Cyclic vomiting syndrome

Cyclic vomiting syndrome (CVS) is a chronic functional disorder of unknown etiology, characterized by recurrent attacks of intense nausea, vomiting, and sometimes abdominal and headaches or migraines. The pathology was first described by pediatrician Samuel Gee in 1882. There are suggestions that Charles Darwin suffered from this syndrome [Hayman, J. A (2009). "Darwin's illness revisited].

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Epidemiology

A prospective study showed that the prevalence of the disease is 3:100,000.

The syndrome usually develops in childhood, usually between the ages of 3 and 7 (according to statistics, 2% of school-age children suffer from CVS), sometimes in adolescence and in adults.

More often than men, women suffer from this pathology, in a ratio of 57:43.

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Causes cyclic vomiting syndrome

The exact cause of cyclic vomiting syndrome is unknown. Although nausea and vomiting are the main symptoms of the syndrome, scientists believe that the symptoms of the disorder develop due to disruptions in the normal communication between the brain and the gut (gut-brain disorder).

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Risk factors

Risk factors for cyclic vomiting syndrome include disturbances in central regulation of the hypothalamic-pituitary-adrenal axis, migraine, and hormonal changes in the body.

Special conditions or events that may trigger an episode of cyclic vomiting:

• Emotional stress, anxiety, or panic attacks, for example, in children - anticipation of school exams or important events (birthdays, holidays, travel), family conflicts.
• Infections (sinusitis, respiratory infections, flu).
• Certain foods (chocolate or cheese), additives (caffeine, nitrites, which are commonly found in processed meats such as hot dogs, monosodium glutamate).
• Hot weather.
• Menstrual periods.
• Seasickness.
• Overeating before bed, fasting.
• Physical exhaustion or excessive physical activity.
• Lack of sleep.
• Motion sickness.

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Pathogenesis

The pathogenesis of cyclic vomiting syndrome is multifactorial, with the participation of genetic, vegetative, central and environmental factors.

Evidence suggests a strong genetic component in children with CVS, features of mitochondrial heteroplasmy, and other associated disorders (eg, migraine and chronic fatigue syndrome). Other theories include autonomic dysfunction, sympathetic hyperreactivity, and possibly involvement of corticotropin-releasing factor (CRF) synthesis defects in the pathogenesis.

In most cases, blood and urine tests reveal signs of energy metabolism disorders. In most cases, mutations in mitochondrial DNA are detected.

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Symptoms cyclic vomiting syndrome

Some patients notice warning signs before the attack begins: prodrome, intense nausea and paleness, increased sensitivity to light, smell and sound, increased blood pressure and temperature, muscle pain and fatigue, a burning sensation along the spine, arms and legs. Some patients express a strong desire to bathe in warm or cold water. Most people can identify triggers that provoke an attack of cyclic vomiting syndrome.

Characteristic symptoms of cyclic vomiting syndrome include:

• Intense attacks of vomiting and nausea occur more than 3 times a week;
• The presence of asymptomatic intervals or intervals with mild symptoms lasting from 1 week to several months.
• The presence of recurring periods (of varying duration) of intense/acute nausea, with or without vomiting, with or without severe pain, with periods of relief of symptoms and then a gradual increase in the signs of cyclic vomiting syndrome until they reach a maximum (peak intensity).
• Vomiting four times during the peak period;
• During examination, it is impossible to establish the etiology of vomiting;
• Exclusion of metabolic disorders, gastrointestinal tract, or central nervous system diseases.

Additional characteristics of cyclic vomiting syndrome may also include abdominal pain, vomiting with bile, headaches and migraine attacks, discomfort during movement, hyperesthesia to light and noise, fever, and pale skin.

Attacks of vomiting and nausea can occur six to twelve times per hour, and an episode can last from a few hours to three weeks, and in some cases months.

Cyclic vomiting syndrome in children

Cyclic vomiting syndrome is a typical childhood disease. An attack can be provoked by stress, emotional experiences from watching a TV show. During the treatment of the disease, it is necessary to consult a pediatrician or gastroenterologist.

Since cyclic vomiting syndrome in children is a poorly studied disease, parents should record all the signs, especially the frequency and frequency of attacks. Changes in appetite, diet, days of anxiety and stress should be recorded. The doctor should also be provided with a full list of medications and vitamins that the child has taken.

At home, the child should be in a comfortable and calm environment with a normal daily routine for his age and adequate sleep.

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Stages

Conventionally, the development of cyclic vomiting syndrome can be divided into 4 phases.

1. In the first, nausea of varying intensity occurs with the urge to vomit.
2. The second phase is characterized by vomiting itself.
3. The third phase is the residual or recovery period. At this stage, the patient gradually regains his appetite, activity increases, and the skin color acquires a natural appearance.
4. The fourth phase is complete recovery.

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Complications and consequences

Severe vomiting attacks lead to complications such as dehydration - hospitalization may be required. Also, low acidity of vomit can damage the esophageal mucosa, which can provoke the development of bleeding (Mallory-Weiss syndrome), caries, gastritis and esophagitis.

