Cyclic vomiting syndrome

Cyclic vomiting syndrome
Synonyms	CVS
Pronounce	N/A
Specialty	N/A
Symptoms	Nausea, vomiting, abdominal pain, headache
Complications	Dehydration, esophagitis, tooth decay
Onset	Childhood, but can occur at any age
Duration	Episodes last hours to days
Types	N/A
Causes	Unknown, but may be related to migraines
Risks	Family history of migraines, anxiety, depression
Diagnosis	Based on symptoms and ruling out other conditions
Differential diagnosis	Gastroenteritis, appendicitis, pancreatitis, intestinal obstruction
Prevention	N/A
Treatment	Hydration, anti-nausea medications, migraine treatments
Medication	Ondansetron, sumatriptan, propranolol
Prognosis	Varies; some improve over time, others have chronic episodes
Frequency	Rare
Deaths	Rare, usually due to complications

Cyclic vomiting syndrome

Cyclic vomiting syndrome (CVS) is a chronic functional condition of unknown pathogenesis.

Clinical features

CVS is characterized as recurring episodes lasting a single day to multiple weeks.

Phases

Each episode is divided into four phases: inter-episodic, prodrome, vomiting, and recovery. Inter-episodic phase (symptom free phase), is characterized as no discernible symptoms, normal everyday activities can occur, and this phase typically lasts one week to one month. The prodrome phase is known as the pre-emetic phase, characterized by the initial feeling an approaching episode, still able to keep down 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. This syndrome is most commonly seen in children usually between ages 3 and 7, however adult diagnosis is quite common.

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)%
UGI 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

Sufferers may vomit or retch 6–12 times in an hour and an episode may last from a few hours to over three weeks and in some cases months, with a median episode duration of 41 hours. The main symptoms of cyclic vomiting syndrome are sudden, repeated attacks—called episodes—of severe nausea and vomiting. You may vomit several times an hour. Episodes can last from a few hours to several days. Episodes may make you feel very tired and drowsy. Each episode of cyclic vomiting syndrome tends to start at the same time of day, last the same length of time, and happen with the same symptoms and intensity as previous episodes. Episodes may begin at any time but often start during the early morning hours. Other symptoms of cyclic vomiting syndrome may include one or more of the following:

• retching‚Äîtrying to vomit but having nothing come out of your mouth, also called dry vomiting
• pain in the abdomen
• abnormal drowsiness
• pale skin
• headaches
• lack of appetite
• not wanting to talk
• drooling or spitting
• extreme thirst
• sensitivity to light or sound
• dizziness
• diarrhea
• fever

Cause

• Experts aren‚Äôt sure what causes cyclic vomiting syndrome. However, some experts believe the following conditions may play a role:
• problems with nerve signals between the brain and digestive tract
• problems with the way the brain and endocrine system react to stress
• mutations in certain genes that are associated with an increased chance of getting CVS

Triggers

Triggers for an episode of cyclic vomiting may include:

• emotional stress
• anxiety or panic attacks, especially in adults
• infections, such as colds, flu, or chronic sinusitis
• intense excitement before events such as birthdays, holidays, vacations, and school outings, especially in children
• lack of sleep
• physical exhaustion
• allergies
• temperature extremes of hot or cold
• drinking alcohol
• menstrual periods
• motion sickness
• periods without eating (fasting)
• Eating certain foods, such as chocolate, cheese, and foods with monosodium glutamate External link (MSG) may play a role in triggering episodes.

Diagnosis

Physical exam and tests

Tests

Blood tests such as CBC, CMP, CRP, ESR etc. to look for anemia, dehydration, inflammation, infection, and liver problems. Urinalysis Upper GI endoscopy Your doctor may perform an upper GI endoscopy to look for problems in your upper digestive tract that may be causing nausea and vomiting. Imaging studies: Ultrasound of the abdomen. Gastric emptying test, also called gastric emptying scintigraphy. Upper GI series. MRI scan or CT scan of the brain.

Treatment

Prodrome phase

• ondansetron (Zofran) or promethazine (Phenergan) for nausea
• sumatriptan (Imitrex) for migraines
• lorazepam (Ativan) for anxiety
• ibuprofen for pain
• Your doctor may recommend over-the-counter medicines to reduce the amount of acid your stomach makes, such as
• famotidine (Pepcid)
• ranitidine (Zantac)
• omeprazole (Prilosec)
• esomeprazole (Nexium)

Vomiting phase During this phase, you should stay in bed and sleep in a dark, quiet room. You may have to go to a hospital if your nausea and vomiting are severe or if you become severely dehydrated. Your doctor may recommend or prescribe the following for children and adults: medicines for

• nausea
• migraines
• anxiety
• pain

medicines that reduce the amount of acid your stomach makes If you go to a hospital, your doctor may treat you with intravenous fluids (IV) for dehydration medicines for symptoms

• IV nutrition if an episode continues for several days

Recovery phase During the recovery phase, you may need IV fluids for a while. Your doctor may recommend that you drink plenty of water and liquids that contain glucose and electrolytes, such as

• broths
• caffeine-free soft drinks
• fruit juices
• sports drinks
• oral rehydration solutions, such as Pedialyte

If you’ve lost your appetite, start drinking clear liquids and then move slowly to other liquids and solid foods. Your doctor may prescribe medicines to help prevent future episodes. Well phase During the well phase, your doctor may prescribe medicines to help prevent episodes and how often and how severe they are, such as

• amitriptyline (Elavil)
• cyproheptadine (Periactin)
• propranolol (Inderal)
• topiramate (Topamax)
• zonisamide (Zonegran)

Your doctor may also recommend coenzyme Q10 Levocarnitine (L-carnitine), or riboflavin as dietary supplements to help prevent episodes.

Prevention

Knowing and managing your triggers can help prevent cyclic vomiting syndrome, especially during the well phase. You should also

• get enough sleep and rest
• treat infections and allergies
• learn how to reduce or manage stress and anxiety
• avoid foods and food additives that trigger episodes

Treating complications

dehydration—plenty of liquids with glucose and electrolytes; or IV fluids and hospitalization for severe dehydration esophagitis —medicines to reduce the amount of acid your stomach makes Mallory-Weiss tears —medicines or