Tag Archives: chronic nausea

Faulty Narrative with Functional Nausea Study

Posted on by

A recent study (SE Tarbell et al J Pediatr 2020 225: 109-108. Children with Functional Nausea—Comorbidities outside the Gastrointestinal Tract) highlights the frequent comorbidities in children with functional nausea. The authors have combined prospective and retrospective elements with specific questionnaires and review of the electronic medical records.

Key points:

  • High rates of comorbidities were noted: Abdominal pain 94%, Headache 83%, Orthostatic Intolerance 81%, Fatigue 75%, Disturbed sleep 71%, Anxiety 59%, and Constipation 57%. Other frequent findings included vomiting in 51%, Allergies 54%, , Joint Pain 46%, Hypermobility in 37%.
  • 69.5% of subjects missed more than 10 days of school due to their symptoms.
  • There was extensive testing in this cohort (n=63), including 96 endoscopies, and 199 radiologic tests. In addition, 4 patients had cholecystectomies.
  • Among 64 EGDs, 28 were considered abnormal. The authors claim that 6 had specific findings: H pylori (n=2), polyps (n=2), celiac disease (n=1), and lactase deficiency (n=1).
    • It is likely that H pylori and celiac disease could have been identified/suspected by non-invasive testing; these two findings may make a diagnosis of functional nausea more tricky.
    • Lactase deficiency could be considered a normal finding.
  • The authors state that 32 of 59 AXRs had “moderate to severe constipation” based on stool burden

Overall, this article makes some useful points about the high rate of comorbidities with functional nausea but I disagree with some of the other discussion points.

The authors claim that “negative tests can reassure families of the absence of a more serious underlying condition.” This assertion has been disputed in other studies. In one study (A Rolfe et al. JAMA Intern Med. 2013;173(6):407-416 Full text: Reassurance After Diagnostic Testing With a Low Pretest Probability of Serious Disease), the authors conclude that ‘diagnostic tests for symptoms with a low risk of serious illness do little to reassure patients, decrease their anxiety, or resolve their symptoms, although the tests may reduce further primary care visits.’

The authors also have a permissive attitude regarding AXRs saying “a radiograph may validate a diagnosis of constipation.” Yet the preponderance of evidence indicates that AXRs are not needed or recommended for the diagnosis of constipation. The juxtaposition of this statement on page 107 of this issue with the next article on page 109 which details a quality improvement process of reducing abdominal radiographs to diagnose constipation in the ED is interesting. The ED physicians in the next article are trying to adhere to evidence-based guidelines; in this article, the authors correctly note that evidence “has shown abdominal radiographs to be unreliable in establishing an association between clinical symptoms of constipation and fecal load on abdominal radiographs.”

My take: Tarbell et al show that in patients with functional nausea, nausea is the tip of the symptom iceberg. Generally, radiographic and endoscopic diagnostic studies have very low yield and should be discouraged.

Related posts:

Understanding Idiopathic Nausea

Posted on by

A recent article describes a retrospective chart review of 45 children with chronic nausea and compares them to 49 children with chronic abdominal pain (J Pediatr 2014; 164: 1104-09).

Key findings:

  • While onset of symptoms was similar, the chronic nausea cohort presented at a median age of 15 years compared with 12 years for the pain cohort.
  • Comorbid conditions like anxiety, dizziness and fatigue were common in chronic nausea cohort.
  • Family history of migraines was note in 71% of nausea cohort compared with 22% in pain cohort
  • Extensive laboratory and imaging was much more frequent in nausea cohort.  With nausea cohort, 78% had abdominal ultrasound, 60% an upper GI, 58% brain imaging with either a CT scan or MRI, 38% gastric emptying, 31% abdominal CT or MRI, and 24% had HIDA.
  • Almost all endoscopies were normal (98% of chronic nausea group and 100% of pain cohort)
  • For nausea cohort treatment, tricyclic antidepressants showed a good response (=at least 50% symptom improvement) in 44% with a mean maximal dose of 50 mg. In contrast, with proton pump inhibitors, only 22% had some improvement (=at least 25% symptom improvement).  Similarly, ondansetron showed some improvement in 50% –though none had a “good response.”
  • Twelve patients (27%) of the nausea cohort met diagnostic criteria for cyclic vomiting syndrome (CVS) (with interepisode nausea) and another nine (20%) developed chronic nausea after ‘outgrowing’ CVS.
  • Postural (orthostatic) tachycardia syndrome (POTS) was noted in 16 of 45 in the nausea cohort based on an orthostatic screen (heart rate ≥30 beats/min during positional changes from 10 minutes in supine position to standing.

As the authors note, their study, conducted between 2006-2012, had numerous limitations, particularly the relative small size and retrospective nature.  In addition, the physician expertise in nausea/vomiting at Children’s Hospital of Wisconsin predisposes to a selection bias.

Take-home message: Nausea can be a severe symptom but is often difficult to manage. Extensive workup has a low yield in absence of other complaints or physical exam findings.

An AGA technical review on nausea and vomiting was published in 2001: GASTROENTEROLOGY 2001;120:263–286 

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.