Floaters

Eventually, everyone sees floaters- the dark wavy lines or spots or cobwebby filaments that drift lazily through the visual field of one eye or the other. Quick eye movements up, down or sideways will clear them from your line of sight, but slowly, because floaters move through a jelly like substance in the center of the eyeball. Like the ghosts wandering around Harry Potter’s Hogwarts School, ocular floaters are most often harmless annoyances. And like so many of life’s problems, they are an accompaniment of aging, particularly in people who are nearsighted (those who require glasses to see clearly at distances).

Blame aging
Aging produces changes in collagen, the structural protein that gives form to much of the body. As a result, we develop skin wrinkles, stiff tendons, unpliable heart valves and brittle cartilage, to name just a few obvious accompaniments of living to old age. Few people know that there is collagen in the middle of the eye, which is filled with a glob of jelly-like material called the vitreous humor. Most descriptions of the vitreous humor conjure up a picture of a clear, colorless ball of Jell-O that fills the posterior chamber of the eye (the space between the lens behind the pupil and the retina lining the interior of the eyeball). The vitreous keeps the eyeball from collapsing and helps hold the retina in place.

Vitreous humor – a complex structure

But appearances are deceiving. Though the transparent, jelly-like glob is composed of 99% water, it is also a delicately complex structure in which collagen plays an important  structural role. Like skin, the vitreous ages. Along with the years come the floaters.
You are born with the vitreous humor in place. Should it be removed, by surgery or trauma, you will not grow another. This is in contrast to the aqueous humor, a clear liquid that fills the space between the cornea that protects the eye and the colored part called the iris (called the anterior chamber of the eye – see diagram). The aqueous humor is manufactured by the ciliary body, a muscular structure that gives rise to the iris. From its manufacture point just behind the iris, the fluid circulates through the pupil, fills the space behind the cornea, and exits via a channel  formed by the junction of the iris and the cornea. This evenly balanced system of fluid manufacture, circulation and exit controls the pressure within the whole eye. No such recycling system exists for the vitreous humor – as in Las Vegas, what happens in the vitreous humor stays in the vitreous humor.

eye anatomy

What happens without recycling?

The  collagen structure within the vitreous humor is an airy honey-comb of interconnected collagen fibrils – microscopic fibers cross-linked and held apart by chemical and electrostatic forces. The network is loosely attached at some points to the retina that lines the inside of the back of the eyeball. The spaces in the honeycomb contain a solution of many minerals and polysaccharide molecules (chains of sugars) dissolved in water. The collagen network is, in part, held open by the pressure of the watery solution. With age, the system has mini-collapses of collagen fibrils, resulting in some clumping of the collagen networks. Floaters are the result. Occasional macrophages (white blood cells that clean up debris) float about, but they are a lonely workforce.

When are floaters more than a nuisance?

A sudden increase in the number of floaters, accompanied by transient light flashes, is sometimes indicative of a segment of the vitreous pulling away from an attachment point on the retina. This condition is known as a posterior vitreous detachment. By itself, a posterior detachment is not a serious problem, but occasionally the point of shrinkage also pulls the retina away from the vascular layer underneath it. Now you have a retinal detachment, and your vision either develops a blind spot or the sensation of a curtain pulled over part of the visual field. Such symptoms require immediate ophthalmologic evaluation and treatment to prevent further detachment of the retina.

Treatment

There is no special treatment for floaters but at times, floaters are troublesome enough for an ophthalmologist to attempt to remove the vitreous humor entirely. The surgery is very difficult and fraught with hazards such as retinal detachment or damage resulting in partial blindness.  Called a vitrectomy, it is a procedure done more often  for other reasons such as  eye trauma. After vitrectomy, the vitreous has to be replaced to maintain the shape of the eye. Research by physicists and bioengineers on suitable replacement substances has been the biggest source of information about the physical nature of the vitreous humor and the origin of the near universal phenomenon of floaters. However, to date the replacement is still done with saline, which is then naturally replaced by the same fluid that fills the anterior chamber.

