Skip to main content
Top
Published in: Current Treatment Options in Gastroenterology 4/2016

01-12-2016 | Stomach (K Koch, Section Editor)

Chronic Unexplained Nausea and Vomiting or Gastric Neuromuscular Dysfunction (GND)? An Update on Nomenclature, Pathophysiology and Treatment, and Relationship to Gastroparesis

Authors: Kimberly N. Harer, MD, Pankaj J. Pasricha, MD

Published in: Current Treatment Options in Gastroenterology | Issue 4/2016

Login to get access

Opinion statement

Chronic unexplained nausea and vomiting is a debilitating condition that dramatically decreases patient quality of life and creates diagnostic and treatment challenges for healthcare providers. Additionally, the significant overlap in symptoms between disorders such as chronic unexplained nausea and vomiting, gastroparesis, and functional dyspepsia has resulted in a blurring of diagnostic lines and added confusion to the therapeutic approach. The identified overlap in clinical symptoms also suggests a common underlying pathophysiological mechanism may drive these conditions, indicating they could possibly be part of a spectrum of gastric neuromuscular disorders instead of discrete processes. This article will discuss the classification, updates in pathophysiology and therapeutic research, and future directions of research in the treatment of chronic unexplained nausea and vomiting.
Literature
1.••
go back to reference Stanghellini V, Chan FKL, Hasler WL, Malagelada JR, Suzuki H, Tack J, et al. Gastroduodenal disorders. Gastroenterology. 150:1380–92. This article outlines the Rome IV criteria for Functional Gastrointestinal Disorders, focusing on gastroduodenal disorders such as functional dyspepsia and Chronic Nausea and Vomiting Syndrome. Stanghellini V, Chan FKL, Hasler WL, Malagelada JR, Suzuki H, Tack J, et al. Gastroduodenal disorders. Gastroenterology. 150:1380–92. This article outlines the Rome IV criteria for Functional Gastrointestinal Disorders, focusing on gastroduodenal disorders such as functional dyspepsia and Chronic Nausea and Vomiting Syndrome.
2.••
go back to reference Pasricha PJ, Colvin R, Yates K, et al. Characteristics of patients with chronic unexplained nausea and vomiting and normal gastric emptying. Clin Gastroenterol Hepatol. 2011;9:567–76. Multi-center study published by the Gastroparesis Consortium that compared patients with gastroparesis symptoms and either delayed emptying (gastroparesis) or normal gastric emptying (CUNV). Investigators found the two groups to be clinically indistinguishable.CrossRefPubMedPubMedCentral Pasricha PJ, Colvin R, Yates K, et al. Characteristics of patients with chronic unexplained nausea and vomiting and normal gastric emptying. Clin Gastroenterol Hepatol. 2011;9:567–76. Multi-center study published by the Gastroparesis Consortium that compared patients with gastroparesis symptoms and either delayed emptying (gastroparesis) or normal gastric emptying (CUNV). Investigators found the two groups to be clinically indistinguishable.CrossRefPubMedPubMedCentral
3.
go back to reference Anaparthy R, Pehlivanov N, Grady J, et al. Gastroparesis and gastroparesis-like syndrome: response to therapy and its predictors. Dig Dis Sci. 2009;54:1003–10.CrossRefPubMedPubMedCentral Anaparthy R, Pehlivanov N, Grady J, et al. Gastroparesis and gastroparesis-like syndrome: response to therapy and its predictors. Dig Dis Sci. 2009;54:1003–10.CrossRefPubMedPubMedCentral
4.
go back to reference Olden KW, Crowell MD. Chronic nausea and vomiting: new insights and approach to treatment. Curr Treat Options Gastroenterol. 2005;8:305–10.CrossRefPubMed Olden KW, Crowell MD. Chronic nausea and vomiting: new insights and approach to treatment. Curr Treat Options Gastroenterol. 2005;8:305–10.CrossRefPubMed
