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What Causes Recurring Episodes Of Nausea?
Question: I have baffled all the doctors, could you please help? Had Roux n y revision surgery November, 2010, nearly constant nausea afterward, for months, till April, 2011 was in a bad car wreck, numerous injuries including TBI, on life support, almost died. Recovered EXCEPT for "spells" that come and go randomly, as well as with some predictability with certain events. A "spell" consists of getting overwhelmingly SICK (EXTREME nausea), dizzy, feel like I'm going to pass out, gushing sounds in my ears, and my heart beats so loud in the back of my neck, it actually jars my whole body! The only thing I can do is sit or lie down ASAP. Have seen 2 cardiologists and one neurologist. Tilt table test positive, diagnosed with Orthostatic Hypotension, prescribed support hose ( simply CANNOT wear them, legs too fat), then tried Midodrine during the day with Nitro patches through the night. Got BAD headaches from the Nitro, so had to stop that. My B/P was at times dangerously high on the Midodrine, so I refused to take it (family history for strokes). Note: my B/P is all over the place. Spells are predictable with bowel movements, or showering, or washing dishes in real hot water, almost 100% predictable when just standing in one place for 20 minutes or longer, but ALSO come completely out of the blue, no obvious precipitating event at all. Also, B/P readings DURING spells are all over the place--high, low, and normal. You just never know. Pulse is almost always low, usually in the 50's. My PCP suggested Post Concussive Syndrome, but none of the specialists have agreed with that. They all continue to insist it's Ortho Hypotension and want to treat me for that. From everything I've read on the internet, it seems like it might be related to vagus nerve damage/autonomic nervous system disorder, but what exactly? And did it start with the bariatric surgery (damage to vagus nerve) or related to TBI? I have no other brain-related residual problems from TBI except for memory......particularly "lose words" when speaking, but also easily forget things I SHOULD remember. Very pale, tired and just "sickly" feeling a lot, never have regained my vigor and stamina from before the surgery and wreck. 65 years old, no other major health issues.
Brief Answer:
Autonomic dysfunction
Detailed Answer:
I read your question carefully and I am sorry about the symptoms you have been feeling.
You seem unconvinced of the fact that it's orthostatic hypotension, but I wonder if it has been explained to you that orthostatic hypotension is precisely a manifestation of autonomic nervous system disorder which you yourself are suggesting. Orthostatic hypotension is just a term to describe failure of the autonomic nervous system to adapt blood pressure to changes in posture, so whether alone or as a part of a more broad involvement of the autonomic nervous system it seems to be your case. The fact that you often have these episodes when having bowel movements, or exposed to heat reinforces the fact that it is an autonomic disorder.
As to the cause, autonomic dysfunction is a described possible complication of traumatic brain injury, at times with episodes which have been named as diencephalic epilepsy (due to the sudden attacks, not to be confused with true epilepsy). The cause is thought to be related to damage to structures of the brain controlling the autonomic nervous system. The fact the episodes started after the trauma confirms that.
Treatment of this type of dysfunction is difficult. Midodrin which you have been prescribed is a valid alternative. Fludrocortisone is another alternative for orthostatic hypertension. Several other alternatives have been tried such as desmopressin, metoclopramide, pyridostigmine if the above do not help or cause marked side effects. So it can be a frustrating experience in finding the most suitable alternative for you, but that is the nature of autonomic disorders.
I remain at your disposal for further questions.
Autonomic dysfunction
Detailed Answer:
I read your question carefully and I am sorry about the symptoms you have been feeling.
You seem unconvinced of the fact that it's orthostatic hypotension, but I wonder if it has been explained to you that orthostatic hypotension is precisely a manifestation of autonomic nervous system disorder which you yourself are suggesting. Orthostatic hypotension is just a term to describe failure of the autonomic nervous system to adapt blood pressure to changes in posture, so whether alone or as a part of a more broad involvement of the autonomic nervous system it seems to be your case. The fact that you often have these episodes when having bowel movements, or exposed to heat reinforces the fact that it is an autonomic disorder.
