Cyclic Vomiting Syndrome Research Articles

Cyclic Vomiting Syndrome in a Baby with 22q 11 Deletion Syndrome

Cyclic vomiting syndrome (CVS) is an episodic disorder that may be associated with migraine. It characterized by recurrent, stereotypic episodes of vomiting and nausea separated by intervals of comparative wellness. We report the first pediatric case of 22q 11 deletion syndrome (22q11DS) and CVS.

The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers.

Functional gastrointestinal disorders (FGIDs) are common worldwide and cover a wide range of disorders attributable to the gastrointestinal tract that cannot be explained by structural or biochemical abnormalities. The diagnosis of these disorders relies on the symptom-based Rome criteria. In 2016 the Rome criteria were revised for infants/toddlers and for children and adolescents. In this review, we discuss the novel Rome IV criteria for infants and toddlers. The criteria for infant colic were drastically changed, whereas only minor changes were made for regurgitation, cyclic vomiting syndrome, functional diarrhea, infant dyschezia and functional constipation. In addition to this, the new Rome IV discusses underlying mechanisms of pain in infants and toddlers, including the neuro-development of nociceptive and pain pathways, the various factors that are involved in pain experience, and methods of pain assessment in infants and toddlers is essential for the clinician who encounters functional pain in this age group. Overall, the Rome IV criteria have become more distinctive for all disorders in order to improve the process of diagnosing pediatric FGIDs.

Benign paroxysmal torticollis in infancy – diagnostic error possibility

Background/Aim. Benign paroxysmal torticollis (BPT) is a rare paroxysmal dyskinesia characterized by attacks of head tilt alone or tilt accompanied by vomiting and ataxia, which may last hours to days. It is claimed that BPT disappears completely in childhood, but that it can evolve into other conditions, such as benign paroxysmal vertigo, cyclical vomiting syndrome, abdominal migraine, hemiplegic migraine, motion sickness and/or migraine with aura. The aim of this manuscript was to renew focus on benign paroxysmal torticollis because the disorder is almost always under-recognized by pediatric practitioners, who often order extensive and unrewarding testing and physiotherapy treatment. Methods. Twelve BPT cases observed during a 5-year period (2009?2014) at the Clinical Centre Nis, Nis, Serbia were reviewed. Data were collected on the features of torticollis, the age of onset, the duration of episodes, associated symptoms, the frequency of episodes, the persistence of symptoms over time, the age when the disorder finally disappeared, sequelae appearing after the 5th birthday, and family history of BPT, migraine or kinetosis. All the children were followed for periods ranging from 48 to 72 months. Results. The series included 6 females and 6 males. The age at onset of BPT was less than 8 months in 84% of the cases. Episodes of torticollis occurred suddenly on waking in all the cases without any trigger factors. The duration of torticollis ranged from a few hours to a few weeks. In 58% of cases, the condition persisted for more than one week. The frequency of the episodes ranged from once every 3 days to once every 25 days. The episodes were more frequent and lasted longer in the early months and tended to cease as the child became older. The age when episodes ended ranged from 11 months to 62 months. In 11 (91.66%) cases, the disorder disappeared before the patient's 5th birthday. No patient had a family history of BPT. In 6 cases, family members had kinetosis. In 5 cases, family members were positive for both migraine and kinetosis. All the children had normal motor development and normal speech and language development. After the disappearance of BPT, two children developed other forms of periodic syndromes: one boy had migraine with aura, and one girl experienced cyclic vomiting. Conclusion. BPT is probably an age-sensitive and migraine-related disorder that is benign in nature. The disorder is often misinterpreted, and children may pointlessly undergo numerous tests. Therefore, it is very important to recognize and observe this condition in order to avoid extensive, unnecessary and unpleasant procedures on the child.

Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment-a Systematic Review.

Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic vomiting associated with cannabis use. Our objective is to summarize the available evidence on CHS diagnosis, pathophysiology, and treatment. We performed a systematic review using MEDLINE, Ovid MEDLINE, Embase, Web of Science, and the Cochrane Library from January 2000 through September 24, 2015. Articles eligible for inclusion were evaluated using the Grading and Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Data were abstracted from the articles and case reports and were combined in a cumulative synthesis. The frequency of identified diagnostic characteristics was calculated from the cumulative synthesis and evidence for pathophysiologic hypothesis as well as treatment options were evaluated using the GRADE criteria. The systematic search returned 2178 articles. After duplicates were removed, 1253 abstracts were reviewed and 183 were included. Fourteen diagnostic characteristics were identified, and the frequency of major characteristics was as follows: history of regular cannabis for any duration of time (100%), cyclic nausea and vomiting (100%), resolution of symptoms after stopping cannabis (96.8%), compulsive hot baths with symptom relief (92.3%), male predominance (72.9%), abdominal pain (85.1%), and at least weekly cannabis use (97.4%). The pathophysiology of CHS remains unclear with a dearth of research dedicated to investigating its underlying mechanism. Supportive care with intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications has shown some benefit in the acute setting. Cannabis cessation appears to be the best treatment. CHS is a cyclic vomiting syndrome, preceded by daily to weekly cannabis use, usually accompanied by symptom improvement with hot bathing, and resolution with cessation of cannabis. The pathophysiology underlying CHS is unclear. Cannabis cessation appears to be the best treatment.

A Case Report of Herpes Esophagitis in an Immunocompetent Patient with Cyclic Vomiting Syndrome

Herpes esophagitis (HE) is common in the immunosuppressed but has rarely been reported in the immunocompetent. A recent case series identified 56 cases of confirmed HE in immunocompetent hosts since 1950. Cyclic Vomiting Syndrome (CVS) is an idiopathic disorder characterized by chronically recurring, self-limited episodes of intense nausea and vomiting with a 2% prevalence in the pediatric population. Complications of acute episodes of CVS include dehydration, electrolyte imbalance, Mallory-Weiss tear, weight loss, and esophagitis. To our knowledge, there have been no reported cases of HE in an immunocompetent patient with a history of CVS until now. 19-year-old male with past medical history of depression and 5 year history of nausea and vomiting, which had recently been diagnosed as CVS after extensive workup. He had been released from the hospital 3 days ago for intractable nausea and vomiting, but presented again to the ED with multiple episodes of vomiting. In the ED he complained of new pleuritic chest pain and tightness. Examination revealed pleural rub. Labs revealed a WBC count of 22.4, a creatinine of 1.4, and a UDS positive for THC. Chest x-ray showed pneumopericardium and pneumomediastinum. Follow-up CT chest confirmed esophageal perforation. He was immediately taken for an EGD, which showed no tear or perforation suggesting that occult perforation had sealed spontaneously. EGD did reveal new ulcerations in the distal third of the esophagus, which had not been seen on EGD in the previous workup of CVS. Biopsies obtained from the ulcers were positive for Herpes Simplex Virus. Subsequent testing for HIV and other sources of immunodeficiency were negative. He was then prescribed course of acyclovir, stabilized, and was discharged. HE is rarely reported in immunocompetent hosts, and has not been previously reported in patients with CVS. Young males are most often affected (male:female ratio 2.3:1) (mean age 35 +/- 18.8 years). HE most often presents with odynophagia, fever, chest pain, and dysphagia. Rarely, HE presents with nausea and vomiting. The disease is often self-limited. While esophagitis has been noted as a complication of CVS, we know of no prior reports of immunocompetent HE associated with CVS. This finding raises questions about the possible relationship between CVS and HE. CVS may predispose patients to infection. Alternatively, some presumed cases of CVS may in fact be rare presentations of HE.

The Cyclic Vomiting Syndrome Threshold: A Framework for Understanding Pathogenesis and Predicting Successful Treatments.