5.
go back to reference Drossman DA, Corazziari E, Delvaux M, et al. Rome III: the functional gastrointestinal disorders. 130 ed; 2006. p. 1377–556. Drossman DA, Corazziari E, Delvaux M, et al. Rome III: the functional gastrointestinal disorders. 130 ed; 2006. p. 1377–556.
6.
go back to reference Dibaise JK, Islam RS, Dueck AC, et al. Psychological distress in Rome III functional dyspepsia patients presenting for testing of gastric emptying. Neuroenterol Motil. 2016;28:196–205.CrossRef Dibaise JK, Islam RS, Dueck AC, et al. Psychological distress in Rome III functional dyspepsia patients presenting for testing of gastric emptying. Neuroenterol Motil. 2016;28:196–205.CrossRef
7.
go back to reference Talley NJ, Verlinden M, Jones M. Can symptoms discriminate among those with delayed or normal gastric emptying in dysmotility-like dyspepsia? Am J Gastroenterol. 2001;96:1422–8.CrossRefPubMed Talley NJ, Verlinden M, Jones M. Can symptoms discriminate among those with delayed or normal gastric emptying in dysmotility-like dyspepsia? Am J Gastroenterol. 2001;96:1422–8.CrossRefPubMed
8.
go back to reference Karamanolis G, Caenepeel P, Arts J, et al. Determinants of symptom pattern in idiopathic severely delayed gastric emptying: gastric emptying rate or proximal stomach dysfunction? Gut. 2007;56:29–36.CrossRefPubMed Karamanolis G, Caenepeel P, Arts J, et al. Determinants of symptom pattern in idiopathic severely delayed gastric emptying: gastric emptying rate or proximal stomach dysfunction? Gut. 2007;56:29–36.CrossRefPubMed
9.
go back to reference Samsom M, Vermeijden JR, Smout AJ, et al. Prevalence of delayed gastric emptying in diabetic patients and relationship to dyspeptic symptoms: a prospective study in unselected diabetic patients. Diabetes Care. 2003;26:3116–22.CrossRefPubMed Samsom M, Vermeijden JR, Smout AJ, et al. Prevalence of delayed gastric emptying in diabetic patients and relationship to dyspeptic symptoms: a prospective study in unselected diabetic patients. Diabetes Care. 2003;26:3116–22.CrossRefPubMed
10.
go back to reference Janssen P, Van Oudenhove L, Bisschops R, Tack J. Idiopathic gastroparesis or functional dyspepsia with delayed gastric emptying: where is the difference? Gastroenterology. 2011;140(7):2145–6.CrossRefPubMed Janssen P, Van Oudenhove L, Bisschops R, Tack J. Idiopathic gastroparesis or functional dyspepsia with delayed gastric emptying: where is the difference? Gastroenterology. 2011;140(7):2145–6.CrossRefPubMed
11.•
go back to reference Stanghellini V, Tack J. Gastroparesis: separate entity or just a part of dyspepsia? Gut. 2014;63(12):1972–8. This article discusses the clinical overlap between gastroparesis and dyspepsia and discusses how the two disorders may be part of a disease spectrum.CrossRefPubMed Stanghellini V, Tack J. Gastroparesis: separate entity or just a part of dyspepsia? Gut. 2014;63(12):1972–8. This article discusses the clinical overlap between gastroparesis and dyspepsia and discusses how the two disorders may be part of a disease spectrum.CrossRefPubMed
12.••
go back to reference Grover M, Farrugia G, Lurken MS, et al. Cellular changes in diabetic and idiopathic gastroparesis. Gastroenterology. 2011;140(5):1575–85. Prospective case-control trial with full-thickness gastric biopsy specimens demonstrating cellular abnormalities in gastroparesis patients, including loss of Kit expression that suggests a loss of Interstitial Cells of CajalCrossRefPubMed Grover M, Farrugia G, Lurken MS, et al. Cellular changes in diabetic and idiopathic gastroparesis. Gastroenterology. 2011;140(5):1575–85. Prospective case-control trial with full-thickness gastric biopsy specimens demonstrating cellular abnormalities in gastroparesis patients, including loss of Kit expression that suggests a loss of Interstitial Cells of CajalCrossRefPubMed
