Cyclic Vomiting Syndrome In Adults Research Articles

Clinical characteristics and long-term outcomes in patients with cyclic vomiting syndrome: A 15-year experience at a tertiary referral center.

Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction (DGBI) characterized by recurrent episodes of nausea and vomiting. Most children outgrow their CVS symptoms and develop migraine headaches, but there are limited data in adults. We thus sought to determine the natural history of CVS in adults. We conducted a retrospective analysis of patients at a specialized tertiary care clinic. Frequency of CVS episodes, emergency department (ED) visits, and hospitalizations were recorded at the index visit and at follow-up. Of 455 CVS patients with complete data, mean age was 33 ± 13 years, 294 (65%) were female, and 392 (86%) were Caucasian. Mean duration of follow-up was 47.4 ± 37.2 months. There was a significant reduction in frequency of CVS episodes/year (18 to 6.8), ED visits (6.1 to 2), and hospitalizations (2.3 to 0.7) (all p-values < 0.001) but only 88 (19%) of patients had complete resolution of episodes at follow-up. On multivariable regression analysis, non-white race [0.33 (0.11-0.98) p = 0.01], comorbidity count [0.77 (0.62-0.95) p = 0.01], cannabis use [0.36 (0.2-0.65) p = 0.0007], and aprepitant use [0.2 (0.08-0.005) p < 0.001] were associated with a reduced odds of complete resolution of CVS episodes. Of note, 19 patients (4%) died. While most adults with CVS improved with specialized care, in contrast to children, only a small subset (~1 in 5) had complete resolution of symptoms. Reasons for the effects of race, cannabis use, and comorbidity burden on outcomes in CVS are unclear and warrant further investigation.

Management of cyclic vomiting syndrome in adults: Evidence review.

BackgroundThis evidence review was conducted to inform the accompanying clinical practice guideline on the management of cyclic vomiting syndrome (CVS) in adults.MethodsWe followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and focused on interventions aimed at prophylactic management and abortive treatment of adults with CVS. Specifically, this evidence review addresses the following clinical questions: (a) Should the following pharmacologic agents be used for prophylaxis of CVS: amitriptyline, topiramate, aprepitant, zonisamide/levetiracetam, or mitochondrial supplements? (b) Should the following pharmacologic agents be used for abortive treatment: triptans or aprepitant?ResultsWe found very low‐quality evidence to support the use of the following agents for prophylactic and abortive treatment of CVS: amitriptyline, topiramate, aprepitant, zonisamide/levetiracetam, and mitochondrial supplements. We have moderate certainty of evidence for the use of triptans as abortive therapy. We found limited evidence to support the use of ondansetron and the treatment of co‐morbid conditions and complementary therapies.ConclusionsThis evidence review helps inform the accompanying guideline for the management of adults with CVS which is aimed at helping clinicians, patients, and policymakers, and should improve patient outcomes.

Mo1561 – Prevalence of Cyclic Vomiting Syndrome in Adults and Outcome of Cannabis Use in This Population: A National Study

Mo1561 – Prevalence of Cyclic Vomiting Syndrome in Adults and Outcome of Cannabis Use in This Population: A National Study

Cyclic vomiting syndrome: epidemiology, diagnosis, and treatment.

Cyclic-vomiting syndrome (CVS) is a chronic functional gastrointestinal disorder characterized by recurrent episodes of nausea and vomiting. Although once thought to be a pediatric disorder, there has been a considerable increase in recognition of CVS in adults. The exact pathogenesis is unknown and several theories have been proposed. Migraine and CVS share a similar pathophysiology as suggested by several studies. Since there are no specific biomarkers available for this disorder, physicians should rely on Rome criteria for the diagnosis. Due to the lack of randomized control trials, the treatment of CVS is primarily empirical.

Cyclic Vomiting Syndrome in Adults and Children: A Hypothesis.