Cyclic vomiting syndrome (CVS) is an uncommon, idiopathic disorder defined by recurrent, sudden-onset attacks of repetitive retching and vomiting that are separated by symptom-free intervals. CVS was long regarded as a disorder primarily experienced by children but is now known to present de novo in adulthood. Adult CVS has garnered more research attention over the past 20 years, and these efforts have identified some acute and prophylactic treatments for this disorder. However, CVS still lacks a unifying disease model, and this has hindered the development of new therapies. Here adult CVS is reframed as a neurogenic disorder, driven by various endophenotypic factors that shape patterns of activity within the neural circuits required for disease expression. The concept of the “CVS threshold” is put forth in parallel with exploring the remarkable similarity of adult CVS with features of chronic migraine, epilepsy, and panic disorder. Because of such shared neural mechanisms and overlapping endophenotypes, many therapies that have been developed for these other disorders could also be useful in managing CVS. This review seeks to achieve three primary aims: (1) to develop a comprehensive, explanatory framework for adult CVS pathogenesis, (2) to use this framework for identifying potentially novel therapies for CVS, and (3) to describe future research directions that are needed to move the field forward.

Adult Cyclic Vomiting Syndrome Is Treatable and Curable

Introduction: Cyclic Vomiting Syndrome (CVS) in adults is underdiagnosed because it is not well recognized by physicians although it accounts for up to 20% of patients referred to a GI practice for evaluation of unexplained vomiting and abdominal pain. Goals of therapy are to induce remission while also addressing the predisposing “trigger” factors. The purposes of this study are to provide an analysis of the clinical profile, treatment responses, and outcomes based on managing adult CVS at a GI motility center. Methods: Our adult CVS database identified 18 patients, 10 female, of ages ranging from 22-60, who were initially diagnosed at our center, received treatment, and had long term follow up of 1 to 4 years by one of the authors. Results: Onset of symptoms ranged from 1-15 years prior to diagnosis (mean of 4). The mean number of yearly ER visits or hospitalizations was 5.8. Weight loss ranged from 5-50 pounds. Ten patients underwent a 4 hour standardized radionuclide gastric emptying test: 6 had rapid emptying and. Six major “triggers” were identified (some patients having >1): anxiety in 17, post-traumatic stress disorder in 2, migraines in 5, chronic marijuana use in 5, poorly controlled diabetes in 5, and menses in 4. All patients were treated with tricyclic antidepressants. Amitriptyline was the first choice, starting at 10mg at night, increasing by 10mg every 2-3 weeks until CVS improved. Two patients were switched to doxepin due to side effects; their max doses were 100mg and 200mg. At the same time the “trigger” factors were aggressively addressed. With this treatment strategy 4 patients (22%) were able to stop their CVS medications and have remained asymptomatic for over 1 year. In addition, 11 patients (61%) responded remarkably with a reduction in the mean number of annual ER visits or hospitalizations from 5.8 to 0.6 and were fully functional. Three patients (17%) reported ongoing, approximately monthly, episodes and had unresolved trigger factors and medication noncompliance. Conclusion: 1) Adult CVS is a treatable and reversible entity; 2) The treatment consisting of high dose TCA & addressing the “trigger factors” was able to prevent cycles in 83% of patients, including 22% that were effectively cured and able to taper off medications without recurrence; 3) The approximately 17% of patients who have ongoing cycles require better control of the predisposing factors as well as reinforcing compliance with the treatment regimen.

Gastric Electrical Stimulation Is an Option for Patients with Refractory Cyclic Vomiting Syndrome.

Background/AimsCyclic vomiting syndrome (CVS) is a disabling migraine variant manifesting as severe episodes of nausea and vomiting and often refractory to many therapies. Gastric electrical stimulation (GES), which can reduce nausea and vomiting in gastroparesis, may provide symptomatic relief for drug-refractory CVS. This study assessed the utility GES in reducing the symptoms of CVS and improving the quality of life.MethodsA one-year, non-randomized, clinical study was conducted. Eleven consecutive patients with drug refractory, cyclic vomiting syndrome based on Rome III criteria and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), underwent treatment with temporary GES (Temp GES) and permanent GES (Perm GES). Post-treatment follow up was done up to one year after permanent gastric electrical stimulation therapy.ResultsTotal symptom score decreased by 68% and 40% after temporary and permanent GES therapies, respectively. Hospital admission events significantly decreased to 1.50 (± 1.00) events from 9.14 (± 7.21) annual admissions prior to treatment with permanent GES. Vomiting episodes fell by 83% post Temp GES and 69% after Perm GES treatments. Mucosal electrogram values also changed after temporary stimulation.ConclusionsIn a small group of drug-refractory CVS patients, treatments with temporary and permanent GES significantly reduced the severity of gastrointestinal symptoms and frequency of hospital admissions.

