1851 The Ever-Mysterious Cyclical Vomiting Syndrome (CVS) and Abdominal Migraine: Recognition and Successful Management Strategies Illustrated by a Case Report

Abstract

INTRODUCTION: Cyclical vomiting syndrome (CVS) is a medically and socially disabling, idiopathic disorder characterized by recurrent, stereotypical bouts of vomiting with periods of normal health, occurring in children, adolescents, and recognized in adults. CVS is associated with substantial morbidity. Lack of awareness and recognition leads to tremendous anxiety, cost burden, and delay in diagnosis. Recently updated, Rome IV classification has attempted to highlight the issue to promote early recognition and diagnosis. We present a case of CVS and abdominal migraine in a 27-year-old female whose illness went unrecognized for 8 years and discuss successful management strategies. CASE DESCRIPTION/METHODS: A 27-year-old female with an 8-year history of recurrent episodic abdominal pains, nausea, vomiting, incidental superior mesenteric artery syndrome, status post laparoscopic duodenojejunostomy at 24, after which she had an apparent 6-month relief of symptoms, and history of anxiety and depression was seen for persistent diffuse abdominal pain, nausea, and 7-8 daily episodes of emesis for 3 weeks. Family history was significant for migraines in her mother. Since her initial symptoms at the age of 19, she experienced episodes of incapacitating nausea, vomiting, and abdominal pain lasting 3-4 weeks followed by symptom-free periods of 2-3 months. She had visited many hospitals, primary care physicians, psychiatrists, and gastroenterologists, and undergone repeated work-ups from basic to complex. Treatment with SSIRs, anti-emetics, valproic acid and even marijuana showed no or minimal benefit. Following thorough history and obtainment of records from other institutions, she was diagnosis and started on a combination of amitriptyline, propranolol, and Co-enzyme Q/L-Carnitine. She has been followed by monthly phone calls for about 1-year, remains symptom-free, and compliant with the regimen. DISCUSSION: Cyclic vomiting syndrome (CVS) is characterized by recurrent bouts of nausea and vomiting with periods of normal health. The pathogenesis is multifactorial, with multiple genetic, autonomic, and environmental factors. Often a great delay in diagnosis, on average 2.6 years in children and 8 years in adults leads to unnecessary testing and cumbersome procedures. In the case of our patient, her illness was unrecognized for many years and her symptoms often dismissed, pushing her into anxiety and depression. A multidisciplinary approach as well as prophylactic and abortive pharmacotherapy is needed to address the issue.