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{{Short description|Human disease}} |
{{Short description|Human disease}} |
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{{tone|date=February 2018}} |
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{{For|the disease caused by cannabinoids|Cannabinoid hyperemesis syndrome}} |
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{{Infobox medical condition (new) |
{{Infobox medical condition (new) |
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| name = Cyclic vomiting syndrome |
| name = Cyclic vomiting syndrome |
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| synonyms = Cyclical vomiting syndrome |
| synonyms = Cyclical vomiting syndrome |
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| field = [[Gastroenterology]] |
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'''Cyclic vomiting syndrome''' ('''CVS''') is a chronic [[Functional disorder|functional condition]] of unknown [[pathogenesis]]. CVS is characterized as recurring episodes lasting a single day to multiple weeks. 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 of an approaching episode, still able to keep down oral medication. [[Vomiting|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. |
'''Cyclic vomiting syndrome''' ('''CVS''') is a [[Chronic condition|chronic]] [[Functional disorder|functional condition]] of unknown [[pathogenesis]]. CVS is characterized as recurring episodes lasting a single day to multiple weeks. 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 of an approaching episode, still able to keep down [[Oral Medications|oral medication]]. [[Vomiting|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. "Cyclic vomiting syndrome (CVS)isa rare abnormality of the neuroendocrine system that affects 2% of children."<ref>{{cite journal | vauthors = Lee LY, Abbott L, Mahlangu B, Moodie SJ, Anderson S | s2cid = 19343777 | title = The management of cyclic vomiting syndrome: a systematic review | language = en-US | journal = European Journal of Gastroenterology & Hepatology | volume = 24 | issue = 9 | pages = 1001–6 | date = September 2012 | pmid = 22634989 | doi = 10.1097/MEG.0b013e328355638f }}</ref> This disorder is thought to be closely related to [[migraine]]s and [[Family history (medicine)|family history]] of migraines.<ref name="Cyclic Vomiting Syndrome in 41 adul">{{cite journal | vauthors = Fleisher DR, Gornowicz B, Adams K, Burch R, Feldman EJ | title = Cyclic Vomiting Syndrome in 41 adults: the illness, the patients, and problems of management | journal = BMC Medicine | volume = 3 | issue = 1 | pages = 20 | date = December 2005 | pmid = 16368014 | pmc = 1326207 | doi = 10.1186/1741-7015-3-20 | doi-access = free }}</ref><ref name=":1">{{cite journal | vauthors = Abell TL, Adams KA, Boles RG, Bousvaros A, Chong SK, Fleisher DR, Hasler WL, Hyman PE, Issenman RM, Li BU, Linder SL, Mayer EA, McCallum RW, Olden K, Parkman HP, Rudolph CD, Taché Y, Tarbell S, Vakil N | display-authors = 6 | title = Cyclic vomiting syndrome in adults | journal = Neurogastroenterology and Motility | volume = 20 | issue = 4 | pages = 269–84 | date = April 2008 | pmid = 18371009 | doi = 10.1111/j.1365-2982.2008.01113.x | hdl = 2027.42/72300 | s2cid = 8718836 | hdl-access = free }}</ref> |
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==Signs and symptoms== |
==Signs and symptoms== |
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{{More citations needed section|date=February 2024}} |
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{| class="wikitable" |
{| class="wikitable" |
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!Children |
!Children |
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|Mean age of diagnosis |
|Mean age of [[diagnosis]] |
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|29–34 years old |
|29–34 years old |
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|3–7 years old |
|3–7 years old |
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|Mean duration of episodes |
|Mean duration of episodes |
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|3–6 days |
|3–6 days |
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|few hours to 4 days |
|few hours to 4 days |
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|Recovery time |
|Recovery time |
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|lasting several days |
|lasting several days |
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|lasting hours to days |
|lasting hours to days |
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|Vomiting |
|Vomiting |
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|Abdominal pain |
|Abdominal pain |
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|common ( |
|common (57–70%) |
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|common ( |
|common (68–80%) |
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|- |
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|Upper Gastrointestinal Complications |
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|common (38%) |
|common (38%) |
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|common ( |
|common (22–32%) |
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|Headaches |
|Headaches |
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|common |
|common |
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|Fever |
|[[Fever]] |
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|not common |
|not common |
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|not common |
|not common |
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|Family history with migraines |
|Family history with migraines |
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|common ( |
|common (30–70%) |
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|common ( |
|common (40–89%) |
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|Psychiatric disorders |
|[[Mental disorder|Psychiatric disorders]] |
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|common |
|common |
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|common |
|common |