Natural history of floaters 

What happens once you begin to notice floaters? They come and they go – eventually sinking out of view. The process is very slow because there is no circulation pattern in the vitreous humor and the body has not assigned a vigorous cleanup crew to the problem. Because of this slowness, and because the vitreous passively absorbs substances from the bloodstream via the blood vessels in the retinal layer, coroners sometimes use the vitreous humor to search for toxic substances like drugs at autopsy. Chemical traces remain there after they have disappeared from other body fluids; and. the vitreous humor also retains its integrity longer than other parts of the body.

Plato’s cave

As for “seeing” floaters? You are not actually looking at the clumps of collagen. Just as in Plato’s story about people in a cave interpreting shadows created by firelight as reality, you see only the shadows of floaters cast on the retina by light coming through the pupil. For this reason, floaters are clearest when you are looking at a bright background such as snow or water. Even when you see floaters with your eyes closed, light is passing through the thin eyelid and into the pupil, the only opening in an otherwise light proof box. Who knew these little annoyances could illustrate a philosophy lesson?

 

 

The Role of Alcohol in Dementia

O God, that men should put an enemy in their mouths to steal away their brains!”

Cassio (Act II, Scene iii)    William Shakespeare

The Diagnostic and Statistical Manual of Mental Disorders, the official compendium of acceptable psychiatric diagnoses, lists a syndrome called “alcohol-induced persistent dementia.” This condition was once described as the “common end reaction of all alcoholics who do not recover from their alcoholism or do not die of some accident or intercurrent episode.”  But alcoholic dementia has never been a frequent diagnosis and alcohol is still not listed as one of the risk factors for dementia. In guidelines for reduction in harm from alcohol consumption, the governments of the US, Canada, Australia, Great Britain and the EU all acknowledge the role alcohol plays in a host of chronic health and social problems, but dementia is not mentioned. Growing epidemiological evidence suggests that this omission is an error, and even that alcohol-related dementia might be a “21st-century silent epidemic.”

Epidemiological Evidence

Some evidence comes from a 2018 British study that correlated the appearance of dementia with the alcohol habits of British civil servants over a period of 23 years. The data showed that people consuming more than 14 units of alcohol a week (the equivalent of 60gm of alcohol or about 6 drinks) had an increased risk of developing dementia.  The more they consumed, the higher the risk.  A 2018 French study concluded, from a vast analysis of hospitalizations related to alcohol disorders, that there was a distinct association of alcohol use disorders with all kinds of dementia, that alcohol was responsible for a much greater proportion of dementia than previously estimated, that alcohol should be considered as one of the main causes of dementia appearing before age 65, and that, of all the risk factors related to dementia, alcohol was the easiest one to change.

A subject that doctors and patients avoid

Abstinence, over time, improves the symptoms of alcohol related dementia. Why, then, do we not make vigorous attempts to educate patients and families in the early stages of dementia evaluations about the possibility that ceasing all alcohol intake might be beneficial, and certainly not harmful, no matter what the cause of the dementia? Doctors who evaluate patients for symptoms of dementia should question patients carefully about their current and past alcohol use patterns. Often, they do not. Patients being evaluated for dementia, and the concerned family members who bring them to the doctor, should provide honest and accurate accounts of alcohol use. Often, they do not. Alcohol use is a subject which people tiptoe around for many different reasons, but one which should be addressed openly and compassionately, with an educational goal.

The path of alcohol through the body

The first goal is understanding how alcohol affects the brain, and how age and sex influence its effects. Alcohol is absorbed into the bloodstream within five minutes of entry to the stomach. On its first pass around the body, it is metabolized by an enzyme called alcohol dehydrogenase. This enzyme declines with age and is less active in women than in men. Alcohol that is not metabolized immediately circulates in the blood and is measurable as a “blood alcohol level.”  Some of it goes to the liver where it is broken down to a substance called acetaldehyde and some is broken down to acids – all these chemicals escape in urine, as well as in your breath and through the skin (the source of the “morning after” boozy smell that lingers long after the party is over).  In the brain, the un-metabolized alcohol enters brain cell membranes and dissolves some of their fats, changing receptors that transmit information from cell to cell. As more and more alcohol is absorbed, blood alcohol levels rise and a predictable sequence of events occurs: mild euphoria, mild in-coordination, then imbalance, confusion, depressed mental activity, stupor, deep anesthesia, and, ultimately, death.