13.
go back to reference Faussone-Pellegrini MS, Grover M, Pasricha PJ, et al. Ultrastructural differences between diabetic and idiopathic gastroparesis. J Cell Mol Med. 2012;16:1573–81.CrossRefPubMedPubMedCentral Faussone-Pellegrini MS, Grover M, Pasricha PJ, et al. Ultrastructural differences between diabetic and idiopathic gastroparesis. J Cell Mol Med. 2012;16:1573–81.CrossRefPubMedPubMedCentral
14.
go back to reference O’Grady G, Angeli TR, Du P, et al. Abnormal initiation and conduction of slow-wave activity in gastroparesis, defined by high-resolution electrical mapping. Gastroenterology. 2012;143:589–598.e1–e3.CrossRefPubMedPubMedCentral O’Grady G, Angeli TR, Du P, et al. Abnormal initiation and conduction of slow-wave activity in gastroparesis, defined by high-resolution electrical mapping. Gastroenterology. 2012;143:589–598.e1–e3.CrossRefPubMedPubMedCentral
15.••
go back to reference Angeli TR, Cheng LK, Du P, Wang TH, Bernard CE, Vannucchi MG, et al. Loss of interstitial cells of Cajal and patterns of gastric dysrhythmia in patients with chronic unexplained nausea and vomiting. Gastroenterology. 2015;149(1):56–66.e5. A case-control study of CUNV patients and age-matched controls that demonstrated a significantly lower ICC density along with dysrhythmic slow wave activity in CUNV patients.CrossRefPubMedPubMedCentral Angeli TR, Cheng LK, Du P, Wang TH, Bernard CE, Vannucchi MG, et al. Loss of interstitial cells of Cajal and patterns of gastric dysrhythmia in patients with chronic unexplained nausea and vomiting. Gastroenterology. 2015;149(1):56–66.e5. A case-control study of CUNV patients and age-matched controls that demonstrated a significantly lower ICC density along with dysrhythmic slow wave activity in CUNV patients.CrossRefPubMedPubMedCentral
16.
go back to reference Pasricha PJ, Grover M, Yates K, et al. Gastroparesis and functional dyspepsia of postprandial discomfort phenotype have similar clinical, pathophysiological and histopathological features. Gastroenterology. 2016;150(Issue 4, Supplement 1):S215.CrossRef Pasricha PJ, Grover M, Yates K, et al. Gastroparesis and functional dyspepsia of postprandial discomfort phenotype have similar clinical, pathophysiological and histopathological features. Gastroenterology. 2016;150(Issue 4, Supplement 1):S215.CrossRef
17.
go back to reference Navari RM, Qin R, Ruddy KJ, Liu H, Powell SF, Bajaj M, Dietrich L, et al. Olanzapine for the prevention of chemotherapy-induced nausea and vomiting. N Engl J Med. 2016;375(2):134–42.CrossRefPubMed Navari RM, Qin R, Ruddy KJ, Liu H, Powell SF, Bajaj M, Dietrich L, et al. Olanzapine for the prevention of chemotherapy-induced nausea and vomiting. N Engl J Med. 2016;375(2):134–42.CrossRefPubMed
18.
go back to reference Langley-DeGroot M, Ma JD, Hirst J, Roeland EJ. Olanzapine in the treatment of refractory nausea and vomiting: a case report and review of the literature. J Pain Palliat Care Pharmacother. 2015;29(2):148–52.CrossRefPubMed Langley-DeGroot M, Ma JD, Hirst J, Roeland EJ. Olanzapine in the treatment of refractory nausea and vomiting: a case report and review of the literature. J Pain Palliat Care Pharmacother. 2015;29(2):148–52.CrossRefPubMed
19.
go back to reference Fonte C, Fatigoni S, Roila F. A review of olanzapine as an antiemetic in chemotherapy-induced nausea and vomiting and in palliative care patients. Crit Rev Oncol Hematol. 2015;95(2):214–21.CrossRefPubMed Fonte C, Fatigoni S, Roila F. A review of olanzapine as an antiemetic in chemotherapy-induced nausea and vomiting and in palliative care patients. Crit Rev Oncol Hematol. 2015;95(2):214–21.CrossRefPubMed
