Chronic vestibular dysfunction as an unappreciated cause of chronic nausea and vomiting

In patients with chronic nausea and/or vomiting, gastroparesis is frequently diagnosed, often on the basis of abnormal gastric emptying scintigraphy (GES). When typical treatments fail, patients may be referred to a referral center. This retrospective study evaluated the diagnoses made in patients referred for chronic nausea and vomiting and appraised the GES utilized to assess these patients. Records of outpatients referred for chronic nausea and vomiting over a 3-year period were analyzed for previous evaluation and treatment, subsequent investigation, and response to treatment. Of 248 patients referred for chronic nausea and vomiting, 156 (63%) were referred with a suspected diagnosis of gastroparesis. Of 102 GES available for review, 95 were done with nonstandardized methods. Repeat standardized testing was normal in 27 of 36 patients (75%). Only 28 patients (11%) had confirmed gastroparesis. The most common specific diagnosis in the entire group was chronic vestibular dysfunction (CVD, 64 patients, 26%) made by abnormal modified Fukuda stepping test, nystagmus, or abnormal Romberg test. CVD patients did not typically report a history of an inner-ear disorder or vertigo. Eighty-nine percent of CVD patients were given trials of antivertiginous medications; of the 39 followed for a median of 5 months, improvement occurred in two thirds. Diagnosis of gastroparesis should not be based on a nonstandardized GES. In our referred patients, gastroparesis was infrequent, while CVD was much more likely. Treatment for CVD may mitigate the nausea and vomiting.