Overview.
Unexplained, non-cyclical, chronic vomiting that occurs more than once a week and may be accompanied by decreased eating, postprandial fullness, loss of appetite, etc. Most often associated with mood, significant mental stimulation, anxiety, and or depression Mainly includes supportive, psychotherapeutic, and symptomatic treatments
Definition
According to the Rome III criteria, functional gastrointestinal disorders include functional dyspepsia, belching, nausea and vomiting, and adult rumination syndrome. Of these, nausea and vomiting disorders are subdivided into three subtypes, i.e., chronic idiopathic nausea, functional vomiting, and cyclic vomiting syndrome [1-2].
Functional vomiting (FV) is defined as recurrent episodes of vomiting after exclusion of organic causes, occurring at least once a week. The time and manner of the episodes are irregular and can occur several times a week [3].
Most episodes of vomiting occur within a short time after a meal and last for a few minutes, and the vomit is from the food consumed. Vomiting does not need to be induced and most vomiting is self-controlled.
Morbidity
Epidemiologically, the incidence of functional vomiting is very low and definitive data are lacking.
Some studies summarizing cases of psychogenic vomiting and studies of patients with unexplained chronic nausea and/or vomiting suggest that the prevalence of vomiting is much higher in women than in men [6]. It tends to be in the group of people who have less physical labor intensity and whose education and family economic situation are mainly of medium to high level.
Etiology
Pathogenesis
The pathogenesis of functional vomiting is unclear and may have central, peripheral or mixed abnormalities. Multiple aspects of emotional cognition, visceral sensation, and visceral movement may be involved.
Current research suggests that genetic inheritance, environmental triggers, visceral hypersensitivity, gastrointestinal inflammation, intestinal flora, and disorders of gastrointestinal motility may be associated with the development of functional gastrointestinal disorders.
Psychological states such as depression, anxiety, and mood shift disorders are strongly associated with vomiting episodes. Imitative learning of parental disease symptoms in childhood, stress in childhood and adult life, including a history of abuse and stressful events, may contribute to functional vomiting.
Predisposing factors
Most episodes are triggered in some way, with dramatic mood changes such as anger or agitation being the most common triggers for vomiting. Other triggers include stress, life pressures, satiety and overexertion.
Symptoms
The clinical symptoms of functional vomiting are non-specific and are mainly characterized by vomiting, which may be accompanied by decreased food intake, postprandial fullness, and loss of appetite.
Main Symptoms
Vomiting
Vomiting occurs within a short period of time (10 to 30 minutes) after a meal and usually lasts for a few minutes.
The vomit is the food consumed.
In most cases, the vomiting is controlled, i.e., the patient can be forced to hold back the vomiting on occasions when he/she thinks he/she should not vomit.
Other
The main accompanying symptoms include decreased food intake, fullness after meals, loss of appetite, acid reflux, belching, and constipation. Nausea, which is often thought to be closely related to vomiting, does not occur in a high percentage of cases.
Complications
Malnutrition
Chronic and repeated vomiting may damage the gastric mucosa and affect normal fasting, leading to malnutrition.
Gastroesophageal reflux disease
Chronic vomiting may cause relaxation of the lower esophageal sphincter, resulting in secondary gastroesophageal reflux disease.
Aspiration Pneumonia
During vomiting, the vomit may be inhaled into the respiratory tract causing pneumonia and other lower respiratory tract infections.
Consultation
Department of Medicine
Gastroenterology
Gastroenterology is the place to go if you have recurrent vomiting, bloating, or loss of appetite.
Psychiatry
If there are obvious psychological triggers, such as a traumatic event, or if people who feel anxious or depressed are experiencing vomiting, the Department of Psychiatry is the place to go.
Preparation
Consultation: registration, preparation of documents, FAQs
Tips for medical treatment
You should not eat or drink anything before the consultation in order to prepare for possible laboratory tests after the consultation.
Preparation Checklist
Symptom list
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
When was the first episode of vomiting?
What is the degree, frequency, regularity, and duration of vomiting?
What is the nature and color of the vomit?
Was the vomiting preceded by anger, excitement, overwork, etc.?
Is the vomiting self-controllable?
Are there any symptoms such as nausea, acid reflux, anorexia, early satiety, etc.?
Are there any symptoms such as anemia, vomiting blood, blood in stool, significant weight loss, etc.?
List of medical history
Any previous digestive disorders such as gastric ulcer, chronic gastritis, gastroesophageal reflux disease (GERD), chronic constipation, etc.?
Any past history of related eating disorders, e.g., anorexia nervosa, undefined eating disorders, etc.?
What are the personal dietary preferences? Do you like hot food, excessively sweet or salty food, spicy or cold food?
Any recent emotional stress, increased work-life stress, prolonged late nights, etc.?
Are there any sleep disorders?
Any family history of genetic disease or tumor?
Checklist
Test results in the past six months, which can be brought to the doctor’s office.
Laboratory tests: blood routine, urine routine, stool routine, biochemistry, etc.
Endoscopy: gastroscopy, etc.
Imaging examination: abdominal ultrasound, abdominal CT, etc.
List of medications used
Medications used in the last 3 months, if available in boxes or packages, bring them to the doctor
Anti-anxiety and depression drugs: paroxetine, sertraline, fluoxetine, etc.
Gastric mucosal protection drugs: bismuth potassium citrate, teprenone capsule, aluminum thioglycollate gel, etc.
Acid-suppressing drugs: omeprazole, rabeprazole, etc.
Gastric stimulants: domperidone, mosapride, etc.
Diagnosis
Diagnosis is based on
Medical history
Functional vomiting is a functional disorder and the following common organic disorders need to be excluded in the diagnosis:
No history of psychiatric disorders such as eating disorders or ruminant syndrome;
No history of self-induced vomiting;
no history of other systemic diseases (e.g., cerebrovascular disease, cervical spondylosis, diabetic ketoacidosis, uremia, etc.) that could explain recurrent vomiting.
Clinical manifestations
Symptoms
The main manifestation is vomiting symptoms that have persisted for at least 6 months.
It may be accompanied by loss of appetite, decreased food intake, loss of appetite, acid reflux and belching.
There is no blood in stool, anemia, lethargy, abdominal mass, or persistent abdominal pain.
Physical signs
No abnormal abdominal mass, abdominal pressure pain, rebound pain and other signs.
Gastrointestinal function related examination
Gastric emptying test
It is the kinetic process by which the stomach contents pass through the pylorus into the duodenum. Gastric emptying is measured by continuous visualization of a reflex standardized test meal after uniformly eating the test meal in small portions, thus observing the speed of expulsion of the test meal from the stomach. It can assist in the diagnosis of functional gastropathy.
Gastric emptying test is a method of evaluating gastric motility. The test should be performed on an empty stomach for at least 8 hours before the test, and menstruating women should be examined during the follicular phase of the menstrual cycle (about 2 weeks after the menstrual period is cleared). To minimize the effect of hormones on gastric emptying.
No medications or other measures (including tobacco and alcohol) that may affect gastric emptying should be used for at least 3 days prior to the test. During this period, subjects should remain active in their daily routine and abstain from water intake.
Surface Electrography
Electrogastrogram detects abnormal gastric electrical rhythms. It aids in determining gastric motility by recording fasting recordings, and gastroelectrographic changes after eating a standardized test meal [7].
The patient should be free from medications and other therapies that may affect the electrical activity of the gastric muscle for at least 72 hours prior to the examination, and should have fasted for at least 8 hours prior to the examination. During the examination, the patient was kept quiet and in a comfortable position, and could not sleep, talk or move around to avoid affecting the examination results.
The severity of vomiting is related to the percentage of normal postprandial rhythm shown on the electrogastrogram. Disturbed postprandial electromyographic activity, delayed emptying, impaired tolerance and sensory hypersensitivity are indicative of disturbed gastric motility [8].
Nutritional meal load test
It is a simple, economical and non-invasive test to assess gastric sensory function. It is a method of assessing gastric function such as measuring gastric adaptability and sensory sensitivity by observing intragastric pressure and fluid infusion at the time of maximal satiety.
Subjects should be prohibited from using relevant medications and measures that may affect gastrointestinal symptoms and function for 72 hours prior to the examination, and should abstain from food and water for more than 8 hours prior to the examination.
Psychological state assessment
People with anxiety, depressed mood, slowed thinking and reduced volitional activity with vomiting need to be evaluated with depression self-assessment scale and anxiety self-assessment scale [9].
Imaging
Abdominal ultrasound, abdominal CT, and MRI can be used to determine the presence of inflammation, tuberculosis, abscesses, benign and malignant tumors, and other lesions in the abdominal organs.
Gastroscopy
Gastroscopy can provide visual and detailed observation of the mucosa and structure of the upper gastrointestinal tract, except for gastric diseases such as gastritis, gastric cancer, gastric ulcer, gastric mesenchymal tumors, and esophageal diseases such as reflux esophagitis and esophageal cancer.
Laboratory Tests
Routine blood and stool tests can help determine whether there is gastrointestinal bleeding, anemia, infection, and so on.
Biochemical tests can clarify whether there are abnormalities in liver and kidney function and electrolyte disorders.
Urine routine examination can exclude ketosis.
Diagnostic Criteria
Functional vomiting is diagnosed according to the Rome III criteria, which must include all of the following conditions [1]:
An average of one or more episodes of vomiting per week.
Absence of eating disorders, ruminant syndrome, or evidence of major psychiatric illness.