20.
go back to reference Yin J, Song J, Lei Y, Xu X, Chen JD. Prokinetic effects of mirtazapine on gastrointestinal transit. Am J Physiol Gastrointest Liver Physiol. 2014;306(9):G796–801.CrossRefPubMed Yin J, Song J, Lei Y, Xu X, Chen JD. Prokinetic effects of mirtazapine on gastrointestinal transit. Am J Physiol Gastrointest Liver Physiol. 2014;306(9):G796–801.CrossRefPubMed
21.••
go back to reference Tack J, Ly HG, Carbone F, Vanheel H, Vanuytsel T, Holvoet L, et al. Efficacy of mirtazapine in patients with functional dyspepsia and weight loss. Clin Gastroenterol Hepatol. 2016;14(3):385–392.e4. A randomized, placebo-controlled pilot study that evaluated mirtazapine versus placebo in functional dyspepsia patients and found a reduction in dyspepsia symptom severity and early satiety in the mirtazapine group compared to baseline measurements.CrossRefPubMed Tack J, Ly HG, Carbone F, Vanheel H, Vanuytsel T, Holvoet L, et al. Efficacy of mirtazapine in patients with functional dyspepsia and weight loss. Clin Gastroenterol Hepatol. 2016;14(3):385–392.e4. A randomized, placebo-controlled pilot study that evaluated mirtazapine versus placebo in functional dyspepsia patients and found a reduction in dyspepsia symptom severity and early satiety in the mirtazapine group compared to baseline measurements.CrossRefPubMed
22.•
go back to reference Jiang SM, Jia L, Liu J, Shi MM, Xu MZ. Beneficial effects of antidepressant mirtazapine in functional dyspepsia patients with weight loss. World J Gastroenterol. 2016;22(22):5260–6. A randomized, placebo-controlled trial comparing mirtazapine, paroxetine, and placebo therapy. Mirtazapine worked best with improvement in functional dyspepsia symptoms, depressive symptoms, and weight gain.CrossRefPubMedPubMedCentral Jiang SM, Jia L, Liu J, Shi MM, Xu MZ. Beneficial effects of antidepressant mirtazapine in functional dyspepsia patients with weight loss. World J Gastroenterol. 2016;22(22):5260–6. A randomized, placebo-controlled trial comparing mirtazapine, paroxetine, and placebo therapy. Mirtazapine worked best with improvement in functional dyspepsia symptoms, depressive symptoms, and weight gain.CrossRefPubMedPubMedCentral
23.
go back to reference Talley NJ, Locke GR, Saito YA, Almazar AE, Bouras EP, Howden CW, et al. Effect of amitriptyline and escitalopram on functional dyspepsia: a multicenter, randomized controlled study. Gastroenterology. 2015;149(2):340–9.e2.CrossRefPubMedPubMedCentral Talley NJ, Locke GR, Saito YA, Almazar AE, Bouras EP, Howden CW, et al. Effect of amitriptyline and escitalopram on functional dyspepsia: a multicenter, randomized controlled study. Gastroenterology. 2015;149(2):340–9.e2.CrossRefPubMedPubMedCentral
24.
go back to reference Parkman HP, Carlson MR, Gonyer D. Metoclopramide nasal spray is effective in symptoms of gastroparesis in diabetics compared to conventional oral tablet. Neurogastroenterol otil. 2014;26(4):521–8.CrossRef Parkman HP, Carlson MR, Gonyer D. Metoclopramide nasal spray is effective in symptoms of gastroparesis in diabetics compared to conventional oral tablet. Neurogastroenterol otil. 2014;26(4):521–8.CrossRef
25.
go back to reference Parkman HP, Carlson MR, Gonyer D. Metoclopramide nasal spray reduces symptoms of gastroparesis in women, but not men, with diabetes: results of a phase 2B randomized study. Clin Gastroenterol Hepatol. 2015;13(7):1256–1263.e1.CrossRefPubMed Parkman HP, Carlson MR, Gonyer D. Metoclopramide nasal spray reduces symptoms of gastroparesis in women, but not men, with diabetes: results of a phase 2B randomized study. Clin Gastroenterol Hepatol. 2015;13(7):1256–1263.e1.CrossRefPubMed
