Pyloric stenosis in the adult patient: A problem of Vagus nerve impingement?
Ross Hauser, MD
We see many patients who have food that gets stuck in their stomach. What is one possible cause for this stuck food? It can be a problem of the pyloric valve or the “doorway” that separates the stomach contents from those of the small intestine. When the pyloric valve doesn’t work properly, food stays in the stomach, and symptoms such as bloating, nausea, vomiting, reflux can occur. Eventually, if food can not get absorbed, weight loss occurs. Sometimes it is life-threatening.
In this article I will present two patient cases from our neck center at Caring Medical, one of these patients has been treated, one is waiting for treatment, and compare these two stories with a case history presented in the medical literature where the patient underwent a distal partial gastrectomy with a Billroth 1 gastroduodenostomy (removal of part of the stomach).
A person contacted our office. Here is her story.
“I am facing malnutrition, starvation and am often unable to work. I am wholly dependent on a GJ-tube (gastrostomy-jejunostomy tube) for daily food and water. I have lost more than half my body weight.”
The reason that this person reached out to us with her problems was that she had tried a vagus nerve stimulator and it temporarily helped her digestion. It offered her a clue that maybe the problem was not originated in her digestive tract, but her problem was originating with her vagus nerve. It may, she thought, be a problem in her neck.
The clues to this person’s problems being connected to the vagus nerve started to reveal themselves.
Like many people with significant cervical spine instability, this person had a job working as a teacher that involved an enormous amount of neck flexion or looking down. In 2016 everything caved in for her after a lymphatic massage and cervical manipulation. Suddenly she developed a tremendous difficulty in eating and when she did eat she would get significant bloating, nausea, and what she described as extreme, extreme distension of the abdomen.
After being prescribed many medications including pyridostigmine and 3 nasogastric tube feedings, and a pyloric stent without much help, she was told she needed surgery for her severe pyloric stenosis. Eventually, she had a G-POEM surgery which did not resolve the GI issues (only two months of relief), she had a J port placed to feed her.
- The gastric peroral endoscopic myotomy (G-POEM) procedure treats patients with gastroparesis. This minimally invasive procedure cuts through the tight pyloric muscle so a permanent opening is made for food to pass between the stomach and the small intestine so the food does not get stuck in the stomach. This procedure does not work for everyone.
In her previous tests, it was noted that her problem of gastroparesis improved, the flow through the stomach and small intestine was better when she was in the supine (lying flat) position, and that some of the ‘food flow’ was hampered in the duodenum (stuck in the portion of the small intestine where the stomach dumps into). Other motility studies did show also delayed esophageal motility. She did not have superior mesenteric artery occlusion (syndrome).
She currently is not able to eat foods or liquids by mouth as she will get nauseated, suffer from severe abdominal bloating, and vomit. She can not drink water by mouth because as she describes it “it is like turning on a light switch” and her symptoms will go crazy. The action of chewing and swallowing can cause the “switch to be turned on.”
Once her abdomen bloats, swells, and hardens, she reports that her whole body will shut down. She will also not a sensation where her spine gets pulled out of place and she is incapacitated with pain. She noted that her body is getting more hunched over with forward or dropped head posture. Her head feels heavy all the time and her eyelids are droopy. She has constant neck and back pain. She states her hands and feet are ice cold to the touch but they feel to her like they “on fire”.
Her history is significant for the treatment of chronic Lyme disease. She feels like she has whole-body inflammation, extreme fatigue, and uveitis (eye inflammation that is currently being treated). She has recently been diagnosed with gastrointestinal neuropathy, autoimmunity, and vagus nerve damage. Other symptoms include cognitive decline, headaches, and even poor balance resulting in difficulty with walking.
She feels her autonomic nervous system isn’t working and is under the care of an autonomic nervous system specialist. She is hopeful that Prolotherapy and the other care at Caring Medical can help her nervous system get more balanced and her vagus nerves to work correctly.
Initial analysis and summary explanations of what is happening in this person’s medical history.
Because of improvements noted when she did something to improve her vagal tone (vagus nerve function), she started to suspect her problems were greatly related to her vagus nerve. Please see our article How You Can Repair Your Vagus Nerves. Another step in this direction of understanding vagus nerve involvement was her diagnosis of gastroparesis.