As to the cause, autonomic dysfunction is a described possible complication of traumatic brain injury, at times with episodes which have been named as diencephalic epilepsy (due to the sudden attacks, not to be confused with true epilepsy). The cause is thought to be related to damage to structures of the brain controlling the autonomic nervous system. The fact the episodes started after the trauma confirms that.
Treatment of this type of dysfunction is difficult. Midodrin which you have been prescribed is a valid alternative. Fludrocortisone is another alternative for orthostatic hypertension. Several other alternatives have been tried such as desmopressin, metoclopramide, pyridostigmine if the above do not help or cause marked side effects. So it can be a frustrating experience in finding the most suitable alternative for you, but that is the nature of autonomic disorders.
I remain at your disposal for further questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I am unconvinced of the diagnosis simply because I have "spells" that come out of the blue, completely unrelated to a postural change. And, during the spells, my B/P is completely NORMAL many times, or even HIGH, when the specialists have told me the spells are due to LOW or FALLING B/P. I have even woke up experiencing the onset of a spell, before I ever even started to get out of bed. Also, the worst spells occur NOT when I have just stood, but AFTER I have been standing upright in the same location and without moving around for 20-30 minutes. I was under the assumption that OH would occur almost immediately after going from lying or sitting to standing position. My husband said it may also be significant to mention a couple other things: 1) That I DID already have severe unrelenting nausea following the bariatric surgery. 2) That some of the other injuries I sustained in the auto accident (from the seat belt) were a perforated intestine and ruptured spleen. And lastly, yes, I had read about some of the drugs you mentioned, and I do believe these are to act on blood pressure, correct? But isn't it dangerous to give any blood pressure drug to INCREASE blood pressure when mine is so static and changing all the time, and at times is already high (example 160/100)? Does any of what I have told you indicate a possible need for a pacemaker? My pulse is so slow, and the doctors did tell me my heart POUNDS in an attempt to try to raise my blood pressure, but for some reason, my heart won't SPEED UP, it just beats HARD. It feels like it jars my whole body! Lastly, is there nothing else that would help, besides the drugs you have recommended? I can no longer work, even if I wanted to, because of the need to be able to go lie down whenever a spell hits, and no employer will put up with that. Our friends and family have started treating me like an invalid, which really distresses me. As long as I don't have a spell, I can do whatever anyone else does. It's just that I never know when a spell is going to hit, and when it does, I'm so sick, I feel like I could die----and not really sure that I won't. What are the chances this will ever go away, so I can lead a normal life again?
Brief Answer:
Read below
Detailed Answer:
Thank you for the additional information.
I still do not think it was related to the bariatric surgery. Nausea and vomiting due to food intolerance can be long term complications of gastric surgery, but the episodes you describe are not related to meals alone.
What I was trying to say before is that having autonomic dysfunction doesn't exclude orthostatic hypotension which may be a symptom of it (among other manifestations, not necessarily through all episodes). Also having high blood pressure doesn't exclude orthostatic hypotension either, on the contrary such patients have high blood pressure values when lying down. It is the regulation process which is dysfunctional.
Whether I am trying to convince you that you have orthostatic dysfunction...no. I can not judge it as I have no data on your pressure values supine and standing, the basic test for it. I assumed that other doctors noted a difference when changing position since they made that diagnosis. It is true that your description though is not classical for orthostatic hypotension episodes.
What I would suggest to clear that dilemma is having blood pressure Holter measuring, carrying a pressure monitoring device monitoring changes during the day, coupled with a diary, in order to assess the relation of blood pressure to the episodes. If there is presence of the episodes with no relationship with drops in pressure seen I would agree with you.
I do not think a heart rate in the 50s constitutes an indication for a pacemaker, it is indicated in values way lower than that when symptomatic (usually requires a ecg holter prolonged ecg monitoring).
