Cyclic Vomiting Syndrome Follow-up

  • Author: Thangam Venkatesan, MBBS; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: Apr 23, 2010
 

Deterrence/Prevention

In some cases of cyclic vomiting syndrome (CVS), avoiding identified dietary triggers such as chocolate, cheese, and monosodium glutamate (MSG) can prevent episodes without the use of medication.[29]

If psychological stresses trigger episodes, stress management techniques or benzodiazepine anxiolytics (lorazepam or diazepam) may help abort attacks. However, avoiding common triggers such as car rides and infection may be impractical or impossible.

Interestingly, consultation with a sympathetic gastroenterologist without drug therapy may decrease the frequency of episodes as much as 70%.[44]

Next

Prognosis

Most published series indicate that cyclic vomiting syndrome lasts an average of 2.5-5.5 years, resolving in late childhood or early adolescence. A few patients continue to be symptomatic through adulthood.

As early as 1898, clinicians observed that some patients went on to develop migraine headaches. The fact that some children with cyclic vomiting syndrome progress to abdominal migraines and then to migraine headaches implies that a sequential progression of age-dependent manifestations of migraines may be noted.

A survey by Abu-Arafeh and colleagues revealed the mean ages of children with cyclic vomiting syndrome, abdominal migraines, and migraine headaches to be 5.3 years, 10.3 years, and 11.5 years, respectively.[30] This supports the developmental progression from vomiting to abdominal pain to headache.

In unpublished data, Li and Hayes found that nearly one third of patients develop migraines after resolution of cyclic vomiting syndrome and predict that nearly 75% develop migraines by age 18 years.

Previous
Next

Patient Education

Families are also encouraged to contact the Cyclic Vomiting Syndrome Association, which is an international voluntary organization that serves the needs of patients in the United States Canada, for ongoing support and information.

Previous
 
Contributor Information and Disclosures
Author

Thangam Venkatesan, MBBS  Assistant Professor, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin

Thangam Venkatesan, MBBS is a member of the following medical societies: American Gastroenterological Association and Indian Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

B UK Li, MD  Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Seth Marcus, MD  Fellow, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Memorial Hospital, Northwestern University

Seth Marcus, MD is a member of the following medical societies: American Academy of Pediatrics and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Shikha Sundaram, MD  Fellow, Department of Gastroenterology, Hepatology and Nutrition, Children's Memorial Hospital of Chicago and Northwestern University

Shikha Sundaram, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association

Disclosure: Nothing to disclose.

Abhilasha Pandey, MBBS  Froedtert Hospital, Medical College of Wisconsin

Disclosure: Nothing to disclose.

Specialty Editor Board

Jayant Deodhar, MD  Associate Professor in Pediatrics, BJ Medical College, India; Honorary Consultant, Departments of Pediatrics and Neonatology, King Edward Memorial Hospital, India

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

David A Piccoli, MD  Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine

David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Steven M Schwarz, MD, FAAP, FACN, AGAF  Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center

Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research

Disclosure: Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor; Johnson & Johnson, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References

  1. Li BU, Misiewicz L. Cyclic Vomiting Syndrome: a brain-gut disorder. Gastroenterol Clin N Am. 2003;32:997-1019. [Medline].

  2. Boles RG, Zaki EA, Lavenbarg T, et al. Are pediatric and adult-onset cyclic vomiting syndrome (CVS) biologically different conditions? Relationship of adult-onset CVS with the migraine and pediatric CVS-associated common mtDNA polymorphisms 16519T and 3010A. Neurogastroenterol Motil. Sep 2009;21(9):936-e72. [Medline].

  3. Boles RG, Adams K, Ito M, Li BU. Maternal inheritance in cyclic vomiting syndrome with neuromuscular disease. Am J Med Genet A. Aug 1 2003;120(4):474-82. [Medline].

  4. Zaki EA, Freilinger T, Klopstock T, et al. Two common mitochondrial DNA polymorphisms are highly associated with migraine headache and cyclic vomiting syndrome. Cephalalgia. Jul 2009;29(7):719-28. [Medline].

