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

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.

Epilepsy surgery in patients with normal or nonfocal MRI scans: integrative strategies offer long-term seizure relief.

PURPOSE: Excisional surgery achieves seizure freedom in a large proportion of children with intractable lesional epilepsy, but the outcome for children without a focal lesion on MRI is less clear. We report the outcome of a cohort predominantly of children with nonlesional intractable partial epilepsy undergoing resective surgery. METHODS: We studied 102 patients with nonlesional intractable partial epilepsy who underwent excisional surgery. The epileptogenic region was identified by integrating clinical exam and video-EEG data complemented by ictal SPECT (n = 40), PET (n = 10), extraoperative subdural monitoring (n = 80), and electrocorticography (n = 22). All patients had follow-up greater than 2 years, 76 patients had 5-year follow-up, and 43 patients had 10-year follow-up. RESULTS: A total of 66 resections were unilobar; 36 were multilobar. One patient died of causes unrelated to seizures or surgery. At 2-year follow-up, 44 of 101 patients were seizure-free, 15 experienced >90% reduction, 17 had >50% reduction, and 25 were unchanged. At 5-year follow-up, 35 of 76 patients were seizure-free, 12 experienced >90% reduction, 12 had >50% reduction, and 17 were unchanged. At 10-year follow-up, 16 of 43 patients were seizure-free, 13 experienced >90% reduction, 7 had >50% reduction, and 7 were unchanged. Outcomes correlated with the presence of convergent focal interictal spikes (p < 0.005) on the scalp EEG and completeness of resection (p < 0.0005). CONCLUSIONS: Our findings demonstrate that excisional surgery is successful in the majority of children with nonlesional partial epilepsy. A multimodal integrative approach can minimize the size of resection and alleviate the need for invasive EEG monitoring. Focal interictal spikes and completeness of resection predict good outcome. The benefits of surgery are long-lasting.