Cyclic Vomiting Syndrome

I know that those of you looking forward to celebrating (in a responsible and socially distant manner) the 4th of July may be expecting a Morsel that is thematically appropriate (ex, Sparkler Injuries). That seems too quaint in times like these though. Today, it seems more appropriate to discuss topics that involve repetitive, unrelenting, and gut-wrenching topics: The Ground Hog Day of medicine. Which leads us to today’s Morsel – Cyclic Vomiting Syndrome:

Cyclic Vomiting Syndrome: Basics

  • Cyclic Vomiting Syndrome (CVS) was 1st described in 1882 (so we didn’t just invent this one yesterday). [Gui, 2019; Donnet 2018]
    • Actually, first mentioned in 1806!
  • CVS has consequences: [Gui, 2019; Donnet 2018]
    • Increased rates of ED visits and hospitalizations
    • Lower Quality of Life Inventory than healthy controls or even those with Inflammatory Bowel Disease.
    • Increased risk for developing migraine in adulthood.
  • It is often misdiagnosed initially. [Gui, 2019; Donnet 2018]
    • Peak prevalence occurs between ages 2 and 7 years.
    • Mean age of diagnosis, though, is 8 – 9.5 years.
    • Can persist into adulthood.
  • CVS is characterized by: [Gui, 2019; Donnet 2018]
    • Acute attacks of vomiting
    • Attacks lasting hours to day
    • CVS attacks typically occur at the same time of the day (often late night / early morning).
    • Cyclic vomiting attacks are eventually followed by symptom-free periods.
    • Symptoms may vary between patients, but are often stereotypical for an individual.
  • The underlying etiology/etiologies are not fully understood, but likely multifactorial and involve: [Gui, 2019; Donnet 2018]
    • Aberrant brain-gut pathways associated with migraines
    • Mitochondrial abnormalities
    • Calcium channel abnormalities
    • Hyperactive hypothalamic-pituitary-adrenal axis
  • CVS has two sets of of diagnostic criteria: [Gui, 2019; Donnet 2018]
    • ROME IV Criteria: a gastroenterological resource
    • International Classification of Headache Disorders (ICHD) – III: a neurologic resource
    • Both criteria include measures of vomiting attacks and durations, but vary slightly.
    • In the end… understand that there are criteria (it isn’t something someone is just diagnosed as having because they have recurrent vomiting).
  • The Differential Dx list is extensive, and CVS is often a diagnosis of exclusion: [Gui, 2019; Donnet 2018]

Cyclic Vomiting Syndrome: Phases

  • The episodic nature of CVS leads to predictable phases of the condition. [Gui, 2019; Donnet 2018]
    • The duration of each phase can vary.
    • Therapies are often best if tailored for the individual’s specific phase.
  • Interepisodic Phase [Gui, 2019; Donnet 2018]
    • Symptom free period.
    • The absence of symptoms between attacks is a key feature of CVS.
    • Those who have unremitting symptoms need to be considered to have alternative Dx.
    • Prophylaxis to prevent / decrease attacks:
      • Propranolol
      • Cyprohepatdine
      • Amitriptyline
  • Prodromal Phase [Gui, 2019; Donnet 2018]
    • Begins in the hours before the onset of acute episode.
    • Main symptoms:
      • Severe nausea (although very young may have hard time describing this)
      • Pallor
      • Fatigue
      • Abdominal Pain
    • Abortive Therapies:
      • Antimigraine medications – Sumatriptan or Frovatriptan
      • Antiemetics – Ondansetron
      • Sedatives – Lorazepam (used in conjunction with Ondansetron)
  • Vomiting Phase [Gui, 2019; Donnet 2018]
    • 75% of the time begins in the late night / early morning hours
    • Characterized by persistent nausea, intense vomiting, and retching.
    • Vomiting frequency is highest within 1st hour and then slowly declines.
    • Rescue Therapies:
      • Antiemetics – Ondansetron, Prochlorperazine (+ diphenhydramine)
      • Sedatives – Lorazepam (used in conjunction with Ondansetron)
      • Dextrose containing IV fluids and electrolyte repletion
  • Recovery Phase [Gui, 2019; Donnet 2018]
    • Begins with remission of nausea.
    • Most notable hallmark is increased sleep (makes sense).
    • Continues until return of strength and appetite and recovery of any weight lost during acute episode.
    • Therapies aimed to assist with recovery:
      • Rest
      • Dextrose containing IV fluids and electrolyte repletion as needed.

Moral of the Morsel

  • Recurrent is not Cyclical. Do not overlook the large Ddx of vomiting!
  • Ask about the pattern. The Stereotype may be best defined by the family.
  • Break the Cycle! Antiemetic alone may not be sufficient. Low dose sedative and dextrose containing fluids can help!
  • Think about migraines! They may, in fact, be linked.

References

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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