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|rare |
|rare |
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|Mitochondrial DNA disorders |
|[[Mitochondrial DNA]] disorders |
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|not reported |
|not reported |
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|reported |
|reported |
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|Cannabis use |
|[[Cannabis (drug)|Cannabis]] use |
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|reported |
|reported |
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|not reported |
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Affected individuals may vomit or [[Retching|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.<ref name="Li1999">{{cite journal | vauthors = Li BU, Fleisher DR | s2cid = 295292 | title = Cyclic vomiting syndrome: features to be explained by a pathophysiologic model | journal = Digestive Diseases and Sciences | volume = 44 | issue = 8 Suppl | pages = 13S–18S | date = August 1999 | pmid = 10490033 | doi = 10.1023/A:1026662402734 }}</ref> [[Gastric acid|Stomach acid]], [[bile]] and, if the vomiting is severe, [[haematemesis|blood]] may be vomited. Some with the condition will ingest water to reduce the [[Gastroesophageal reflux disease|irritation of bile and acid on the esophagus]] during emesis. Between episodes, the affected individual is usually normal and healthy otherwise but can be in a weak state of [[Fatigue (medical)|fatigue]] or experience [[myalgia|muscle pain]]. In approximately half of cases the attacks, or episodes, occur in a time-related manner. Each attack is stereotypical; that is, in any given individual, the timing, frequency and severity of attacks is similar. Some affected people experience episodes that progressively get worse when left untreated, occurring more frequently with reduced symptom free phase.<ref name="Bhandari_2018">{{cite journal | vauthors = Bhandari S, Jha P, Thakur A, Kar A, Gerdes H, Venkatesan T | s2cid = 3324893 | title = Cyclic vomiting syndrome: epidemiology, diagnosis, and treatment | journal = Clinical Autonomic Research | volume = 28 | issue = 2 | pages = 203–209 | date = April 2018 | pmid = 29442203 | doi = 10.1007/s10286-018-0506-2 }}</ref> |
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Episodes may happen every few days, every few weeks or every few months, for some happening at common uniform times, typically mornings.<ref name="Bhandari_2018" /> For other |
Episodes may happen every few days, every few weeks or every few months, for some happening at common uniform times, typically mornings.<ref name="Bhandari_2018" /> For other affected people, there is not a pattern in time that can be recognized. Some with the condition have a warning of an episodic attack; they may experience a prodrome, some documented prodromal symptoms include: unusually intense nausea and [[pallor]], excess salivation, [[Perspiration|sweating]], [[Flushing (physiology)|flushing]], rapid/irregular heartbeat, [[diarrhea]], [[anxiety]]/[[panic]], food aversion, restlessness/insomnia, [[irritability]], [[depersonalization]], fatigue/listlessness, intense feelings of being hot or chilled, intense thirst, shivering/shaking, retching, [[tachypnea]], abdominal pain/cramping, limb [[paresthesia]]s, [[hyperesthesia]], [[photophobia]], [[phonophobia]], [[headache]], and [[Shortness of breath|dyspnea]], heightened sensitivity, especially to light, though sensitivity to smell, sound, pressure, and temperature, as well as oncoming muscle pain and fatigue, are also reported by some patients. Many experiences a full [[panic attack]] when nausea begins and continue to panic once the vomiting has begun. Medications like [[Lorazepam]], [[Alprazolam]], and other [[benzodiazepines]] are prescribed by their doctors and instructed to take immediately at the onset of any of their CVS symptoms and/or triggers. Some prodromal symptoms are present inter-episodically as well as during acute phases of illness. The majority of affected people can identify triggers that may precede an attack. The most common are various foods, [[infection]]s (such as [[colds]]), [[menstruation]], extreme physical exertion, lack of sleep, and psychological [[stress (biological)|stress]]es, both positive and negative.{{citation needed|date=May 2020}} |
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An affected person may also be light-sensitive (photophobic), sound-sensitive (phonophobic) or, less frequently, temperature- or pressure-sensitive during an attack.<ref name="Lindley 2005">{{cite journal|vauthors=Lindley KJ, Andrews PL|s2cid=25060114|date=September 2005|title=Pathogenesis and treatment of cyclical vomiting|journal=Journal of Pediatric Gastroenterology and Nutrition|volume=41|issue=Suppl 1|pages=S38-40|doi=10.1097/01.scs.0000180299.04731.cb|pmid=16131963|doi-access=free}}</ref> Some people also have a strong urge to bathe in warm or cold water. In fact, many people with CVS experience a [[Compulsive behavior|compulsion]] to be submerged in hot water, and end up taking several baths during the duration of an episode. For some the psychological compulsion to be in hot water is so extreme that they cannot stop themselves from taking very long baths in near scalding hot water several times per day. For some of these people, they may have just finished taking a lengthy bath in extremely hot water and immediately feel this compulsion again and end up taking another bath right after drying off. Some people with the condition experience [[insomnia]], diarrhea (GI complications), hot and cold flashes, and excessive sweating before an episode. Some report that they experience a restless sensation or stinging pain along the spine, hands, and feet followed by weakness in both legs. Some of these symptoms may be due to dehydration or [[hypokalemia]] from excessive vomiting, rather than the underlying cause of CVS. |
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==Genetics== |
==Genetics== |