26.
go back to reference Tack J, Rotondo A, Meulemans A, Thielemans L, Cools M. Randomized clinical trial: a controlled pilot trial of the 5-HT4 receptor agonist revexepride in patients with symptoms suggestive of gastroparesis. Neurogastroenterol Motil. 2016;28(4):487–97.CrossRefPubMed Tack J, Rotondo A, Meulemans A, Thielemans L, Cools M. Randomized clinical trial: a controlled pilot trial of the 5-HT4 receptor agonist revexepride in patients with symptoms suggestive of gastroparesis. Neurogastroenterol Motil. 2016;28(4):487–97.CrossRefPubMed
27.
go back to reference Carbone F, Rotondo A, Andrews CN, et al. A controlled cross-over trial shows benefit of prucalopride for symptom control and gastric emptying enhancement in idiopathic gastroparesis. Gastroenterology. 2016;150(Issue 4, Supplement 1):S213–4.CrossRef Carbone F, Rotondo A, Andrews CN, et al. A controlled cross-over trial shows benefit of prucalopride for symptom control and gastric emptying enhancement in idiopathic gastroparesis. Gastroenterology. 2016;150(Issue 4, Supplement 1):S213–4.CrossRef
29.
go back to reference Clarke JO, Snape WJ. Pyloric sphincter therapy botulinum toxin, stents, and pyloromyotomy. Gastroenterol Clin N Am. 2015;44:127–36.CrossRef Clarke JO, Snape WJ. Pyloric sphincter therapy botulinum toxin, stents, and pyloromyotomy. Gastroenterol Clin N Am. 2015;44:127–36.CrossRef
30.
go back to reference Friedenberg FK, Palit A, Parkman HP, Hanlon A, Nelson DB. Botulinum toxin A for the treatment of delayed gastric emptying. Am J Gastroenterol. 2008;103(2):416–23.CrossRefPubMed Friedenberg FK, Palit A, Parkman HP, Hanlon A, Nelson DB. Botulinum toxin A for the treatment of delayed gastric emptying. Am J Gastroenterol. 2008;103(2):416–23.CrossRefPubMed
31.
go back to reference Arts J, Holvoet L, Caenepeel P, et al. Clinical trial: a randomized-controlled crossover study of intrapyloric injection of botulinum toxin in gastroparesis. Aliment Pharmacol Ther. 2007;26:1251–8.CrossRefPubMed Arts J, Holvoet L, Caenepeel P, et al. Clinical trial: a randomized-controlled crossover study of intrapyloric injection of botulinum toxin in gastroparesis. Aliment Pharmacol Ther. 2007;26:1251–8.CrossRefPubMed
32.
go back to reference Clarke JO, RZ S, Kord Valeshabad A, et al. Through-the- scope transpyloric stent placement improves symptoms and gastric emptying in patients with gastroparesis. Endoscopy. 2013;45(Suppl 2):E189–90.PubMed Clarke JO, RZ S, Kord Valeshabad A, et al. Through-the- scope transpyloric stent placement improves symptoms and gastric emptying in patients with gastroparesis. Endoscopy. 2013;45(Suppl 2):E189–90.PubMed
33.
go back to reference Khashab MA, Besharati S, Ngamruengphong S, Kumbhari V, El Zein M, Stein EM, et al. Refractory gastroparesis can be successfully managed with endoscopic transpyloric stent placement and fixation (with video. Gastrointest Endosc. 2015;82(6):1106–9.CrossRefPubMed Khashab MA, Besharati S, Ngamruengphong S, Kumbhari V, El Zein M, Stein EM, et al. Refractory gastroparesis can be successfully managed with endoscopic transpyloric stent placement and fixation (with video. Gastrointest Endosc. 2015;82(6):1106–9.CrossRefPubMed
34.
go back to reference Mekaroonkamol P, Li LY, Dacha S, Xu Y, Keilin SD, Willingham FF, et al. Gastric peroral endoscopic pyloromyotomy (G-POEM) as a salvage therapy for refractory gastroparesis: a case series of different subtypes. Neurogastroenterol Motil. 2016;28(8):1272–7.CrossRefPubMed Mekaroonkamol P, Li LY, Dacha S, Xu Y, Keilin SD, Willingham FF, et al. Gastric peroral endoscopic pyloromyotomy (G-POEM) as a salvage therapy for refractory gastroparesis: a case series of different subtypes. Neurogastroenterol Motil. 2016;28(8):1272–7.CrossRefPubMed
