What is Cyclic Vomiting Syndrome?
Cyclical vomiting syndrome (CVS) is a condition defined by frequent episodes of strong nausea and vomiting, which can last from a few hours to several days. This happens without any detectable underlying disease or infection. CVS was first recognized in children back in the late 1800s, and we currently know that it also affects adults. People with this condition often go through rigorous health check-ups over many months or even years.
Unexpectedly, there isn’t any single definitive test that can identify CVS. In contrast, it’s often diagnosed after other possibilities have been ruled out due to recurring similar symptoms. These individuals might go through many tests, imaging procedures, and sometimes even surgery. The lab results typically do not point to any specific condition, but signs of dehydration are common.
The impact of CVS is not just on the patients’ health, but it also significantly affects their economic stability and daily life. Children with CVS can miss a considerable number of school days each year. Adults, on the other hand, frequently end up in the emergency department, often causing them to miss work.
What Causes Cyclic Vomiting Syndrome?
The precise reason behind CVS, or cyclic vomiting syndrome, is still not completely known. In children, many believe that CVS could be an early sign that they might experience migraines in the future. There’s a well-documented connection between the two, however, the exact cause hasn’t been pinned down yet.
Some research links CVS to issues with the body’s natural processes or problems with mitochondria, the powerhouses of our cells. CVS has also been connected to allergies to certain foods, stress, and lack of sleep.
Interestingly, CVS seems to occur more often during a person’s menstrual cycle, suggesting hormones might play a role in triggering the condition. Moreover, people who have used cannabis for a long time can also experience CVS.
Risk Factors and Frequency for Cyclic Vomiting Syndrome
Cyclic Vomiting Syndrome (CVS) prevalence and incidence can be challenging to determine due to frequent misdiagnoses. However, it’s estimated that about 1.9% to 2.3% of people have this condition, with around 3.2 new cases per 100,000 people every year. CVS is most frequently found among white people and is slightly more common in females. While children commonly develop CVS between the ages of 3 to 7, it can occur at any age, with cases reported in infants and the elderly. Adults can also develop CVS without having experienced any episodes in their childhood.
Signs and Symptoms of Cyclic Vomiting Syndrome
Cyclic vomiting syndrome, or CVS, is a condition where a person experiences cycles of severe vomiting. This can come on suddenly and may last for hours to days. Prior to these episodes, individuals might experience abdominal pain, feel nauseous, lose their appetite, and feel tired. What distinguishes this condition is the fact that these bouts of vomiting come back after periods of feeling completely healthy, which can last weeks to months.
Many people with this condition report having sought medical help multiple times and from multiple providers, often without a definite diagnosis or relief from their symptoms. Some people might have even had surgeries, such as gallbladder removal, without seeing any improvement.
During a physical examination, doctors might notice signs of dehydration like dry mouth and increased heart rate. They might also detect tenderness in the abdomen. However, these signs aren’t exclusive to CVS and therefore can’t confirm a diagnosis on their own.
- Sudden onset of severe vomiting
- Abdominal pain
- Nausea
- Loss of appetite
- Fatigue
- Recurring cycles of symptoms
- Periods of feeling healthy between episodes
- Possible history of multiple medical consultations
- Possible history of previous surgeries without symptom relief
- Signs of dehydration during physical examination
- Possible tenderness in the abdomen
Testing for Cyclic Vomiting Syndrome
Patients with suspected cyclic vomiting syndrome (CVS) often undergo a range of tests. These can include a complete blood count, a comprehensive metabolic profile, lipase testing, urinalysis, and imaging tests such as a gallbladder ultrasound or CT scan of the abdomen and pelvis. Some patients also have a medical procedure called an esophagogastroduodenoscopy. These tests may need to be repeated during different episodes to help doctors identify the cause of the symptoms.
There are several guidelines that doctors consider when diagnosing CVS. One widely-accepted set of guidelines is the Rome IV Criteria. According to these criteria, patients must have recurring episodes of vomiting that start suddenly and last less than a week. Patients must have at least three separate episodes in the past year, with two happening in the last six months. There should be at least a week between episodes. Patients generally have no vomiting between episodes, although they may experience milder symptoms. These criteria need to be met for three months, with symptoms starting at least six months before diagnosis. An additional recommended factor to consider for CVS diagnosis is personal or family history of migraine headaches.