It is well researched and documented that Gastroparesis is caused by a malfunctioning vagus nerve. The vagus nerve is responsible for sending messages to the muscles and valves of the digestive tract on how to and when to move food through your digestive tract. When the vagus nerve malfunctions, food moves too slowly or stops moving. A more detailed explanation of this problem along with research can be found in our article: How neck pain and cervical spine instability cause nausea, gastroparesis, and other digestive problems.
Nausea and gastroparesis caused by cervical spine instability
In this video Ross Hauser, MD describes the problems and symptoms of nausea and gastroparesis caused by cervical spine instability.
Summary transcriptions and explanatory notes:
- We are seeing many nauseated patients.
- A lot of these patients have seen gastroenterologists, they have had endoscopy performed and the result have revealed nothing.
- Some of these patients will ultimately get a diagnosis of gastroparesis which simply means that their stomach is not working.
At 0:54 of this video, Dr. Hauser refers to Vagus nerve compression and how this could cause gastroparesis.
This is a patient case from Caring Medical’s Hauser Neck Center.
This patient is a 28-year-old man. He came into our center with the hopes that he would be able to address and alleviate his need for continual endoscopic balloon dilations. The goal of the treatment plan was to assess if his pyloric valve malfunction was due to nerve compression in his cervical spine. In essence, was this problem, a neck problem.
The patient had a long medical history of digestive problems.
- At age eight he started experiencing an inability to hold down food, chronic vomiting bile, and food, severe heartburn, and regurgitation. He was not able to eat much or large meals as a child. His doctors were able to give him some relief with a prescription for Prilosec.
- He was eventually diagnosed with severe pyloric stenosis by a gastroenterologist who started endoscopic balloon dilations on a four-month rotation. According to the patient’s history, at each endoscopy, the GI specialist would find that the pyloric sphincter had closed again.
The initial examination
Upon evaluation for a possible neck connection, the patient noted that he has a fairly constant uncomfortable tightness in his neck, especially at the end of the day. He works as a researcher and works at a computer and lab station for the great majority of his day.
On examination he had:
- a lot of neck tenderness,
- a crepitation (cracking noises in his neck) was observed,
- and his uvula deviated slightly to the left and his palate was lower on the right.
- His right ear felt hotter than his left.
- His right optic nerve sheath was swollen at 5.9 mm, his left 4.2mm.
- Digital motion x-ray analysis found: Straightening of the cervical curve, anterolisthesis of C2-3, C3-4, C4-5, and a 2.8 mm lateral overhang on the right of C1 on C2 (none on the left). He was diagnosed with cervicovagopathy from atlantoaxial instability and rotational (to the right) atlas subluxation.
Let’s start explaining some of these problems we observed:
“His uvula deviated slightly to the left and palate was lower on the right.” A quick explanation of the significance of a deviated uvula.
There are various clues that the vagus nerve is involved in the different and complex neurological, cardiac, and gastrointestinal problems some people have. One of the simplest ways to send us down the path of vagus nerve function is to simply look down the throat of the patient and see if the uvula (the small finger-like tissue that hangs at the back of the soft palate) deviates to one side, we call that a deviated uvula and a deviated uvula is one of the biggest clues that the vagus nerve is not functioning correctly and could be a cause of the gastrointestinal problems the patient is facing.
What are we seeing in this image?
We are seeing a comparison of a normal uvula and a deviated uvula. Here in this image, the uvula is pointing to the patient’s ride side of the mouth. This is a clue that vagus nerve compression may be suspected in the different and complex neurological, cardiac, and gastrointestinal problems some people have.
Intracranial pressure: “His right optic nerve sheath was swollen at 5.9 mm, his left 4.2mm.”
- When Intracranial pressure is increased you can get changes in your vision, you can get double vision or you can get graying of the vision. You can even see an image and you look away and you still see that image. There are all kinds of vision problems that are from upper cervical instability that can include the primary problem this patient mentions, everything is his field of vision tilts to the right.
- Papilledema is the swelling of the optic nerve of the eye from raised intracranial pressure. Intracranial pressure can occur when the cerebrospinal fluid that protects the brain, which is constantly produced and replaced, does not drain out properly and the new, fresh fluid that comes in, “overflows,” the inner skull.
- Papilledema type symptoms and conditions are problems we see in many patients. Again, let’s stress that these symptoms and conditions are common to many of the problems we see in patients who have cervical spine instability or craniocervical instability, and a clear sign of the complexity of these people’s cases and the involvement of nerve compression.
What are we seeing in this image?
