Cyclical vomiting syndrome

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

[1], [2], [3]

Epidemiology

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

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

Most often this pathology affects women, than men, in the ratio of 57:43.

[4], [5], [6], [7], [8]

Causes of the syndrome of cyclic vomiting

The exact cause of the syndrome of cyclic vomiting is unknown. Although nausea and vomiting are the main signs of this syndrome, scientists believe that the symptoms of the disorder develop due to disturbances in normal interaction between the brain and intestines (intestinal brain disorder).

[9], [10], [11], [12], [13]

Risk factors

Factors of risk of cyclical vomiting syndrome are violations of central regulation in the hypothalamic-pituitary-adrenal axis, migraine, hormonal changes in the body.

Special conditions or events that may cause a cyclic vomiting episode:

• Emotional stress, anxiety, or panic attacks, for example, in children - waiting for school exams or important events (birthdays, holidays, travel) family conflicts.
• Infections (sinusitis, respiratory infections, influenza).
• Certain foods, (chocolate or cheese), additives (caffeine, nitrites, which are usually found in sausages, such as hot dogs, glutamate sodium).
• Hot weather.
• Menstrual periods.
• Seasickness.
• Overeating before going to bed, fasting.
• Physical exhaustion or excessive physical activity.
• Lack of sleep.
• Sleighting in transport.

[14], [15], [16], [17], [18]

Pathogenesis

The pathogenesis of cyclical vomiting syndrome is multifactorial, involving genetic, vegetative, central and environmental factors.

These studies indicate a strong genetic component in children with CVS, signs of mitochondrial heteroplasmia and other related disorders (eg, migraine and chronic fatigue syndrome). Other theories suggest vegetative dysfunction, sympathetic hyperreactivity and, possibly, involvement in the pathogenesis of a corticotropin-releasing factor (CRF) synthesis disorder.

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

[19], [20], [21], [22],

Symptoms of the syndrome of cyclic vomiting

Some patients notice the forebears before the attack: prolongation, intense nausea and pallor, increased sensitivity to light, smell and sound, increased pressure and temperature, muscle pain and fatigue, a burning sensation along the spine, arms and legs. Some patients express a strong desire to swim in warm or cold water. Most people can identify triggers that trigger an attack of cyclical vomiting syndrome.

Characteristic symptoms of cyclical vomiting syndrome include:

• Intensive attacks of vomiting and nausea occur more often 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 different duration) with intense / acute nausea, with or without vomiting, with or without severe pain, with periods of symptom relief and subsequent gradual enhancement of the symptoms of cyclic vomiting syndrome until they peak (peak intensity).
• Four times vomiting during the heat;
• When testing the etiology of vomiting is not possible to establish;
• Exclusion of metabolic disorders, diseases of the gastrointestinal tract, or central nervous system.

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

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

Cyclical vomiting syndrome in children

The syndrome of cyclic vomiting is a characteristic childhood disease. An attack can provoke stress, emotional distress from watching a TV show. During the treatment of the disease, it is necessary to consult a pediatrician or a gastroenterologist.

Because the syndrome of cyclic vomiting in children is a little studied disease, parents should record all the signs, especially the frequency and frequency of seizures. It is necessary to record the changes in appetite, diet, days of anxiety and stress. Also, the doctor must present the entire list of medicines and vitamins, which the child took.

At home, the child should be in a comfortable and peaceful environment with a normal day regimen and a full-fledged sleep.

[23], [24], [25], [26]

Stages

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

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

[27]

Complications and consequences

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

Infants, children, the elderly, and people with a weakened immune system have a greater risk of developing dehydration. Parents should pay attention to the following signs, which may indicate dehydration in children:

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

Immediately call an ambulance if the following symptoms occur:

• strong thirst;
• the appearance of a dark color of urine;
• rare urination;
• lethargy, dizziness, fainting.

