One symptom that is dreaded by both patients and physicians is nausea. A helpful review on this topic (K Kovacic, C DiLorenzo. JPGN 2016; 62: 365-71) provides information on functional nausea. A few points:
- Endoscopy has low yield. One cited study suggested that in the absence of clinical alarm symptoms, 98% of endoscopies were normal.
- 4-hour nuclear medicine study ‘may be justified.’
Therapeutic: Numerous drug/alternative therapies are discussed -most with a paucity of data. These include:
- Alternatives agents: Ginger, STW5 (iberogast), peppermint oil
- Antiemetics: Ondansetron, promethazine, prochlorperazine
- TCAs: amitriptyline, nortriptyline, imipramine, doxepin
- SSRIs: citalopram, fluoxetine, paroxetine
- Anxiolytics: buspirone
- Tetracyclic antidepressant: mirtazapine
- Antimigraine: cyprohepatadine, propranolol, topiramate, levetiracetam
- Prokinetics: erythromycin, metoclopropramide, domperidone
- Others: fludrocortisone, aprepitant, cannabionids
- Psychology: “early involvement of a psychologist and emphasis on coping strategies and maintaining functioning with continued school attendance is a primary goal.”
The authors note that retrospective data in children suggest that TCAs have a response rate of ~50% (defined as more than a 50% improvement). In one study, the mean dose of amitriptyline was 50 mg at bedtime.
In a related study, Madani et al (JPGN 2016; 62: 409-13) describe their experience (retrospective review) using cyproheptadine in children with a range of functional gastrointestinal disorders. The most common indications were functional abdominal pain (36%), functional dyspepsia (23%), combination disorder (17%) and abdominal migraines (12%). Overall, they included 151 children and they report 110 (72.8%) had complete symptom improvement; the remainder had either partial or no improvement. In those who responded, the mean initial dose was 0.14 mg/kg/day; the final mean dose was nearly identical. Adverse effects of sleepiness was reported in 13% and weight gain in 10%.
- Brave New World: Psychotropic Manipulation & Pediatric …
- Understanding Idiopathic Nausea | gutsandgrowth
- NEJM: Functional Dyspepsia | gutsandgrowth
- Does buspirone help functional dyspepsia? | gutsandgrowth
- A 6-Year Study of Amitriptyline, Escitalopram, and Functional
- Anxiety and Functional Abdominal Pain | gutsandgrowth
- Cognitive Behavioral Therapy for Childhood Abdominal Pain
Link: Impressive “water swallowing” NEJM video (thanks to Jose Garza for sharing). In a person who had undergone an esophagogastric bypass as a child. Still photo below: