Cyclic Vomiting Syndrome

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Cyclic Vomiting Syndrome

 

Definition

Cyclic vomiting syndrome (CVS) is a rare idiopathic disorder characterized by recurring periods of vomiting in an otherwise normal child or adult. It was first described in 1882 by a physician named Gee. CVS is sometimes called abdominal migraine because it may be caused by some of the same mechanisms in the central nervous system that cause migraine headaches.

Description

Children in the pre-school or early school years are most susceptible to CVS, although it can appear anywhere from infancy to adulthood. One doctor reports that 43 of the 233 patients with CVS that he has treated were adults when their symptoms began. The average age of patients at onset is 5.2 years, but CVS has been diagnosed in patients as old as 73. This disorder was identified over a century ago, but its cause is still unknown. Episodes can be triggered by emotional stress or infections (particularly sinusitis), can last hours or days, and can return at any time. Abdominal pain is a frequent feature.
CVS appears to affect all races equally. The female:male ratio has been reported as 11:9.

Causes and symptoms

The cause of CVS is still a mystery. Similarities to migraine suggest a common cause, but as yet no firm evidence has surfaced. It is known, however, that 82% of patients with CVS have a family history of migraine compared to 14% of control subjects. Patients can usually identify some factor that precedes an attack. Vomiting can be protracted and lead to such complications as dehydration, chemical imbalances, and tearing, burning, and bleeding of the esophagus (swallowing tube). Between attacks, there is no sign of any illness.
CVS has four distinct stages or phases:
  • Prodrome. A prodrome is a warning symptom (or group of symptoms) that appears just before an acute attack of an illness. Patients with CVS often feel pain in the abdomen a few minutes or hours before the vomiting starts. Adults with CVS often have anxiety or panic attacks as a prodrome.
  • Episode phase. During this phase, the patient is actively nauseated and vomiting. He or she may also feel drowsy or exhausted.
  • Recovery phase.
  • Symptom-free interval.

Diagnosis

The most important and difficult aspect of CVS is to be sure there is not an acute and life-threatening event in progress. So many different diseases can cause vomiting—from bowel obstruction to epilepsy—that an accurate and timely diagnosis is critical. Because there is no way to prove the diagnosis of CVS, the physician must instead disprove every other diagnosis. This process, which is known as a diagnosis of exclusion, can be tedious, expensive, exhausting, and involve almost every system in the body. The first episode may be diagnosed as a stomach flu when nothing more serious turns up. Only after several episodes and several fruitless searches for a cause will a physician normally consider the diagnosis of CVS.
A careful history-taking is critical to making the correct diagnosis of CVS. A family history of migraine, particularly on the mother's side of the family, should alert the doctor to the possibility that the patient has CVS.
In some cases, the doctor may refer the patient to a psychiatrist for evaluation in order to rule out anxiety disorders or an eating disorder.

Treatment

Several different medications have given good results in small trials. The antimigraine drugs amitriptyline and cyproheptadine performed well for one study group. Propranolol is sometimes effective, and erythromycin helped several patients in one study, not because it is an antibiotic but because it irritates the stomach and encourages it to move its contents forward instead of in reverse.
Another medication that has been reported to be successful in treating children with CVS is dexmedetomidine (Precedex), a drug originally developed to sedate patients on respirators in intensive care settings. The researchers found that dexmedetomidine relieved the anxiety as well as the nausea associated with CVS.

Alternative treatment

Constitutional homeopathic medicine can work well in treating CVS because it addresses rebalancing the whole person, not just the symptoms.
According to a 1999 article in the journal Medical Acupuncture, weekly outpatient acupuncture treatments are also helpful to some children with CVS.

Prognosis

The disease may go on for many years without a change in pattern. If the acute complications of prolonged vomiting can be successfully prevented or managed, most patients can lead normal lives between episodes. Medications may ease the symptoms during attacks.

Resources

Periodicals

Fleisher, David R., MD. "Cyclic Vomiting Syndrome in Adults." Code "V": The Official Newsletter of the CVSA—USA/Canada 11 (Spring 2003): 1-3.
Khasawinah, T. A., A. Ramirez, J. W. Berkenbosch, and J. D. Tobias. "Preliminary Experience with Dexmedetomidine in the Treatment of Cyclic Vomiting Syndrome." American Journal of Therapeutics 10 (July-August 2003): 303-307.
Li, B. U., and L. Misiewicz. "Cyclic Vomiting Syndrome: A Brain-Gut Disorder." Gastroenterology Clinics of North America 32 (September 2003): 997-1019.
Lin, Yuan-Chi, MD, and Brenda Golianu, MD. "Acupuncture as Complementary Treatment for Cyclic Vomiting Syndrome." Medical Acupuncture 13 (March 1999): 1-4.
Sundaram, Shikha, MD, and B. Uk Li, MD. "Cyclic Vomiting Syndrome." eMedicine August 10, 2002. http://www.emedicine.com/ped/topic2910.htm.

Organizations

Cyclic Vomiting Syndrome Association in the United States and Canada (CVSA—USA/Canada). 3585 Cedar Hill Road, NW, Canal Winchester, OH 43110. (614) 837-2586. http://www.cvsaonline.org.
National Organization for Rare Disorders, Inc. (NORD). 55 Kenosia Avenue, P. O. Box 1968, Danbury, CT 06813. (800) 999-6673 or (203) 744-0100. http://www.rarediseases.org.

Other

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Cyclic Vomiting Syndrome. NIH Publication No. 01-4548. Bethesda, MD: NIDDK, 2001. http://digestive.niddk.nih.gov/ddiseases/pubs/cvs/index.htm.

Key terms

Abdominal migraine — Another term that is sometimes used for CVS.
Idiopathic — Of unknown cause or spontaneous origin. CVS is sometimes called an idiopathic disorder because its cause(s) are still not known.
Prodrome — A symptom or group of symptoms that appears shortly before an acute attack of illness. The term comes from a Greek word that means "running ahead of."
References in periodicals archive ?
I have a debilitating disorder, cyclical vomiting syndrome, which is rare and more typical in children.
I have suffered with cyclical vomiting syndrome for 10 years - but was only diagnosed in 2017.
Caitlin White from Perth, Scotland, is suffering from a rare condition called cyclical vomiting syndrome and severe gastroparesis.
Conditions associated with vomiting cycles include: cyclical vomiting syndrome, associated with a family history of migraines and psychological stressors; hyperemesis gravidarum, which occurs during pregnancy; psychogenetic vomiting, typically associated with major depression disorder and conversion disorder; bulimia, associated with induced and purgative vomiting; Addison's disease, associated with chronic fatigue, weight loss, hyperpigmentation, hypotension, hyponatremia and hypercalcemia; and even acute migraine signs (Wallace, Andrews, Garmany & Jelley, 2011).
-- At least five episodic syndromes in children can precede pediatric and adult migraine, including infant colic, benign paroxysmal torticollis, benign paroxysmal vertigo, abdominal migraine, and cyclical vomiting syndrome, said Dr.
(8.) Kothare SV Efficacy of flunarizine in the prophylaxis of cyclical vomiting syndrome and abdominal migraine.
Montana, from Sheldon in Birmingham, suffers from a rare condition called Cyclical Vomiting Syndrome which can be triggered by anything from stress to excitement.
Efficacy of funarizine in the prophylaxis of cyclical vomiting syndrome and abdominal migraine.
Abdominal migraine is a brain-gut disorder and is considered to be a spectrum of disorder with cyclical vomiting syndrome and cranial migraine.
Of those, patients who suffer from psychological distress are even more likely to suffer long-term from disorders like irritable bowel syndrome, cyclical vomiting syndrome and dyspepsia.
A study conducted by Di Florio and Gouke points out the significant effect of low-dose intravenous infusion of midazolam on treatment of persistent PONV.18 Also, Palmer and Cameron reported a case of successful use of intravenous midazolam and clonidine for treatment of cyclical vomiting syndrome.19 Moreover, Unlugenc et al showed that midazolam was effective for treatment of established PONV and its anti-emetic effect lasted more than its sedative effect.20 A double-blinded trial by Entezariasl and his colleagues reveals that Metoclopramide plus dexamethasone combination significantly decreased nausea and vomiting both in the recovery room and 24 hours afterwards and is recommended for high-risk groups, especially in outpatient surgeries.21