Cyclic Vomiting Syndrome: Causes, Tests and Treatment Options
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Causes Outlook What is intractable vomiting? Stomach Flu Remedies. Top 16 Ways to Get Rid of Nausea. Read this next. Nausea and Vomiting. How to Fall Asleep in 10, 60, or Seconds You can do a lot of prep work to make the perfect sleep environment. Do You Live with Anxiety? Therefore, the diagnosis for CVS is more frequently delayed in adults than in children.
However, in a study by Prakash et al. The only difference was the duration of vomiting episodes that lengthened progressively from infancy into adulthood. Migraine and motion sickness are commonly associated with vomiting episodes of CVS.
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Epilepsy is approximately 10 times more common in CVS patient than in general population. Children with CVS often accompany psychiatric disorders such as anxiety disorders or depression. Therefore, the diagnosis of CVS should be done very carefully, ruling out all possible organic causes of cyclic vomiting. Clinically differential diagnosis of CVS includes gastrointestinal disorders such as bowel obstruction, inflammatory disease of gastrointestinal tracts, pancreatic diseases, and hepatobiliary diseases; infectious diseases such as parasite infestation and protozoa infection, otitis media, chronic sinusitis, and hepatitis; neurologic disorders such as migraine, epilepsy, and space occupying CNS lesions; metabolic and endocrine disorders such as diabetes mellitus, Addison disease, pheochromocytoma, aminoaciduria, organic aciduria, fatty acid oxidation disorders, mitochondrial disorders, and urea cycle defects; medications and toxins such as antibiotics, NSAIDs, laxatives, high dose fat soluble vitamins, hormones, etc.
The etiology and pathogenesis of CVS still remain unknown.
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It is assumed that various factors can affect the development of vomiting episodes in CVS, and severe hypotheses have been suggested as possible etiologies: migraine variant, 27 mitochondrial diseases including mitochondrial fatty acid oxidation disorders, 28 , 29 gastrointestinal motility disorder, 30 corticotropin-releasing factor in response to stress, 31 disorder of the brain-gut axis, 32 autonomic dysfunction, 33 abdominal epilepsy, ion channel dysfunction, and altered psychodynamics, etc. Recent concept on CVS is mitochondrial energy depletion due to mitochondrial mutation along with precipitating stress or excitement may predispose the onset of vomiting episodes in patients with CVS.
Food allergy was also suggested as a possible pathogenesis of CVS by Lucarelli et al. However, there have been no more studies on the relationship between CVS and food allergy; it is yet controversial.
Thorough history taking and physical examination are essential to diagnose the CVS and to rule out organic diseases causing cyclic vomiting. Alarm symptoms and signs are important clues for the differential diagnosis of cyclic vomiting in children. Suspicious alarm symptoms and signs clinically suggestive of organic diseases are bilious vomiting, severe abdominal pain accompanied by abdominal tenderness, hematemesis, attacks precipitated by acute illness and prior fasting or high protein meal, neurologic symptoms and signs such as irritability, altered mental status, seizure, abnormal eye movements, papilledema, and motor asymmetry , and progressively worsening vomiting episodes.
Laboratory studies including complete blood count, liver function tests, electrolytes, glucose, blood urea nitrogen, creatinine, amylase, lipase, ammonia, urinalysis, and pregnancy test for adolescents, are basically recommended in all patients. Laboratory metabolic findings include hypoglycemia, substantial anion gap metabolic acidosis, respiratory alkalosis, or hyperammonemia especially during vomiting episodes.
Barium contrast study of upper gastrointestinal tract with small bowel follow through, abdominal sonography, or abdominal computed tomography are useful radiologic methods to find out organic lesions possibly which can cause cyclic vomiting features. Barium studies are usually performed to rule out organic gastrointestinal diseases including chronic intestinal pseudo-obstruction and malrotation. If a patient reveals neurologic manifestations, electroencephalography and brain magnetic resonance imaging can be excellent diagnostic tools to detect intracranial abnormalities.
Recommended diagnostic algorithm of the CVS in children is shown in Figure 1.
When children diagnosed as CVS begin to manifest prodromal symptoms, various therapeutic trials can be applied to prevent the attack of vomiting episode. These kinds of prophylactic therapy in prodromal phase includes the control of stressful life style lying down in a dark, quiet environment or hot bath , high carbohydrate ingestion, anti-emetic agents ondansetron and granisetron , anti-anxiety agents lorazepam , anti-migraine agents sumatriptan and zolmitriptan , 17 and has been mainly tried in pediatric patients.
However, the effectiveness of these therapies was not proved due to the lack of data.