To see how patients' clinical descriptions compare to the third classification of International Classification of Headache Disorders (ICHD-III beta). CVS is an episodic syndrome associated with migraine. It is a rare disorder of childhood and adulthood. New criteria are proposed in the third classification of International Classification of Headache Disorders. This study describes children and adults' CVS characteristics at a French tertiary-care center, according to the ICHD-II and ICHD-III beta criteria. Clinical features, and results of paraclinical tests were characterized. Fifteen patients were included: 8 adults, 2 children, and 5 adolescents. Familial history of migraine or CVS was respectively noticed in 12 and 4 patients. The duration of premonitory, emetic, and postdromal phases was evaluated from hours to days. Some symptoms described in theses phases are also described in migrainous population, with a comparable frequency. Cranial or systemic autonomic symptoms were respectively reported in 47% and 93%. Nine patients described a circadian periodicity, and six patients described a circannual periodicity. The predictable periodicity was from 1 week to 12 months. A brain perfusion SPECT showed an increased hypothalamic perfusion during emetic phase in one patient. CVS is a rare episodic syndrome associated with migraine. Some clinical features and paraclincal tests suggest a chronobiological disease.

Cannabinoid hyperemesis and the cyclic vomiting syndrome in adults: recognition, diagnosis, acute and long-term treatment.

The cannabinoid hyperemesis syndrome (CHS) and the cyclic vomiting syndrome in adults (CVS) are both characterized by recurrent episodes of heavy nausea, vomiting and frequently abdominal pain. Both syndromes are barely known among physicians. Literature is inconsistent concerning clinical features which enable differentiation between CVS and CHS. We performed a literature review using the LIVIVO search portal for life sciences to develop a pragmatic approach towards these two syndromes. Our findings indicate that complete and persistent resolution of all symptoms of the disease following cannabis cessation is the only reliable criterion applicable to distinguish CHS from CVS. Psychiatric comorbidities (e.g. panic attacks, depression), history of migraine attacks and rapid gastric emptying may serve as supportive criteria for the diagnosis of CVS. Compulsive bathing behaviour, a clinical observation previously attributed only to CHS patients is equally present in CVS patients. Long-term follow-up is essential in order to clearly separate CHS from CVS. However, long-term follow-up of CVS and CHS cases is seldom. We provide a standard operating procedure applicable to a broad spectrum of health care facilities which addresses the major issues of CVS and CHS: awareness, diagnosis, treatment, and follow-up.

Cyclic vomiting syndrome: treatment options.

Cyclic vomiting syndrome is a disorder characterized by recurrent episodes of severe nausea and vomiting separated by symptom-free periods. Our aims were to review treatments of adult cyclic vomiting syndrome as well as to identify areas for further clinical research and the unanswered questions in this field. We conducted a PubMed search using such keywords as "cyclic vomiting syndrome," "nausea," "vomiting," "treatment," "trigger factors" and "tricyclic antidepressants" and combined this information with the knowledge and clinical research from the authors. Available data show that in adult cyclic vomiting syndrome, there is an impressive and sustained response to high-dose tricyclic antidepressants. In up to 13% who are regarded as poor responders to tricyclic antidepressants, a predictable profile can be identified related to coexisting psychological disorders, marijuana use, poorly controlled migraine headache or chronic narcotic use. Cyclic vomiting syndrome in adults is being an increasingly recognized entity. Tricyclic antidepressants are the main treatment for controlling symptoms. Eliminating and addressing trigger factors are an essential part of management.

Rapid or normal gastric emptying as new supportive criteria for diagnosing cyclic vomiting syndrome in adults.