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There is no known genetic pathogenesis for CVS. Recent studies suggest many affected individuals have a family history of related conditions, such as migraines, psychiatric disorders and gastrointestinal disorders. Inheritance is thought to be maternal, a possible genetic |
There is no known genetic pathogenesis for CVS. Recent studies suggest many affected individuals have a family history of related conditions, such as migraines, psychiatric disorders and gastrointestinal disorders. Inheritance is thought to be maternal, a possible genetic [[mitochondria]]l inheritance. Adolescents show higher possible mitochondrial inheritance and maternal inheritance than found in adults. Single [[base-pair]] and DNA rearrangements in the [[mitochondrial DNA]] (mtDNA) have been associated with these traits.<ref>{{cite web| title= Cyclic vomiting syndrome? | url= https://medlineplus.gov/genetics/condition/cyclic-vomiting-syndrome/| website= medlineplus.gov| publisher= [[National Institutes of Health]]| place= US| language= en-us| date= | access-date= 1 September 2022}}</ref><ref>{{cite journal | vauthors = Venkatesan T, Zaki EA, Kumar N, Sengupta J, Ali M, Malik B, Szabo A, van Tilburg MA, Boles RG | display-authors = 3| title = Quantitative pedigree analysis and mitochondrial DNA sequence variants in adults with cyclic vomiting syndrome | journal = [[BMC Gastroenterology]] | volume = 14 | issue = 1 | pages = 181 | date = October 2014 | pmid = 25332060 | pmc = 4287476 | doi = 10.1186/1471-230X-14-181 | doi-access = free}}</ref> |
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==Diagnosis== |
==Diagnosis== |
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===Diagnostic criteria=== |
===Diagnostic criteria=== |
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Due to the lack of specific biomarkers available for the disorder, and if all other possible causes can be ruled out (such as [[intestinal malrotation]]), physicians rely on the [[Rome IV|Rome IV process]] criteria in order to diagnose patients.<ref name="Bhandari_2018"/> Patients must meet all three of the following criteria to receive diagnosis: |
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Although there are differences{{such as|date=December 2018}} between early-onset CVS (babies and children) and late-onset CVS (in adults),<ref name="Bhandari_2018" /> there are established criteria to aid in diagnosis of CVS, namely: |
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#A history of three or more periods of intense, acute nausea and unremitting vomiting, as well as pain in some cases, lasting hours to days and even weeks or months<ref name="pmid28745840">{{cite journal | vauthors = Sagar RC, Sood R, Gracie DJ, Gold MJ, To N, Law GR, Ford AC | s2cid = 11299617 | title = Cyclic vomiting syndrome is a prevalent and under-recognized condition in the gastroenterology outpatient clinic | journal = Neurogastroenterology and Motility | volume = 30 | issue = 1 | pages = e13174| date = January 2018 | pmid = 28745840 | doi = 10.1111/nmo.13174 | url = http://eprints.lincoln.ac.uk/29512/1/29512%20CVS%20paper.pdf }}</ref> |
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# Stereotypical episodes of acute vomiting each with a duration of less than 1 week |
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#Intervening symptom-free or reduced-symptom intervals, lasting weeks to months |
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# A history of at least three discrete episodes in the prior year and at least two episodes in the past 6 months, each occurring at least 1 week apart |
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#There are repeated cycles of periods (of varying duration) with intense/acute nausea, with or without vomiting, with or without severe pain, followed by periods of reduced symptoms, followed by gradual increase in CVS symptoms until it peaks (peak intensity is generally relative to cycle intensity). |
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# An absence of vomiting between episodes, but other milder symptoms can be present between cycles |
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#Exclusion of metabolic, gastrointestinal, genitourinary or central nervous system structural or biochemical disease, e.g., individuals with specific physical causes (such as [[intestinal malrotation]]) |
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Criteria must be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. A history of family history of migraine headaches can also be used in facilitating diagnosis.<ref name="rome">{{cite web |title=Rome IV Criteria |url=https://theromefoundation.org/rome-iv/rome-iv-criteria/ |website=Rome Foundation |access-date=23 July 2022 |archive-url=https://web.archive.org/web/20220723174730/https://theromefoundation.org/rome-iv/rome-iv-criteria/ |archive-date=23 July 2022 |language=English |date=16 January 2016}}</ref> |
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==Treatment== |
==Treatment== |
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Treatment for cyclic vomiting syndrome depends on the evident phase of the disorder.<ref>{{Cite web|title=Cyclic Vomiting Syndrome: Symptoms, Diagnosis, Treatment & Causes|url=https://my.clevelandclinic.org/health/diseases/14894-cyclic-vomiting-syndrome|access-date=2021-03-17|website=Cleveland Clinic}}</ref> |
Treatment for cyclic vomiting syndrome depends on the evident phase of the disorder.<ref>{{Cite web|title=Cyclic Vomiting Syndrome: Symptoms, Diagnosis, Treatment & Causes|url=https://my.clevelandclinic.org/health/diseases/14894-cyclic-vomiting-syndrome|access-date=2021-03-17|website=Cleveland Clinic}}</ref> |
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Because the symptoms of CVS are similar (or perhaps identical) to those of the disease well-identified as "[[ICHD classification and diagnosis of migraine#Abdominal migraine|abdominal migraine]]," [[Preventive healthcare|prophylactic]] migraine medications, such as [[topiramate]] and [[amitriptyline]], have seen recent success in treatment for the prodrome |