It is hard to make additional recommendations or predictions when the cause hasn't been determined and there is a discordance between the opinion of the medical professionals who examined you and your findings. I believe if the test I suggested confirms blood pressure drops the recommendation remains the medications above. Otherwise alternative causes should be sought such as a form of partial seizure due to the trauma (temporal lobe seizures can manifest with autonomic seizures). Also a psychological nature could be considered, common after brain injury.
Read below
Detailed Answer:
Thank you for the additional information.
I still do not think it was related to the bariatric surgery. Nausea and vomiting due to food intolerance can be long term complications of gastric surgery, but the episodes you describe are not related to meals alone.
What I was trying to say before is that having autonomic dysfunction doesn't exclude orthostatic hypotension which may be a symptom of it (among other manifestations, not necessarily through all episodes). Also having high blood pressure doesn't exclude orthostatic hypotension either, on the contrary such patients have high blood pressure values when lying down. It is the regulation process which is dysfunctional.
Whether I am trying to convince you that you have orthostatic dysfunction...no. I can not judge it as I have no data on your pressure values supine and standing, the basic test for it. I assumed that other doctors noted a difference when changing position since they made that diagnosis. It is true that your description though is not classical for orthostatic hypotension episodes.
What I would suggest to clear that dilemma is having blood pressure Holter measuring, carrying a pressure monitoring device monitoring changes during the day, coupled with a diary, in order to assess the relation of blood pressure to the episodes. If there is presence of the episodes with no relationship with drops in pressure seen I would agree with you.
I do not think a heart rate in the 50s constitutes an indication for a pacemaker, it is indicated in values way lower than that when symptomatic (usually requires a ecg holter prolonged ecg monitoring).
It is hard to make additional recommendations or predictions when the cause hasn't been determined and there is a discordance between the opinion of the medical professionals who examined you and your findings. I believe if the test I suggested confirms blood pressure drops the recommendation remains the medications above. Otherwise alternative causes should be sought such as a form of partial seizure due to the trauma (temporal lobe seizures can manifest with autonomic seizures). Also a psychological nature could be considered, common after brain injury.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I had read on the internet of bariatric surgery patients who had similar symptoms, and it was suggested that the vagus nerve is actually cut as a part of the standard surgery to transform the stomach into a gastric "pouch" and that damage to the vagus nerve was the cause of the symptoms. And I did read that the vagus nerve is involved in the symptoms associated with bowel movements.
Yes, I was checked in the office for blood pressure changes during lying, standing, and then prolonged standing and there were indeed significant changes, which is why I was put on the Nitro patches for nighttime (lying down) and the Midodrine during the day. I wasn't told this at the time, but I believe the condition is called coexistent supine hypertension and orthostatic hypotension (SH‐OH). However, as I said, I was unable to tolerate the Nitro patches, and it seemed dangerous at times to take the Midodrine when my B/P was already high. Would you at least offer an opinion on that (taking the med when the B/P is already high)? Isn't that dangerous?
I didn't understand why you mentioned diencephalic epilepsy. I looked it up. It has nothing to do with what I described to you as my symptoms. Surely you weren't suggesting that as a diagnosis?
I do NOT have psychological issues, and that is somewhat offensive, although I'm sure you didn't mean it to be. These symptoms are very real, not psychosomatic. I'm a social worker. I know the difference. I have, however, become so frustrated with trying to find a cure or effective treatment to the point I'm almost resigned to giving up, and just living my life the best I can-----sitting down or lying down when I need to, taking care of my home whenever I have days I feel good. It's very discouraging, though. Already, we have spent a lot of money we could barely afford trying to get medical treatment for my problems, and still, I am right back where I was to start with.
I did have Holter event monitoring about 3 years ago, as ordered by a cardiologist. I thought it was to detect possible cardiac arrhythmias, though, I didn't know it was for B/P, or that it even could monitor B/P? It was just a little pendant I wore around my neck that communicated with a separate boxlike device---no sphygmomanometer capability that was apparent to me.