BackgroundCyclic vomiting syndrome (CVS) in adults is a disorder characterized by recurrent and stereotypic episodes of severe nausea, vomiting and abdominal pain separated by symptom-free intervals. Our goal was to investigate gastric emptying (GE) in CVS patients.Material/MethodsThis was a retrospective study of 30 adult patients who met Rome III diagnostic criteria for CVS. Rapid GE was defined using two different predefined criteria as either <50% isotope retention or <65% isotope retention at 1st hour and/or <20% at 2nd hour.ResultsOf the 30 patients (25 had 4-hr GE) diagnosed with CVS, 22 were females and 8 males with a mean age of 39 years. Overall, 20 (80%) of the 25 CVS patients met the predefined criteria of <50% retention for rapid GE in the first hour. Fifteen (60%) met the 2-hour criteria for rapid emptying of <20% retention. Five (16.6%) patients of the 25 had a normal GE with a mean retention at the first hour of 65% (52–78%). Nine (36%) also met another predefined criteria of <35% retention for rapid GE in the first hour. Sixteen (64%) met criteria for normal GE.Conclusions(1) In adult CVS patients, GE is either rapid or normal, clearly distinguishing this entity from gastroparesis. (2) Cyclic vomiting syndrome is an important new etiology to explain the finding of rapid GE on a radionuclide test. (3) We suggest that rapid gastric emptying should be added as supportive criteria for diagnosing CVS in adults.

Review article: cyclic vomiting syndrome in adults – rediscovering and redefining an old entity

Cyclic vomiting syndrome is a disorder characterised by recurrent episodes of severe nausea and vomiting separated by symptom-free periods. To review the history, epidemiology, clinical aspects, pathophysiology, diagnosis and treatments of adult cyclic vomiting syndrome as well as to identify areas for further clinical research and the unanswered questions in this field. We conducted a PubMed search using such keywords as cyclic vomiting syndrome; nausea; vomiting; pathophysiology; diagnosis; treatment; trigger factors; gastric emptying test; autonomic nerve function test; gastrointestinal hormones; outcome and natural history and combined this information with the knowledge and extensive clinical research and publications from the authors. Available data show that in adult cyclic vomiting syndrome, severe epigastric and sometimes diffuse abdominal pain accompanies most cycles of nausea and vomiting interspersed with periods of symptomatic remission. Psychological disorders, specifically anxiety and depression are common, and gastric emptying is actually rapid in approximately 60% of patients and normal in the remainder. There is an impressive and sustained response to high-dose tricyclic antidepressants. In up to 15% who are regarded as poor responders to tricyclic antidepressants, a predictable profile can be identified related to co-existing psychological disorders, marijuana use, poorly controlled migraine headache or chronic narcotic use. Cyclic vomiting syndrome in adults is an entity that is being increasingly recognised, but the need to educate Internists, Gastroenterologists and Emergency Department staff remains an ongoing challenge.

Autonomic nerve function in adult patients with cyclic vomiting syndrome

Cyclic vomiting syndrome (CVS) in adults is a disorder characterized by recurrent and stereotypic episodes of severe nausea and vomiting separated by symptom-free periods. Autonomic dysfunction has been a postulated mechanism for the pathogenesis of this disorder in children but has not been explored in adults. Our goals were to investigate autonomic nerve function in adult patients with CVS. The sympathetic nervous system was evaluated through postural changes in heart rate and blood pressure and sympathetic skin response in the hand and foot. The parasympathetic nervous system was tested through heart rate response to deep breathing [expiration/inspiration (E/I)], Valsalva and postural indices (30 : 15 ratio). All patients had a 4-h standard isotope labeled egg beater meal gastric emptying test (GET). Twenty-two adult (18 female), mean age 35 ± 11 (range 19-61 years), who met Rome III criteria for CVS were included. History of migraine headache was reported in three patients. Five (23%) had pediatric onset. Of 21 patients who completed the test, nine patients had 21 abnormalities detected in their autonomic nerve testing profile and the remaining 12 had normal autonomic function results. Orthostatic tachycardia was observed in two (mean heart rate increase 39 beats min(-1)) and a decline in blood pressure (BP) in three patients (mean BP drop 30/14 mmHg). Parasympathetic abnormalities were elicited in six patients with an abnormal response to deep breathing and E/I index <1.25. Sympathetic nerve dysfunction was reported in seven patients with absent sympathetic skin response in the foot and/or hand. Twelve (57%) of CVS group had rapid GET (<50% retention at 1 h). The frequency of abnormal autonomic nerve function was not significantly higher in rapid GET subgroup. (i) Autonomic nerve dysfunction is common in adult CVS patients, being observed in 43% of our cohort; (ii) Sympathetic abnormalities dominate; and (iii) Rapid gastric emptying, present in 57% of patients, did not correlate with autonomic testing results. These new data provide more insight into the pathophysiology of CVS in adults and help explain the spectrum of clinical manifestations observed in this entity.

