Pathophysiological and psychosocial study in patients with functional vomiting

Chronic nausea and vomiting syndrome and impact on quality of life

INTRODUCTION AND AIM

Chronic nausea and vomiting syndrome is a disorder of gut-brain interaction that affects the productive-age population. Our aim was to determine the association of this disorder with quality of life, workplace performance, and socioeconomic impact related to gastrointestinal health.

METHODS

A cross-sectional study on a Mexican population was conducted. The patients were classified as having chronic nausea and vomiting syndrome or other disorders of gut-brain interaction. A comparative analysis of quality of life, workplace productivity, annual medical consultations, and digestive health-related expenses was carried out, applying a logistic regression model.

RESULTS

One thousand patients were included, 79.2% of whom met the criteria for a disorder of gut-brain interaction. Of the 792 patients, 10.3% presented with chronic nausea and vomiting syndrome. Said syndrome was associated with a negative impact on usual activities (OR 4.34, 95% CI 1.90-9.30, p ≤ 0.001), pain/discomfort (OR 2.09, 95% CI 1.31-3.33, p ≤ 0.001), anxiety/depression (OR 2.08, 95% CI 1.30-3.40, p ≤ 0.001), workplace presenteeism (OR 3.96, 95% CI 2.47-6.44, p ≤ 0.001), and workplace absenteeism (OR 2.54, 95% CI 1.52-4.16, p ≤ 0.001). There was also a higher number of annual medical consultations for digestive health (p = 0.013), without generating a greater annual expense due to digestive health (p = 0.08).

CONCLUSIONS

Chronic nausea and vomiting syndrome produces a negative impact on quality of life, which could be secondary to its symptomatology or its association with anxiety and depression.

Abnormalities on Electrogastrography in Nausea and Vomiting Syndromes: A Systematic Review, Meta-Analysis, and Comparison to Other Gastric Disorders

BACKGROUND

Functional nausea and vomiting syndromes and gastroparesis, collectively grouped as nausea and vomiting syndromes (NVS), are overlapping conditions with incompletely understood pathophysiology. Gastric slow wave abnormalities are thought to contribute.

AIMS

This study aimed to systematically review and meta-analyze the prevalence of slow wave abnormalities measured by electrogastrography (EGG) in patients with NVS.

METHODS

MEDLINE, EMBASE, EMBASE classic, and CENTRAL databases were systematically searched for articles using EGG in adults (≥ 18 years) with NVS. EGG metrics of interest were percentage time in bradygastria, normogastria, and tachygastria as well as dominant frequency and dominant power. Outcomes were also compared with functional dyspepsia (FD), gastroesophageal reflux disease (GORD), and control cohorts.

RESULTS

Seven hundred and sixty NVS patients and 308 controls were included from 24 studies. Overall, 64% of patients had EGG abnormalities. Average percent time in normogastria was low during fasting (50%; 95% CI 40-63%) and fed (53%; 95% CI 41-68%) states in patients, with substantial periods in fasting bradygastria (34.1%; 95% CI 25-47%) and postprandial tachygastria (21%; 95% CI 17-26%). Across gastric disorders, pooling of 84 studies showed a comparably high prevalence of EGG abnormalities in NVS (24 studies; n = 760) and GORD (13 studies; n = 427), compared to FD (47 studies; n = 1751) and controls (45 studies; n = 1027).

CONCLUSIONS

Frequency-based gastric slow wave abnormalities are prominent in NVS. The strength and consistency of these associations across many studies suggests that gastric dysrhythmia may be an important factor in NVS, motivating the development of more reliable methods for their clinical assessment.

Psychogenic vomiting: A case series

Psychogenic vomiting is a syndrome in of recurrent vomiting without any organic pathology. It must be differentiated from cyclical vomiting syndrome, functional vomiting, and chronic idiopathic nausea. It occurs as a result of an emotional or psychic disturbance. This condition is highly disabling, increasingly recognized, and under-researched. In India, the number of patients reporting to the psychiatric outpatient department with eating disorders is comparatively very less. We describe how two patients with diagnostic dilemmas who were treated successfully after psychiatric intervention.