Because the symptoms of CVS are similar (or perhaps identical) to those of the disease well-identified as "[[ICHD classification and diagnosis of migraine#Abdominal migraine|abdominal migraine]]," [[Preventive healthcare|prophylactic]] migraine medications, such as [[topiramate]] and [[amitriptyline]], have seen recent success in treatment for the prodrome and vomiting phases, reducing the duration, severity, and frequency of episodes.<ref>{{cite journal | vauthors = Paul SP, Barnard P, Soondrum K, Candy DC | title = Antimigraine (low-amine) diet may be helpful in children with cyclic vomiting syndrome | language = en-US | journal = Journal of Pediatric Gastroenterology and Nutrition | volume = 54 | issue = 5 | pages = 698–9 | date = May 2012 | pmid = 22302150 | doi = 10.1097/MPG.0b013e31824ca0a2 | doi-access = free }}</ref> |
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Therapeutic treatment for the prodromal phase, characterized by the anticipation of an episode, consists of [[Sumatriptan/naproxen sodium|sumatriptan]] (nasal or oral) an anti-migraine medication, [[Nonsteroidal anti-inflammatory drug|anti-inflammatory drugs]] to reduce abdominal pain, and possible [[Antiemetic|anti-emetic]] drugs. These options may be helpful in preventing an episode or reducing the severity of an attack.<ref>{{Cite journal| |
Therapeutic treatment for the prodromal phase, characterized by the anticipation of an episode, consists of [[Sumatriptan/naproxen sodium|sumatriptan]] (nasal or oral) an anti-migraine medication, [[Nonsteroidal anti-inflammatory drug|anti-inflammatory drugs]] to reduce abdominal pain, and possible [[Antiemetic|anti-emetic]] drugs. These options may be helpful in preventing an episode or reducing the severity of an attack.<ref>{{Cite journal|last1=Kowalczyk|first1=Monika|last2=Parkman|first2=Henry|last3=Ward|first3=Lawrence|title=Adult Cyclic Vomiting Syndrome Successfully Treated with Intranasal Sumatriptan|journal=Journal of General Internal Medicine|year=2010|volume=25|issue=1|pages=88–91|doi=10.1007/s11606-009-1162-y|issn=0884-8734|pmc=2811593|pmid=19911235}}</ref><ref>{{Cite journal|last1=Vidula|first1=Mahesh K.|last2=Wadhwani|first2=Anil|last3=Roberts|first3=Kaleigh|last4=Berkowitz|first4=Lyle L.|title=Use of a once-daily NSAID in treatment of cyclic vomiting syndrome|journal=Journal of General Internal Medicine|year=2014|volume=29|issue=3|pages=543–546|doi=10.1007/s11606-013-2624-9|issn=1525-1497|pmc=3930795|pmid=24129856}}</ref> |
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The most common therapeutic strategies for those already in the vomiting phase are maintenance of salt balance by appropriate intravenous fluids |
The most common therapeutic strategies for those already in the vomiting phase are maintenance of salt balance by appropriate intravenous fluids. Sedation via high dose intravenous [[Benzodiazepine|benzodiazepines]], typically [[lorazepam]], has been shown to shorten the length of emergency department stays for some patients.<ref>{{Cite journal |last1=Liu |first1=Joy |last2=Young |first2=Kimberly |last3=Silvernale |first3=Casey |last4=Sawhney |first4=Veer |last5=Ludwig |first5=Andrew |last6=Cangemi |first6=David |last7=Lembo |first7=Anthony |last8=Kuo |first8=Braden |date=October 2018 |title=Acute Management of Cyclic Vomiting Syndrome Patients in the Emergency Department Setting: 440 |url=https://journals.lww.com/ajg/Fulltext/2018/10001/Acute_Management_of_Cyclic_Vomiting_Syndrome.440.aspx |journal=Official Journal of the American College of Gastroenterology {{!}} ACG |language=en-US |volume=113 |pages=S256–S257 |doi=10.14309/00000434-201810001-00440 |issn=0002-9270}}</ref> Having vomited for a long period prior to attending a hospital, patients are typically severely dehydrated. 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.<ref>{{Cite web|date=2021-01-26|title=Understanding Cyclic Vomiting Syndrome Doctor Q&A|url=https://www.migraineagain.com/cyclic-vomiting-syndrome/|access-date=2021-03-17|website=Migraine Again|language=en-US}}</ref> Many patients seek comfort during episodes by taking prolonged showers and baths typically quite hot. The use of a heating pad may also help reduce abdominal pain.<ref name="Cyclic Vomiting Syndrome in 41 adul"/> |
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Lifestyle changes may be recommended, such as extended rest, reduction of stress, frequent small meals, abstain from [[fasting]] |
Lifestyle changes may be recommended, such as extended rest, reduction of stress, frequent small meals, and to abstain from [[fasting]]. A diet change may be recommended avoid food [[allergen]]s, eliminating trigger foods such as chocolates, cheese, beer, and red wine.<ref name=":2">{{cite journal | vauthors = Li BU, Lefevre F, Chelimsky GG, Boles RG, Nelson SP, Lewis DW, Linder SL, Issenman RM, Rudolph CD | s2cid = 3910188 | display-authors = 6 | title = North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition consensus statement on the diagnosis and management of cyclic vomiting syndrome | language = en-US | journal = Journal of Pediatric Gastroenterology and Nutrition | volume = 47 | issue = 3 | pages = 379–93 | date = September 2008 | pmid = 18728540 | doi = 10.1097/MPG.0b013e318173ed39 | doi-access = free }}</ref><ref name=":1" /> |
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Some patients experience relief from inhaled isopropyl alcohol.<ref name="NEJM">{{cite web |url=https://www.jwatch.org/na46286/2018/03/09/inhaled-isopropyl-alcohol-superior-oral-ondansetron |title=Inhaled Isopropyl Alcohol Superior to Oral Ondansetron as an Antiemetic |author=<!--Not stated--> |date= 2018-03-09|publisher=New England Journal of Medicine Journal Watch jwatch.org }}</ref> |
Some patients experience relief from inhaled isopropyl alcohol.<ref name="NEJM">{{cite web |url=https://www.jwatch.org/na46286/2018/03/09/inhaled-isopropyl-alcohol-superior-oral-ondansetron |title=Inhaled Isopropyl Alcohol Superior to Oral Ondansetron as an Antiemetic |author=<!--Not stated--> |date= 2018-03-09|publisher=New England Journal of Medicine Journal Watch jwatch.org }}</ref> |
