Nausea, vomiting and rumination....

Dr John P Wright

Updated: 1 February 2010

One of the more enigmatic symptoms in gastroenterology is nausea and vomiting. The differential diagnosis is wide and will depend on the demographics of the patient. Children, adolescents, females and the elderly are subject to particular problems.

In all groups the most common cause of nausea is psychogenic. We have all had the feeling of epigastric tightness related to anxiety and fear. It is not beyond our experience to imagine vomiting in moments of intense stress. Yet when it comes to chronic psychological stress many patients find it hard to accept what is obvious to their families and friends and prefer to seek an organic cause at almost any cost.

Acute symptoms due to viral infections and “food poisoning” which last for hours or days should be self apparent. Longer lasting symptoms raise a multitude of possibilities. Drug interactions and toxicities particularly in the elderly would be the next important consideration but these would have appeared in the history taking.

Gastric acid problems are an important cause of nausea. A common misconception is that it is an acid excess that is the root cause of these symptoms, This is not so, as the problem is as much the handling of acid. We all reflux acid into the oesophagus but some do not clear it as rapidly as normal. These people have nausea and belching with or without heartburn. Response to a proton pump inhibitor is usually dramatic. If response is less than expected a higher dose rather than a change of agent may be required.

A very unusual condition but apparently increasing in adolescents is the “Rumination syndrome”. This is a behavioural disorder that consists of daily, effortless regurgitation of undigested food within minutes of starting or completing ingestion of a meal. Characteristically there is no preceding nausea. One of the strange observations about this condition is that the regurgitated food consists of recognizable food, which often tastes just like the food ingested and is not bitter or sour. It is this feature which gives rise to the name “rumination syndrome”. In some patients there appears to be an association with bulimia and it may represent an atypical eating disorder.

How the vomiting occurs is not clear. It may be a type of belch reflex with a reduced oesophageal and increased abdominal pressure.

As might be expected early morning nausea and vomiting is classically associated with early pregnancy. For most this leads to self diagnosis and congratulations but for others labour pains finally provide the proof of diagnosis.

At the other end of the age spectrum peptic ulcer in the elderly may not present with standard dyspepsia. Nausea, anorexia and weight loss may only be explained in these patients when a gastroscopy shows the duodenal ulcer. It is always gratifying to see the response to a proton pump inhibitor. Rapid return of appetite and re-integration into the community follows.

More serious organic disease such as liver disease, small bowel disease, metabolic disease and raised intracranial pressure need to be considered when more standard diagnoses are no present. In the final analysis however it is the psychogenic causes which require identification at the primary level. The occult pregnancy in the young and the silent duodenal ulcer in the elderly make the day.