Infants, children, older adults, and people with weakened immune systems are at greater risk of developing dehydration. Parents should watch for the following signs that may indicate dehydration in children:

• dry mouth and tongue;
• absence of tears when crying;
• unusual moodiness or drowsiness;
• sunken eyes or cheeks;
• fever.

Seek emergency medical attention immediately if you experience any of the following symptoms:

• intense thirst;
• the appearance of dark urine;
• rare urination;
• lethargy, dizziness, fainting.

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Diagnostics cyclic vomiting syndrome

Cyclic vomiting syndrome is a disease that is quite difficult to diagnose. There are no reliable tests or diagnostic studies that could confirm such a diagnosis. The disease can only be verified by excluding all other causes that can provoke an attack of vomiting.

The number of additional studies is directly proportional to the nature of the symptoms. The doctor may prescribe fibroendoscopy, computed tomography, and ultrasound of the abdominal cavity.

In order to determine whether cyclic vomiting is caused by thyroid dysfunction or other metabolic diseases, laboratory blood tests are prescribed.

To rule out brain tumors and other disorders of the nervous system, it will be necessary to conduct an MRI of the head.

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Treatment cyclic vomiting syndrome

Treatment of this disease is based on experience and observation (i.e. empirical). Specific treatment methods must be adapted to each individual case.

The goal of therapy is to reduce the intensity of symptoms and prevent further relapses.

Before starting treatment, it is necessary to consult a psychologist, psychoneurologist and neuropathologist. Specialists will help to make an accurate diagnosis in order to prescribe the right treatment. First of all, it is necessary to adhere to a certain diet and exclude the consumption of smoked and fatty foods, sweet carbonated, hot and alcoholic drinks.

The goal of therapy at the prodrome stage is to stop the progression of the attack. Taking medications at an early stage can stop the further development of the episode. However, people do not always have time to stop the attack at this stage, since it often begins in the morning, as soon as the patient wakes up. Doctors recommend the following drugs for both children and adults:

• Ondansetron (Zofran) or lorazepam (Ativan).
• Ibuprofen for stomach pain.
• Ranitidine (Zantac), lansoprazole (Prevacid), or omeprazole (Prilosec, Zegerid), to control stomach acid.
• Sumatriptan (Imitrex) as a nasal spray, injection, or tablet that dissolves under the tongue to relieve migraine attacks.

Treatment in the vomiting phase. When vomiting occurs, it is advisable for a person to stay in bed. If vomiting is severe, it is better to call an ambulance. Gastroenterologists may recommend for both children and adults:

• Medicines for pain, nausea, reducing stomach acid, anxiety, migraines, drugs to prevent dehydration.

Sometimes strong antiemetic drugs such as ondansetron (Zofran) or granisetron (Kytril), dronabinol (Marinol) may be prescribed to prevent and reduce the severity of an attack.

Treatment in the recovery phase. During the recovery phase, it is very important to maintain proper nutrition. Drinking plenty of fluids will help replenish lost electrolytes. An IV may be required.

Treatment in Phase IV: During this phase, medications may be used to prevent or relieve future episodes of vomiting. Medications may need to be taken daily for 1 to 2 months. The following medications may be prescribed for both children and adults to prevent cyclic episodes of cyclic vomiting syndrome, reduce their severity, and reduce their frequency:

• Amitriptyline (Elavil).
• Propranolol (anaprilin).
• Cyproheptadine (Periactin).

Recent studies have shown the effectiveness of coenzyme Q10 and L-carnitine in preventing vomiting. Both are natural substances, sold without a prescription. Coenzyme Q10 is involved in energy production, and L-carnitine is involved in fat transport and metabolism. In some cases, vomiting becomes less frequent or disappears altogether. One study found that their effects are synergistic (more powerful) when combined with amitriptyline. Side effects of these drugs are rare and usually mild; L-carnitine can cause nausea and diarrhea.

Other equally important recommendations regarding treatment:

• You need to sleep with your head elevated on a high pillow,
• It is forbidden to wear excessively tight and constricting clothing,
• It is necessary to do non-heavy physical exercises that provoke abdominal tension.
• If a child has an attack of cyclic vomiting, the parents must be present to provide the necessary assistance.

Prevention

Almost all patients who suffer from cyclic vomiting syndrome know very well what exactly can provoke an attack. If such attacks occur more than once a month or require hospital treatment, the attending physician can prescribe a preventive complex of drugs.

Also, a good night's sleep, the absence of stressful situations, the exclusion of certain foods, such as cheese and chocolate, and fractional meals in small portions are recommended will have a positive effect on the general condition of the patient.

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Forecast

Mortality from this disease is low. In severe cases, fluid loss can lead to electrolyte imbalances and be potentially life-threatening. With adequate medical interventions, the prognosis for the syndrome is favorable.

Cyclic vomiting syndrome is a disease that should be treated by a doctor. At the first symptoms, you should contact a therapist, pediatrician, if it concerns children, or a gastroenterologist.

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