  5. Hirano M, Pavlakis SG. Mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes (MELAS): current concepts. J Child Neurol. Jan 1994;9(1):4-13. [Medline].

  6. Ito M, Le ST, Chaudhari D, et al. Screening for mitochondrial DNA heteroplasmy in children at risk for mitochondrial disease. Mitochondrion. 2001;1:269-278. [Medline].

  7. Salpietro CD, Briuglia S, Merlino MV, et al. A mitochondrial DNA mutation (A3243G mtDNA) in a family with cyclic vomiting. Eur J Pediatr. 2003;162:727-728. [Medline].

  8. Gordan N. Recurrent vomiting in childhood, especially of neurological origin. Dev Med Child Neurol. May 1994;36(5):463-7. [Medline].

  9. Cullen KJ, MacDonald WB. The periodic syndrome: its nature and prevalence. Med J Aust. Aug 3 1963;50(2):167-73. [Medline].

  10. Fleisher DR. The cyclic vomiting syndrome described. J Pediatr Gastroenterol Nutr. 1995;21 Suppl 1:S1-5. [Medline].

  11. 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. Dec 21 2005;3:20. [Medline]. [Full Text].

  12. Rashed H, Abell TL, Familoni BO, Cardoso S. Autonomic function in cyclic vomiting syndrome and classic migraine. Dig Dis Sci. Aug 1999;44(8 Suppl):74S-78S. [Medline].

  13. To J, Issenman RM, Kamath MV. Evaluation of neurocardiac signals in pediatric patients with cyclic vomiting syndrome through power spectral analysis of heart rate variability. J Pediatr. Sep 1999;135(3):363-6. [Medline].

  14. Khasawinah TA, Ramirez A, Berkenbosch JW, Tobias JD. Preliminary experience with dexmedetomidine in the treatment of cyclic vomiting syndrome. Am J Ther. Jul-Aug 2003;10(4):303-7. [Medline].

  15. Chelimsky TC, Chelimsky GG. Autonomic abnormalities in cyclic vomiting syndrome. J Pediatr Gastroenterol Nutr. Mar 2007;44(3):326-30. [Medline].

  16. Chelimsky G, Madan S, Alshekhlee A, Heller E, McNeeley K, Chelimsky T. A comparison of dysautonomias comorbid with cyclic vomiting syndrome and with migraine. Gastroenterol Res Pract. 2009;2009:701019. [Medline]. [Full Text].

  17. Fleisher DR, Matar M. The cyclic vomiting syndrome: a report of 71 cases and literature review. J Pediatr Gastroenterol Nutr. Nov 1993;17(4):361-9. [Medline].

  18. Li BU, Fleisher DR. Cyclic vomiting syndrome: features to be explained by a pathophysiologic model. Dig Dis Sci. Aug 1999;44(8 Suppl):13S-18S. [Medline].

  19. Li BU, Murray RD, Heitlinger LA, et al. Is cyclic vomiting syndrome related to migraine?. J Pediatr. May 1999;134(5):567-72. [Medline].

  20. Smith CH. Recurrent vomiting in children: Its etiology and treatment. J Pediatr. 1937;10:719-42.

  21. Withers GD, Silburn SR, Forbes DA. Precipitants and aetiology of cyclic vomiting syndrome. Acta Paediatr. Mar 1998;87(3):272-7. [Medline].

  22. Sato T. Prevalence of Syndrome of ACTH-ADH discharge in Japan. Clin Pediatr Endocrinol. 1993;2:7-12.

  23. Sato T, Funahashi T, Mukai M, et al. Periodic ACTH discharge. J Pediatr. Aug 1980;97(2):221-5. [Medline].

  24. Sato T, Igarashi N, Minami S, et al. Recurrent attacks of vomiting, hypertension and psychotic depression: a syndrome of periodic catecholamine and prostaglandin discharge. Acta Endocrinol (Copenh). Feb 1988;117(2):189-97. [Medline].