Tolerance reflects changes in brain cell membranes

Depending on tolerance, alcohol’s effects on brain function occur at varying blood alcohol concentrations, with some alcoholics able to remain awake and alert at blood alcohol levels that might kill novice drinkers. Enzymatic breakdown of alcohol occurs a little faster in people accustomed to heavy drinking, but most of their tolerance to alcohol’s effects comes from persistent changes in their brains.

Altered brain cell membranes change the personality

Brain scans of chronic alcoholics typically show atrophy – shrinkage of the brain tissue, and, at autopsy, the brain of a chronic heavy drinker may show loss of some cells and white matter. But unless there are coexisting problems like old trauma, Alzheimer’s disease or vascular damage, there is no specific pathology that identifies alcoholic dementia. In life though, the result of altering brain cell membranes chronically by dissolving parts of them in alcohol is dementia – the gradual disintegration of a personality structure with persistent impairments in attention and memory, problem solving, language use, planning abilities, visuo-spatial understanding, and in emotional control and responsiveness. Memory problems can be the most prominent feature in alcoholic dementia, and emotional instability and paranoia also occur.

Not all bad

Is all alcohol bad for the brain? Not necessarily. Both studies mentioned earlier confirm a modest increased risk of dementia in strict teetotalers, an observation made many times in the past and never well understood. Research in the last decade suggests that small amounts of alcohol enhance the function of the “glymphatic” system, a term coined to describe the way spinal fluid flows deep into the brain and clears waste from it.  Sleep and exercise also heighten this pattern of spinal fluid flow. (Exercise is known to have a protective effect on the brain, lowering dementia risk. Sleep deprivation, at its extreme, produces symptoms indistiguishable from dementia. More research into the glymphatic system may help explain these observations.)  The slightly increased risk of dementia in teetotalers is not considered a reason to begin drinking for someone who prefers to abstain.

Understanding alcoholic beverages

Knowledge and awareness are keys to moderation in alcohol consumption. The alcohol in beer and wine comes from fermentation of sugars. Alcohol in whiskey, vodka and other spirits comes from distillation and the process produces additional chemicals which are like alcohol, but more toxic.  The percentage of alcohol in beers, wines and spirits can vary widely. As a rough guide, standard drinks like a 12 oz. beer (typically 5% alcohol), a 5 oz. glass of wine (12%alcohol) and a 1.5oz. shot glass of distilled liquor (40% alcohol) contain roughly the same amount of alcohol – 12-14 gms.  Label reading is important since the percentage of alcohol can vary significantly among different beers and wines.  A 12 oz. craft beer may be the equivalent of 1.4 drinks because of a 7% alcohol content.

The risk of dementia begins to climb after about 60gm/week for men and 40gm/week for women on a regular basis – about 5-6 servings. It takes about an hour to metabolize 150 mgm of alcohol/per kilogram of body weight, which translates to about 1 oz. of 90 proof whiskey for a man of average weight. Take in more over that hour and the excess alcohol circulates in the blood and begins dissolving membranes in the brain, and mental effects appear. As alcohol is cleared from the body recovery occurs in the brain and the mental symptoms resolve. With chronic, repetitive, excessive exposure, some changes fail to reverse and dementia is the result.

If you are concerned about alcohol “stealing away your brain,” and want to rethink drinking, there is much useful information for you at the link below.

https://www.rethinkingdrinking.niaaa.nih.gov/How-much-is-too-much/Whats-the-harm/How-Can-You-Reduce-Your-Risks.aspx

The Gratitude Attitude: Five Best Days

Gratitude is an attitude that mental health professionals say promotes mental well-being. They advise practices such as noting three good things about each day and writing them down at night. Studies actually show that such habits durably improve mood. In the giving spirit of the Christmas season I would like to share with you one of our family traditions that, in retrospect, I realize promotes the gratitude attitude over the course of each year.

