Cyclic vomiting syndrome (CVS) is a chronic disorder of gut-brain interaction (DGBI) diagnosed by clinical criteria called Rome criteria as there are no biomarkers (blood tests or x-ray tests) that can be used to detect this condition.
CVS is common and affects about 2% of the US population. CVS affects both sexes and can occur at all ages. CVS includes stereotypic episodes of severe nausea and vomiting that can last from a few hours up to a week. Other symptoms include abdominal pain, feelings of panic, feeling hot and cold, sweats and diarrhea.
CVS can be quite debilitating and has a significant negative impact on patients, families, and the healthcare system. Short-term disability and absenteeism from work and school are common. There is a significant cost burden due to CVS for both the patient as well as the health care system. Further funding and research to better understand the cause of CVS and develop better treatment are critical to improving outcomes.
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Unfortunately, patients with these symptoms may go for years without a correct diagnosis. Initially, patients may be thought to have viral gastroenteritis. However, characteristically these patients often have repeated trips to Emergency Departments seeking relief of the vomiting and the often-accompanying abdominal pain and dehydration. Lack of awareness of this syndrome in adults often delays the diagnosis of CVS. Fortunately, this is being corrected, as more information is becoming available.
The symptom episodes of CVS tend to follow the same pattern for each individual patient over time. The symptom episodes are characterized by four phases:
- prodromal phase- During this phase, the patient may experience intense sweating and nausea or feel like an episode of vomiting is about to start.
- emetic (vomiting phase)- This phase is characterized by intense, persistent nausea, vomiting, and other symptoms (abdominal pain, prostration, and lethargy). This phase lasts from hours to days.
- recovery phase- This phase begins with the settling down of nausea and ends when hunger, tolerance of oral intake, and vigor return to normal.
- inter-episodic phase- This phase occurs between vomiting episodes when the patient is relatively symptom-free. This phase typically lasts weeks to months
Though many patients return to normal health in between episodes, some patients continue to experience mild nausea and/or abdominal pain in between episodes. In addition, patients with CVS also have other comorbidities such as migraine headaches, autonomic dysfunction, anxiety, and depression which need to be identified and managed.
There have been several recent studies of adult patients with cyclic vomiting syndrome. The most uniform feature of the patients in one study was the stereotypical nature of the nausea, vomiting, and abdominal pain with intermittent symptom free periods. The abdominal pain appears to be more pronounced in the adult patients than in pediatric patients. The ages of patients ranged from 18 to 62 years, indicating that many characteristics of CVS are similar irrespective of age of the patient.
The cause of CVS is not known. However, important advances are being made in the clinical understanding of this disorder which may open the way for new treatments.
Treatment of cyclic vomiting syndrome remains largely based on clinical experience. In general, the treatment approach to a patient with CVS should include consideration of lifestyle changes including avoidance of potential triggering factors, drug therapy to prevent subsequent episodes, abortive and/or supportive care treatment during acute episodes, and support of the family.
Medication treatment for patients with CVS is often divided into acute treatment of the vomiting episodes and chronic treatment to try to prevent the episodes. There is a lack of data on the outcomes of patients, particularly adult patients with CVS, to different types of treatment.
A variety of agents are often tried to reduce the nausea and vomiting during the vomiting phase. Antiemetic agents can reduce the severity of episodes and are best used in conjunction with sedatives. This may include the antiemetic agents – prochlorperazine (Compazine) and ondansetron (Zofran). Patients with CVS may respond well to intravenous lorazepam (Ativan), an anti-anxiety medication. Antimigraine triptans can also be used to try to abort episodes.
Tricyclic antidepressants, although not classified as antiemetic agents, can prevent nausea and vomiting since they appear to influence the brain’s regulation of the vomiting process. Tricyclic agents play a favorable role in migraine, depression, anxiety, and the abdominal pain associated with irritable bowel syndrome (IBS). They appear to be appropriate therapy to try for the potentially complex disease mechanisms of CVS. Prophylactic antimigraine and anticonvulsive agents are also used to prevent episodes.
It is helpful to have an organized approach to treat these patients in the emergency room where they often need to go for treatment of the acute vomiting phase.
If you have CVS, having a letter from your physician to always have with you that describes the syndrome and the appropriate personal treatment can be very helpful. It can help avoid delays in diagnosis and appropriate treatment in the event you need emergency treatment.
Anticipatory support and early treatment intervention are cornerstones to the treatment of CVS.
Cyclic vomiting syndrome can occur in adults as well as children and is an increasingly recognized disorder. Important advances are being made in our clinical understanding of this disorder. New treatments are becoming available. Long-term outcomes and the natural history of cyclic vomiting syndrome in adults will require more studies.
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Adapted from IFFGD Publication: Cyclic Vomiting Syndrome in Adults by Farid Namin, MD, Center for Gastrointestinal Nerve and Muscle Function, University of Kansas Medical Center, Kansas City, KS; Richard W. McCallum, MD, Associate Professor and Founding Chairman of Internal Medicine; Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX; Kathleen Adams, President and Research Liaison, Cyclic Vomiting Syndrome Association; Henry P. Parkman, MD, Associate Professor of Medicine and Physiology, Temple University School of Medicine, Philadelphia, PA.