Psychological intervention in cyclic vomiting syndrome in adolescents: A case series

Objective: Cyclic vomiting syndrome (CVS) is difficult to diagnose, thus there is often a delay in diagnosis or a misdiagnosis. In the absence of an adequate understanding of the pathophysiology of the syndrome, it is under-recognised and treatment is difficult. The present case series aimed to assess and manage three adolescents with CVS.Method: The Children's Apperception Test was administered on the three Asian adolescents who were referred for the management of CVS to the Department of Clinical Psychology at a tertiary care hospital in New Delhi, India. A treatment module was developed to treat CVS in these adolescents.Results: A strong link was found between the psychological stressors and their physical manifestations in the episodes of vomiting. Therapeutic management with a focus on behavioural modification, adaptive coping skills, and a healthy therapeutic relationship was found to be efficacious in gradually remitting this condition.Conclusions: Thus, the focus of treatment in cases of CVS should be to understand the psychological underpinning and help the adolescents to incorporate healthy coping strategies.

Epidemiology, Clinical Characteristics, and Associations for Rome IV Functional Nausea and Vomiting Disorders in Adults

BACKGROUND & AIMS

Functional nausea and vomiting disorders (FNVDs) are classified as chronic nausea and vomiting syndrome (CNVS) or cyclic vomiting syndrome (CVS)-CVS includes cannabinoid hyperemesis syndrome. We investigated the population prevalence of FNVDs, their characteristics, and associated factors.

METHODS

In the year 2015, an Internet cross-sectional health survey was completed by 5931 adults in the general populations of 3 English-speaking countries; 2100 participants were in the United States, Canada, or the United Kingdom. Quota-based sampling was used to generate demographically balanced and population-representative samples. The survey collected data on demographics, health care visits, medications, somatic symptom severity, quality of life, and symptom-based diagnostic criteria for Rome IV FNVDs as well as for irritable bowel syndrome and functional dyspepsia. Subsequent comparisons were made between Rome IV FNVD subjects and individuals without FNVDs (controls).

RESULTS

Overall, 2.2% of the population (n = 131) fulfilled symptom-based diagnostic criteria for Rome IV FNVDs: the United States (3%) had a greater prevalence than Canada (1.9%) or the United Kingdom (1.8%) (P = .02). The prevalence of CNVS was similar among the countries, ranging from 0.8% to 1.2%. However, the prevalence of CVS was higher in the United States (2%) than in Canada (0.7%) or the United Kingdom (1%) (P = .03). The proportion of subjects with CVS taking cannabis did not differ significantly among countries (P = .31), although the 7 cases of cannabinoid hyperemesis syndrome were in the United States. A significantly higher proportion of subjects with CVS reported a compulsive need for hot water bathing to alleviate emetic symptoms than subjects with CNVS (44% vs 19%; P = .03); this behavior was independent of cannabis but augmented by its use. Subjects with FNVDs had significantly greater health impairment and health care utilization than controls. On multivariate analysis, independent factors associated with FNVDs were younger age, increasing somatic symptom severity, lower quality of life, presence of irritable bowel syndrome, and functional dyspepsia. However, on subgroup analysis, somatic symptom severity was associated with CVS but not CNVS, whereas poor quality of life was associated with CNVS but not CVS.

CONCLUSIONS

Based on a cross-sectional health survey of adults in the general populations of 3 English-speaking countries, approximately 2% of subjects meet symptom-based criteria for Rome IV FNVDs and have considerable health impairments. Hot water bathing to alleviate emetic symptoms is reported for all FNVDs, and is perpetuated by cannabis use.

Anxiety and IBS revisited: ten years later

Background and aim

Irritable bowel syndrome (IBS) has been associated with high prevalence of psychological and psychiatric disorders. However, the association between IBS and each of its subtypes (diarrhea IBS-D, constipation IBS-C, mixed IBS-M) with anxiety still remains unclear. The purpose of this study was to perform a comparative analysis of the association between anxiety and IBS on a period of ten years.

Methods

PubMed was searched for studies analyzing IBS and anxiety, published at 10 years interval. The study presents a comparative analysis of the articles that were published between 2003–2005 and 2013–2015, investigating the correlation between anxiety and IBS.

Results

The initial search identified 220 articles, from which 156 were published between 2013 and 2015, and 64 were published between 2003 and 2005. Of these articles, 15 articles were included in the review. Out of these 15 articles, 10 articles analyzed the correlation between anxiety-depression status in IBS patients using specific questionnaires, 2 articles analyzed genetic variables in IBS, 1 article analyzed serotonin and monoamine oxidase levels in IBS, 1 article analyzed serum levels of IL-1β and IL-10 in IBS, 1 article analyzed somatostatin and vasoactive intestinal peptide levels in IBS. The result was a review of 15 studies that analyzed the association between IBS and anxiety.