M1324 Cyclic Vomiting Syndrome in Adults: Relationship to Cannabis use, Migraine Headaches, and Intervening Symptoms.

M1324 Cyclic Vomiting Syndrome in Adults: Relationship to Cannabis use, Migraine Headaches, and Intervening Symptoms.

Who are the nonresponders to standard treatment with tricyclic antidepressant agents for cyclic vomiting syndrome in adults?

Cyclic vomiting syndrome in adults is a disorder characterized by recurrent and stereotypic episodes of severe nausea and vomiting separated by symptom-free periods. To investigate the demographic and clinical characteristics of adult cyclic vomiting syndrome patients not responding to standard tricyclic antidepressant (TCA) therapy. A total of 132 adults (62 men) with cyclic vomiting syndrome were followed for a mean of 1.6 years. Of these, 17 (eight men) patients were identified as nonresponders based on the criteria of unchanged, increased or minimally changed (<25%) frequency/duration of episodes and/or emergency department visits/hospitalizations. Demographic and clinical characteristics at baseline and annually up to 4 years were investigated. The nonresponders were receiving TCAs at an average dose of 90 mg/day compared to a mean dose of 85 mg/day in responders. Compared with the responders, the nonresponders were significantly more likely to have a history of migraine (P < 0.05); co-existing psychological disorders (P < 0.05); chronic marijuana use (P < 0.05) and reliance on narcotics for pain control between cyclic vomiting syndrome episodes (P < 0.05). (1) Nonresponse to standard therapy in adult cyclic vomiting syndrome patients occurs in approximately 13% and is not explained by under dosing with TCA therapy. (2) The main risk factors for nonresponse are: co-existing migraine headache, psychiatric disorder, chronic narcotic and marijuana use, which should be addressed aggressively when symptom exacerbations continue during attempts to induce remission in cyclic vomiting syndrome with high-dose TCA therapy.

Cyclic Vomiting Syndrome in Adults - How Much Work Up is Necessary?

Cyclic Vomiting Syndrome in Adults - How Much Work Up is Necessary?

Rome III Criteria for Cyclic Vomiting Syndrome in Adults: What is the Role of Gender?

Rome III Criteria for Cyclic Vomiting Syndrome in Adults: What is the Role of Gender?

M1228 The ROME III Criteria for Diagnosing Cyclic Vomiting Syndrome in Adults: Does It Perform?

M1228 The ROME III Criteria for Diagnosing Cyclic Vomiting Syndrome in Adults: Does It Perform?

Cyclic vomiting syndrome in adults: disregarding a possible epileptic component?

Cyclic vomiting syndrome in adults: disregarding a possible epileptic component?

