Cyclic vomiting syndrome

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For the disease caused by cannabinoids, see Cannabinoid hyperemesis syndrome.
Cyclic vomiting syndrome
Other namesCyclical vomiting syndrome
SpecialtyGastroenterology

Cyclic vomiting syndrome (CVS) is a

oral medication. Emetic or vomiting phase is characterized as intense persistent nausea, and repeated vomiting typically lasting hours to days. Recovery phase is typically the phase where vomiting ceases, nausea diminishes or is absent, and appetite returns. "Cyclic vomiting syndrome (CVS) is a rare abnormality of the neuroendocrine system that affects 2% of children."[1] This disorder is thought to be closely related to migraines and family history of migraines.[2][3]

Signs and symptoms

Adults Children
Mean age of diagnosis 29–34 years old 3–7 years old
Mean duration of episodes 3–6 days few hours to 4 days
Mean Inter-episodic duration 1–3 months 1 week to 1 month
Presence of Prodrome phase common common
Recovery time lasting several days lasting hours to days
Vomiting universal up to 6 times an hour universal up to 6 times an hour
Abdominal pain common (57–70%) common (68–80%)
Upper Gastrointestinal Complications common (38%) common (22–32%)
Headaches common common
Fever not common not common
Dehydration needing IV fluids common common with longer attacks
Family history with migraines common (30–70%) common (40–89%)
Psychiatric disorders common common
Inter-episodic nausea/pain common rare
Mitochondrial DNA disorders not reported reported
Cannabis use reported not reported
Unpleasant triggers common (67%) common harder to pinpoint

Affected individuals may vomit or

fatigue or experience muscle pain. In approximately half of cases the attacks, or episodes, occur in a time-related manner. Each attack is stereotypical; that is, in any given individual, the timing, frequency and severity of attacks is similar. Some affected people experience episodes that progressively get worse when left untreated, occurring more frequently with reduced symptom free phase.[5]

Episodes may happen every few days, every few weeks or every few months, for some happening at common uniform times, typically mornings.

stresses, both positive and negative.[citation needed
]

An affected person may also be light-sensitive (photophobic), sound-sensitive (phonophobic) or, less frequently, temperature- or pressure-sensitive during an attack.[6] Some people also have a strong urge to bathe in warm or cold water. In fact, many people with CVS experience a compulsion to be submerged in hot water, and end up taking several baths during the duration of an episode. For some the psychological compulsion to be in hot water is so extreme that they cannot stop themselves from taking very long baths in near scalding hot water several times per day. For some of these people, they may have just finished taking a lengthy bath in extremely hot water and immediately feel this compulsion again and end up taking another bath right after drying off. Some people with the condition experience insomnia, diarrhea (GI complications), hot and cold flashes, and excessive sweating before an episode. Some report that they experience a restless sensation or stinging pain along the spine, hands, and feet followed by weakness in both legs. Some of these symptoms may be due to dehydration or hypokalemia from excessive vomiting, rather than the underlying cause of CVS.

Genetics

There is no known genetic pathogenesis for CVS. Recent studies suggest many affected individuals have a family history of related conditions, such as migraines, psychiatric disorders and gastrointestinal disorders. Inheritance is thought to be maternal, a possible genetic

base-pair and DNA rearrangements in the mitochondrial DNA (mtDNA) have been associated with these traits.[7][8]

Diagnosis

The cause of CVS has not been determined and there are no diagnostic tests for CVS. Several other medical conditions, such as cannabinoid hyperemesis syndrome (CHS), can mimic the same symptoms, and it is important to rule these out. If all other possible causes have been excluded, a diagnosis of CVS using Rome criteria by a physician may be appropriate.[5]

Once formal investigations to rule out gastrointestinal or other causes have been conducted, these tests do not need to be repeated in the event of future episodes.[6]

Diagnostic criteria

Due to the lack of specific biomarkers available for the disorder, and if all other possible causes can be ruled out (such as

Rome IV process criteria in order to diagnose patients.[5]
Patients must meet all three of the following criteria to receive diagnosis:

  1. Stereotypical episodes of acute vomiting each with a duration of less than 1 week
  2. A history of at least three discrete episodes in the prior year and at least two episodes in the past 6 months, each occurring at least 1 week apart
  3. An absence of vomiting between episodes, but other milder symptoms can be present between cycles

Criteria must be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. A history of family history of migraine headaches can also be used in facilitating diagnosis.[9]

Treatment

Treatment for cyclic vomiting syndrome depends on the evident phase of the disorder.[10]

Because the symptoms of CVS are similar (or perhaps identical) to those of the disease well-identified as "abdominal migraine," prophylactic migraine medications, such as topiramate and amitriptyline, have seen recent success in treatment for the prodrome and vomiting phases, reducing the duration, severity, and frequency of episodes.[11]

Therapeutic treatment for the prodromal phase, characterized by the anticipation of an episode, consists of

sumatriptan (nasal or oral) an anti-migraine medication, anti-inflammatory drugs to reduce abdominal pain, and possible anti-emetic drugs. These options may be helpful in preventing an episode or reducing the severity of an attack.[12][13]