Conclusions

IBS is a heterogeneous disorder caused by numerous psychological, immunological, infectious, endocrine and genetic factors. In recent years, the number of studies concentrating on genetic factors, cytokines and hormones has increased in comparison with the 2003–2005 period, when clinical investigation, using mainly questionnaires was the essential method. Also, the total number of papers investigating anxiety and IBS, considerably increased. The recent studies have confirmed the fact that IBS symptoms are often exacerbated during stressful events and the psychiatric treatment has a positive effect on gastro-intestinal symptomatology.

Current status of multichannel electrogastrography and examples of its use

Electrogastrography (EGG) is a non-invasive diagnostic motility for recording gastric myoelectrical activity. Gastric myoelectrical activity was first recorded in 1922. Advances in recording equipment enabled widespread use of cutaneous EGG after 1985. Later, introduction of multichannel EGG (M-EGG) enabled measurement of electrical activity transmission. At present, M-EGG findings are used as objective indicators of gastric motility disorders caused by various diseases. EGG measures two categories of gastric electrical activity: electrical response activity, or spike potentials; and electrical control activity, or slow waves. The appearance of abnormal rhythmic electrical activity is indicative of abnormalities in gastric motility. The normal frequency range of gastric electrical activity (normogastria) is around 3 cycles per min. Multiple EGG parameters assist in the assessment of gastric myoelectrical activity, and significant correlations between EGG and other gastric motility tests have been demonstrated in many studies. In Japan, however, EGG remains in the exploratory stage, and its clinical use is limited. There are large variations in procedures and systems used in previous studies, thus there is a need for standardization of EGG procedures and technical terminology. Here, we outline the current status of EGG and report the M-EGG procedures used in our department in addition to our M-EGG findings.

The abstract of this manuscript was presented during an educational seminar titled "Current status of gastrointestinal motility tests and keys for immediate implementation" at the 54th Annual Meeting of the Japan Society of Smooth Muscle Research

Correlation between gastrointestinal hormones and anxiety-depressive states in irritable bowel syndrome

The aim of this study was to investigate the mechanism(s) of action of gastrointestinal hormones in the pathogenesis of irritable bowel syndrome (IBS), and the correlation between gastrointestinal hormones and psychological factors. Patients with IBS were divided into IBS with normal emotional state ratings and IBS in anxiety-depressive states groups. The two groups were then subdivided into IBS-constipation predominant (IBS-C) and IBS-diarrhea predominant (IBS-D) groups. Non-IBS patients with normal depression and anxiety ratings were recruited as controls. The serum concentrations of somatostatin (SS) and vasoactive intestinal peptide (VIP) were measured by radioimmunoassay, and the expression of SS and VIP in the colonic mucosa was detected by immunohistochemistry and radioimmunoassay. The anxiety-depression scores of patients with IBS were significantly different from those of the control group (P<0.05). The expression levels of SS and VIP in the serum and colonic mucosa of the patients with IBS were higher compared with those of the control group. Furthermore, the expression level of SS in the IBS-C group demonstrated a significantly larger increase than that in the IBS-D group (P<0.05); however, there was no significant difference in the expression of VIP between the IBS-C and IBS-D groups (P>0.05). In addition, the expression levels of SS and VIP in the IBS groups with normal emotional state ratings were notably different from those in the IBS groups in anxiety-depressive states (P<0.05). Anxiety-depressive states may lead to changes in the secretion of SS and VIP, and subsequently to changes in gastrointestinal motility and function.

Age-related symptom and life quality changes in women with irritable bowel syndrome

AIM

To explore age-related changes in symptoms and quality of life (QoL) of women with irritable bowel syndrome (IBS).

METHODS

Two-hundred and fifty-four female adult outpatients with IBS attending the Department of Gastroenterology at the First Affiliated Hospital of Nanjing Medical University between January, 2008 and October, 2008 were approached. Patients with a history of abdominal surgery, mental illness or those who had recently taken psychotropic drugs were excluded. A physician obtained demographic and abdominal symptom data. All patients were asked to complete the Zung Self-Rated Anxiety and Depression Scale (SDS/SAS) and the IBS-specific QoL questionnaire. The patients were divided into six groups according to age, in 10-year increments: 18-27 years, 28-37 years, 38-47 years, 48-57 years, 58-67 years and 68-75 years (maximum 75 years). Age-related differences of abdominal pain or discomfort were analyzed using rank-sum tests. Differences in SDS/SAS and IBS-QoL scores between age groups were analyzed using one-way analysis of variance. Pearson's correlations evaluated potential associations between IBS symptoms, psychological factors and QoL in each age group.

