Area postrema syndrome: A short history of a pearl in demyelinating diseases.

In this topical review, we discuss the history of the area postrema syndrome, with special attention given to early studies aimed at identifying the area postrema and its function, possible early cases of the syndrome and its current relevance in neuroimmunology and demyelinating diseases. In 1896, Retzius named a structure in the posterior medulla oblongata as the area postrema. The work of Borison in the middle of the 20th century led to the elucidation of its function as a "vomiting center." The historical medical literature is filled with excellent examples that could be described as "area postrema syndrome." While severe and bilateral optic neuritis and transverse myelitis still constitute the classic components of neuromyelitis optica spectrum disorder (NMOSD), intractable vomiting and hiccups due to area postrema involvement is now recognized as essentially pathognomonic, indeed a shiny pearl in neuroimmunology and demyelinating diseases.

Olanzapine in the Treatment of Refractory Nausea and Vomiting in Palliative Care Settings.

The patients often present to palliative care with intractable nausea and vomiting. This may reduce the effectiveness of oral drugs and significantly affects the quality of life of these patients. Despite multiple drugs available for treatment, it is often difficult to control the symptoms. Olanzapine is an atypical antipsychotic and acts on multiple receptors and may help in treating vomiting in a patient with advanced malignancy. We report a case of gallbladder carcinoma who presented to us with intractable vomiting which was not relieved with a combination of traditional antiemetics but showed marked improvement with olanzapine.

Gastrointestinal Peptides During Chronic Gastric Electrical Stimulation in Patients With Intractable Vomiting.

OBJECTIVES: Gastric electrical stimulation (GES) is an alternative therapy to treat patients with intractable vomiting. A preclinical study has demonstrated the modulation of the gastrointestinal (GI) peptide ghrelin by GES but such mechanism has never been investigated in patients. The aim of this work was to assess the effect of GES on GI peptide levels in patients with intractable vomiting. MATERIALS AND METHODS: Twenty-one patients were randomized to receive either ON or OFF GES, 14 completed the study (10 ON, 4 OFF stimulation). Vomiting episodes, gastric emptying, and gastrointestinal quality of life index (GIQLI) were assessed. Gastric and blood samples were collected before and four months after the ON period of gastric stimulation. mRNA and/or peptide levels were assessed in gastric biopsies for ghrelin, leptin, and NUCB2/nesfatin-1 and in duodenal biopsies for glucagon-like peptide 1 (GLP-1) and peptide YY (PYY) using RT-qPCR and multiplex technology. Ghrelin, leptin, GLP-1, PYY, gastric inhibitory peptide (GIP), and NUCB2/nesfatin-1 levels also were quantified in blood samples. RESULTS: Among clinical parameters, vomiting episodes were slightly reduced by GES (p = 0.09). In tissue, mRNA or protein levels were not modified following chronic GES. In blood, a significant reduction of postprandial PYY levels (p < 0.05) was observed at M4 and a reduction of NUCB2/nesfatin-1 levels in fasted patients (p < 0.05). Increased plasma leptin levels after GES were correlated with reduction of vomiting and improvement of GIQLI. CONCLUSIONS: GES reduces NUCB2/nesfatin-1 levels under fasting conditions and postprandial PYY levels in patients suffering from nausea and/or vomiting refractory to pharmacological therapies.

The Etiology and Outcome of Area Postrema Syndrome in Childhood: Two Cases and a Literature Review.

BACKGROUND: Area postrema syndrome (APS), a rare childhood condition, manifests as intractable nausea and hiccups. APS has high diagnostic significance in neuromyelitis optica syndrome spectrum disorders (NMOSD) and can be the initial presentation of other critical diseases, including brainstem glioma. METHODS: We described two representative cases of unrelated Japanese patients with APS. An etiologic evaluation, including a detailed intracranial neuroradiological examination and autoantibodies assessment, was performed. We also reviewed the literature focusing on the prognosis of pediatric APS symptoms. RESULTS: A 14-year-old girl with aquaporin-4 antibody-positive NMOSD showed a good prognosis with immunotherapy, whereas another nine-year-old girl with irresectable medullary low-grade glioma had persistent symptoms for more than 10 years. All reported children aged >12 years were diagnosed with NMOSD, and patients aged <13 years showed heterogeneous etiologies. CONCLUSIONS: Distinctive time courses and neuroimaging features were key clinical findings for the diagnostic and therapeutic processes in these patients. This literature review highlights the wide spectrum and prognosis of pediatric-onset APS.

Air All in the Wrong Places: A Case of Pneumorrhachis Secondary to Chronic Vomiting.