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Intravenous Haloperidol may be an effective treatment.<ref>{{Cite journal |last1=Schwartz |first1=Brad E. |last2=Baker |first2=Karen Keller |last3=Bleinberger |first3=Andrew J. |last4=Lleshi |first4=Amina |last5=Cruz-Cano |first5=Raul |date=2021 |title=Intravenous haloperidol for the treatment of intractable vomiting, cyclical vomiting, and gastroparesis |journal=World Journal of Emergency Medicine |volume=12 |issue=3 |pages=228–231 |doi=10.5847/wjem.j.1920-8642.2021.03.012 |issn=1920-8642 |pmc=8188283 |pmid=34141040}}</ref> |
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==Prognosis== |
==Prognosis== |
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Fitzpatrick et al. (2007) identified 41 children with CVS. 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. As many as 39% of the children had resolution of symptoms immediately or within weeks of the diagnosis. Vomiting had resolved at the time of follow-up in 61% of the sample. Many children, including those in the remitted group, continued to have somatic symptoms such as headaches (in 42%) and abdominal pain (in 37%).<ref name="pmid18070235">{{cite journal | vauthors = Fitzpatrick E, Bourke B, Drumm B, Rowland M | title = The incidence of cyclic vomiting syndrome in children: population-based study | journal = The American Journal of Gastroenterology | volume = 103 | issue = 4 | pages = 991–5; quiz 996 | date = April 2008 | pmid = 18070235 }}</ref> |
Fitzpatrick et al. (2007) identified 41 children with CVS. 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. As many as 39% of the children had resolution of symptoms immediately or within weeks of the diagnosis. Vomiting had resolved at the time of follow-up in 61% of the sample. Many children, including those in the remitted group, continued to have somatic symptoms such as headaches (in 42%) and abdominal pain (in 37%).<ref name="pmid18070235">{{cite journal | vauthors = Fitzpatrick E, Bourke B, Drumm B, Rowland M | title = The incidence of cyclic vomiting syndrome in children: population-based study | journal = The American Journal of Gastroenterology | volume = 103 | issue = 4 | pages = 991–5; quiz 996 | date = April 2008 | doi = 10.1111/j.1572-0241.2007.01668.x | pmid = 18070235 | s2cid = 25698609 }}</ref> |
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⚫ | Most children who have this disorder miss on average 24 school days a year.<ref name=":2" /> The frequency of episodes is higher for some people during times of excitement.<ref name=":2" /> Charitable organizations to support affected people and their families and to promote knowledge of CVS exist in several countries. |
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A 2005 study by Fleisher et al. identified 41 adults who had been previously seen for complaints compatible with CVS. The average age at presentation of the sample was 34 years, and the mean age at onset was 21 years. The mean duration of the CVS at the time of consultation was 12 years. Of the 39 patients surveyed, 85% had episodes that were fairly uniform in length. Most patients reported these attacks in the morning hours. Of those 39 patients, 32% were completely disabled and required financial support due to CVS. Despite this, data suggests that the prognosis for CVS is generally favorable.<ref name="Cyclic Vomiting Syndrome in 41 adul" /> |
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Most children who have this disorder miss on average 24 school days a year.<ref name=":2" /> The frequency of episodes is higher for some people during times of excitement.<ref name=":2" /> Charitable organizations to support |
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Complications can include dehydration, [[dental caries]], or an [[esophageal tear]].<ref name="NHS">{{cite web|url=https://www.nhs.uk/conditions/cyclical-vomiting-syndrome/|title=Cyclical vomiting syndrome|author=<!--Not stated-->|date=2017-10-18|publisher=NHS Gov.UK}}</ref> |
Complications can include dehydration, [[dental caries]], or an [[esophageal tear]].<ref name="NHS">{{cite web|url=https://www.nhs.uk/conditions/cyclical-vomiting-syndrome/|title=Cyclical vomiting syndrome|author=<!--Not stated-->|date=2017-10-18|publisher=NHS Gov.UK}}</ref> |
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The average age at onset is 3–7 years, with described cases as young as 6 days and as old as 73 years.<ref name=LM2003>{{cite journal | vauthors = Li BU, Misiewicz L | title = Cyclic vomiting syndrome: a brain-gut disorder | journal = Gastroenterology Clinics of North America | volume = 32 | issue = 3 | pages = 997–1019 | date = September 2003 | pmid = 14562585 | doi = 10.1016/S0889-8553(03)00045-1 }}</ref> Typical delay in diagnosis from onset of symptoms is 3 years.<ref name=LM2003 /> Females show a slight predominance over males.<ref name="LM2003" /> |
The average age at onset is 3–7 years, with described cases as young as 6 days and as old as 73 years.<ref name=LM2003>{{cite journal | vauthors = Li BU, Misiewicz L | title = Cyclic vomiting syndrome: a brain-gut disorder | journal = Gastroenterology Clinics of North America | volume = 32 | issue = 3 | pages = 997–1019 | date = September 2003 | pmid = 14562585 | doi = 10.1016/S0889-8553(03)00045-1 }}</ref> Typical delay in diagnosis from onset of symptoms is 3 years.<ref name=LM2003 /> Females show a slight predominance over males.<ref name="LM2003" /> |
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One study found that 3 in 100,000 five-year-olds are diagnosed with the condition.<ref>{{cite journal | vauthors = Drumm BR, Bourke B, Drummond J, McNicholas F, Quinn S, Broderick A, Taaffe S, Twomey J, Rowland M | display-authors = 6 | title = Cyclical vomiting syndrome in children: a prospective study | journal = Neurogastroenterology and Motility | volume = 24 | issue = 10 | pages = 922–7 | date = October 2012 | pmid = 22762244 | doi = 10.1111/j.1365-2982.2012.01960.x }}</ref> Two studies on childhood CVS suggest nearly 2% of school-age children may have CVS.<ref>{{cite journal | vauthors = Abu-Arafeh I, Russell G | title = Cyclical vomiting syndrome in children: a population-based study | journal = Journal of Pediatric Gastroenterology and Nutrition | volume = 21 | issue = 4 | pages = 454–8 | date = November 1995 | pmid = 8583299 | doi = 10.1097/00005176-199511000-00014 | s2cid = 20399340 }}</ref><ref>{{cite journal | vauthors = Cullen KJ, Ma Cdonald WB | title = The periodic syndrome: its nature and prevalence | journal = The Medical Journal of Australia | volume = 50 | issue = 2 | pages = 167–73 | date = August 1963 | pmid = 14024194 | doi = 10.5694/j.1326-5377.1963.tb24739.x}}</ref> |