  25. Sato T, Uchigata Y, Uwadana N, et al. A syndrome of periodic adrenocorticotropin and vasopressin discharge. J Clin Endocrinol Metab. Mar 1982;54(3):517-22. [Medline].

  26. Tache Y. Cyclic vomiting syndrome: the corticotropin-releasing-factor hypothesis. Dig Dis Sci. Aug 1999;44(8 Suppl):79S-86S. [Medline].

  27. Lee C, Sarna SK. Central regulation of gastric emptying of solid nutrient meals by corticotropin releasing factor. Neurogastroenterol Motil. Dec 1997;9(4):221-9. [Medline].

  28. Zobel AW, Nickel T, Kunzel HE, et al. Effects of the high affinity corticotrophin-releasing hormone receptor 1 antagonist R121919 in major depression: the first 20 patients treated. J Psychiatr Res. 2000;34:171-81. [Medline].

  29. Li BU, Balint JP. Cyclic vomiting syndrome: evolution in our understanding of a brain-gut disorder. Adv Pediatr. 2000;47:117-60. [Medline].

  30. Abu-Arafeh I, Russell G. Prevalence and clinical features of abdominal migraine compared with those of migraine headache. Arch Dis Child. May 1995;72(5):413-7. [Medline]. [Full Text].

  31. Fitzpatrick E, Bourke B, Drumm B, Rowland M. The incidence of cyclic vomiting syndrome in children: population-based study. Am J Gastroenterol. Apr 2008;103(4):991-5; quiz 996. [Medline].

  32. Fitzpatrick E, Bourke B, Drumm B, Rowland M et al. The incidence of cyclic vomiting syndrome in children: population-based study. Am 2008 Apr;103(4):991-5 (Pubmed). Am 2008 Apr;103. [Medline].

  33. Venkatesan T, Tarbell S, Adams K, McKanry J, Barribeau T, Beckmann K, et al. A survey of emergency department use in patients with cyclic vomiting syndrome. BMC Emerg Med. Feb 24 2010;10:4. [Medline]. [Full Text].

  34. [Guideline] 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. Sep 2008;47(3):379-93. [Medline].

  35. Pfau BT, Li BU, Murray RD, et al. Differentiating cyclic from chronic vomiting patterns in children: quantitative criteria and diagnostic implications. Pediatrics. Mar 1996;97(3):364-8. [Medline].

  36. Shepherd HA, Harvey J, Jackson A, Colin-Jones DG. Recurrent retching with gastric mucosal prolapse. A proposed prolapse gastropathy syndrome. Dig Dis Sci. Feb 1984;29(2):121-8. [Medline].

  37. Hoyt CS, Stickler GB. A study of 44 children with the syndrome of recurrent (cyclic) vomiting. Pediatr. 1960;25:775-80. [Medline].

  38. Li BU. Cyclic vomiting: the pattern and syndrome paradigm. J Pediatr Gastroenterol Nutr. 1995;21 Suppl 1:S6-10. [Medline].

  39. Venkatasubramani N, Venkatesan T, Li BUK. Extreme Emesis: Cyclic Vomiting Syndrome. Practical Gastroenterology. September 2007;31:21-34.

  40. Allen JH, de Moore GM, Heddle R, Twartz JC. Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse. Gut. Nov 2004;53(11):1566-70. [Medline]. [Full Text].

  41. Donnino MW, Cocchi MN, Miller J, Fisher J. Cannabinoid hyperemesis: A case series. J Emerg Med. Sep 16 2009;[Medline].

  42. Hejazi RA, Lavenbarg TH, Foran P, McCallum RW. Who are the non-responders to standard treatment with tricyclic antidepressant agents for cyclic vomiting syndrome in adults? A large single center experience. Aliment Pharmacol Ther. Oct 10 2009;[Medline].

  43. Li BU, Murray RD, Heitlinger LA, et al. Heterogeneity of diagnoses presenting as cyclic vomiting. Pediatrics. Sep 1998;102(3 Pt 1):583-7. [Medline].