35.
go back to reference Khashab MA, Stein E, Clarke JO, et al. Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video. Gastrointest Endosc. 2013;78:764–8.CrossRefPubMed Khashab MA, Stein E, Clarke JO, et al. Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video. Gastrointest Endosc. 2013;78:764–8.CrossRefPubMed
36.
go back to reference Gonzalez JM, Vanbiervliet G, Vitton V, et al. First European human gastric peroral endoscopic myotomy, for treatment of refractory gastroparesis. Endoscopy. 2015;47(Suppl 1):E135–6.PubMed Gonzalez JM, Vanbiervliet G, Vitton V, et al. First European human gastric peroral endoscopic myotomy, for treatment of refractory gastroparesis. Endoscopy. 2015;47(Suppl 1):E135–6.PubMed
37.
go back to reference Chaves DM, de Moura EG, Mestieri LH, et al. Endoscopic pyloromyotomy via a gastric submucosal tunnel dissection for the treatment of gastroparesis after surgical vagal lesion. Gas-trointest Endosc. 2014;80:164.CrossRef Chaves DM, de Moura EG, Mestieri LH, et al. Endoscopic pyloromyotomy via a gastric submucosal tunnel dissection for the treatment of gastroparesis after surgical vagal lesion. Gas-trointest Endosc. 2014;80:164.CrossRef
38.
go back to reference Shlomovitz E, Pescarus R, Cassera MA, et al. Early human experience with per-oral endoscopic pyloromyotomy (POP. Surg Endosc. 2015;29:543–51.CrossRefPubMed Shlomovitz E, Pescarus R, Cassera MA, et al. Early human experience with per-oral endoscopic pyloromyotomy (POP. Surg Endosc. 2015;29:543–51.CrossRefPubMed
39.
go back to reference Khashab MA, Ngamruengphong S, Carr-Locke D, Bapaye A, Benias PC, Serouya S, et al. Gastric peroral endoscopic myotomy for refractory gastroparesis: results from the first multicenter study on endoscopic pyloromyotomy (with video), Gastrointestinal Endoscopy (2016) Khashab MA, Ngamruengphong S, Carr-Locke D, Bapaye A, Benias PC, Serouya S, et al. Gastric peroral endoscopic myotomy for refractory gastroparesis: results from the first multicenter study on endoscopic pyloromyotomy (with video), Gastrointestinal Endoscopy (2016)
40.
go back to reference Wellington J, Scott B, Kundu S, Stuart P, Koch KL. Effect of endoscopic pyloric therapies for patients with nausea and vomiting and functional obstructive gastroparesis. Auton Neurosci. 2016. Jul 16. pii: S1566-0702(16)30102-3. Wellington J, Scott B, Kundu S, Stuart P, Koch KL. Effect of endoscopic pyloric therapies for patients with nausea and vomiting and functional obstructive gastroparesis. Auton Neurosci. 2016. Jul 16. pii: S1566-0702(16)30102-3.
Metadata
Title
Chronic Unexplained Nausea and Vomiting or Gastric Neuromuscular Dysfunction (GND)? An Update on Nomenclature, Pathophysiology and Treatment, and Relationship to Gastroparesis
Authors
Kimberly N. Harer, MD
Pankaj J. Pasricha, MD
Publication date
01-12-2016
Publisher
Springer US
Published in
Current Treatment Options in Gastroenterology / Issue 4/2016
Print ISSN: 1092-8472
Electronic ISSN: 1534-309X
DOI
https://doi.org/10.1007/s11938-016-0113-z

Other articles of this Issue 4/2016

Current Treatment Options in Gastroenterology 4/2016 Go to the issue

Motility (H Parkman and R Schey, Section Editors)

Cannabinoids and GI Disorders: Endogenous and Exogenous

Intractable Disease in the Elderly: When Conventional Therapy Fails (S Katz, Section Editor)

Interactions Between Inflammatory Bowel Disease Drugs and Chemotherapy

Motility (H Parkman and R Schey, Section Editors)

How to Diagnose and Treat Functional Chest Pain