Cyclic Vomiting Syndrome Management and Treatment | Cleveland Clinic
Recommended medications during prodromal phase of CVS are as follows: 5-HT 3 receptor antagonists ondansetron and granisetron , anti-histamines diphenhydramine , phenothiazines promethazine , benzodiazepines lorazepam , and anti-migraine agent sumatriptan. However, it is recommended to try out this agent as early as possible to terminate an episode in children 12 years and older who have mild episodes less than 1 episode per month. No treatment has been proved to be effective in controlling emetic phase of CVS until now.
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The goal of therapy during emetic phase is the termination of vomiting episodes as soon as possible for a patient to return to usual life and the prevention of complications such as dehydration and electrolyte imbalance, caused by intensive vomiting. In acute phase of emetic episodes, patients should be admitted to the hospital to provide dark, quiet surroundings and to prevent severe dehydration and correct electrolyte imbalance with hydration of intravenous fluids.
Gastric acid suppressing agents including proton pump inhibitors omeprazole and H 2 receptor antagonists ranitidine may be helpful in preventing mucosal damage of the esophagus. Intravenous anxiolytic agent, lorazepam 0.
Who can get CVS?
Intravenous injection of 5-HT 3 receptor antagonists ondansetron 0. The goal of long-term prophylactic therapy of CVS is to prevent repetitive vomiting episodes or to decrease the severity of symptoms during episodes, thus, allowing patients to continue normal life.
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Prophylaxis of symptomatic vomiting episodes is focused on the identification and avoidance of triggering factors and prophylactic drugs. If precipitants causing vomiting episodes can be identified in each patient, it may be possible to prevent the attacks of episodes by avoiding stressful events, infection, specific foods, sleep deprivation, triggering foods chocolate and cheese , and motion sickness.
Medical prophylaxis in children with CVS is composed of various medicines that are known to be somewhat effective in preventing vomiting episodes: amitriptyline, cyproheptadine, propranolol, etc. Table 5. Based on the similarity in clinical features between CVS and migraine, anti-migraine agents cyproheptidine, pizotifen, propranolol, etc. Tricyclic anti-depressive agent, amitriptyline is more effective as prophylactic drugs in children older than 5 years and adults. Although most prophylactic medications are relatively safe even in children, heart rate monitoring and electrocardiogram monitoring are required while administering and dosing up propronolol and amitriptyline because these drugs can cause bradycardia and arrhythmia, respectively, as side effects.
There were several trials on other prophylactic agents. In a study by Vanderhoof et al. Anti-epileptic drugs were not effective regardless of electroencephalogram finding, however, a few studies are reporting the efficacy of valproic acid 42 and phenobarbital. Recently, alternative prophylactic medications including coenzyme Q10 and carnitine are suggested to be possibly effective.
Review article: cyclic vomiting syndrome in adults – rediscovering and redefining an old entity
It is difficult to predict the response to medication in individuals. Therefore, various factors that can affect the efficacy of therapy, that is, age, co-morbid diseases, drug dosage, and adverse effects of drugs, should be considered before initiating prophylactic medication. However, long-term prophylactic strategies are not confirmed yet. Further studies are needed in the future on the effective prophylaxis of CVS based on its pathogenesis. It is not easy to predict clinical course and long-term outcome of CVS in children due to lack of data.
Many patients eventually recover from CVS, but some patients suffer from migraine headache later. And, vomiting episodes are repeated even in adulthood in more than one third of CVS children. Because CVS is a relatively common functional gastrointestinal disorder in children, we should be careful in approaching the patients manifesting cyclic vomiting.
CVS has its own unique clinical features of recurrent severe vomiting episodes and intervening wellness, which can affect long-term morbidity in patients. Early diagnosis applying the diagnostic criteria for CVS to rule out organic diseases is important in patients. Recommended therapeutic strategies for CVS are targeting the reduction of symptoms and complications in prodromal phase and emetic phase.
Long-term prophylaxis is focused on the prevention of vomiting episodes. 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.
Lifestyle changes may be recommended, such as extended rest and reduction of stress. Some patients experience relief from inhaled isopropyl alcohol. Fitzpatrick et al. 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. Most children who have this disorder miss on average 24 school days a year. There is little hard evidence of death as a result of the condition. However, in severe cases the fluid loss can lead to potentially life-threatening electrolyte imbalances. The patient can also become malnourished if the attacks last too long without adequate replenishment of nutrients.
With adequate medical interventions, most patients can be properly supported during an episode. The average age at onset is 3—7 years, but CVS has been seen in infants who are as young as 6 days and in adults who are as old as 73 years. It is not clear how common the condition is. However, diagnosis is problematic and, as knowledge of CVS has increased in recent years, more and more cases are emerging.
Cyclic vomiting syndrome was first described in France by Swiss physician Henri Clermond Lombard  and first described in the English language by pediatrician Samuel Gee in It has been suggested that Charles Darwin's adult illnesses may have been due to this syndrome. From Wikipedia, the free encyclopedia.