One study found that 3 in 100,000 five-year-olds are diagnosed with the condition.<ref>{{cite journal | vauthors = Drumm BR, Bourke B, Drummond J, McNicholas F, Quinn S, Broderick A, Taaffe S, Twomey J, Rowland M | display-authors = 6 | title = Cyclical vomiting syndrome in children: a prospective study | journal = Neurogastroenterology and Motility | volume = 24 | issue = 10 | pages = 922–7 | date = October 2012 | pmid = 22762244 | doi = 10.1111/j.1365-2982.2012.01960.x | s2cid = 22054244 }}</ref> Two studies on childhood CVS suggest nearly 2% of school-age children may have CVS.<ref>{{cite journal | vauthors = Abu-Arafeh I, Russell G | title = Cyclical vomiting syndrome in children: a population-based study | journal = Journal of Pediatric Gastroenterology and Nutrition | volume = 21 | issue = 4 | pages = 454–8 | date = November 1995 | pmid = 8583299 | doi = 10.1097/00005176-199511000-00014 | s2cid = 20399340 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Cullen KJ, Ma Cdonald WB | title = The periodic syndrome: its nature and prevalence | journal = The Medical Journal of Australia | volume = 50 | issue = 2 | pages = 167–73 | date = August 1963 | pmid = 14024194 | doi = 10.5694/j.1326-5377.1963.tb24739.x}}</ref> |
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==History== |
==History== |
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== See also == |
== See also == |
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* [[Migraine]] |
* [[Migraine]] |
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* [[Cannabis hyperemesis syndrome]] |
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== References == |
== References == |
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== Further reading == |
== Further reading == |
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{{refbegin}} |
{{refbegin}} |
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* {{cite journal | vauthors = Abu-Arafeh I, Russell G | title = Cyclical vomiting syndrome in children: a population-based study | journal = Journal of Pediatric Gastroenterology and Nutrition | volume = 21 | issue = 4 | pages = 454–8 | date = November 1995 | pmid = 8583299 | doi = 10.1097/00005176-199511000-00014 | s2cid = 20399340 }} |
* {{cite journal | vauthors = Abu-Arafeh I, Russell G | title = Cyclical vomiting syndrome in children: a population-based study | journal = Journal of Pediatric Gastroenterology and Nutrition | volume = 21 | issue = 4 | pages = 454–8 | date = November 1995 | pmid = 8583299 | doi = 10.1097/00005176-199511000-00014 | s2cid = 20399340 | doi-access = free }} |
||
* {{cite journal | vauthors = Fleisher DR | title = The cyclic vomiting syndrome described | journal = Journal of Pediatric Gastroenterology and Nutrition | volume = 21 |
* {{cite journal | vauthors = Fleisher DR | title = The cyclic vomiting syndrome described | journal = Journal of Pediatric Gastroenterology and Nutrition | volume = 21 | issue = Suppl 1 | pages = S1-5 | year = 1995 | pmid = 8708859 | doi = 10.1097/00005176-199501001-00003 | s2cid = 9994376 | doi-access = free }} |
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* {{cite journal | vauthors = Fleisher DR | title = Empiric guidelines for the management of cyclic vomiting syndrome. | journal = Child Health Publications | publisher = University of Missouri Library System | url = https://mospace.umsystem.edu/xmlui/handle/10355/5142 |hdl=10355/5142 |date=July 2008}} |
* {{cite journal | vauthors = Fleisher DR | title = Empiric guidelines for the management of cyclic vomiting syndrome. | journal = Child Health Publications | publisher = University of Missouri Library System | url = https://mospace.umsystem.edu/xmlui/handle/10355/5142 |hdl=10355/5142 |date=July 2008}} |
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* {{cite journal | vauthors = Rasquin-Weber A, Hyman PE, Cucchiara S, Fleisher DR, Hyams JS, Milla PJ, Staiano A | title = Childhood functional gastrointestinal disorders | journal = Gut | volume = 45 |
* {{cite journal | vauthors = Rasquin-Weber A, Hyman PE, Cucchiara S, Fleisher DR, Hyams JS, Milla PJ, Staiano A | title = Childhood functional gastrointestinal disorders | journal = Gut | volume = 45 | issue = Suppl 2 | pages = II60-8 | date = September 1999 | pmid = 10457047 | pmc = 1766693 | doi = 10.1136/gut.45.2008.ii60 }} |
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* {{cite journal | vauthors = Raucci U, Borrelli O, Di Nardo G, Tambucci R, Pavone P, Salvatore S, Baldassarre ME, Cordelli DM, Falsaperla R, Felici E, et. al. | title = Cyclic vomiting syndrome in children | journal = Frontiers in Neurology | date = November 2020 | pmid = 33224097 | pmc = 7667239 | doi = 10.3389/fneur.2020.583425 }} |
* {{cite journal | vauthors = Raucci U, Borrelli O, Di Nardo G, Tambucci R, Pavone P, Salvatore S, Baldassarre ME, Cordelli DM, Falsaperla R, Felici E, et. al. | title = Cyclic vomiting syndrome in children | journal = Frontiers in Neurology | date = November 2020 | volume = 11 | page = 583425 | pmid = 33224097 | pmc = 7667239 | doi = 10.3389/fneur.2020.583425 | doi-access = free }} |
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* {{cite journal | vauthors = Terzaghi M, Sartori I, Rustioni V, Manni R | title = Cyclic vomiting syndrome in adults: disregarding a possible epileptic component? | journal = Neurogastroenterology and Motility | volume = 21 | issue = 1 | pages = 95–6 | date = January 2009 | pmid = 19140956 | pmc = 2886424 | doi = 10.1111/j.1365-2982.2008.01211.x }} |
* {{cite journal | vauthors = Terzaghi M, Sartori I, Rustioni V, Manni R | title = Cyclic vomiting syndrome in adults: disregarding a possible epileptic component? | journal = Neurogastroenterology and Motility | volume = 21 | issue = 1 | pages = 95–6 | date = January 2009 | pmid = 19140956 | pmc = 2886424 | doi = 10.1111/j.1365-2982.2008.01211.x }} |
