Nausea, belching, and rumination disorders

Nausea, belching and rumination encompass a spectrum of functional gastroduodenal disorders which can be very challenging to diagnose and manage to both the general practitioner and general gastroenterologist. Nausea is the impending urge to vomit and the treatment of nausea involves targeting multiple receptors which include dopamine antagonists, serotonin 5-HT3 antagonists, anticholinergics, antihistamines, and neurokinin receptor antagonists as well as rectifying the underlying etiology. Successful management in nausea may involve the simultaneous targeting of different receptors. Belching is the process of venting excess air and it can be managed with dietary interventions, cognitive behavioral therapy and speech therapy. Rumination is the effortless fountain-like regurgitation of food and/or liquids that usually starts within 5-20 min of meal ingestion. Management involves the implementation of “distraction” therapy which includes diaphragmatic breathing relaxation and biofeedback approaches. There is recent data that tricyclic antidepressants (e.g., nortriptyline) may also be an effective adjunct to diaphragmatic breathing and biofeedback. Moreover, patients with functional gastroduodenal disorders may require esophageal pH-impedance testing. Most of all these patients benefit from a thoughtful and detailed history taking by a physician skilled in gastrointestinal motility disorders because the clinical presentation is the key to the diagnosis of the entities. In addition, this in-depth analysis of patients’ presentations must include specific attention to the brain-gut axis and specifically how “stress, " emotional or traumatic experiences are integrated into the onset of the symptoms. Educating the patient about the diagnosis and explaining the details and why it occurs is crucial in maximizing patient participation in therapy. Obtaining the patient’s trust that the right diagnosis has been made and establishing rapport are also key to good therapeutic outcomes in these entities.