[28], [29], [30]

Diagnostics of the syndrome of cyclic vomiting

Cyclical vomiting syndrome is a disease that is difficult to diagnose. There are no reliable analyzes and diagnostic studies that could confirm such a diagnosis. To check up disease it is possible only having excluded all other reasons which can provoke an attack of vomiting.

The number of additional studies is directly proportional to the nature of the symptomatology. The doctor can prescribe a fibroendoscopy, a computer tomography, ultrasound of the abdominal cavity.

In order to determine whether the cause of cyclic vomiting dysfunction of the thyroid gland or other metabolic diseases prescribe laboratory blood tests.

To exclude neoplasms of the brain and other disorders of the nervous system, it will be necessary to perform an MRI of the head.

[31], [32], [33]

Treatment of the syndrome of cyclic vomiting

Treatment of this disease is based on experience and observation (that is, empirical). Specific methods of treatment should be adapted for each individual case.

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

Before the beginning of treatment it is necessary to consult a psychologist, a psychoneurologist and a neurologist. Specialists will help to make an accurate diagnosis in order to properly prescribe the treatment. First of all, it is necessary to adhere to a certain diet and exclude the use of smoked and fatty foods, sweet fizzy, hot and alcoholic beverages.

The purpose 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 an attack on this phase, since it often begins in the morning, when the patient has just awakened. Doctors recommend the following drugs for children and adults:

• Ondansetron (Zofran) or lorazepam (Ativan).
• Ibuprofen with abdominal pain.
• Ranitidine (Zantac), lansoprazole (Prevacid) or omeprazole (Prilosec, Zegerid), to control the acidity of the stomach.
• Sumatriptan (Imitrex) in the form of a nasal spray, injections or tablets that dissolves under the tongue - to relieve a migraine attack.

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

• medications for pain, nausea, reduced gastric acidity, anxiety, migraine, drugs to prevent dehydration.

Sometimes potent antiemetics such as ondansetron (Zofran) or granisetron (Kytril), dronabinol (Marinol), which prevent and reduce the severity of the attack, can be prescribed.

Treatment in the recovery phase. It is very important to maintain proper nutrition during the recovery phase. Abundant drink will help to replace lost electrolytes. You may need to set up a dropper.

Treatment in phase IV. During this phase, drugs can be used to prevent or alleviate future episodes of vomiting. You may need to take medication daily for 1 to 2 months. The following medicines for children and adults can be prescribed to prevent cyclic episodes of the syndrome of cyclic vomiting, reducing their severity and 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 participates in the processes of energy production, and L-carnitine - in the transportation of fats and metabolism. In some cases, vomiting becomes less frequent or disappears altogether. One study showed that their effects are synergistic (more powerful) in combination with amitriptyline. The side effects of these drugs are rare and usually insignificant; L-carnitine can cause nausea and diarrhea.

Other, no less important recommendations for treatment:

• Sleep is necessary with a raised head on a high pillow,
• It is forbidden to wear excessively tight and tight clothes,
• It is necessary to engage in not heavy physical exercises that provoke the stress of the press.
• At an attack of cyclic vomiting in the child, the presence of parents is necessary to provide the necessary help.

Prevention

Almost all patients who suffer from the syndrome of cyclic vomiting, know perfectly well what exactly can provoke an attack. If they happen more often than once a month or require treatment in a hospital, the attending doctor can prescribe a preventive drug complex.

Also beneficial for the general condition of the patient is a full sleep, the absence of stressful situations, the exclusion of certain foods, such as cheese and chocolate, it is recommended fractional meals in small portions.

[34], [35], [36], [37], [38], [39]

Forecast

Mortality is a result of this disease is low. In severe cases, fluid loss can lead to an imbalance of electrolytes and potentially life-threatening. With adequate medical interventions, the syndrome forecast is favorable.

Cyclical vomiting syndrome is a disease that a doctor should treat. At the first symptoms it is necessary to address to the therapist, the pediatrician, if it concerns the children or the gastroenterologist.

[40], [41], [42]