The most common therapeutic strategies for those already in the vomiting phase are maintenance of salt balance by appropriate intravenous fluids. Sedation via high dose intravenous benzodiazepines, typically lorazepam, has been shown to shorten the length of emergency department stays for some patients.[14] Having vomited for a long period prior to attending a hospital, patients are typically severely dehydrated. For a number of patients, potent anti-emetic drugs such as ondansetron (Zofran) or granisetron (Kytril), and dronabinol (Marinol) may be helpful in either preventing an attack, aborting an attack, or reducing the severity of an attack.[15] Many patients seek comfort during episodes by taking prolonged showers and baths typically quite hot. The use of a heating pad may also help reduce abdominal pain.[2]

Lifestyle changes may be recommended, such as extended rest, reduction of stress, frequent small meals, and to abstain from fasting. A diet change may be recommended avoid food allergens, eliminating trigger foods such as chocolates, cheese, beer, and red wine.[16][3]

Some patients experience relief from inhaled isopropyl alcohol.[17]

Intravenous Haloperidol may be an effective treatment.[18]

Prognosis

Fitzpatrick et al. (2007) identified 41 children with CVS. The mean age of the sample was 6 years at the onset of the syndrome, 8 years at first diagnosis, and 13 years at follow-up. As many as 39% of the children had resolution of symptoms immediately or within weeks of the diagnosis. Vomiting had resolved at the time of follow-up in 61% of the sample. Many children, including those in the remitted group, continued to have somatic symptoms such as headaches (in 42%) and abdominal pain (in 37%).[19]

Most children who have this disorder miss on average 24 school days a year.[16] The frequency of episodes is higher for some people during times of excitement.[16] Charitable organizations to support affected people and their families and to promote knowledge of CVS exist in several countries.

A 2005 study by Fleisher et al. identified 41 adults who had been previously seen for complaints compatible with CVS. The average age at presentation of the sample was 34 years, and the mean age at onset was 21 years. The mean duration of the CVS at the time of consultation was 12 years. Of the 39 patients surveyed, 85% had episodes that were fairly uniform in length. Most patients reported these attacks in the morning hours. Of those 39 patients, 32% were completely disabled and required financial support due to CVS. Despite this, data suggests that the prognosis for CVS is generally favorable.[2]

Complications can include dehydration,

esophageal tear.[20]

Epidemiology

The average age at onset is 3–7 years, with described cases as young as 6 days and as old as 73 years.[21] Typical delay in diagnosis from onset of symptoms is 3 years.[21] Females show a slight predominance over males.[21]

One study found that 3 in 100,000 five-year-olds are diagnosed with the condition.[22] Two studies on childhood CVS suggest nearly 2% of school-age children may have CVS.[23][24]

History

Cyclic vomiting syndrome was first described in France by Swiss physician Henri Clermond Lombard[25] and first described in the English language by pediatrician Samuel Gee in 1882.[26]

It has been suggested that Charles Darwin's adult illnesses may have been due to this syndrome.[27][further explanation needed]

See also

References

  1. S2CID 19343777
    .
  2. ^
    PMID 16368014
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  3. ^
    S2CID 8718836
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  4. S2CID 295292
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  5. ^
    S2CID 3324893
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  6. ^
    S2CID 25060114
    .
  7. ^ "Cyclic vomiting syndrome?". medlineplus.gov. US: National Institutes of Health. Retrieved 1 September 2022.
  8. PMID 25332060
    .
  9. ^ "Rome IV Criteria". Rome Foundation. 16 January 2016. Archived from the original on 23 July 2022. Retrieved 23 July 2022.
  10. ^ "Cyclic Vomiting Syndrome: Symptoms, Diagnosis, Treatment & Causes". Cleveland Clinic. Retrieved 2021-03-17.
  11. PMID 22302150
    .
  12. PMID 19911235
    .
  13. PMID 24129856
    .
  14. ISSN 0002-9270
    .
  15. ^ "Understanding Cyclic Vomiting Syndrome Doctor Q&A". Migraine Again. 2021-01-26. Retrieved 2021-03-17.
  16. ^
    S2CID 3910188
    .
  17. ^ "Inhaled Isopropyl Alcohol Superior to Oral Ondansetron as an Antiemetic". New England Journal of Medicine Journal Watch jwatch.org. 2018-03-09.
  18. PMID 34141040
    .
  19. S2CID 25698609
    .
  20. ^ "Cyclical vomiting syndrome". NHS Gov.UK. 2017-10-18.
  21. ^
    PMID 14562585
    .
  22. S2CID 22054244
    .
  23. S2CID 20399340
    .
  24. PMID 14024194
    .
  25. ^ Lombard HC (1861). "Description d'une névrose de la digestion, caractérisée par des crises périodiques de vomissements et une profonde modification de l'assimilation". Gazette Médicale de Paris: 312.
  26. ^ Gee S (1882). "On fitful or recurrent vomiting". St Bartholomew Hospital Reports. 18: 1.
  27. S2CID 32616636
    .

Further reading

External links
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