Pneumorrhachis (PR) is a rare phenomenon in which air is present in the spinal canal. PR can be stratified into different categories based on etiology, with spontaneous PR being the least common. In this report, we describe the case of a 33-year-old male with a four-year history of emesis secondary to chronic gastroparesis who presented with pleuritic chest pain radiating to the neck. A CT scan of the chest showed pneumomediastinum, with air extending into the soft tissues of the neck and the spinal canal. A literature review found a trend between maneuvers that increase intrathoracic pressure, such as emesis or coughing, and the incidence of spontaneous pneumomediastinum, in which air may freely communicate with the epidural space of the spinal canal. Currently, there are no guidelines for the management of patients with PR. From our experience, conservative management of asymptomatic PR is an appropriate approach for these patients.

Intractable Vomiting Secondary to Gastric Outlet Obstruction by a Duplication Cyst.

Gastric duplication cysts are a rare finding in the adult population. Duplication cysts comprise 4% of the alimentary tract duplications, and about 67% are usually discovered within the first year of life. They can be located anywhere in the gastrointestinal tract, with the majority located in the greater curvature of the stomach. Duplication cysts may be identified on imaging studies in asymptomatic patients or may present with nonspecific symptoms that can include emesis and abdominal pain. We describe a case of a communicating cyst in the antrum of the stomach leading to gastric outlet obstruction in a 19-year-old male.

A Case of Intractable Vomiting: Was It the Celiac Artery Compression?

Celiac artery compression syndrome is a rare and poorly understood condition. Compression of the celiac artery by the median arcuate ligament causes intractable nausea, vomiting, and postprandial pain. We present a case of a 55-year-old male with a 50-pound unintentional weight loss and intractable vomiting, whose symptoms persisted despite robotic median arcuate ligament release. He later returned to the emergency department where he was found to have a low gallbladder ejection fraction on imaging indicative of biliary dyskinesia, for which he underwent a cholecystectomy. Eventually, his symptoms improved, and he was able to return to his baseline body weight.

Intractable Vomiting in an 11-Month-Old Boy With Trisomy 21: A Case Report on Abnormal Calcium/Calcinosis/Creatinine in Down Syndrome.

Abnormal calcium/calcinosis/creatinine in Down syndrome (ABCD syndrome) is a very rare condition with no clear etiology. In this paper, we describe our clinical encounter with this disease. We report the case of an 11-month-old male infant with Down syndrome (DS) who presented to the hospital with intractable vomiting and decreased oral intake and urine output. The evaluation revealed an acute kidney injury (AKI) and hypercalcemia. Although his AKI improved with intravenous hydration, his hypercalcemia persisted. Extensive studies were notable for an elevated urinary excretion of calcium and bilateral medullary nephrocalcinosis seen on renal ultrasound (US). As a result, he was diagnosed with ABCD syndrome. Dietary calcium restriction was implemented. During his follow-up visit with a pediatric endocrinologist, his serum calcium was found to be normalized. To our knowledge, this is only the seventh case report on ABCD syndrome in the literature.

Multiple sclerosis with intractable vomiting and atypical area postrema lesion.

BACKGROUND: Area postrema syndrome is considered as one of the most typical presentations of neuromyelitis optica spectrum disorders (NMOSDs) (Wingerchuk et al., 2015). The involvement of area postrema is rarely seen in multiple sclerosis (MS). We are here report a case of a young woman with multiple sclerosis, presented with intractable vomiting, and her MRI brain showed acute T2 hyperintense signal over the area postrema. CASE PRESENTATION: A 36-year-old Asian woman who is known to have schizophrenia and multiple sclerosis since 2012. She was noted to have spastic gait, and the MRI brain in 2012 showed multiple perpendicular periventricular T2 lesions suggestive of multiple sclerosis (MS). However, she defaulted her neurologist follow-up and was not on any treatment for MS. She was admitted in 2016 with intractable vomiting, and her MRI brain showed T2 hyperintense signal over area postrema with focal contrast enhancement. Her MRI cervical spine was normal. The visual evoked potential study showed bilateral prolonged P100 latencies. Oligoclonal bands were detected in her CSF analysis. Both the serum aquaporin-4 IgG (AQP4 IgGs) antibody and myelin oligodendrocyte glycoprotein (MOG-IgGs) were negative. Her intractable vomiting resolved after a short course of intravenous methylprednisolone. She was treated as MS with interferon-beta 1a. She has been in remission since 2016, and her functional status also improved from the expanded disability status scale (EDSS) of 2.0 (in 2016) to 1.0 (in 2020). CONCLUSION: We proposed that although area postrema lesion is typically seen in NMOSDs, it may also be seen in MS. Current MRI criteria for MS and NMOSDs are not sufficiently specific, and the diagnostic criteria should only be used in the appropriate clinical context.

