Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School Boston, MA.
J Clin Gastroenterol. 2019 Mar;53(3):170-178. doi: 10.1097/MCG.0000000000001164.
Nausea and vomiting result from complex interactions between afferent and efferent pathways of the gastrointestinal tract, central nervous system, and autonomic nervous system. Afferent pathways from the vagus nerve, vestibular system, and chemoreceptor trigger zone project to nucleus tractus solitarius, which in turn relays signals to the central pattern generator to initiate multiple downstream pathways resulting in symptoms of nausea and vomiting. There is increasing evidence that the central pathway of chronic nausea is different from that of acute nausea and vomiting-and closely resembles that of neuropathic pain. This improved understanding of chronic nausea has resulted in a paradigm shift with regard to management strategy. Although conventional therapies such as antiemetics and prokinetics are commonly used to manage acute nausea and vomiting, they are historically not as effective in treating chronic nausea. Recently, neuromodulator agents, such as tricyclic antidepressants, gabapentin, olanzapine, mirtazapine, and benzodiazepines, and cannabinoids have been shown to be efficacious in the treatment of nausea and vomiting, and may be useful in the treatment of chronic symptoms. There is a need to study these agents, especially in the management of chronic functional nausea. Improved understanding of the central and peripheral circuitry of nausea and vomiting symptoms will allow for enhanced utilization of the currently available medications, and the development of novel therapeutic options.
恶心和呕吐是由胃肠道的传入和传出途径、中枢神经系统和自主神经系统之间的复杂相互作用引起的。来自迷走神经、前庭系统和化学感受器触发区的传入途径投射到孤束核，孤束核反过来将信号中继到中枢模式发生器，启动多个下游途径，导致恶心和呕吐的症状。越来越多的证据表明，慢性恶心的中枢途径与急性恶心和呕吐不同，与神经性疼痛的途径非常相似。这种对慢性恶心的理解的提高导致了管理策略的范式转变。尽管传统的治疗方法，如止吐药和促动力药，通常用于治疗急性恶心和呕吐，但在治疗慢性恶心方面历史上效果不佳。最近，神经调节剂，如三环类抗抑郁药、加巴喷丁、奥氮平、米氮平、苯二氮䓬类和大麻素，已被证明对恶心和呕吐有效，并且可能对治疗慢性症状有用。需要研究这些药物，特别是在慢性功能性恶心的治疗中。对恶心和呕吐症状的中枢和外周电路的更好理解将有助于更好地利用现有的药物，并开发新的治疗选择。
