Queasy not Cwazy Chronic Relationships EhWhats Nausea Not all in - PDF document

“Queasy not Cwazy” – Chronic Relationships Eh…What’s Nausea Not all in your Head Nausea - Not all in your Head Up Doc? Bob Issenman Bob Issenman McMaster University McMaster University McMaster Children’s Hospital McMaster Children’s Hospital NASPGHAN 2012 NASPGHAN 2012 I have the following financial relationships to Drugs Lacking Specific US disclose: Indication Abbott Labs – Professional Advisory Board Nestle - Professional Advisory Board  Domperidone Domperidone * Janssen - Professional Advisory Board * Products or services produced by this company is relevant to my presentation. . Objectives  Review the pathophysiology of chronic nausea in children and adolescents  Review the evidence for remediation of chronic  Review the evidence for remediation of chronic nausea  Outline an approach to the patient with refractory symptoms

Case Presentation Three month visit  10 year male transferred for 10 year male transferred for  Father: Father: ongoing management of ongoing management of  Parents “spending all night on internet” Parents “spending all night on internet” recurrence of hematochezia recurrence of hematochezia  Patient is unwell and being homeschooled  Patient is unwell and being homeschooled Patient is unwell and being homeschooled Patient is unwell and being homeschooled  Previously diagnosed pan Previously diagnosed pan- -  Principle complaint is Principle complaint is chronic nausea chronic nausea ulcerative colitis confirmed on ulcerative colitis confirmed on  Patient looks well atient looks well – – P/E normal P/E normal repeat colonoscopy/biopsy repeat colonoscopy/biopsy  Meds: Meds: 5’ASA 500 mg 5’ASA 500 mg tid tid, 5’ASA 0.5 , 5’ASA 0.5 gm gm enema nightly enema nightly  Responds to weaning course of Responds to weaning course of  Labs : Labs : Hgb Hgb 136 WBC 8 Eos 0.7 ESR 1 136 WBC 8 Eos 0.7 ESR 1 prednisone 2mg/kg over 8 weeks prednisone 2mg/kg over 8 weeks Next steps? Strategy  Family requests letter supporting Family requests letter supporting  Parental Anxiety identified as a distinct problem Parental Anxiety identified as a distinct problem homeschooling homeschooling  Parents and patient interviewed separately arents and patient interviewed separately  Watch + wait or investigate?  Watch + wait or investigate? Watch + wait or investigate? Watch + wait or investigate?  Investigations? Investigations?  Labs Labs  Diagnostic Investigations Diagnostic Investigations  Endoscopy Endoscopy Strategy  Parental Anxiety Parental Anxiety  Patients symptoms improve on “sleepovers” Patients symptoms improve on “sleepovers”  Patient Re Patient Re- -Interview Interview  3 stools per day 3 stools per day - - intermittent urgency intermittent urgency  Only occasional blood per rectum Only occasional blood per rectum O l O l i i l bl l bl d d t t  Nausea is the Debilitating Symptom Nausea is the Debilitating Symptom accounting for school absence accounting for school absence

Investigation Investigation  Colonoscopy Colonoscopy  Colonoscopy Colonoscopy  Minimal Rectal Inflammation Minimal Rectal Inflammation  Minimal Rectal Minimal Rectal Inflammation Inflammation Inflammation Inflammation  Upper Endoscopy  Upper Endoscopy Upper Endoscopy Upper Endoscopy  Upper Endoscopy Upper Endoscopy  Esophageal Furrowing Esophageal Furrowing  Esophageal Furrowing Esophageal Furrowing  White Plaques White Plaques  White Plaques White Plaques  Pathology Pathology – Eosinophilic Eosinophilic Esophagitis Esophagitis Outcome  On further inquiry parents report: On further inquiry parents report:  Black mould in basement Black mould in basement extending to bathroom wall extending to bathroom wall extending to bathroom wall extending to bathroom wall adjacent to patient’s bedroom adjacent to patient’s bedroom  Symptoms resolve with mould Symptoms resolve with mould remediation remediation Chronic Nausea - 6 months of cases Chronic Nausea - 6 months of cases  *10 y/o male *10 y/o male – – E Eosinophilic esophagitis osinophilic esophagitis  *10 y/o male *10 y/o male – – E Eosinophilic esophagitis osinophilic esophagitis  17 y/o male 17 y/o male – – Gastroparesis Gastroparesis  * 17 y/o male Gastroparesis (Family dysfunction) * 17 y/o male Gastroparesis (Family dysfunction)  10 y/o male  10 y/o male 10 y/o male – 10 y/o male Dysautonomia – Dysautonomia ysautonomia ysautonomia  *10 y/o male Dysautonomia (Family dysfunction)  *10 y/o male Dysautonomia (Family dysfunction) *10 y/o male Dysautonomia (Family dysfunction) *10 y/o male Dysautonomia (Family dysfunction)  16 y/o female 16 y/o female – – Post Infectious Dyspepsia Post Infectious Dyspepsia  16 y/o female 16 y/o female – – Post Infectious dyspepsia Post Infectious dyspepsia  16 y/o male 16 y/o male – – Functional Dyspepsia Functional Dyspepsia  16 y/o male 16 y/o male – – Functional Dyspepsia Functional Dyspepsia  16 y/o male 16 y/o male– – Post Concussive Syndrome Post Concussive Syndrome  16 y/o male 16 y/o male– – Post Concussive Syndrome Post Concussive Syndrome  15 y/o female 15 y/o female – – Gastroparesis Gastroparesis/GB Dyskinesia /GB Dyskinesia  *15 y/o female *15 y/o female – – Gastroparesis/GB Dyskinesia Gastroparesis/GB Dyskinesia (H Had been kicked out of home for marijuana use) ad been kicked out of home for marijuana use)

Chronic Nausea – Differential Dx. Less Obvious Causes of Chronic Nausea  Stress Stress – – Physical, Psychological Physical, Psychological Gastroesophageal Reflux/ Gastroesophageal Reflux/Eosinophilic Eosinophilic Esophagitis Esophagitis 1. 1.  Infection Infection – – Hepatitis, Mononucleosis, Sepsis, Helicobacter Hepatitis, Mononucleosis, Sepsis, Helicobacter Hiatus Hernia/Prolapse Gastropathy Hiatus Hernia/Prolapse Gastropathy 2. 2. Chronic Sinusitis, Urinary Tract Infection Chronic Sinusitis, Urinary Tract Infection  CNS CNS – – Infection/ Space Occupying Lesion, Infection/ Space Occupying Lesion, Meunier’s Meunier’s 3. 3. Pregnancy Pregnancy Pregnancy Pregnancy 4 4 4. 4.  GI Disease  GI Disease GI Disease – Gastritis/enteritis, Gall Bladder , Pancreas + Liver GI Disease Gastritis/enteritis, Gall Bladder , Pancreas + Liver Gastritis/enteritis Gall Bladder Pancreas + Liver Gastritis/enteritis Gall Bladder Pancreas + Liver Anxiety Anxiety – – The Queasy Teen The Queasy Teen 5. 5.  Endocrine Endocrine – – Adrenal Insufficiency Adrenal Insufficiency Autonomic Dysfunction Autonomic Dysfunction 6. 6.  Metabolic Metabolic – – Hyper Hyper - -Hypoglycemia, Uremia, Fatty Acid Defects Hypoglycemia, Uremia, Fatty Acid Defects Post Viral Gastroparesis Post Viral Gastroparesis 7. 7.  Drug, Intoxicants and Poisons Drug, Intoxicants and Poisons Vertebral Compression Vertebral Compression 8. 8.  Physical Stress Physical Stress – – Motion Sickness, Heat Stroke, Overexertion Motion Sickness, Heat Stroke, Overexertion Drugs Drugs – – i.e. Chemotherapy, * i.e. Chemotherapy, * Cannabis Cannabis 9. 9.  Emotional Stress Emotional Stress - - Anxiety Anxiety Common Denominator - Stress Neuroendocrine Response to Stress  Afferent Inputs Afferent Inputs  Sympathetic discharge Sympathetic discharge  Auditory Auditory- -Opthalmologic Opthalmologic Discord Discord  ACTH ACTH  Chemoreceptors  Chemoreceptors Chemoreceptors Chemoreceptors  Cortisol Releasing Factor CRF  Cortisol Releasing Factor CRF Cortisol Releasing Factor CRF Cortisol Releasing Factor CRF  Pain Pain – –Trauma/fracture Trauma/fracture  Antidiuretic Hormone ADH Antidiuretic Hormone ADH  Psychic Stress Psychic Stress The Endocrinology of Vomiting The Vomiting Centre Y Tache 1998  Paraventricular reticular Paraventricular reticular  ADH markedly elevated in cyclic vomiting ADH markedly elevated in cyclic vomiting - - G Robertson G Robertson formation in the lateral formation in the lateral medulla (Meadows 1995) medulla (Meadows 1995)  Nausea is a potent stimulus to huge ADH secretion Nausea is a potent stimulus to huge ADH secretion  Vomiting may be Vomiting may be ADH blood flow to stomach and intestine ADH blood flow to stomach and intestine produced by stimulation produced by stimulation p p y y of the region of the region Gastroparesis Gastroparesis  Vomiting centre receives Vomiting centre receives input from vagal input from vagal and and  “Stress” releases corticotrophin “Stress” releases corticotrophin- -release factor (CRF) release factor (CRF) sympathetic afferent sympathetic afferent  CRF acts in the CNS and periphery to inhibit gastric CRF acts in the CNS and periphery to inhibit gastric nerves nerves  The emetic signal travels The emetic signal travels emptying and empty the lower bowel emptying and empty the lower bowel by by either either system from the system from the stimulating organ stimulating organ