Abdominal Epilepsy: A Rare Cause of Paroxysmal Abdominal Symptoms Associated with Epilepsy

INTRODUCTION: Abdominal epilepsy is an uncommon disorder in which gastrointestinal symptoms, most commonly abdominal pain result from seizure activity. It is characterized by 1) otherwise unexplained, paroxysmal gastrointestinal symptoms, 2) CNS symptoms consistent with epilepsy, 3) an abnormal electroencephalogram with findings specific for a seizure disorder and 4) improvement with anticonvulsant medication. We present a case of abdominal epilepsy in a patient with history of Temporal lobe seizure disorder. CASE: A 56 year old man presented with episodes of lower abdominal pain for 6-7 months, lasting for seconds to minutes, not associated with meals, nausea, vomiting or blood in stool. His past medical history included temporal lobe epilepsy and psoriatic arthritis. He reported neurologic symptoms preceding abdominal pain characterized by feelings of disconnect, seeing surreal colors and feeling Deja-vu. Physical exam, including vitals was normal. Lab studies showed normal CBC, CMP and FIT test. Urine porphyrin test was negative. Video EEG during the time of presentation with similar complaints showed seizure activity in the temporal lobe confirming the diagnosis of abdominal epilepsy. His medication was switched from levetiracetam to lamotrigine which improved his symptoms. DISCUSSION: Abdominal epilepsy is a rare disease in which gastrointestinal symptoms result from seizure activity. Manifestations include recurrent abdominal pain, nausea, vomiting and bloating associated with diverse CNS symptoms like confusion, fatigue, headache, dizziness and syncope. Differential diagnoses include other causes of paroxysmal gastrointestinal symptoms, such as porphyria, familial Mediterranean fever, cyclical vomiting syndrome and abdominal migraine. In patients with abdominal symptoms and headache, it is often difficult to differentiate abdominal migraine from abdominal epilepsy. An EEG is a simple, non-invasive approach to differentiate between these two entities. Patients with abdominal epilepsy usually have specific EEG abnormalities, particularly of a temporal lobe seizure disorder. Once the diagnosis is confirmed, treatment is focused on controlling the seizures. The prognosis is good with usually a dramatic response to anti-epileptic medication. KEY WORDS: Abdominal pain, Seizure, Temporal lobe epilepsy.

A New Approach to the Prophylaxis of Cyclic Vomiting: Topiramate.

Background/AimsThe aim of this study was to compare the efficacy and tolerability of topiramate and propranolol in preventing pediatric cyclic vomiting syndrome.MethodsA retrospective medical-record review of patients who underwent prophylaxis after receiving a diagnosis of cyclic vomiting syndrome was performed. Patients who completed at least 12 months of treatment were included in the analysis. Responder rate, and adverse-event rates were also calculated from all patients. Response to treatment was assessed as the total number of vomiting attacks per year. Patients in whom the frequency of vomiting attack reduced greater or equal to 50% were defined as responders, and the remaining patients were classified as nonresponders.ResultsA total of 38 patients who were treated prophylactically with either topiramate (16 patients) or propranolol (22 patients) were identified. Fifty-nine percent of the patients in the propranolol group and 81% of the patients in the topiramate group reported freedom from attacks. A decrease of more than 50% in attacks per year occurred in 23% of patients in the propranolol group and 13% of patients in the topiramate group. The responder rates were 81% for propranolol group and 94% for topiramate group (P = 0.001). Despite minor adverse effects (drowsiness, nervousness, and dizziness) observed in a few patients, the adverse event rates were not significantly different between the 2 groups (P = 0.240).ConclusionsThe efficacy of topiramate was superior to propranolol for the prophylaxis of pediatric cyclic vomiting syndrome.

