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The patient is a 27-year-old male with chronic nausea after eating that began in mid-2020, following a dengue-like illness (not laboratory-confirmed) during a period of significant stress. For the first two years the nausea came and went, with several spontaneous remissions lasting months at a time. By 2022–2023 it had become a daily, persistent problem.

Careful self-tracking has revealed a consistent pattern: his nausea is driven by meal load. Nausea and bloating rise 30–120 minutes after eating, move together, and scale with how much he eats, how quickly, and how much fat a meal contains. By 2024 he had found that slow, low-fat meals of about 400–450 kcal kept symptoms manageable, while meals above 500–600 kcal reliably triggered them. He has since learned that volume matters as much as calories, and that caloric drinks like juice, sports drinks or broth affect him the same way food does, while the same amount of water does not. His nausea is usually lighter in the morning, builds through the day, and eases when he takes a break from eating. He also has occasional evening vertigo (a spinning sensation), pill- and food-sticking that began in early 2025 and improved when he cut back on pills, and psoriasis on his forehead.

Endoscopy in 2023 showed bile reflux and gastritis, but gastric emptying and abdominal CT were normal. Over 2023–2025, many treatments made things worse, including PPIs (after brief early benefit), rifaximin, betaine HCl, probiotics and gut-lining supplements. A few things reliably helped: rotating herbal antimicrobials (less gas and bloating), digestive enzymes and bitters before meals, regular exercise, and daily vagus-nerve stimulation. By 2025 he had built his life around these strategies, including hiring private chefs to prepare small, low-fat, precisely portioned meals.

In fall 2025, despite near-perfect adherence to everything that had helped, his symptoms became the worst they had ever been. Over November and December he started a bile-reflux regimen (sucralfate, an alginate, a bile-acid binder and ursodiol), cromolyn, and, on December 21, mirtazapine. Mirtazapine helped almost immediately, and January 2026 was his best month in over two years. On a strict routine of small, slow, low-fat meals, daily vagal stimulation, structured workdays, exercise and good sleep, his nausea was often brief and manageable, and he was working long, productive days.

That improvement didn't last. Since around March 2026 his symptoms have worsened again, even though he has been more disciplined than ever. His private-chef meals are now down to about 1 cup and 200–300 kcal, with under 7 g of fat per 400 kcal, eaten slowly and spaced through the day. He uses two vagus-nerve stimulators, exercises daily (gym and soccer), uses a short CBT routine during flares, and keeps his days structured and social. Even so, he lives with a baseline of moderate nausea, is often hungry, and struggles to eat enough to maintain his weight. Targeted medication trials haven't helped: acotiamide (June–September) had no effect, and a week of metoclopramide in September made him feel dramatically worse, improving once he stopped it.

There are encouraging signs. Flares now resolve much faster than they used to, socially engaging and novel days are often nearly symptom-free, and several earlier lab abnormalities (low white-cell counts, a positive ANA and a low gallbladder ejection fraction) have normalized. He continues mirtazapine, which remains his most helpful medication but causes significant drowsiness, and a new medication trial is planned next. The central puzzle remains why small, slowly eaten meals still trigger nausea when his gastric emptying is normal and nearly every lifestyle factor he can control has already been optimized.