Cyclical Vomiting Syndrome
(CVS)
“an overview”
David Pillinger
10/27/08
CVS
“Idiopathic disorder characterized
by recurrent, stereotypical bouts
of vomiting with intervening
periods of normal health”
Must Meet 4 Defined Criteria!!
• 3 or more recurrent discrete episodes of
vomiting
• Varying intervals of completely normal health
between episodes; absence of nausea and
vomiting between episodes “on-off pattern”
• Episodes are stereotypical with regard to timing
of onset, symptoms, and duration for that person
• Utter absence of an organic cause for vomiting
Epidemiology
• Historically a childhood disorder though
now recognized increasingly in adults.
• Adult average age at diagnosis 41 though
average age of symptom development 35.
• Range 4-12 symptomatic cycles per year
• Mean of 6-8 (1-24) days per cycle.
• M:F ~ 1:1
• More common in Caucasians
Pathogenesis
• Remains Idiopathic
**CVS has been strongly linked to Migraine
Headaches and Abdominal Migraines**
Many patients have a strong FH of migraine
headaches. (82% of patients)
high response rate to anti-migraine therapy
Pathogenesis Cont..
CVS has also been linked to:
-food allergies
-dysautonomia
-mitochondrial (MCAD) and metabolic d/o
-endocrine (corticotropin-releasing factor inducing gastric
stasis and vomiting by vagal stimulation)
-catamenial (onset w/ menses)
-chronic cannabis use (resolution of CVS reported with
cessation)
Typical Cycle Course
• Symptom-free interval: period between episodes when no
symptoms are present.
• Prodrome: 1/3 of patients experience this. symptoms consist of
nausea, abdominal pain, lethargy, anorexia, and pallor. A migraine-
like visual aura is rare. Most episodes occur without warning.
• Episode: consists of nausea and vomiting 6/hr; writhing, abdominal
pain, inability to eat, drink, or take medicines without vomiting;
paleness; drowsiness; and exhaustion. 50% of patients develop
erosive esophagitis, less commonly Mallory-Weiss tears. No
improvement with anti-reflux meds.
• Recovery: begins when the nausea and vomiting stop. Healthy
color, appetite, and energy return.
**Pattern of episode variable, but stereotypical for an individual patient.
Triggers
2 Most Common Triggers:
INFECTION (sinusitis, URI’s)
PSYCHOLOGICAL STRESS
(both positive and negative stressors)
• Other frequently reported stressors include
physical stress, inadequate sleep, onset of
menses, chocolate and cheese
Clinical Manifestations
• Prolonged hot baths or showers – many patients take
frequent long hot showers during episodes. patients
report that contact with hot water lessens their nausea
and effect ceases as soon as they are out of water
• “Guzzle and Vomit” – patients will drink large amounts of
water and then vomit which is done for the purposes of
diluting the irritants in their vomitus and to achieve the
momentary lessening of nausea that follows rapid
emptying of the stomach
• Physical stress response, HTN, tachycardia, loose
stooling, neutrophilia, bandemia, in addition to
psychological and emotional irritability.
CVS REMAINS A DIAGNOSIS OF
EXCLUSION…
*must distinguish from functional
nausea and vomiting which is
present nearly continuously
Now… Empiric Therapy
Patient Support…
Anxiety is surprisingly prevalent in adult patients
3 main sources:
(a) the burden of illness, including physical
suffering and the economic and marital stress
caused by it
(b) anticipatory anxiety for the episode-to-come
(c) anxiety originating in psychological trauma
experienced during childhood or prior to the
onset of CVS
Support cont…
• Anxiety can lead to the deterioration in the course of
CVS, adults typically become fearful that they have an
illness no one can diagnose or treat
• characterized by coalescence of attacks, i.e.,
increasingly frequent episodes and more anxiety and
dyspeptic nausea between episodes.
• Complete coalescence causes the patient to be sick for
weeks or months at a time and sick more than well.
• In a series of 41 adults with CVS, 32% had coalescence
of episodes to the extent that they were completely
disabled and required financial support.
Fin
Cyclic Vomiting Syndrome Association
CVSAONLINE.ORG
References
1. Am J Gastroenterol. 2007;102(12):2832-2840.
2. CVSAonline.org
3. Li, BU. Cyclic vomiting syndrome: Light
emerging from the black box. 1999