European Guideline on Chronic Nausea and Vomiting-A UEG and ESNM Consensus for Clinical Management

Abstract

Introduction: Chronic nausea and vomiting are symptoms of a wide range of gastrointestinal and non-gastrointestinal conditions. Diagnosis can be challenging and requires a systematic and well-structured approach. If the initial investigation for structural, toxic and metabolic disorders is negative, digestive motility and gut-brain interaction disorders should be assessed. United European Gastroenterology (UEG) and the European Society for Neurogastroenterology and Motility (ESNM) identified the need for an updated, evidence-based clinical guideline for the management of chronic nausea and vomiting.

Methods: A multidisciplinary team of experts in the field, including European specialists and national societies, participated in the development of the guideline. Relevant questions were addressed through a literature review and statements were developed and voted on according to a Delphi process.

Results: Ninety-eight statements were identified and voted following the Delphi process. Overall agreement was high, although the grade of scientific evidence was low in many areas. Disagreement was more evident for some pharmacological treatment options. A diagnostic algorithm was developed, focussing on the differentiating features between gastrointestinal motility and gut-brain interaction disorders with predominant nausea and vomiting.

Conclusion: These guidelines provide an evidence-based framework for the evaluation and treatment of patients with chronic nausea and vomiting.

Keywords: Delphi; guidelines; nausea; vomiting.

FIGURE 1

Diagnostic algorithm for chronic nausea and vomiting. Target patients are those with chronic (> 4 weeks) chronic nausea and vomiting. The consensus recommends an initial assessment of secondary forms of chronic nausea and vomiting, summarized in Table 1. If the evaluation for secondary forms is negative, a potential motility or functional digestive disorder should be considered. At this point, it is crucial to differentiate regurgitation and rumination from vomiting (Table 2). Vomiting typically involves retching, whereas regurgitation and rumination are effortless. Rumination syndrome may be diagnosed based on the characteristic features without further testing. However, confirmation, especially in less clear cases, may be obtained using oesophageal impedance manometry. If the clinical picture suggests regurgitation, objective testing for gastroesophageal reflux disease and oesophageal motility disorders is recommended. Patients with persistent unexplained nausea and vomiting, in whom rumination and regurgitation have been excluded, should be evaluated for a gastric or intestinal motility disorder. If there is no objective evidence of an underlying gastrointestinal motility disorder, the most likely diagnosis is a gut‐brain interaction disorder, either cyclic vomiting syndrome or chronic nausea and vomiting syndrome. These disorders are clinically discriminated by the vomiting pattern. When the patient presents vomiting episodes, separated by paucisymptomatic periods, the most likely diagnosis will be cyclic vomiting syndrome. If the patient with episodic vomiting is a regular cannabis user, cannabinoid hyperemesis should be considered. In patients with continuous, non‐episodic nausea and vomiting, the most likely diagnosis will be chronic nausea and vomiting syndrome.