Lastly, would there be any possible benefit to seeing an electrophysiologist cardiologist?
Are there any other specialty doctors on this service who my question could be referred to for other possible suggestions?
Thank you.
Yes, I was checked in the office for blood pressure changes during lying, standing, and then prolonged standing and there were indeed significant changes, which is why I was put on the Nitro patches for nighttime (lying down) and the Midodrine during the day. I wasn't told this at the time, but I believe the condition is called coexistent supine hypertension and orthostatic hypotension (SH‐OH). However, as I said, I was unable to tolerate the Nitro patches, and it seemed dangerous at times to take the Midodrine when my B/P was already high. Would you at least offer an opinion on that (taking the med when the B/P is already high)? Isn't that dangerous?
I didn't understand why you mentioned diencephalic epilepsy. I looked it up. It has nothing to do with what I described to you as my symptoms. Surely you weren't suggesting that as a diagnosis?
I do NOT have psychological issues, and that is somewhat offensive, although I'm sure you didn't mean it to be. These symptoms are very real, not psychosomatic. I'm a social worker. I know the difference. I have, however, become so frustrated with trying to find a cure or effective treatment to the point I'm almost resigned to giving up, and just living my life the best I can-----sitting down or lying down when I need to, taking care of my home whenever I have days I feel good. It's very discouraging, though. Already, we have spent a lot of money we could barely afford trying to get medical treatment for my problems, and still, I am right back where I was to start with.
I did have Holter event monitoring about 3 years ago, as ordered by a cardiologist. I thought it was to detect possible cardiac arrhythmias, though, I didn't know it was for B/P, or that it even could monitor B/P? It was just a little pendant I wore around my neck that communicated with a separate boxlike device---no sphygmomanometer capability that was apparent to me.
Lastly, would there be any possible benefit to seeing an electrophysiologist cardiologist?
Are there any other specialty doctors on this service who my question could be referred to for other possible suggestions?
Thank you.
Brief Answer:
Read below
Detailed Answer:
Hello again!
I will try to address your remarks one by one.
I still do not believe the bariatric surgery to be a cause. It can cause symptoms related to meals, but as you yourself say your episodes happen during different conditions and can't be explained by that only, it can contribute but not alone. Also hypotension in orthostatic hypotension is due to dysfunction of noradrenergic transmission, the sympathetic autonomous nervous system, not the parasympathetic one where vagus belongs.
So it seems your doctors have been careful and have done the necessary tests. As I said before it is often associated with supine (lying down) hypertension. One of the causes of autonomic dysfunction with orthostatic hypotension is trauma, hence my suggesting it as the most probable cause. Of course other causes such as Parkinson's, multiple system atrophy, diabetes, kidney or liver disease, vitamin B12 deficiency should be excluded but I suppose your doctors have done that since you were seen by a neurologist.
As for using drugs which can raise blood pressure, yes that is a worry and I know it is not a perfect solution that is why we always try non drug measures like compressive high stockings, small frequent meals with low carbohydrate content etc. At times however when orthostatic hypotension affects quality of life some medication has to be used and we try to achieve a balance by using them during the day and hypotensive drugs during the night.
As to my mentioning the term epilepsy, perhaps using that term wasn't necessary on my part, as I said in parenthesis it's not related to the real epilepsy. It is used at times for autonomic phenomena which can happen post trauma in the form of acute events, actually involving often tachycardia apart from nausea and dizziness, so after you cleared out that your heart rate is actually low it's not the case.
I am not sure why you find a psychological origin offensive. Disorders like anxiety can affect up to 30% of the population according to some studies, that number can be even higher after traumatic injury. So even if that was the case there is nothing offensive about that, it is just a disorder like any other which can manifest in many different ways. However I mentioned it only as a last resort, if everything else has been ruled out, which doesn't seem to be the case since tests have proven there was dysautonomy, so there is an objective cause.
