I have felt nauseous all day every day for six months. I have had scans, blood tests and even a camera inserted into my abdomen to try to find the cause. But all tests have proved inconclusive.
I have been told that my symptoms are probably due to stress. I’ve lost a lot of weight and am nutritionally depleted. I don’t know what to do.
A. Imundi, Liverpool.
Persistent nausea without any treatable cause being detected is a disabling condition — many patients have told me severe nausea is more difficult to tolerate than pain — and the weight loss that you have experienced confirms the considerable impact on your health.
I recall seeing a patient some years ago with exactly this complaint. Just as with yourself, there were detailed investigations, but no diagnosis, and it was concluded at the time that her nausea had a psychological cause, rather than a physical one.
Health fact: Vomiting, of which the sensation of nausea is a part, involves many complex interactions between the nervous and hormonal systems, over which you have no sway
I am in no way suggesting that you are inventing your nausea or somehow deliberately making yourself ill. Instead, nausea, like panic, can be outside a person’s conscious control.
Vomiting, of which the sensation of nausea is a part, involves many complex interactions between the nervous and hormonal systems, over which you have no sway.
To give you an idea of the complexity, there is an area in the brain, the chemoreceptor trigger zone, that is sensitive to many factors (including hormones, drugs and toxins) and which can trigger nausea as a result.
There is another area, the nucleus tractus solitarius, that acts as a central generator for vomiting.
There are multiple connections between these two centres and other areas of the brain that influence this sensation, such as the hypothalamus (which also controls hormones, among other things), the limbic system (the seat of emotions) and the cerebral cortex, where nausea may be consciously perceived if, say, you see something revolting.
In a patient with unremitting nausea, an appraisal of their history, followed by clinical examination and investigations, as you have had, is essential.
The most common physical causes include gastritis, where the stomach lining is inflamed — for example, by drinking spirits, taking aspirin or by food poisoning.
When no physical cause is forthcoming, the possibility of psychological nausea must be confronted — which is why you were told that your symptoms were due to stress.
Not finding an understandable cause is, itself, causing anxiety — and I do have a suggestion.
Medical journals have reported patients’ stories where anxiety combined with depression has manifested as nausea, and I can recall reading two such cases that responded well to treatment with the antidepressant escitalopram. Indeed, depression can exist in a ‘masked’ form and generate symptoms (such as fatigue, weight loss, nausea and headache) without necessarily causing sadness or depression of mood.
You may wish to ask for a referral to a psychiatrist, as antidepressant medication may be appropriate but can only be prescribed with skill and experience.
I am 77 and have suffered from erectile dysfunction for at least seven years. I have tried pills (PDE5 inhibitors), a vacuum device and a cream (alprostadil).
It occurred to me that if the blocked arteries behind heart disease can be opened up with stents, why can’t these be used to improve blood flow to the penis?
Name and address supplied.
Thank you for taking the time to pose such a thoughtful question about a condition that is so intimate.
Erectile dysfunction (ED), the inability to experience a satisfactory erection, has a number of causes, including atheromas (fatty deposits) narrowing the arteries that supply blood to the penis.
As you rightly say, when similar deposits narrow the coronary arteries, they can be opened up in a procedure called angioplasty. Here, a long, fine tube is inserted into an artery at the groin and guided up to the heart.
Did you know? Erectile dysfunction has a number of causes, including atheromas (fatty deposits) narrowing the arteries that supply blood to the penis
Once in place, a balloon is fed through it and inflated to squash away the fatty deposit, widening the artery. A stent (a metal tube) can also be inserted to keep the artery open.
The reason why this has not also proved useful in ED is, in part, due to anatomy — for example, the blood vessels supplying the heart are relatively short.
In contrast, the route that blood takes to the penis is much more tortuous and involves multiple arteries — so, by the time that atheromas have formed in enough places to cause ED, stents in one or two will have little effect.
To complicate matters, patients with atheroma so severe it causes ED may also have type 2 diabetes, which may lead to nerve damage in the penis.
My colleague, a vascular surgeon, advises that if the narrowing is limited to the iliac arteries in the abdomen, angioplasty may be useful. But I am afraid this is the exception, rather than the rule.
There are two other options. One is Muse, where a tiny pellet of alprostadil (to boost blood flow to the penis) is inserted into the urethra. For many, this is successful and better than the cream.
The other is alprostadil given as an injection at a dose of five, ten, 20 or 40 micrograms into the penis via a fine needle (not nearly as uncomfortable as many fear). This can be outstandingly successful.
I suggest you talk to your GP about being referred to a urologist to discuss these options.