Efficacy of Long Term Treatment Regimens on Cyclic Vomiting Syndrome in Adults

Purpose: Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent and stereotypic episodes of severe nausea and vomiting separated by symptom-free periods. It is now diagnosed more in adults than children. It's recurrent and disabling character requires more preventive and therapeutic options to reduce emergency department (ED) visits and hospitalizations and improve quality of life in these patients. Methods: In an open labelled study of 45 patients diagnosed with CVS based on Rome III criteria, we investigated the long term efficacy of tricylclic antidepressant (TCA) alone or in combination with Propranolol or Keppra on frequency and duration of CVS episodes and frequency of ED visits or hospitalizations during one and two years follow up. All received detailed information about the disorder, psychological support and help in identifying the trigger events as well as standard back ground support with Alprazolam for anxiety, Dicyclomine for abdominal pain and Promethazine for back up nausea. Demographic data, TCA dosage, duration and frequency of CVS episodes, ED visits and hospitalizations and subjective global assessment at baseline and during TCA therapy were recorded. Adverse effects with TCA were monitored. 5 stopped the medication, 2 within 3 months and 1 after 12 months, as their symptoms had completely resolved, 1 because of a lack of response and 1 due to severe hallucinations. Results: The results are summarized in Table. We followed 40 patients (19 female), mean age 35 years (18–63) on TCA and or TCA plus Keppra (N = 1) or Propranolol (N = 1) for one year and 23 for two years. 37 were on amitriptyline, 2 on nortriptyline and 1 on doxepine. Mean age of symptoms onset was 26 years and 32 years for making the diagnosis of CVS. The goal dose of TCA was 1 mg/kg and the actual doses achieved were 25–200 mg (average 90 mg, qhs). Side effects were reported in 35 percent of our patients and included: dry mouth, somnolence, constipation, postural hypotension, chronic fatigue, blurred vision, and mild hallucinations. 86 percent reported an improved quality of life by subjective global assessment.Table: Effect of Tricyclic Antidepressant therapy on Cyclic Vomiting Syndrome Charecteristics.Conclusion: Long-term TCA therapy significantly reduces the frequency and duration of CVS episodes, ED visits & hospitalizations and improves quality of life. (P < 0.05) These data indicate that TCAs are the treatment of choice for adult CVS patients. Their efficacy could be explained by the hypothesized role of the brain-gut axis in the pathogenesis of this disorder.

Gastric Emptying Patterns in Cyclic Vomiting Syndrome in Adults

Gastric Emptying Patterns in Cyclic Vomiting Syndrome in Adults

Cyclic vomiting syndrome in adults

Cyclic vomiting syndrome (CVS) was initially described in children but can occur in all age groups. Cyclic vomiting syndrome is increasingly recognized in adults. However, the lack of awareness of CVS in adults has led to small numbers of diagnosed patients and a paucity of published data on the causes, diagnosis and management of CVS in adults. This article is a state-of-knowledge overview on CVS in adults and is intended to provide a framework for management and further investigations into CVS in adults.

Clinical, psychiatric and manometric profile of cyclic vomiting syndrome in adults and response to tricyclic therapy1

Our goal was to investigate 31 adult patients (mean age 29 years, range 18-62 years) meeting Rome II criteria for cyclic vomiting syndrome (CVS). All subjects completed a clinical questionnaire, a Hamilton Rating Scale for Anxiety (HAM-A) and Zung Depression Inventory. Gastric emptying time was assessed in 30 subjects and electrogastrogram (EGG) in 11 between acute attacks. Twenty-seven patients treated with amitriptyline completed a follow-up questionnaire. The mean age of onset of the patients was 30 years (range 14-53 years) and cycles of nausea and vomiting were accompanied by often-severe epigastric and diffuse abdominal pain. A typical attack ranged from 1 to 14 days, with the majority being 4-6 days. The HAM-A revealed that 84% had an anxiety disorder, and based on Zung Depression Inventory 78% suffered from mild-to-severe depression. Only 4 (13%) patients reported migraine, but 14 had a family history of migraine. Gastric emptying time was rapid in 23 (77%), normal in 4 and delayed in 3. The EGG was abnormal in 7 of 11 patients, with 4 having tachygastria. Of 13 patients using marijuana, 7 had symptom relief, while 2 had resolution of CVS after stopping use. The overall treatment experience in the 24 patients receiving amitriptyline up to 1 mg kg(-1) day(-1) for at least 3 months indicated that 93% had decreased symptoms and 26% achieved full remission. Cyclic vomiting syndrome in adults has the following hallmarks: prominence of accompanying abdominal pain and increased prevalence of anxiety and depression, rapid gastric emptying and tachygastric EGG, and successful suppression of attacks by chronic amitriptyline therapy.