Gastric Emphysema Induced by Severe Vomiting.

Gastric emphysema or air in the stomach wall is a rare condition resulting from the disruption of gastric mucosa and entry of air into the stomach wall which could be from severe vomiting, instrumentation or endoscopy, gastric ischemia, and dissection of air from the mediastinum. Treatment is usually conservative and supportive. We report the case of a 70-year-old woman with a three-day history of nausea and vomiting who presented with gastric emphysema on computed tomography (CT) imaging; she responded very well with conservative treatment and was discharged in a stable condition.

Burden of Comorbidities in Hospitalizations for Cannabis Use-associated Intractable Vomiting during Post-legalization Period.

Objective The aim of this study was to observe the trends of intractable vomiting and cannabis use disorder (CUD) with demographic characteristics, medical and psychiatric comorbidities, and hospitalization outcomes. Methods We conducted a retrospective cohort study using the nationwide inpatient sample (2010 to 2014). Patients aged 16-50 years discharged with a primary diagnosis of intractable vomiting and CUD were included (N = 9,601). We used the linear-by-linear association chi-square test and independent-sample T-test for measuring the categorical and continuous data, respectively. Results The number of intractable vomiting hospitalizations with CUD had an increasing trend (P < 0.001) with a 28.6% increase over five years. About half of the study population included young (16-30 years, 48.4%) males (57.2%). There was a decreasing trend (P = 0.041) in the prevalence of intractable vomiting with CUD in non-Hispanic Whites and Blacks, whereas there was 778% increase in Hispanics. The mean length of stay was 3.2 days which had a decreasing linear trend, and total hospital charges showed an increasing trend (P < 0.001), averaging $22,890. Electrolyte disorders (55.3%), hypertension (25.3%), chronic lung disease (11.9%), and deficiency anemia (10.3%) constituted the majority of comorbidities, with anemia showing a statistically significant increasing trend (P = 0.004). Anxiety disorders increased from 20.8% to 30.8% over five years, whereas depression decreased from 19.2% to 16.4% (P < 0.001). Concomitant tobacco abuse/dependence was present in 41.2% of patients with CUD. Conclusion The results of our study show that the intractable vomiting hospitalizations related to CUD have increased significantly over a five-year period. The general public and healthcare practitioners should be made aware of the paradoxical gastrointestinal side effects of cannabis.

Intractable Vomiting and Hiccups: An Atypical Presentation of Neuromyelitis Optica.

Neuromyelitis optica is an inflammatory disorder of the central nervous system. It involves the immune-mediated demyelination of predominantly the optic nerves and the spinal cord, which can lead to optic neuritis and transverse myelitis, respectively. Patients usually present with symptoms related to the eyes or the spinal cord, like loss of vision, pain in the eyes, visual field defects or numbness and weakness of limbs. Vomiting and hiccups are common cases encountered in medicine clinics and can sometimes be an atypical presentation of this disorder. Here we present a case of a 33-year-old female who initially presented to our tertiary care centre with repeated episodes of bilious vomiting and intractable hiccups for 10 days. After multiple investigations over a couple of days, the patient was found to be positive for anti-NMO antibodies and displayed neuro-radiological findings on MRI brain and spine, which finally led to the diagnosis of neuromyelitis optica spectrum disorder (NMOSD). Through this case we highlight the importance of suspecting NMO in a patient with complaints of intractable vomiting and hiccups, so that early intervention and treatment can prevent further disabling complications of the disease.

A Small Glossopharyngeal Schwannoma Presenting with Intractable Vomiting: Case Presentation and Literature Review.

BACKGROUND: Glossopharyngeal schwannomas are rare tumors. Clinical and radiologic presentation closely resembles those of vestibular schwannomas. Their clinical presentation varies from vestibulocochlear dysfunction to glossopharyngeal and vagal nerve dysfunction. CASE DESCRIPTION: We report a case of a small glossopharyngeal schwannoma presenting with intractable recurrent sudden episodes of vomiting that subsided after tumor resection. To our knowledge, this is the only case in the literature of glossopharyngeal schwannoma presenting with nerve irritation in the form of intractable emesis. CONCLUSIONS: Small glossopharyngeal schwannomas can present with irritative symptoms of the ninth cranial nerve causing vomiting refractory to medical treatment. Intracranial imaging should be considered in the investigation of unexplained intractable vomiting even if the gross neurologic examination is normal.

