Electrophysiologic, morphologic, and serologic features of chronic unexplained nausea and vomiting: Lessons learned from 121 consecutive patients

Abell, Thomas L.; Familoni, Babajide; Voeller, Guy; Werkman, Robert; Dean, Pat; Waters, Bradford; Smalley, David; Salameh, J.R.

doi:10.1016/j.surg.2008.12.006

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Volume 145, Issue 5 , Pages 476-485, May 2009

Electrophysiologic, morphologic, and serologic features of chronic unexplained nausea and vomiting: Lessons learned from 121 consecutive patients

Thomas L. Abell, MD
- Division of Digestive Diseases, University of Mississippi Medical Center, Jackson, MS
- Reprint requests: Thomas L. Abell, MD, Division of Digestive Diseases, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216.
Babajide Familoni, PhD
- Department Electrical Engineering, University of Memphis, Memphis, TN
Guy Voeller, MD
- Department of Surgery, University of Tennessee-Memphis, Memphis, TN
Robert Werkman, MD
- Penn State University, Hershey, PA
Pat Dean, MD
- GI Pathology Partners, Memphis, TN
Bradford Waters, MD
- Division of Gastroenterology, University of Tennessee-Memphis, Memphis, TN
David Smalley, PhD
- Department of Laboratory Medicine, University of Tennessee-Memphis, Memphis, TN
J.R. Salameh, MD
- Department of Surgery, Georgetown University, Washington, DC

Accepted 16 December 2008. published online 27 February 2009.

Background

Despite substantive morbidity, unexplained nausea and vomiting has not been evaluated in a systematic manner via surgically obtained biopsies and direct electrophysiology of the gut, and this information has not been correlated with serologic information. We investigated consecutive patients with unexplained and refractory chronic nausea and vomiting to define the presence of morphologic, physiologic, and/or serologic abnormalities.

Methods

In all, 101 of 121 consecutive patients who experienced chronic nausea and vomiting of unknown etiology evaluated in 1 tertiary referral center over a 10-year period were profiled qualitatively by full-thickness small bowel biopsies with hematoxylin and eosin (H&E) and Smith's Silver stains, quantitatively by intraoperative gastric electrophysiology, and semiquantitatively, when it became available, by serum autoimmune Western blot analysis.

Results

Overall, 79 of 101 patients had abnormal full-thickness biopsy (70 neuropathies and 9 myopathies) and frequent serum autoimmune abnormalities (mean score = 13.2, normal < 3.0). In addition, 96 of 101 patients had abnormal frequency and/or uncoupling on gastric electrophysiology. Patients with small-intestinal myopathy showed a diversity of diagnoses; some patients with neuropathy had abdominal pain that correlated with autoimmune scores on Western blot.

Conclusion

Patients with refractory and unexplained nausea and vomiting have a high incidence of both small bowel morphologic abnormalities (primarily neuropathies) and gastric electrophysiologic abnormalities, which are associated commonly with serologic autoimmune activation. Similar histomorphologic, physiologic, and serologic measures should be considered in the diagnostic evaluation of any patient with refractory or unexplained nausea and vomiting.