No history of self-induced or prolonged marijuana use and no central nervous system disease or metabolic disorder that could explain the recurrent vomiting.
Symptoms have been present for at least 6 months prior to diagnosis, and the above diagnostic criteria must have been met in the last 3 months.
Differential Diagnosis
Idiopathic gastroparesis
Similarities: Both may present with vomiting.
Differences: Idiopathic gastroparesis is characterized by vomiting a few hours after a meal, more nausea than vomiting, and gastric dysmotility.
Periodic nausea and vomiting syndrome
Similarities: Both can present with nausea and vomiting.
Differences: There is a history of migraine headaches, and the vomiting occurs periodically, is not related to eating, and cannot be controlled on its own. It may be accompanied by nausea, sweating and other prodromal symptoms.
Treatment
There is no clear and effective treatment for functional vomiting. Nutritional support and symptomatic treatment are the basics. Traditional antiemetic therapy is not effective. Psychotherapy may be helpful [5].
Treatment aim: to relieve symptoms and reduce attacks.
Principles of treatment: nutritional supportive therapy, symptomatic treatment, and drug treatment methods are mainly used.
Supportive treatment
Nutritional support
Focus on evaluating whether the patient has dehydration, electrolyte disorders and malnutrition, and provide timely treatment to ensure water-electrolyte balance. If necessary, enteral nutrition support can be given.
Lifestyle improvement
For patients with a long course of disease and delayed gastric emptying, they should pay attention to small meals, choose easy-to-digest foods, and avoid high-fat diets and carbonated beverages at the early stage of treatment.
Symptomatic treatment
Antiemetic treatment
Traditional antiemetic drugs such as 5-HT3 receptor antagonists such as ondansetron and phenothiazines such as iproniazid are effective in relieving the symptoms of functional vomiting.
Diazepam analogs such as lorazepam administered intravenously may improve symptoms in some patients.
Dronabinol and aprepitant are helpful in refractory vomiting.
Improvement of gastric sensitivity and tolerance
The opioid agonists fedotoxin and acimadoline may improve vomiting symptoms.
Sumatriptan, buspirone, and nitric oxide relax the fundus, improve gastric tolerance, and reduce the incidence of vomiting.
Psychotherapy
Non-pharmacologic treatment
Psychotherapy such as cognitive-behavioral therapy, relaxation training, joint psychotherapy, psychodynamic therapy, hypnotherapy and other psychotherapies are helpful for those who have significant anxiety, depressive states, negative life events and symptoms that are closely related to emotions and stress [10].
Medication
For patients with severe depressive tendencies, antidepressants such as tricyclic antidepressants and pentazocine reuptake inhibitors can be applied.
Common drugs include: chlorpromazine, amitriptyline, promethazine, paroxetine, sertraline and so on.
Others
Gastric electrical stimulation: It can improve the clinical symptoms and quality of life of patients with refractory vomiting.
Electroacupuncture stimulation: Stimulation of two acupoints, Neiguan and Shusanli, especially Neiguan, by electroacupuncture can relieve vomiting to a certain extent, but the mechanism is not clear.
Prognosis
Cure
After regular treatment, most patients have a good prognosis for functional vomiting, but the symptoms may recur intermittently and chronically. Related to mood fluctuations, easily triggered by psychosocial factors that can easily cause tension, unpleasant emotions and internal conflicts, and those with heavy psychological burdens, the symptoms are not easy to disappear [4].
There is no standardized treatment for functional vomiting, and empirical drug therapy has limited effect. Nutritional and psychosocial supportive therapy is very important for patients with functional vomiting. The value of behavioral therapy and psychotherapy remains unclear.
Daily
Daily management
Dietary management
Avoid eating high-fat, stimulating, spicy foods and carbonated beverages and coffee.
Try to eat easy-to-digest foods, such as rice, rice porridge, yogurt and other easy-to-digest foods. Eat a moderate amount of fresh food such as vegetables and fruits.
Eat three meals regularly, on time and in quantities, do not overeat and chew slowly.
Life Management
Quit smoking and drinking, regular work and rest, avoid staying up late.
Moderate exercise can improve the patient’s mood and keep him/her in a happy mood, and a reasonable daily exercise program should be formulated. At the same time, avoid sitting for a long time to enhance the immunity of the body.
Psychological management
Most patients with functional vomiting may be emotionally unstable, have strong emotional reactions to stimuli, and are prone to anxiety and depression. If necessary, professional psychological help should be sought.
Prevention
When the patient is suffering from stress or traumatic time that is difficult to cope with or bear, or when there is severe anxiety, depression and other pathological psychological states, the patient should consult the Department of Psychiatry of a regular hospital, and actively treat the primary disease to avoid further progression of the disease.
Adopt good sleep, diet and exercise habits, and actively enhance the body’s resistance. Adjust the mood, keep a calm mind and reduce the occurrence of stress reactions.