Acute intractable vomiting: Do I belong somewhere else?

Patients suffering from acute intractable vomiting are usually treated in the Gastroenterology department. The causes of acute intractable vomiting range from acute pancreatitis and acute intestinal obstruction to cardiac causes like acute myocardial infarction and neurological causes like posterior circulation stroke. However, most of the underlying causes of acute intractable vomiting also produce other telltale signs/symptoms. Rarely, isolated acute intractable vomiting may be the initial symptom of a recurrent neurological syndrome of neuromyelitis optica spectrum disorder (NMOSD). Not only can it be promptly treated if diagnosed correctly, but also a timely diagnosis may help in prevention of recurrent neurological deficits, which can sometimes be life threatening. We present three cases of NMOSD that presented with intractable vomiting and were treated in a Gastroenterology facility prior to their diagnosis.

Intractable vomiting caused by vertebral artery compressing the medulla: A case report.

Vertebral artery compressing the medulla and causing intractable vomiting has only been reported once previously. We report a case of a 69-year-old woman with intractable nausea and vomiting causing a 50 pound weight loss and who failed medical management and whose symptoms were completely reversed following microvascular decompression (MVD).

Intractable vomiting and hiccups as the presenting symptom of neuromyelitis optica.

Vomiting and hiccups can be due to peripheral or central causes. Neurological diseases causing vomiting and hiccups are due to lesions of medulla involving area postrema and nucleus tractus solitarius. Neuromyelitis optica (NMO) is one such disease which involves these structures. However refractory vomiting and hiccups as the presenting symptom of NMO is unusual. Here we report a patient with NMO in whom refractory vomiting and hiccups were the sole manifestation of the first attack. Diagnosis can be missed at this stage leading to delay in treatment and further complications. This case demonstrates the importance of considering NMO in any patient presenting with refractory vomiting and hiccups and with local and metabolic causes ruled out and linear medullary lesion on magnetic resonance imaging may indicate the diagnosis even when the classical clinical criteria are not met. Anti NMO antibody testing should be done and if positive appropriate treatment should be initiated to prevent further neurological damage.

Adult rumination syndrome: Differentiation from psychogenic intractable vomiting.

Rumination syndrome is known to exist in infants and mentally retarded adults since long time. In past few years, some reports appeared that showed its existence in adult patients also. It is frequently confused with the intractable vomiting in adults and misdiagnosis leads to delay in appropriate management. We are here describing the case of a female patient with rumination syndrome where specific points in the history delineated the presence of this illness and helped in appropriate management. The patient became symptom free soon after the diagnosis was reached.

A Case of Cerebral Salt Wasting Syndrome in Neuromyelitis Optica Spectrum Disorder

Neuromyelitis optica spectrum disorder (NMOSD) may present with area postrema syndrome, which is characterized by intractable vomiting and hiccups. Hyponatremia is common in NMOSD and is mostly associated with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). In contrast to SIADH, cerebral salt wasting syndrome (CSWS) causes hyponatremia, which is associated with severe natriuresis and extracellular volume depletion in patients with cerebral disease. To our knowledge, hyponatremia associated with CSWS has not been reported in a patient with NMOSD. Here, we describe a NMOSD presenting with hyponatremia, which may be caused by CSWS following area postrema syndrome.

Intractable Vomiting as an Initial Manifestation of Neuromyelitis Optica

No abstract available.

<b>A Case of Intractable Vomiting After Distal Gastrectomy Treated with Bakumondoto</b> / 日本東洋医学雑誌

There have been few reports on an antiemetic effect of bakumondoto. An 84 year old man was referred to the department of internal medicine for Kampo treatment of intractable vomiting since having a gastrectomy 6 years previously. He had experienced persistent regurgitation of gastric fluids at dawn and antiemetic and antiacid drugs were of little help. He had had a gastrojejunostomy 4 years previously for an intestinal obstruction. After the gastrojejunostomy, vomiting persisted despite of the administration of antiacids, rikkunshito or daikenchuto. Physical examination revealed only slight edema of the legs. An upper gastrointestinal series, blood tests and head CT scan revealed no specific vomiting cause. After referral to our department, we tried hangeshashinto, and shinbuto in vain. Then we prescribed bakumondoto. He reported that the frequency of his vomiting reduced in 3 weeks, and that the vomiting disappeared in 2 more weeks. Thus we consider that not only cough but also vomiting can be treated with bakumondoto.