasting for three to six days in a patient-specific stereotypic
pattern.
Diagnostic approach
Some of the heterogeneous group of disorders underlying chronic nausea
and vomiting can be identified by directed testing such as a blood
count for eosinophilia, and a neurologic evaluation. Most patients
with unexplained chronic nausea and vomiting should undergo
esophagogastroduodenoscopy to look for esophagitis or gastric outlet
obstruction, and to permit biopsy confirmation of malignancy or,
rarely, eosinophilic gastroenteritis.
However, as in patients evaluated for chronic dyspepsia (a disorder
that often overlaps with nausea and vomiting), endoscopy and other
routine tests are often normal, suggesting an idiopathic (functional)
etiology.
Let me summarize your diagnostic tests thus far:
EGD --> gastritis and hiatal hernia
gastric emptying study --> negative
24-hr pH test --> negative but you were on PPIs
thyroid and "hormones" --> negative
esophageal manometry --> low LES pressure
brain MRI --> negative
Looking at the picture you have provided, you have 2 obvious reasons
for chronic nausea and vomiting: your low LES pressure and the
presence of a hiatal hernia. These should be addressed before moving
onto more esoteric causes.
A low LES is connected with hiatal hernias. From UptoDate:
"One report added credence to the role of hiatal hernia by
demonstrating that patients with larger hiatal hernias have weaker
LES, more reflux, and worse esophagitis than those with small or no
hiatal hernia" (5)
"Thus, although neither hiatus hernia nor a hypotensive LES alone
results in severe gastroesophageal junction incompetence, the two
conditions interact with each other. This conclusion is consistent
with the clinical experience that exercise, tight fitting garments,
and activities involving bending at the waist exacerbate heartburn,
especially after having consumed meals that reduce LES pressure." (4)
The mere presence of an unrepaired hiatus hernia is enough to cause
your chronic symptoms, as the most common symptoms are epigastric or
substernal pain, postprandial fullness, substernal fullness, nausea,
and retching.
There are surgical options to repairing a low LES. Many surgical
approaches focus on restoring a physiologic equivalent to the normal
LES. The most common procedures (Nissen fundoplication, Belsey Mark
IV, and Hill repair) claim about an 85 percent success rate in
relieving symptoms and healing esophagitis, although recurrent
symptoms may develop in about 10 percent of initially successful
cases. These options should be discussed with your surgeon -
obtaining a second opinion would not hurt.
Summary
You have 2 clear reasons for your chronic nausea and vomiting: a low
LES and a hiatal hernia. If they are not addressed, it is likely that
they will continue to contribute to your symptoms. All options to
treat these conditions should be exhausted before considering other
causes. Obtain a second surgical or gastroenterological opinion if
necessary.
Other options that may be considered include i) a CT scan/ultrasound
to rule out any cancer, hepatobiliary or pancreatic disease; or, ii)
improved treatment of irritable bowel (which would be considered
should every other test be negative).
I stress that this answer is not intended as and does not substitute
for medical advice - please see your personal physician for further
evaluation of your individual case.
Please use any answer clarification before rating this answer. I will
be happy to explain or expand on any issue you may have.
Thanks,
Kevin, M.D.
Search strategy:
No internet search engine was used in this answer. All sources are
from physician-written and peer-reviewed sources.
Bibliography:
1) Brzana, RJ, Koch, KL. Gastroesophageal reflux disease presenting
with intractable nausea. Ann Intern Med 1997; 126:704.
2) Longstreth. Approach to the patient with nausea and vomiting.
UptoDate, 2002.
3) Bityutskiy, LP, Soykan, I, McCallum, RW. Viral gastroparesis: A
subgroup of idiopathic gastroparesis--clinical characteristics and
long-term outcomes. Am J Gastroenterol 1997; 92:1501.
4) Kahrilas. Hiatas hernia. UptoDate, 2002.
5) Schwaitzberg. Surgical management of esophageal reflux. UptDate,
2002. |
Clarification of Answer by
kevinmd-ga
on
10 Mar 2003 11:07 PST
Hello,
It is possible that we are justing using different terminology. You
may be referring to videofluoroscopy of the esophagus. From UptoDate:
"Videofluoroscopy — An alternative to conventional barium studies is
videofluoroscopy, which permits accurate visualization and analysis of
the rapid sequence of events which make up a swallow. It is ideal for
viewing the elevation of the hyoid and larynx, the relaxation of the
UES, and contraction of the pharynx.
The video, taken from both anteroposterior and lateral directions, can
be replayed at much slower speeds or even frame-by-frame to facilitate
accurate analysis. This helps identify abnormal movement of a bolus,
such as aspiration, pooling in pharyngeal recesses, movement of
anatomic structures, muscle activities throughout the area, and exact
oral and pharyngeal transit times. The effects of different barium
consistencies and positions should be tested. Thick or solid boluses
should be used for patients who primarily complain of solid food
dysphagia.
Examination during standard videofluoroscopy is limited to the
cervical esophagus. Thus, it does not exclude lesions in the distal
esophagus, which may sometimes give rise to symptoms referable to the
cervical region." (1)
As to why they are ruling out surgery, I cannot comment on that since
I am not involved with your case. This is an issue that needs to be
discussed with your personal surgeon.
This answer is not intended as and does not substitute for medical
advice - the information presented is for patient education only.
Please see your personal physician for further evaluation of your
individual case.
Thanks,
Kevin, M.D.
Bibligraphy:
1) Lembo. Diagnosis and treatment of oropharyngeal dysphagia.
UptoDate, 2002.
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