Cyclic vomiting syndrome

Background

  • Recurrent episodes of vomiting, otherwise normal health in between
  • 32% of patients disabled by illness by time of diagnosis[1]
  • Pathophysiology not well understood
  • Average age at onset ~21yo
  • Females slightly more affected than males
  • Marijuana use is risk factor

Clinical Features

  • Pediatric diagnostic criteria[2]
    • At least 5 episodes or minimum of 3 over 6 mo
    • Nausea/vomitingepisodes lasting 1hr-10d, with 1 week in between
    • Stereotypical pattern and symptoms
    • Return to baseline health in between
    • Symptoms not due to another condition
  • Adult – Rome III criteria [3]
    • Stereotypical episodes of vomiting with acute onset lasting less than 1 week.
    • At least 3 episodes per year.
    • No nausea/vomiting between episodes.
    • Symptoms not due to another cause
  • Symptoms usually begin in early morning or upon waking
  • Prodrome of nausea--> vomiting
  • Episodes peak/decline over ~8h
  • Nausea typically not relieved by vomiting
  • +/-
    • Abdominal pain
    • Diarrhea
    • Fever
    • Headache
    • Vertigo

Differential Diagnosis

Nausea and vomiting

Critical

Emergent

Nonemergent

Evaluation

  • Clinical diagnosis of exclusion
  • Evaluate for alternate etiologies
  • Assess for dehydration, electrolyte abnormalities if clinically warranted

Management

  • Avoid triggers
    • Many patients have known triggers, such as diet, psychological stressors, sleep deprivation, cannabis, or infection.
  • May be on medications typically used for migraine prophylaxis
  • Abortive antiemetics therapy
    • Ondansetron- works better with benzos or diphenhydramine
    • Promethazine, prochlorperazine
    • Triptans (e.g. sumatriptan)
  • Supportive therapy
    • IVF with dextrose
    • Place in quiet, dark room +/- sedative

Disposition

  • If symptoms can be controlled, may discharge
  • For intractable vomiting unable to be controlled with medications, admit

See Also

  • Cannabinoid hyperemesis syndrome

External Links

References

  1. ↑ Fleisher DR, Gornowicz B, Adams K, Burch R, Feldman EJ. Cyclic Vomiting Syndrome in 41 adults: the illness, the patients, and problems of management. BMC Med. 2005 Dec 21. 3:20.
  2. ↑ Li BU, Lefevre F, Chelimsky GG, et al. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition consensus statement on the diagnosis and management of cyclic vomiting syndrome. J Pediatr Gastroenterol Nutr. 2008 Sep. 47(3):379-93.
  3. ↑ Venkatasubramani N, Venkatesan T, Li BUK. Extreme Emesis: Cyclic Vomiting Syndrome. Practical Gastroenterology. September 2007. 31:21-34.
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