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{{refend}} |
{{refend}} |
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== External links == |
== External links == |
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* [http://www.emedicine.com/ped/topic2910.htm Cyclic Vomiting Syndrome Emedicine article] |
* [http://www.emedicine.com/ped/topic2910.htm Cyclic Vomiting Syndrome Emedicine article] |
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* [https://web.archive.org/web/20050301042940/http://digestive.niddk.nih.gov/ddiseases/pubs/cvs/ CVS page] at the US National Digestive Diseases Clearinghouse, NIH Publication No. 04-4548 |
* [https://web.archive.org/web/20050301042940/http://digestive.niddk.nih.gov/ddiseases/pubs/cvs/ CVS page] at the US National Digestive Diseases Clearinghouse, NIH Publication No. 04-4548 |
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{{DEFAULTSORT:Cyclic Vomiting Syndrome}} |
{{DEFAULTSORT:Cyclic Vomiting Syndrome}} |
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[[Category: |
[[Category:Neurological disorders]] |
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[[Category:Pediatrics]] |
[[Category:Pediatrics]] |
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[[Category:Syndromes affecting the gastrointestinal tract]] |
[[Category:Syndromes affecting the gastrointestinal tract]] |
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[[Category:Syndromes of unknown causes]] |
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⚫ |
Cyclic vomiting syndrome | |
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Other names | Cyclical vomiting syndrome |
Specialty | Gastroenterology |
Cyclic vomiting syndrome (CVS) is a chronic functional condition of unknown pathogenesis. CVS is characterized as recurring episodes lasting a single day to multiple weeks. 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 of 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. "Cyclic vomiting syndrome (CVS) is a rare abnormality of the neuroendocrine system that affects 2% of children."[1] This disorder is thought to be closely related to migraines and family history of migraines.[2][3]
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Adults | Children | |
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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%) |
Upper Gastrointestinal 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 |
Affected individuals 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.[4] Stomach acid, bile and, if the vomiting is severe, blood may be vomited. Some with the condition will ingest water to reduce the irritation of bile and acid on the esophagus during emesis. Between episodes, the affected individual is usually normal and healthy otherwise but can be in a weak state of fatigue or experience muscle pain. In approximately half of cases the attacks, or episodes, occur in a time-related manner. Each attack is stereotypical; that is, in any given individual, the timing, frequency and severity of attacks is similar. Some affected people experience episodes that progressively get worse when left untreated, occurring more frequently with reduced symptom free phase.[5]
Episodes may happen every few days, every few weeks or every few months, for some happening at common uniform times, typically mornings.[5] For other affected people, there is not a pattern in time that can be recognized. Some with the condition have a warning of an episodic attack; they may experience a prodrome, some documented prodromal symptoms include: unusually intense nausea and pallor, excess salivation, sweating, flushing, rapid/irregular heartbeat, diarrhea, anxiety/panic, food aversion, restlessness/insomnia, irritability, depersonalization, fatigue/listlessness, intense feelings of being hot or chilled, intense thirst, shivering/shaking, retching, tachypnea, abdominal pain/cramping, limb paresthesias, hyperesthesia, photophobia, phonophobia, headache, and dyspnea, heightened sensitivity, especially to light, though sensitivity to smell, sound, pressure, and temperature, as well as oncoming muscle pain and fatigue, are also reported by some patients. Many experiences a full panic attack when nausea begins and continue to panic once the vomiting has begun. Medications like Lorazepam, Alprazolam, and other benzodiazepines are prescribed by their doctors and instructed to take immediately at the onset of any of their CVS symptoms and/or triggers. Some prodromal symptoms are present inter-episodically as well as during acute phases of illness. The majority of affected people can identify triggers that may precede an attack. The most common are various foods, infections (such as colds), menstruation, extreme physical exertion, lack of sleep, and psychological stresses, both positive and negative.[citation needed]
An affected person may also be light-sensitive (photophobic), sound-sensitive (phonophobic) or, less frequently, temperature- or pressure-sensitive during an attack.[6] Some people also have a strong urge to bathe in warm or cold water. In fact, many people with CVS experience a compulsion to be submerged in hot water, and end up taking several baths during the duration of an episode. For some the psychological compulsion to be in hot water is so extreme that they cannot stop themselves from taking very long baths in near scalding hot water several times per day. For some of these people, they may have just finished taking a lengthy bath in extremely hot water and immediately feel this compulsion again and end up taking another bath right after drying off. Some people with the condition experience insomnia, diarrhea (GI complications), hot and cold flashes, and excessive sweating before an episode. Some report that they experience a restless sensation or stinging pain along the spine, hands, and feet followed by weakness in both legs. Some of these symptoms may be due to dehydration or hypokalemia from excessive vomiting, rather than the underlying cause of CVS.