We began taking our boys to Colorado to learn to ski when they were very little. Economic and time constraints meant one week a year, determined by my husband’s surgical on-call schedule. That week included the turn of the year on New Year’s Eve. Children’s skiing torchlight parades, followed by dinner at a Chinese restaurant and early bedtimes gradually gave way to a movie (usually laughably bad) followed by dinner at a locals’ Italian restaurant with paper-covered tablecloths and crayons for doodling. The family expanded to include our boys’ friends – first as children and teenagers along for a vacation, then as young men who worked as ski instructors. Somewhere along the way we began the habit of discussing our five best days of the year over New Year’s Eve dinner.

The crayons and the paper table covers are very convenient – everyone begins jotting down their five best days, in order, almost as soon as the menus arrive. The entire dinner time winds up devoted to going around the table in five rounds, hearing from each person about what made each wonderful day and how they decided where to rank it in the list. The choices are life stories in snapshots, changing with growth and priorities. They are funny, poignant and surprising. We also hear from people who have been with us on past New Year’s Eves, calling, e-mailing, or texting their top five days, sometimes accompanied by pictures. They all get heard.

The reason this tradition promotes gratitude is a very practical one. If you know you are going to have to come up with your five best days of the year on New Year’s Eve you learn pretty quickly that memories are weak. You cannot cram for this test. You have to start noticing potential top five days as they happen over the course of the year. You start writing them down. Pretty soon you actually have a little journal and it contains good stuff. The good things that happen in life start to break into your awareness and compete with danger-surveillance program that runs continually in the background of your mind. All good, with none of the side effects of mood enhancing drugs (which fail in the long run anyway).

Just as a matter of historical interest, we traced this tradition back to its origins. It actually began with my husband’s surgical training at Massachusetts General Hospital. The surgical interns and residents on the general surgery service met at the end of each day and were asked to talk about the cases they helped with and to explain what they had learned. The practice helped everyone process what they had done and learn from their experiences. As a family, we were always sit-down dinner people,  with candles even when there was still a high chair at the table. Like the surgery residents, we  always talked about everyone’s day. Skiing days included lots of bests. Best fall, best jump, best run, best lift ride. The evolution to a summing up of bests at the end of a year was inevitable. What is a surprise is the way the practice has continued and spread from our families to others. Maybe you would like to give it a try.

Human Diversity: A Mind Thing

(A version of this essay was published in Minnesota Medicine in March, 2005.)

The first snowy egret I ever saw was standing in a shallow pool, a beautiful white creature with a wispy headdress floating in a gentle breeze. When he lifted off, trailing his long black legs, I was startled by a flash of bright yellow – he looked like he was wearing a child’s rubber boots, designed to hug a bird’s clawed feet. He did a loop around the pond in  flying low in a peculiar, non-aerodynamic position. His legs hung down rather than stretching out parallel to his body. He dipped closer to the water and his dangling yellow feet brushed the surface. He’s landing, I thought. But he didn’t. He repeated the maneuver four times.  He’s afraid to land, I thought. But then he touched down with hardly a splash, and dipped his beak to catch a fish, then another, and another. In a moment of bird-watching epiphany, I realized that his feet were like a fisherman’s lure. He’d rounded up his lunch. 

I looked around the pond. I’d just watched a bird with bright yellow feet use them to attract the curiosity of his prey. Across the water was a bird with a lower bill that expanded into a pouch to collect fish as he skimmed, openmouthed, over the water. Perched high above was another, just about to dine on a large fish he’d  skewered with  fearsome talons. What an impressive display of diversity!  If people were this diverse, New England fishermen would grow waterproof, blubber lined hands, typists would develop extra fingers, and mothers really would have eyes in the backs of their heads.  

