Is this you?
That’s the question I get a lot when people read these topics. And it’s important if I can connect with someone who needs some help.
Today I’m talking about nausea, but in a more protracted presentation. So weeks of vertigo (the room spinning about you while you are still) or nausea, just in and of it’s self. And there is no other G.I. symptoms associated with like diarrhea or fever or heartburn.
Once your primary care physician or gastroneurologist has been tapped out for ideas, you enter the worlds of the ENT surgeon and neurologist. Leave medical care and judgment calls to them. The following is just for education purposes only. So, if you find that the following applies to you or loved one, don’t practice medicine on yourselves. Get help.
Most nausea from a little bit of G.I. upset is gone in less than a couple days. Nausea you get from Gastroenteritis, Gerd , and the like (gastroesophageal reflux disease) are either short-lived or associated with heartburn. Nausea from hepatitis tends to be associated with jaundice or white stools or both.
No, what I’m talking about with chronic nausea is something that goes on and on, day after day, week after week.
There are really two main classes of this type of chronic nausea. One is from central causes, one is from peripheral causes. What I mean by central causes is the central nervous system. What I mean by peripheral is anything outside your brain and spinal cord.
When it comes to chronic nausea and vertigo, you can get a lot from a good history. The person with peripheral nausea/vertigo will have more self-limited symptoms. They wake up in the morning nauseated or with the room spinning. They’ve learned that if they vomit once or twice in the morning when they first get up, the symptoms seem to go away and they can pull themselves together enough to move forward and have a productive day.
The patient with central nausea/vertigo will have more refractory symptoms. No matter how much they vomit when they first wake up, the nausea and vertigo persists, usually well into the afternoon and evening (often a sign of a brain tumor unfortunately). This implies something more central. That is… It’s much more likely that they are going to have pathology in their brain or spinal cord. An MRI or CT scan of the head is in the cards. Neurologists and ENT surgeons can hmm and a-ha all day long, and get academic about what may be the cause. But imaging is almost always going to be necessary. It’s the answer key folks. You gotta know! But first comes the exam.
So, once they are at the doctor, preferably a neurologist or ENT… What is the doctor likely to find on physical exam? Something called nystagmus. It’s a beating of the eyes that the doctor can elicit with certain maneuvers (Fairly unfriendly maneuvers unfortunately like cold water in your ears, so don’t try the stuff at home). And the various qualities of nystagmus can point to either peripheral or central disease.
Qualities of nystagmus when a patient presents to the doctor for persistent chronic nausea and vomiting are as follows:
Latency – peripheral diseases are positive for latency: there is a pause before you get the couple of beats of nystagmus when you try eliciting it with certain maneuvers
Suppress-ability – repeating the testing for nystagmus makes the nystagmus occur less and less; if you get eight beats of nystagmus the first time you test for, the second time you test for you will get less like five or six; then less again at the next repeat testing; like that
Fatiguability – the nystagmus beating of the eyes goes away after a few beats; so, it stops after only a couple of beats
Furthermore, if your physician finds problems with your cranial nerves, your nystagmus is probably more from a Central nervous system process, not just something peripheral.
If the symptoms you are having relating to your chronic non-GI nausea correct after the a.m., the disease you are having is probably more peripheral… So, not your central nervous system.
If your physician finds nystagmus that demonstrates qualities of latency, plus easy suppressability, and also rapid fatiguability, similarly, your disease is more likely to be something not involving your central nervous system. It’s more likely to be a peripheral problem