CYCLIC VOMITING SYNDROME
DEFINITION:
A disorder of unknown etiology characterized by repeated,
unpredictable, and explosive episodes of vomiting with intervals of
normal health between episodes.
EPIDEMIOLOGY:
- incidence: ?
- age of onset:
- usually in preschool or early school-aged children
- peaks between 3-4 years of age
- some adult-onset cases reported
- risk factors:
- ?
- a higher prevalence of irritable bowel disease, migraines,
motion sickness, recurrent headaches, and epilepsy is found in
CVS patients and their families
PATHOGENESIS:
- first described by Dr. Samuel Gee in 1882
- clinical description of Cyclic Vomiting Syndrome (CVS) by
C.S. Hoyl and G.B. Stickler in 1960 (Pediatrics 25:775-780)
- diagnostic criteria derived from the first International
Scientific Symposium on CVS at St. Bartholemew's Hospital in
1994
- summary of this Symposium published in J. of Pediatric
Gastroenterology and Nutrition (Suppl. 1) in 1995
CLINICAL FEATURES:
- recurrent, severe, discrete episodes of vomiting
- various intervals of normal health between episodes
- duration of vomiting episodes varies from hours to days
- no apparent cause of vomiting
2. Supportive Criteria
- stereotypical: each episode is similar within
individuals as to the time of onset, intensity, duration,
frequency, and associated symptoms & signs
- self-limited: episodes resolve spontaneously if left
untreated
2. Associated Symptoms
- headache
- photophobia
- abdominal pain
- nausea
- motion sickness
3. Associated Signs
- fever
- pallor
- diarrhea
- excessive salivation
- dehydration
- social withdrawal
2. Episode Characteristics
- episodes begin most commonly during the night and/or upon
arising in the morning
- the duration of episodes lasts from 12-48 hours in a
majority of patients
- in 85% of patients, the duration of each episode is the same
- the frequency of attacks averages 12 per year but ranges
from 1-70 per year
- episodes are cyclical in about 50% of patients
- some patients have a prodrome prior to an attack of malaise,
anxiety, or mild nausea lasting minutes to hours
- triggers (identified in 77% of cases):
- common triggers
- emotional stress, excitement (birthdays, holidays,
vacations), infections
- uncommon triggers
- physical exhaustion, hot weather, motion sickness,
overeating, eating at bedtime, specific foods, asthma,
menstruation
- behavioural manifestations during an episode:
- compulsive fluid intake, significant distress and
complaints, behavioural regression, withdrawn and
uncommunicative
- complications:
- dehydration, electrolyte imbalances, SIADH, hematemesis,
Mallory-Weiss tear, peptic esophagitis
INVESTIGATIONS:
- electrolytes, BUN, and creatinine may be abnormal during an
episode
2. Imaging Studies
MANAGEMENT:
- IV fluids for dehydration
- correction of any electrolyte disturbance
- a quiet, dark, nonstimulating environment during an episode
2. Medical
- antiemetics (promethazine, ondansetron, dimenhydrinate)
- anxiolytics (lorazepam)
2. Prophylactic
- antiepileptics (phenobarbital, carbamazepine)
- gastrointestinal prokinetic agents (cisapride,
erythromycin)
- antimigraines
- amitriptyline
- in a recent study, 73% of patients had a complete
response while 18% had a partial response
- cryproheptadine
- in the same study, 66% of patients had a complete
response while 17% had a partial response
3. Prognosis
- a self-limited disorder but the duration cannot be predicted
ADDITIONAL REFERENCES:
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