RESULTS

There were no differences in the distribution of IBS subtypes between age groups (χ(2) = 20.516, P = 0.153). Differences in the severity of abdominal pain/discomfort with age were statistically significant (χ(2) = 25.638, P < 0.001); patients aged 48-57 years, 58-67 years or 68-75 years had milder abdominal pain/discomfort than those in the younger age groups. The severity of anxiety or depressive symptoms did not differ between age groups (SDS, χ(2) = 390.845, P = 0.110; SAS, χ(2) = 360.071, P = 0.220). Differences of IBS-QoL scores were statistically significant between age groups (χ(2) = 1098.458, P = 0.011). The scores of patients in the 48-57-year group were lower than those in the 18-27-year and 28-37-year groups (48-57-year group vs 18-27-year group, 74.88 ± 8.76 vs 79.76 ± 8.63, P = 0.021; 48-57-year group vs 28-37-year group, 74.88 ± 8.76 vs 79.04 ± 8.32, P = 0.014). The scores in the 68-75-year group were lower than those in the 18-27-year, 28-37-year and 38-47-year groups (68-75-year group vs 18-27-year group, 71.98 ± 9.83 vs 79.76 ± 8.63, P = 0.003; 68-75-year group vs 28-37-year group, 71.98 ± 9.83 vs 79.04 ± 8.32, P = 0.002; 68-75-year group vs 38-47-year group,71.98 ± 9.83 vs 76.44 ± 8.15, P = 0.039). Anxiety and depression were negatively correlated with QoL in all age groups (SDS and QoL: 18-27-year group, r = -0.562, P = 0.005; 28-37-year group, r = -0.540, P < 0.001; 38-47-year group, r = -0.775, P < 0.001; 48-57-year group, r = -0.445, P = 0.001; 58-67-year group, r = -0.692, P < 0.001; 68-75-year group, r = -0.732, P < 0.001. SAS and QoL: 18-27-year group, r = -0.600, P = 0.002; 28-37-year group, r = -0.511, P < 0.001; 38-47-year group, r = -0.675, P < 0.001; 48-57-year group, r = -0.558, 58-67-year group, P = 0.001; r = -0.588, P < 0.001; 68-75-year group, r = -0.811, P < 0.001). A negative correlation between abdominal pain severity and QoL was found in patients aged more than 58 years (58-67-year group, r = -0.366, P = 0.017; 68-75-year group, r = -0.448, P = 0.048 ), but not in younger patients (18-27-year group, r = 0.080, P = 0.716; 28-37-year group, r = -0.063, P = 0.679; 38-47-year group, r = -0.029, P = 0.812; 48-57-year group, r = -0.022, P = 0.876).

CONCLUSION

Factors affecting QoL should always be treated in IBS, especially emotional problems in young adults. Even mild abdominal pain should be controlled in elderly patients.

Influence of insomnia and insomnia-related psychological factors on symptoms of female patients with irritable bowel syndrome

AIM: To investigate the influence of insomnia and insomnia-related psychological factors on the symptoms of female patients with irritable bowel syndrome (IBS).

METHODS: Two hundred and forty-five adult female outpatients with IBS who were treated at the Department of Gastroenterology of the First Affiliated Hospital of Nanjing Medical University were included in this study. A questionnaire survey was conducted using a demographic information questionnaire, a symptom questionnaire, athens insomnia scale (AIS), self-rating anxiety scale (SAS), and self-rating depression scale (SDS). According to AIS scores, female patients with IBS were divided into insomnia group and non-insomnia group. The influence of insomnia on typical symptoms, somatic symptoms and psychological symptoms of IBS, and the relationship between psychological factors and IBS were analyzed.

RESULTS: The insomnia and non-insomnia groups differed significantly in their rating of abdominal pain/discomfort in terms of severity and duration (P < 0.05), but there was no difference in attack frequency between the two groups. The incidence of somatic symptoms, scores of SAS and SDS, and scores of SAS' and SDS' (sleep-related entries were removed) were all significantly higher in the insomnia group than in the non-insomnia group (all P < 0.01). Severity, attack frequency and duration of abdominal pain/discomfort were all positively correlated with SAS and SDS scores (all P < 0.05).