Yes there is Holter EKG, that is I assume what you have done before. But there is also 24 hour blood pressure monitoring which is called blood pressure holter, different machines and aims, the common thing is just that they measure a value for prolonged periods to see daily variations.
If your values go under 50 you could see a electrophysiologist cardiologist, perhaps an EKG holter can be repeated, but if they remain over 50 I do not think any intervention by pace maker is necessary, I agree with the explanation of heart trying to pump more blood during those episodes to compensate for change in blood pressure.
There are many doctors on this site, if you browse the list of specialties you can see them all, I am only a member like you, who being a licensed doctor has the right to receive and answer questions, not a administration staff so my access to other specialists is limited to the list you see on the site interface. I think a neurologist or a cardiologist are the most appropriate specialists for your case. Because it is not an easy straightforward case and it can involve close monitoring and therapy changes over time, I suggest you to be followed by a clinic specialized in autonomic disorders, you can still use this site for a second opinion.
I hope you will feel better soon
Read below
Detailed Answer:
Hello again!
I will try to address your remarks one by one.
I still do not believe the bariatric surgery to be a cause. It can cause symptoms related to meals, but as you yourself say your episodes happen during different conditions and can't be explained by that only, it can contribute but not alone. Also hypotension in orthostatic hypotension is due to dysfunction of noradrenergic transmission, the sympathetic autonomous nervous system, not the parasympathetic one where vagus belongs.
So it seems your doctors have been careful and have done the necessary tests. As I said before it is often associated with supine (lying down) hypertension. One of the causes of autonomic dysfunction with orthostatic hypotension is trauma, hence my suggesting it as the most probable cause. Of course other causes such as Parkinson's, multiple system atrophy, diabetes, kidney or liver disease, vitamin B12 deficiency should be excluded but I suppose your doctors have done that since you were seen by a neurologist.
As for using drugs which can raise blood pressure, yes that is a worry and I know it is not a perfect solution that is why we always try non drug measures like compressive high stockings, small frequent meals with low carbohydrate content etc. At times however when orthostatic hypotension affects quality of life some medication has to be used and we try to achieve a balance by using them during the day and hypotensive drugs during the night.
As to my mentioning the term epilepsy, perhaps using that term wasn't necessary on my part, as I said in parenthesis it's not related to the real epilepsy. It is used at times for autonomic phenomena which can happen post trauma in the form of acute events, actually involving often tachycardia apart from nausea and dizziness, so after you cleared out that your heart rate is actually low it's not the case.
I am not sure why you find a psychological origin offensive. Disorders like anxiety can affect up to 30% of the population according to some studies, that number can be even higher after traumatic injury. So even if that was the case there is nothing offensive about that, it is just a disorder like any other which can manifest in many different ways. However I mentioned it only as a last resort, if everything else has been ruled out, which doesn't seem to be the case since tests have proven there was dysautonomy, so there is an objective cause.
Yes there is Holter EKG, that is I assume what you have done before. But there is also 24 hour blood pressure monitoring which is called blood pressure holter, different machines and aims, the common thing is just that they measure a value for prolonged periods to see daily variations.
If your values go under 50 you could see a electrophysiologist cardiologist, perhaps an EKG holter can be repeated, but if they remain over 50 I do not think any intervention by pace maker is necessary, I agree with the explanation of heart trying to pump more blood during those episodes to compensate for change in blood pressure.
There are many doctors on this site, if you browse the list of specialties you can see them all, I am only a member like you, who being a licensed doctor has the right to receive and answer questions, not a administration staff so my access to other specialists is limited to the list you see on the site interface. I think a neurologist or a cardiologist are the most appropriate specialists for your case. Because it is not an easy straightforward case and it can involve close monitoring and therapy changes over time, I suggest you to be followed by a clinic specialized in autonomic disorders, you can still use this site for a second opinion.
I hope you will feel better soon
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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