Dr James Le Fanu: 27 September
There are few more invidious situations than being told, after lots of medical tests, that doctors ‘can find nothing wrong’. This is a particular hazard for those with symptoms of dyspepsia – stomach pains, heartburn and nausea – where, thanks to the endoscope, it is possible to scrutinise every inch of the upper gut – yet ‘everything seems fine’.
Forty years ago, the medical verdict would have been that the symptoms must be psychological. Thus, back in 1976, psychiatrists at the Mayo Clinic in the US, in a report on patients with persistent nausea, attributed the symptoms of a woman in her mid-30s to ‘marital unhappiness and fear of pregnancy’, while for a widow in her 60s ‘recurrent helplessness and dramatic behaviour’ were allegedly to blame. Their failure to respond to treatment with psychotherapy and antidepressants only con rmed how deep-rooted their psychological problems must be.
Gratifyingly, we now know better. When the lining of the stomach is in amed with (for example) gastritis, the nerves in the stomach wall somehow interpret what is amiss and transmit messages to the nausea centre in the brain that are perceived as the sensation of feeling sick. It is possible, however, for those same nerves to be ‘hypersensitive’, transmitting those ‘I feel sick’ messages to the brain even when the lining of the stomach is normal. The same applies to the nerves that mediate the sensations of heartburn, or ulcer pain or poor motility of the gut.
Two observations favour this explanation. First, it is possible to demonstrate that these dyspeptic patients have a lower threshold to noxious stimuli in the gut. Second, their symptoms respond to appropriate therapy. Thus, when those hypersensitive nerves interpret the normal amount of acid in the stomach as being excessive (and thus likely to cause in ammation) then acidsuppressing drugs should abolish the resulting sense of nausea – as indeed they do.
It’s tragic to reflect how much better it would have been for those patients of 40 years ago had the psychiatrists, rather than inflicting on them psychotherapy and antidepressants, prescribed a six-week course of the recently discovered acidsuppressing drug Tagamet. Their symptoms would almost have certainly resolved almost overnight.
This week’s medical query comes courtesy of a lady from Shefield who’s been troubled by migraine for most of her life. Her attacks have, however, become much more frequent in the past year and occur once or twice a day though of short duration (an hour or so) with visual symptoms predominant. They tend to occur in the middle of the night. She has not changed her lifestyle in any way that might account for this and wonders what the explanation might be.
There is no obvious reason why these migraine attacks should have become much more common – or for their nocturnal timing. Their increased frequency, however, probably warrants a preventative treatment. The simplest would be to start with a low dose of the betablocker drug atenolol.
Email drjames@lady.co.uk
Forty years ago, the medical verdict would have been that the symptoms must be psychological. Thus, back in 1976, psychiatrists at the Mayo Clinic in the US, in a report on patients with persistent nausea, attributed the symptoms of a woman in her mid-30s to ‘marital unhappiness and fear of pregnancy’, while for a widow in her 60s ‘recurrent helplessness and dramatic behaviour’ were allegedly to blame. Their failure to respond to treatment with psychotherapy and antidepressants only con rmed how deep-rooted their psychological problems must be.
Gratifyingly, we now know better. When the lining of the stomach is in amed with (for example) gastritis, the nerves in the stomach wall somehow interpret what is amiss and transmit messages to the nausea centre in the brain that are perceived as the sensation of feeling sick. It is possible, however, for those same nerves to be ‘hypersensitive’, transmitting those ‘I feel sick’ messages to the brain even when the lining of the stomach is normal. The same applies to the nerves that mediate the sensations of heartburn, or ulcer pain or poor motility of the gut.
Two observations favour this explanation. First, it is possible to demonstrate that these dyspeptic patients have a lower threshold to noxious stimuli in the gut. Second, their symptoms respond to appropriate therapy. Thus, when those hypersensitive nerves interpret the normal amount of acid in the stomach as being excessive (and thus likely to cause in ammation) then acidsuppressing drugs should abolish the resulting sense of nausea – as indeed they do.
It’s tragic to reflect how much better it would have been for those patients of 40 years ago had the psychiatrists, rather than inflicting on them psychotherapy and antidepressants, prescribed a six-week course of the recently discovered acidsuppressing drug Tagamet. Their symptoms would almost have certainly resolved almost overnight.
This week’s medical query comes courtesy of a lady from Shefield who’s been troubled by migraine for most of her life. Her attacks have, however, become much more frequent in the past year and occur once or twice a day though of short duration (an hour or so) with visual symptoms predominant. They tend to occur in the middle of the night. She has not changed her lifestyle in any way that might account for this and wonders what the explanation might be.
There is no obvious reason why these migraine attacks should have become much more common – or for their nocturnal timing. Their increased frequency, however, probably warrants a preventative treatment. The simplest would be to start with a low dose of the betablocker drug atenolol.
Email drjames@lady.co.uk