Chronic nausea and vomiting: a diagnostic approach

ABSTRACT

Introduction

Chronic nausea and vomiting (CNV) are commonly encountered symptoms in medical practice. CNV is the presenting symptom in a variety of gastrointestinal and non-gastrointestinal disorders. However, in a significant percentage of patients without an obvious underlying cause, CNV poses a significant diagnostic challenge to the evaluating physician.

Areas covered

A comprehensive clinical history and physical examination form the foundation for further diagnostic work-up. In the present review, we discuss the diagnostic approach to CNV, highlighting the epidemiology, pathophysiology, causes, and modes of evaluation of this condition. Specific investigations, carefully guided by clinical assessment and tailored for each patient, would be more beneficial in diagnosing CNV than empirically performing a blanket of investigations.

Expert opinion

Whilst CNV remains a historically challenging diagnostic and therapeutic dilemma, research into this topic is limited. Hence, there is a growing call for more research into diagnostic modalities for CNV. With scientific advancement and further research, it is hoped that easy-to-use, cheap, noninvasive novel diagnostic modalities for CNV will be available soon.

KEYWORDS:

• Chronic
• diagnostic approach
• evaluation
• gastric emptying
• nausea
• vomiting

Article highlights

• Chronic nausea and vomiting (CNV) are the presenting symptoms in various gastrointestinal and non-gastrointestinal disorders.

• Gastrointestinal causes of CNV include mucosal disease, obstruction, hepatobiliary, and gastroduodenal, while non-gastrointestinal causes of CNV include medication & toxins, metabolic & endocrine, central nervous system, and psychiatric.

• A comprehensive clinical history and physical examination form the foundation for further diagnostic work-up.

• Specific investigations, carefully guided by the findings of the history and examination and tailored for each patient, are beneficial in diagnosing CNV.

• The initial evaluation should focus on differentiating gastrointestinal causes from non-gastrointestinal causes.

• After excluding anatomic, mechanical, and biochemical causes of CNV, further evaluation should look for gastrointestinal reasons with delayed or normal gastric emptying.

• The initial evaluation may include metabolic and endocrine panel, abdominal X-ray, upper gastrointestinal endoscopy, CT abdomen, small bowel series, CT or MRI brain, and psychiatric evaluation

• Further targeted evaluation, as indicated may include studies of gastric emptying (gastric emptying scintigraphy, breath testing, and wireless motility capsule) and electrogastrography (EGG).

Author’s contributions

MA Niriella and N Devanarayana conceptualised the paper. H Jayasena, AP De Silva and MA Niriella collected and analysed the evidence as well as drafted the manuscript. MA Niriella, M Withanage, AP De Silva and N Devanarayana were substantially involved in the revision of the manuscript. All authors checked the final manuscript before submission.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes consultancies, employment, expert testimony, honoraria, speakers bureaus, retainers, grants, stock options, ownership or patent received or pending or royalties.

Reviewer disclosure

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.