There is no known genetic pathogenesis for CVS. Recent studies suggest many affected individuals have a family history of related conditions, such as migraines, psychiatric disorders and gastrointestinal disorders. Inheritance is thought to be maternal, a possible genetic mitochondrial inheritance. Adolescents show higher possible mitochondrial inheritance and maternal inheritance than found in adults. Single base-pair and DNA rearrangements in the mitochondrial DNA (mtDNA) have been associated with these traits.[7][8]
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The cause of CVS has not been determined and there are no diagnostic tests for CVS. Several other medical conditions, such as cannabinoid hyperemesis syndrome (CHS), can mimic the same symptoms, and it is important to rule these out. If all other possible causes have been excluded, a diagnosis of CVS using Rome criteria by a physician may be appropriate.[5]
Once formal investigations to rule out gastrointestinal or other causes have been conducted, these tests do not need to be repeated in the event of future episodes.[6]
Due to the lack of specific biomarkers available for the disorder, and if all other possible causes can be ruled out (such as intestinal malrotation), physicians rely on the Rome IV process criteria in order to diagnose patients.[5] Patients must meet all three of the following criteria to receive diagnosis:
Criteria must be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. A history of family history of migraine headaches can also be used in facilitating diagnosis.[9]
Treatment for cyclic vomiting syndrome depends on the evident phase of the disorder.[10]
Because the symptoms of CVS are similar (or perhaps identical) to those of the disease well-identified as "abdominal migraine," prophylactic migraine medications, such as topiramate and amitriptyline, have seen recent success in treatment for the prodrome and vomiting phases, reducing the duration, severity, and frequency of episodes.[11]
Therapeutic treatment for the prodromal phase, characterized by the anticipation of an episode, consists of sumatriptan (nasal or oral) an anti-migraine medication, anti-inflammatory drugs to reduce abdominal pain, and possible anti-emetic drugs. These options may be helpful in preventing an episode or reducing the severity of an attack.[12][13]
The most common therapeutic strategies for those already in the vomiting phase are maintenance of salt balance by appropriate intravenous fluids. Sedation via high dose intravenous benzodiazepines, typically lorazepam, has been shown to shorten the length of emergency department stays for some patients.[14] Having vomited for a long period prior to attending a hospital, patients are typically severely dehydrated. 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.[15] Many patients seek comfort during episodes by taking prolonged showers and baths typically quite hot. The use of a heating pad may also help reduce abdominal pain.[2]
Lifestyle changes may be recommended, such as extended rest, reduction of stress, frequent small meals, and to abstain from fasting. A diet change may be recommended avoid food allergens, eliminating trigger foods such as chocolates, cheese, beer, and red wine.[16][3]
Some patients experience relief from inhaled isopropyl alcohol.[17]
Intravenous Haloperidol may be an effective treatment.[18]
Fitzpatrick et al. (2007) identified 41 children with CVS. 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. As many as 39% of the children had resolution of symptoms immediately or within weeks of the diagnosis. Vomiting had resolved at the time of follow-up in 61% of the sample. Many children, including those in the remitted group, continued to have somatic symptoms such as headaches (in 42%) and abdominal pain (in 37%).[19]
Most children who have this disorder miss on average 24 school days a year.[16] The frequency of episodes is higher for some people during times of excitement.[16] Charitable organizations to support affected people and their families and to promote knowledge of CVS exist in several countries.
A 2005 study by Fleisher et al. identified 41 adults who had been previously seen for complaints compatible with CVS. The average age at presentation of the sample was 34 years, and the mean age at onset was 21 years. The mean duration of the CVS at the time of consultation was 12 years. Of the 39 patients surveyed, 85% had episodes that were fairly uniform in length. Most patients reported these attacks in the morning hours. Of those 39 patients, 32% were completely disabled and required financial support due to CVS. Despite this, data suggests that the prognosis for CVS is generally favorable.[2]
Complications can include dehydration, dental caries, or an esophageal tear.[20]
The average age at onset is 3–7 years, with described cases as young as 6 days and as old as 73 years.[21] Typical delay in diagnosis from onset of symptoms is 3 years.[21] Females show a slight predominance over males.[21]
One study found that 3 in 100,000 five-year-olds are diagnosed with the condition.[22] Two studies on childhood CVS suggest nearly 2% of school-age children may have CVS.[23][24]
Cyclic vomiting syndrome was first described in FrancebySwiss physician Henri Clermond Lombard[25] and first described in the English language by pediatrician Samuel Gee in 1882.[26]
It has been suggested that Charles Darwin's adult illnesses may have been due to this syndrome.[27][further explanation needed]
Diseases of the human digestive system
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