In this image, vision problems caused by cervical spine instability and increased intraocular pressure or elevated intraocular pressure. These problems can include diminished ocular blood flow, Exaggerated pupillary hippus dilating, Hampered accommodation or human ocular accommodation mechanism or accommodation reflex, increased intraocular pressure or elevated intraocular pressure, Limited pupillary constriction, Optic nerve damage. The patient we are describing, in this case, has swollen optical nerve sheaths.
Neck symptoms on examination
- He has limited motion of his neck.
- He gets clicking and grinding in his neck after he turns his head in a circle and turning it from left to right.
- He does have a history of self-manipulating and cracking his neck which he did stop.
- He gets headaches 1-2 times per week.
- He has a history of dizzy spells. Rarely he gets vertigo.
- He occasionally has visual episodes where everything tilted roughly 10 degrees to the right. This can occur after turning his head to the right.
- Please see our article: Oscillopsia caused by cervical spine instability and neck pain.
- Please see our article: Chronic Neck Pain and Vision Problems.
- There is no ear fullness, tinnitus, or sensitivity to sound.
- He does get hoarse after talking for a while.
What is the treatment plan for someone like this? Gastric surgery?
For most people that display symptoms of pyloric valve malfunction and pyloric stenosis, a conservative care option of medications, continual endoscopic balloon dilations, and the eventual need for surgery is a common path. Not all people will need surgery, those who get surgery may experience total relief of symptoms or partial relief of symptoms or small or no relief of symptoms. It will depend if the surgery was addressing the correct problem.
Let’s look at a case report noted in the medical research literature.
Let’s begin with a case written up in the Journal of Community Hospital Internal Medicine Perspectives. (1)
- A 50-year-old female patient went to the emergency room with acute onset upper abdominal pain associated with nausea, vomiting, foul-smelling black tarry stools, and anorexia.
- She reported experiencing chronic abdominal pain, vomiting, and diarrhea since she was 13 years old.
- She saw 6–8 doctors a month in her youth with most doctors attributing her symptoms to a sensitive stomach or food poisoning.
- She had an esophagogastroduodenoscopy in 2013 that showed a hiatal hernia. She had another esophagogastroduodenoscopy in 2017 which, according to the patient, was inconclusive in determining a cause of her symptoms.
- In this visit to the emergency room, she had a gastric emptying study done. The results showed a delayed gastric emptying.
- She was eventually diagnosed with possible Adult Idiopathic hypertrophic pyloric stenosis. The patient was discharged and had multiple endoscopic dilations over the coming months with minimal relief in symptoms.
- After discussion with gastroenterology, general surgery, and the patient who wished for a more permanent treatment for her underlying condition, she underwent a distal partial gastrectomy with a Billroth 1 gastroduodenostomy (removal of part of the stomach).
- Postoperatively, the patient had a gradual and slow recovery, and on her 3-month follow-up visit, she reported considerable improvement of her symptoms.
The difficulty in diagnosis and a mention of the vagus nerve
The doctors in this case report offered a summary of what patients like this one they reported on and our case history may face in trying to get themselves treated and their symptoms alleviated. Here are their learning points. Watch at the end for a very small mention of vagus nerve involvement.
“Adult idiopathic hypertrophic pyloric stenosis is a rare disease that is under-reported due to a difficulty in diagnosis. This challenge in diagnosis is evident by our patient, who consulted multiple doctors and underwent procedures over the years before her diagnosis of Adult idiopathic hypertrophic pyloric stenosis was made.”
The majority of researchers believe Adult idiopathic hypertrophic pyloric stenosis to be the persistence of the mild juvenile form of hypertrophic pyloric stenosis however, it still seems unclear as to the reason for the prolonged asymptomatic period until the age of 30–60 years in some patients.
(This is my note: Some people’s symptoms disappear after the exit adolescence and then develop again later in life. The doctors of this study call this somewhat of a mystery as to why this happens. We suggest in some, not all people, the involvement of upper cervical spine instability and disc degenerative disease possibly compressing the vagus and other nerves.)
Some researchers postulate edema, spasm, or inflammation triggers pyloric occlusion in a predisposed individual.
The difficulty in diagnosis and a mention of the vagus nerve
The doctors of this case study suggest “other possible etiologies include protracted pylorospasm, vagal hyperactivity, and changes in Auerbach’s plexus.” In other words the possibility of a neurological problem. It is important to stress that this may be a possible cause for the gastrointestinal difficulties the patient suffers from. It may not be a problem for every person suffering from this condition. I will present the evidence below that for some, the vagus nerve compression caused by cervical spine instability and problems in the neck may be causing their issues.