CONCLUSION: Insomnia and insomnia-related psychological factors (anxiety, depression) can aggravate the symptoms of female patients with IBS.

Sex differences in the symptoms and psychological factors that influence quality of life in patients with irritable bowel syndrome

OBJECTIVE

To investigate the relationship between gender and symptomatology, psychological factors, and quality of life (QOL) in irritable bowel syndrome (IBS).

METHODS

The diagnosis of IBS was made on the basis of the Rome III Criteria. A physician obtained demographic and symptom data, Zung Self-Rated Anxiety and Depression Scale scores (SAS/SDS), and IBS-specific quality-of-life ratings (IBS-QOL).

RESULTS

Of the 4015 patients approached, 452 patients were diagnosed with IBS. Age ranged from 14 to 79 years (44.05 ± 14.89 years) and the male to female ratio was 1 : 1.3. The gender composition between the four IBS subtypes differed significantly (P<0.01). Male and female patients differed in their rating of abdominal pain/discomfort in terms of severity and time (P<0.01). Groups did not differ with regard to attack frequency. Female patients more frequently reported headache, dizziness, backache, muscular soreness, inappetence, insomnia, and fatigue (P<0.01). In comparison with men, anxiety and depression scores were significantly higher in women (P<0.01). Severity, duration, and frequency of abdominal pain/discomfort did not correlate with IBS-QOL scores. Insomnia/fatigue was negatively correlated with IBS-QOL scores (P<0.01). SAS and SDS scores were negatively correlated with IBS-QOL (total score and each subscale; P<0.01).

CONCLUSION

There are significant gender differences in the symptoms, psychological rating, and QOL scores in IBS. Somatic symptoms, anxiety, and depression all contribute to the negative impact of IBS. Our findings suggest that gender differences should be recognized in IBS treatment.

Psychiatric Co-morbidity and Efficacy of Mirtazapine Treatment in Young Subjects With Chronic or Cyclic Vomiting Syndromes: A Case Series

The aim of this case report was to evaluate the psychiatric co-morbidity and efficacy of mirtazapine treatment in young subjects with chronic or cyclic vomiting syndromes. This is a case series of 8 young subjects (age range of 6-16 years, 11.12 ± 3.52 years) who were referred or consulted to child psychiatry department. They were referred or consulted by pediatric gastroenterology or surgery departments for the presence of non-remitting and medically unexplained vomiting. They were investigated for co-morbid psychiatric disorders using a structured psychiatric interview. An open trial of mirtazapine was conducted for the treatment and/or prevention of vomiting. Primary outcome measure was Clinical Global Impression-Improvement scale. Subjects were diagnosed with chronic (n = 5) or cyclic (n = 3) vomiting syndromes. Duration of vomiting ranged from 6 months to 10 years (3.5 ± 3.2 years). All subjects received multiple psychiatric diagnoses with anxiety disorders being the most frequent. Maximum mirtazapine dosage was 7.5-30 mg/day (16.00 ± 6.16 mg/day). Three subjects showed complete remission and 5 subjects showed much to very much improvement in vomiting. Most frequent side effects were increased appetite, weight gain and sedation. Young subjects with chronic or cyclic vomiting may frequently suffer anxiety and/or depressive symptoms or disorders. Mirtazapine could be an effective treatment option for the treatment of vomiting and co-morbid anxiety or depressive disorders in these subjects. More systematic research are needed on this topic.

Thyrotoxic vomiting: a case report and possible mechanisms

The symptoms related to gastrointestinal (GI) tract are sometimes chief complaints in patients with endocrine disease. Thyrotoxicosis is a rare, but notable cause for unexplained and repeated vomiting. Here, we report an adolescent patient with thyrotoxicosis who was initially presented with repeated vomiting and epigastric pain. A 13-year-old female was referred to a GI outpatient department for evaluation of vomiting and abdominal pain from a pediatric clinic. Esophagogastroduodenoscopy revealed acute gastritis with duodenogastric reflux and suspicious reflux esophagitis of minimal change, but there was no significant improvement after treatment and as a result she was admitted to the emergency room. She was subsequently diagnosed as Graves' disease because an initial laboratory test at the GI outpatient department revealed thyroid stimulating hormone < 0.01 µIU/mL and additional blood tests showed elevated thyroid hormones and positive thyroid stimulating hormone receptor antibody. The vomiting and epigastric pain improved remarkably after treatment with antithyroid drugs. Clinicians should consider the possibility of thyrotoxicosis in patient with unexplained and repeated vomiting.