But people are pretty much the same as far as their bodily equipment goes.  Five fingers on each of two hands, ten toes divided between two feet, two eyes, upright posture, and a narrow range of physical abilities, notwithstanding the spread between ordinary and Olympian. The traits we associate with human diversity are superficial – hair color and texture, skin color, facial appearance. Almond shaped or round, eyes still see. Long, elegant skeletal frames and short squat ones all support bodies against the universal force of gravity. Skin pigmentation protects the body covering from the sun, more or less depending on the power of the sun in the areas of the world where the people originated. We are much more like each other than we are different in our biology. The birds have it all over us in the diversity contest.  

After my egret experience, I packed up my binoculars, got on my bike and headed home, humbled a little by the thought that all of the talk and concern about diversity among people is overblown, maybe just another representation of man’s abiding sense of self-importance. But along the way I passed bikes and cars, houses and stores, a radio broadcast tower, and a museum.  I crossed a bridge between two islands and waved to a fisherman in his boat. And I realized that each of these man made things  I passed began as an idea, somewhere, some time, in somebody’s head. We might not differ much in anatomy and physiology, but no two of us have identical thoughts. The mind is the site of the real diversity among humans. The mind is plastic and ever developing. It records, collates, recalls, communicates, and combines unrelated information in new ways. Yellow feet catch the eye, but minds change the world.

Medicating Childhood Behavior: Caution Ahead

In Hannibal Missouri, Huckleberry Finn’s house sits next door to Mark Twain’s.  Tom Blankenship, the real boy who lived in the tiny house, was the model for the wild and fictional Huck, as Mark Twain was for the impish prankster Tom Sawyer.  In the sleepy little town set on the banks of the Mississippi River, it is easy to imagine the two real boys living the lives Twain created for his characters. And it is just as easy to imagine what would happen to two such boys in the modern world. Twain and Blankenship would be disruptive children, seeing the school psychologists and being medicated for attention deficit disorder.  Is this progress, or are too many children today labeled with psychological disorders and taking drugs to modify behavior?

Reasons for psychoactive medication use in children

The most legitimate reason for identifying and labeling children as disordered is that some psychological disorders that appear early in life express themselves more severely in adulthood than later onset versions do. Early treatment helps prevent more dysfunction later, especially in problems like autism. Other reasons may be less admirable.  Prescribing drugs to treat emotional and behavioral symptoms is easier and less time consuming than dealing with the psychological problems that lie beneath the symptoms, problems which do not reflect abnormal brains.

How did we get to medicating behavior?

Attempts to treat psychological symptoms with drugs began in earnest with the serendipitous discovery in the 1950s that certain drugs, used for treating infections and high blood pressure, appeared to elevate mood. They seemed to have a direct effect on behavior.  Pharmaceutical companies then began to develop drugs specifically targeted to brain function.  Later, scientists discovered that these drugs led to changes of levels of chemicals in the brain that transmit information between nerve cells and they developed the neurochemical theory of psychological disorders.  The drug age of treatment of anxiety, depression and psychosis took off on the assumption that the drugs treated some native chemical imbalance in the brain. Because there is no direct evidence for such imbalance, some respected psychiatrists now question the neurochemical theory. Additionally, careful review of many drug studies show their effects to be little better than placebos (sugar pills). Nevertheless, drug treatment of psychological symptoms has ballooned in all age groups, particularly in the late 1900s and early 2000s. Between 1987 and 1996 the use of psychoactive drugs in children from ages 6-17 jumped 2-3 times. By 2000, 8.8% of 6-17 year olds were taking some kind of psychoactive drug. By 2017 the number of children medicated for behavior was over 7 million.

The diagnoses that prompt drug treatment in children

The behaviors of modern children that prompt treatment are divided into diagnostic categories: attention deficit disorder (ADD or ADHD); mood, anxiety and disruptive behavioral disorders; autistic spectrum disorders and childhood schizophrenia. The latter two categories reflect distinct disorders of brain function, but the first four are defined by behaviors that are often related to age and circumstances. But even autistic spectrum disorder diagnoses capture many children with behaviors that were once considered part of the normal range of human personality and behavior – social ineptness, obsessional interests and unusual styles of learning and communicating.