At our center, we see many patients with a myriad of mysterious and simultaneous conditions and symptoms. Typically they also start treatment with us by explaining and showing us the shopping bag full of medications that they are taking for each symptom and the very thick print out of all the tests that they have had performed over the years.
As a reminder, the patient in our case had:
- Neck pain and limited motion of his neck.
- Headaches 1-2 times per week.
- Dizzy spells.
- Vision problems.
In addition to his gastric distress.
Vagus nerve problems or problems of vagal tone
If your symptoms were limited to gastrointestinal distress, you would be in the hands of capable gastroenterologists and you would be managed and likely greatly helped. But what if your problems were bigger? What if there was a neurologic-like problem?
What are we seeing in this image?
If you look at the illustration above you will see where the Vagus nerve is closely related to the C1 – C2 – C3 vertebrae. While doctors usually discuss the vagus nerve in the singular sense, there are two vagus nerves, one on each side of the neck and in combination, they are referred to as the vagal nerves. This means that the degenerative damage in your neck can significantly impact the function of one or both vagus nerves. The one on the left side of your body and the one on the right side of your body.
Vagus nerve and digestion
In my article Cervical spine instability as a cause of your digestive disorders, I give a detailed overview of the problem. I will summarize that article here:
When a patient comes into our center for cervical spine instability issues and they describe digestive problems, the digestive difficulties are usually one of many symptoms, as I described above. One of the causes of this myriad of symptoms may be found in compression of the vagus nerve. Among the many functions of the vagus nerve is that it provides 75% of the total input for the parasympathetic nervous system, part of the Autonomic nervous system.
Explanatory note: Autonomic nervous system divided into two: the sympathetic nervous system and the parasympathetic nervous system
- The sympathetic nervous system controls energy flow to the digestive systems during times of flight/fight. It slows down digestion so the legs and arms can get the blood they need as a priority. The parasympathetic nervous system restarts the digestive system when the stress passes. A malfunctioning Autonomic nervous system can lead to many digestive problems symptoms including the development of Adult idiopathic hypertrophic pyloric stenosis and Small intestinal bacterial overgrowth among other conditions.
The vagus nerve is responsible for managing our intestinal activity as well as managing the sphincter muscles in the gastrointestinal tract.
Gastrointestinal symptoms and vagus nerve compression
In this video Ross Hauser, MD. discusses a myriad of gastrointestinal symptoms that may be caused by vagus nerve compression typically found in cervical spine instability.
Below is a summary transcript with explanatory notes:
- We see many patients with clicking, grinding, crunching in their neck. They have terrible migraine headaches, neck stiffness, dizziness, ringing in the ears, swallowing difficulties, and other disabling symptoms. But our overall assessment also includes our look into these people’s gastrointestinal symptoms.
(0:40) What are we looking for by way of gastrointestinal symptoms?
- We are looking for symptoms of:
- Very sensitive stomach
- Crohn’s disease
- Ulcerative Colitis
- Irritable Bowel Syndrome
Some of these people have a long history of gastrointestinal symptoms and cervical spine instability, yet the connection was never made for them. Yet a connection can be obvious.
In the illustration below, the many things the vagus nerve is responsible for are outlined. Highlighting digestive disorders, we see that the vagus nerve:
- Controls throat muscles to assist in swallowing
- Regulates insulin secretion and glucose balance (homeostasis) in the liver
- Regulates and controls digestion. Provides your brain with the feeling of satiation or “I’m full.” Helps regulate gastric juices, gut motility (the ability to move food through the digestive tract), and the production and regulation of stomach acids.
The vagus nerve, and its important role in digestion that we explained above, runs right in front of the C1 vertebra.
Treating cervical ligaments with Prolotherapy – published research from Caring Medical
Prolotherapy is an injection technique that stimulates the repair of unstable, torn or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can stress tendons, atrophy muscles, pinch on nerves, such as the vagus nerve, and cause other symptoms associated with cervical instability including problems of digestion among others.
In this patient’s case we treated him, not with surgery to remove a portion of his stomach, or even cervical spine surgery, but rather with simple dextrose injections into his neck and cervical spine and a program to correct and restore the natural curvature of his neck and remove pressure and compression from the vagus nerve.