  44. Li BU. Cyclic vomiting syndrome and abdominal migraine: periodic syndromes with gastrointestinal symptoms. Int Semin Pediatr Gastroenterol Nutr. 2000;9(3):1-8.

  45. Olson AD, Li BU. The diagnostic evaluation of children with cyclic vomiting: A cost-effectiveness assessment. Pediatr. 2002;141:724-8. [Medline].

  46. Forbes D, Withers G. Prophylactic therapy in cyclic vomiting syndrome. J Pediatr Gastroenterol Nutr. 1995;21 Suppl 1:S57-9. [Medline].

  47. Li BU. Cyclic vomiting syndrome: a pediatric Rorschach test. J Pediatr Gastroenterol Nutr. Nov 1993;17(4):351-3. [Medline].

  48. Li BU. Cyclic vomiting: new understanding of an old disorder. Contemp Pediatr. 1996;13:48-62.

  49. Andersen JM, Sugerman KS, Lockhart JR, Weinberg WA. Effective prophylactic therapy for cyclic vomiting syndrome in children using amitriptyline or cyproheptadine. Pediatrics. Dec 1997;100(6):977-81. [Medline].

  50. Gokhale R, Huttenlocher PR, Brady L, Kirschner BS. Use of barbiturates in the treatment of cyclic vomiting during childhood. J Pediatr Gastroenterol Nutr. Jul 1997;25(1):64-7. [Medline].

  51. Vanderhoof JA, Young R, Kaufman SS, Ernst L. Treatment of cyclic vomiting in childhood with erythromycin. J Pediatr Gastroenterol Nutr. Nov 1993;17(4):387-91. [Medline].

  52. [Best Evidence] Winner P, Pearlman EM, Linder SL, et al. Topiramate for migraine prevention in children: a randomized, double-blind, placebo-controlled trial. Headache. Nov-Dec 2005;45(10):1304-12. [Medline].

  53. Van Calcar SC, Harding CO, Wolff JA. L-Carnitine administration reduces number of episodes in cyclic vomiting syndrome. Clin Pediatr. 2002;41:171-174. [Medline].

  54. Namin F, Patel J, Lin Z, et al. Clinical, psychiatric and manometric profile of cyclic vomiting syndrome in adults and response to tricyclic therapy. Neurogastroenterol Motil. Mar 2007;19(3):196-202. [Medline].

  55. Hejazi RA, Reddymasu SC, Namin F, Lavenbarg T, Foran P, McCallum RW. Efficacy of tricyclic antidepressant therapy in adults with cyclic vomiting syndrome: a two-year follow-up study. J Clin Gastroenterol. Jan 2010;44(1):18-21. [Medline].

  56. Boles RG, Lovett-Barr MR, Preston A, Li BU, Adams K. Treatment of cyclic vomiting syndrome with co-enzyme Q10 and amitriptyline, a retrospective study. BMC Neurol. Jan 28 2010;10:10. [Medline]. [Full Text].

  57. Clouse RE, Sayuk GS, Lustman PJ, Prakash C. Zonisamide or levetiracetam for adults with cyclic vomiting syndrome: a case series. Clin Gastroenterol Hepatol. Jan 2007;5(1):44-8. [Medline].

  58. Benson JM, Zorn SL, Book LS. Sumatriptan in the treatment of cyclic vomiting. Ann Pharmacother. Oct 1995;29(10):997-9. [Medline].

  59. Axelrod FB, Gouge TH, Ginsburg HB, et al. Fundoplication and gastrostomy in familial dysautonomia. J Pediatr. Mar 1991;118(3):388-94. [Medline].

  60. Boles RG, Adams K, Li BU. Maternal inheritance in cyclic vomiting syndrome. Am J Med Genet A. Feb 15 2005;133(1):71-7. [Medline].

  61. Boles RG, Chun N, Senadheera D, Wong LJ. Cyclic vomiting syndrome and mitochondrial DNA mutations. Lancet. Nov 1 1997;350(9087):1299-300. [Medline].

  62. Boles RG, Williams JC. Mitochondrial disease and cyclic vomiting syndrome. Dig Dis Sci. Aug 1999;44(8 Suppl):103S-107S. [Medline].