The North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) set forth another set of criteria for diagnosing CVS in children and teenagers. According to these recommendations, patients must have at least five attacks ever, or at least three attacks within six months. Each episode consists of intense nausea and vomiting lasting between an hour and ten days, and the episodes must be at least a week apart. Each individual patient would show a stereotypical pattern and symptoms. During each episode, vomiting occurs at least four times per hour for at least one hour. Patients return to their normal health between episodes. Importantly, these symptoms can’t be explained by another disorder.
Treatment Options for Cyclic Vomiting Syndrome
There’s currently no cure for Cyclic Vomiting Syndrome (CVS), but treatments are available to help manage the condition. The treatments can be split into three categories: preventive, stoppage, and supportive.
Supportive treatments are key, and they are provided in emergency settings even when CVS hasn’t been officially diagnosed. They involve giving intravenous fluids to combat dehydration and medications to reduce nausea, such as ondansetron or prochlorperazine. Ketorolac is often administered to help with pain. In some cases, medicines like lorazepam or diphenhydramine are given to help the patient relax or sleep. Keeping the person in a quiet, dimly lit space is also recommended.
Since there’s some scientific evidence suggesting a link between migraines and CVS, sumatriptan — a medication usually used to treat migraines — is sometimes used to stop a CVS episode if the condition is diagnosed. Amitriptyline is tried as a daily preventive therapy, but the dosage is kept low. Other preventive medicines that have been explored include cyproheptadine, propranolol, topiramate, and erythromycin. Research on these medications has produced mixed results, so there isn’t a single proven medicine that works in all cases.
Medical professionals will conduct tests to check the patient’s hydration levels. If the patient is dehydrated or has an electrolyte imbalance, actions are taken to correct that.
Many times, people with CVS come to the emergency department without a clear diagnosis. It’s important for health care providers to take a detailed medical history of these patients to correctly diagnose and plan treatment. If a patient keeps having repeated episodes of symptoms and no cause is found, or if a patient has had abdominal surgeries but the symptoms didn’t go away, then doctors might begin to consider CVS. In such cases, a referral to a pediatric or adult gastroenterologist — doctors who specialize in treating digestive system problems — should be made for further examination and treatment.
What else can Cyclic Vomiting Syndrome be?
Many different health conditions can start off with feelings of sickness and vomiting. These can include stomach flu (also known as gastroenteritis), gallbladder disease, stomach ulcers, appendicitis, and pancreatitis, amongst others. Other reasons for these symptoms could be infections or exposure to harmful substances, blockages in the digestive system, irritable bowel syndrome, mental health issues, nervous system disorders, metabolic disorders, or pregnancy in women who are capable of having children.
What to expect with Cyclic Vomiting Syndrome
While there’s no definitive cure for CVS, lowering triggers like lack of sleep or stress can help lessen its occurrences. Some children may stop experiencing CVS as they grow older, but it’s challenging to predict who will stop having vomiting cycles in the future. Teenagers and adults should be questioned about their use of cannabis, as stopping its usage can decrease or even eliminate CVS episodes.
Possible Complications When Diagnosed with Cyclic Vomiting Syndrome
Complications might include kidney damage because of dehydration or imbalance of electrolytes. Instances of Mallory Weiss tears (small tears in the lining of the lower end of the esophagus) and gastritis (inflammation of the stomach lining) could occur after an episode of vomiting. Unnecessary surgeries or procedures without symptom relief can be considered as another type of complication. These surgeries could also lead to complications.
Here are potential complications laid out:
- Kidney damage due to dehydration or electrolyte imbalance
- Mallory Weiss tears after an episode of vomiting
- Gastritis after an episode of vomiting
- Unnecessary surgeries or procedures without symptom relief
- Complications arising from these surgeries or procedures
Preventing Cyclic Vomiting Syndrome
There are times when the exact cause of vomiting is not known, but it can often be linked to physical or emotional stress, lack of sleep, or menstrual cycle. Properly addressing these potential cause can help lessen the occurrences. It’s also crucial to regularly check-in with a stomach specialist, also known as a gastroenterologist, to rule out other possible reasons for the vomiting and to decide if preventive medicine may help.
To help figure out what exactly prompts the vomiting, maintain a journal noting each instance. This can aid in identifying any personal triggers.