Treatment consisted of:
- atlas and other vertebral subluxations,
- cervical curve correction for loss of cervical curve and
- Prolotherapy to stabilize the cervical segments that are unstable.
Atlantoaxial instability: C1 and C2 hypermobility causes cervical spine instability and nerve compression
Atlantoaxial instability is the abnormal, excessive movement of the joint between the atlas (C1) and axis (C2). This junction is a unique junction in the cervical spine as the C1 and C2 are not shaped like cervical vertebrae. They are more flattened so as to serve as a platform to hold the head up. The bundle of ligaments that support this joint is strong bands that provide strength and stability while allowing the flexibility of head movement and allow unimpeded access (prevention of herniation or “pinch”) of blood vessels that travel through them to the brain.
In a 2015 paper appearing in the Journal of Prolotherapy, (2) our research team wrote that cervical ligament injury should be more widely viewed as the underlying pathophysiology (the cause of) atlantoaxial instability and the primary cause of cervical myelopathy (disease) including the problems of related to vagus nerve malfunction and its myriad of symptoms including those mentioned above.
The case for identifying loss of cervical lordosis as the cause of your symptoms
The cervical ligaments are strong bands of tissues that attach one cervical vertebra to another. In this role, the cervical ligaments become the primary stabilizers of the neck. When the cervical ligaments are healthy, your head movement is healthy, pain-free, and non-damaging. The curve of your cervical spine is in correct anatomical alignment.
When the cervical spine ligaments are weakened, they cannot hold the cervical spine in proper alignment or in its proper anatomical curve. Your head begins to move in a destructive, degenerative manner on top of your neck. This is when cervical artery compression can occur.
In our 2014 research lead by Danielle R. Steilen-Matias, MMS, PA-C, published in The Open Orthopaedics Journal (3), we demonstrated that when the neck ligaments are injured, they become elongated and loose, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to nerve impingement and the varying problems these impingements can cause.
Treating and stabilizing the cervical ligaments can alleviate these problems by preventing excessive abnormal vertebrae movement, the development or advancing of cervical osteoarthritis, and the myriad of problematic symptoms they cause including nerve and arterial compression.
Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term alleviation of symptoms (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization is achieved and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable.
Digital motion X-Ray C1 – C2
The way we assess cervical instability is by Digital Motion X-Ray. The DMX is a movie of the movement of the bones with various neck motions. When you watch the video, you will see a moving image of this patient’s neck. This gives our clinicians insight into the patient’s range of motion where impingement or compression may be occurring.
- Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
- The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine.
- This is treated with Prolotherapy injections to the posterior ligaments that can cause instability.
- At 0:40 of this video, a repeat DMX is shown to demonstrate the correction of this problem.
You can also visit this page on our site for more information on Digital Motion X-ray (DMX)
Non-surgical treatment – Cervical Spine Stability and Restoring Lordosis -Making a case for regeneration and repair of the spinal ligaments
Utilizing these techniques this is the current outcome of our 28-year old male patient:
- After the first series of treatments, the patient reported that his neck pain and symptoms felt 15% better. As a side note, the patient also had his knee treated with Prolotherapy and noted a 50% improvement in pain and function.
- In the first three weeks following treatment, his gastroesophageal reflux symptoms were improved by 40%. He also noted he could go to sleep earlier as he did not have to wait until he felt confident that when he laid down in bed he would get reflux. He felt his digestion was moving through his digestive track smoother. He had not had a headache since the first treatment (though he normally got them several times a week). There was also improvement in his crepitation.
He had one more treatment and had to stop treatments because of a job transfer. It has now been four months since his last treatment and he notes continual improvement in all of his neck related symptoms including those related to his severe pyloric stenosis.
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and it helped answer many of the questions you may have surrounding Pyloric stenosis and digestive conditions in the adult patient. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
Please visit the Hauser Neck Center Patient Candidate Form
1 Hassan SM, Mubarik A, Muddassir S, Haq F. Adult idiopathic hypertrophic pyloric stenosis-a common presentation with an uncommon diagnosis. Journal of community hospital internal medicine perspectives. 2018 Mar 4;8(2):64-7. [Google Scholar]
2 Hauser R, Steilen-Matias D, Fisher P. Upper cervical instability of traumatic origin treated with dextrose prolotherapy: a case report. Journal of Prolotherapy. 2015;7:e932-e935.
3 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]