Non-medical factors involved in the rise in psychoactive drug prescriptions

Non-medical factors which have added to the enthusiasm for drug treatment of behavioral symptoms have been the tremendous changes in society since World War II –in family structure and values, leisure time activities, employment patterns, the educational system and in the non-governmental institutions like churches and community groups that used to provide moral and structural support.  While schools once neglected girls’ needs, boys are now immersed in an educational system geared to girls, who are more verbally adept at younger ages than boys are.  Sitting still and learning to read is a task that boys confront several years earlier than they used to, and many lack the required maturity.  When they fail and act out, they are thought to be inattentive and impulsive, garnering them ADD evaluations and drug treatment significantly more often than girls.

Changes in the practice of medicine

Changes in the practice of medicine, with more emphasis on tests and drugs now than on time spent in direct contact with patients and families, also contribute to the ease with which drugs are used as the primary approach to all kinds of medical problems, not just psychological ones. Another problem for children is “off-label” drug use, a term applied to the perfectly legal practice of prescribing drugs for reasons other than those used in the trials that determined their safety. It is estimated that 70% of all pediatric drug use is off-label, and for most of the psychoactive drugs used in children, testing has been done only in adults. In addition, the majority of psychoactive drugs used in children are prescribed by family practice or general pediatricians, not by psychiatrists. Pediatric psychotherapists, whose help might supplant the need for drugs or improve the outcome of drug treatment, are in short supply. For children without private insurance, psychoactive drug prescription rates are higher than for the privately insured.

Long term concerns

The concerns about widespread use of psychoactive drugs in children extend beyond the many side effects such as decreased appetite, insomnia, cardiac problems, and sudden death  (stimulants used for ADD), and weight gain, sleepiness, liver problems , diabetes, and increased suicide rates (antidepressants , antipsychotics and mood stabilizers).  Some neurodevelopmental biologists think  we may be trading one set of problems for another delayed and potentially more troublesome set,  because psychoactive drugs  have long term effects on the immature brain that are not seen in the adult. The developing brain is meant to learn from experience and modify its behavior in a process we call maturation and  it is not at all clear that interfering in development with drugs that change behavior passively is superior to helping the child learn without drugs,  by improving the social environment and providing competent psychological help.  We should remember that role models for Huck and Tom grew up to be a judge and a famous writer.

Nausea and Vomiting: the Great Equalizers

In 1832, British scientist Charles Darwin, who is famous for his evolutionary theory of biology, wrote a letter to his father after having been at sea for more than a month, saying: “The misery I endured from sea-sickness is far far beyond what I ever guessed at.” Much later in the letter, Darwin goes on to make the following pronouncement: “If it was not for sea-sickness, the whole world would be sailors.”

In these statements, Darwin, is, of course, referring to the all-consuming symptoms of nausea and vomiting associated with seasickness. In Darwin’s case, these symptoms were particularly severe and continued to plague him even on land. Modern medical detectives theorize that he may have had a rare genetic problem called mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke (MELAS) syndrome, which he would have inherited from his mother. One does not, however, need to have any experience with rare diseases to empathize with the misery he describes. Nausea and vomiting are the great equalizers of men, stripping all sufferers of energy, ambition, and desire. Virtually everyone has experienced both symptoms.

Why do we vomit? 

Like diarrhea, nausea and vomiting are probably evolutionarily developed, protective mechanisms designed to rid the body of toxins. Why these symptoms spill over into motion sickness and inner ear problems is a mystery, but the answer may have something to do with the fact that many toxins affect the inner ear. Some scientists speculate that over eons of evolutionary time the ear came to use the same warning symptoms experienced with seasickness to alert the body to other problems, such as trouble controlling balance. Nausea and vomiting are universal symptoms. The threshold for their appearance is highly variable. While triggers are usually physical, the symptoms can also come from the mind itself. Vomiting can be triggered by great distress, and in some people undergoing chemotherapy, antianxiety agents can diminish “anticipatory” nausea.