  63. Cupini LM, Santorelli FM, Iani C, et al. Cyclic vomiting syndrome, migraine, and epilepsy: A common underlying disorder?. Headache. 2003;43:407-409. [Medline].

  64. Goto Y, Nonaka I, Horai S. A mutation in the tRNA(Leu)(UUR) gene associated with the MELAS subgroup of mitochondrial encephalomyopathies. Nature. Dec 13 1990;348(6302):651-3. [Medline].

  65. Li BU. Cyclic Vomiting Syndrome. Curr Treat Options Gastroenterol. Oct 2000;3(5):395-402. [Medline].

  66. Li BU, Robbins JL, Vu KT. Morbidity and treatment in cyclic vomiting syndrome. Gastroenterol. 1996;110:25A.

  67. Sarna SK. Tachykinins and in vivo gut motility. Dig Dis Sci. 1999;44:S114-8. [Medline].

  68. Stickler GB. Relationship between cyclic vomiting syndrome and migraine. Clin Pediatr (Phila). Jul-Aug 2005;44(6):505-8. [Medline].

  69. Welch KM. Scientific basis of migraine: speculation on the relationship to cyclic vomiting. Dig Dis Sci. 1999;44:26S-30S. [Medline].

 
Previous
Next
 
Cyclic versus chronic temporal patterns of recurrent vomiting. The number of emeses is plotted over a 2-month period. The chronic pattern, represented by a thin dashed line, has low grade on nearly a daily basis (eg, gastroesophageal reflux). The cyclic pattern, represented by a heavy solid line, involves high-intensity episodes intermittently once every several weeks (eg, cyclic vomiting syndrome).
Table 1. Characteristics of Emergency Department Visits in Patients With Cyclic Vomiting Syndrome
CharacteristicAdults



(n = 104)



Children



(n = 147)



Number of ED visits per patient with cyclic vomiting syndrome (Median)15 (range, 1-200)10 (range, 1-175)
Number of ED visits prior to a diagnosis of cyclic vomiting syndrome (Median)7 (Range, 1-150)5 (Range, 0-65)
Diagnosis not made in the ED89 (93%)119 (93%)
Diagnosis not recognized in the ED in patients with an established diagnosis of cyclic vomiting syndrome84 (88%)97 (80%)
Number of different ED visited (Mean ± standard deviation)4.69 ± 4.722.6 ± 2.42
Table 2. Clinical Features in Adults and Children with Cyclic Vomiting Syndrome[39]
Feature ChildrenAdults
Age of Onset4.8 y (Earliest, 6 d)35 y (Latest, 73 y)
Delay in Diagnosis2.6 y8 y
Female-to-Male Ratio57:4317:24
FrequencyEvery 2-4 wkEvery 3 mo
Duration (Mean)1-2 d (range, 1-10 d)6 d (range, 1-21 d)
Periodicity49%Not reported
Early Morning Onset42%50%
Stereotypical Episodes99%85%
Prodrome72%, 1.5 h93%
SymptomsNausea, anorexia, pallorNausea, epigastric pain
Recovery to Oral Feeding6 h24 h
Relieving FactorsDeep sleepHot bath/shower (56%)
Precipitating FactorsStress (47%), infection (31%)Menses (57%), anxiety
Comorbid conditionsAnxietyNot reported
Interepisodic nausea< 6%63%
Coalescence of EpisodesFew50%
Vomiting6/hr at peak, bile (81%)8.5/hr
Systemic SymptomsPallor, salivation, listlessnessIntense thirst (33%)
GI SymptomsAnorexia, nausea, diarrhea, abdominal painAbdominal pain, diarrhea
Neurologic SymptomsHeadache, photophobia, phonophobia, abdominal painIrritable, confused
Natural history≥ 28% progress to migraineNot reported
Family history82%57%
ComplicationsDehydration, esophagitisDehydration, esophagitis, laparotomy (18%)
Morbidity14-25 d of missed school/year32% completely disabled
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.