The scientific literature devoted to studying nausea and vomiting is full of words like “probably,” “possibly,” and “perhaps,” which reflects the lack of full understanding of the subjects. Nausea is a subjective sensation, a queasy feeling, which seems to come from the stomach but is felt primarily in the head—a feeling that vomiting may soon occur, though not necessarily. Nausea is often accompanied by the need to lie down or even to sleep, by an inability to concentrate, and by lack of interest in one’s surroundings. In people suffering from nausea, the muscular activity of the stomach and intestines is slower than normal. As nausea progresses toward vomiting, sweating and increased saliva production occurs, the skin pales, and the heart rate increases.

Vomiting is an action

Vomiting is an action and is much better understood than the sensation of nausea. It begins with a masterfully coordinated sequence of muscular actions that are carried out by the upper portion of the gastrointestinal tract, working in reverse to bring stomach contents back up the esophagus to the throat and mouth. When a person vomits, the muscles are all recruited to expel the mess with great force. Once vomiting occurs, nausea often subsides, at least temporarily.

Nausea is a sensation

Nausea has many different causes, including the presence of drugs and toxins, primary gastrointestinal problems, inner ear problems, hormonal and other metabolic problems, and brain problems. In most circumstances of nausea and vomiting, the symptoms are acute (appearing suddenly in a previously stable individual) and self-limited, meaning that they get better on their own within hours to days. The most common causes of short-lived symptoms are side effects of medications, surgery when anesthesia is used, viral or bacterial toxins, motion sickness, and migraine headaches. The most common causes of longer lasting episodes are the hormonal changes that take place during pregnancy, the side effects of chemotherapy and radiation treatments used to treat cancer, and episodes of inner ear problems that provoke a severe, spinning dizziness that is triggered when a person changes head position.

Searching for the cause of nausea: pay attention to other symptoms

Nausea and vomiting may also be symptoms of more serious illnesses, particularly when the cause is not easily identified or the symptoms do not resolve in the usual few days of discomfort that are experienced with a stomach flu. Often other, associated symptoms point to the source of trouble. Primary stomach disorders, like ulcers, can produce nausea, particularly after eating, and abdominal pains or blood in the stool lead to the correct diagnosis. Other abdominal problems, like bowel obstruction, gall bladder disease, and pancreatic cancer, can cause significant abdominal pain along with nausea and vomiting. Nausea caused by liver disease might be associated with increased abdominal size or yellowing of the whites of the eyes. Severe headaches and lethargy are symptoms of increased pressure in the brain, which can cause what is known as “projectile vomiting,” – sudden, unexpected, and very forceful expulsion of the stomach’s contents. Dizziness and double vision along with nausea may point to an impending stroke in the brainstem.

Treatment

The stomach and the brain work together in normal digestion, and when something goes awry, the neurotransmitters in the brain play a role in producing nausea. This brain-gut connection is at the heart of attempts to treat the symptoms of nausea with drugs, which fall into two categories. The first category consists of drugs that increase normal gut muscle action; drugs in the second category act by blocking neurotransmitters in the brain and the nerves leading to the gastrointestinal tract.

Drugs from both of these categories are used in postoperative care and in cancer chemotherapy and radiation treatment, and drugs from one or both of these categories are often tried in cases of persistent nausea, while an attempt is made to discover the underlying cause of the symptom. Drugs that block histamine receptors, such as over-the-counter remedies containing dimenhydrinate and prescription patches containing scopolamine, are most helpful in cases of motion sickness.

All of these drugs have side effects, the most common of which are drowsiness and mood disturbances. The most troublesome possible side effect is involuntary, small, twitchy movements. In self-limited cases of nausea and vomiting such as stomach flus, it is probably safest to retreat to bed and sleep, without using pharmacologic interventions other than over-the-counter nausea and vomiting remedies. When suffering from an acute case of nausea and vomiting, remaining hydrated is important, but the stomach is likely to revolt against more than a tablespoon or two of water at a time until the vomiting has stopped completely. Ginger may have some value in calming the stomach; ginger ale is a good first beverage in recovery. Unlike Charles Darwin, who had more complex, chronic and undiagnosed bouts of vomiting, you will most likely recover and forget how miserable you felt.

No more posts.