A New Guidelines For Using Erythromycin In Management Of Childhood Cyclic Vomiting Syndrome

Cyclic vomiting syndrome (CVS) is a functional disorder without any determined cause, though some motility disorders are considered in stream of this syndrome. There is no clear treatment for CVS and all treatments are borrowed from treatment of other similar diseases such as migraine. Clinical practice guideline instructs the pediatricians and pediatric gastroenterologists for treatment of CVS in both inpatient and outpatient settings. Since there is no practical guideline for the empirical management of CVS, this guideline was prepared for framing the treatments in a scienti­c and simple way for this disorder.

Genetic analysis of hyperemesis gravidarum reveals association with intracellular calcium release channel (RYR2)

Hyperemesis Gravidarum (HG), severe nausea/vomiting in pregnancy (NVP), can cause poor maternal/fetal outcomes. Genetic predisposition suggests the genetic component is essential in discovering an etiology. We performed whole-exome sequencing of 5 families followed by analysis of variants in 584 cases/431 controls. Variants in RYR2 segregated with disease in 2 families. The novel variant L3277R was not found in any case/control. The rare variant, G1886S was more common in cases (p = 0.046) and extreme cases (p = 0.023). Replication of G1886S using Norwegian/Australian data was supportive. Common variants rs790899 and rs1891246 were significantly associated with HG and weight loss. Copy-number analysis revealed a deletion in a patient. RYR2 encodes an intracellular calcium release channel involved in vomiting, cyclic-vomiting syndrome, and is a thyroid hormone target gene. Additionally, RYR2 is a downstream drug target of Inderal, used to treat HG and CVS. Thus, herein we provide genetic evidence for a pathway and therapy for HG.

Anxiety and physiological responses to the Trier Social Stress Test for Children in adolescents with cyclic vomiting syndrome.

This study compared anxiety and physiological responses during the Trier Social Stress Test for Children (TSST-C) in adolescents. 38 subjects (26 females) were enrolled: 11 cyclic vomiting syndrome (CVS), 11 anxiety, and 16 controls. Salivary cortisol, α-amylase and heart rate variability (HRV) were assessed during the TSST-C. Anxiety was measured by the Screen for Childhood Anxiety Related Emotional Disorders (SCARED), Anxiety Disorders Interview Schedule, and State-Trait Anxiety Inventory for Children (STAI-C). 11 anxiety and 7 CVS subjects had ≥1 anxiety disorder. 82% in the anxiety and CVS groups met criteria for an anxiety disorder on the SCARED. Combining groups, cortisol increased from baseline to recovery during the TSST-C (p=0.0004) and the stressor to recovery (p=0.005). α-amylase did not differ during the TSST-C for the total sample, but increased for anxiety compared to controls from baseline to recovery (p=0.01). HRV decreased during the stressor (p=0.0001) and increased at recovery (p=0.004). No associations were found between biomarkers and trait anxiety. Associations were found between baseline HRV and pre-test state anxiety (r=-0.406, p=0.012) and between recovery HRV and post-test state anxiety (r=-0.501, p=0.002) for the total sample. Anxiety is prevalent in CVS warranting screening. HRV may serve as a biomarker for evaluating stress as a potential trigger for CVS episodes. State but not trait anxiety was associated with changes in HRV, suggesting acute anxiety may be more relevant in linking stress and CVS episodes.

Single Center Experience with Hydroxyzine in the Treatment of Cyclic Vomiting Syndrome

Background To this date, there has been no specific therapy proven to be effective for cyclic vomiting syndrome (CVS) in controlled trials. Multiple regimens have been proposed including: cyproheptadine, propranolol, amitriptyline, and phenobarbital. These medications are not without major side effects. The aim of this study was to describe the authors’ experience with hydroxyzine in children with CVS. Materials and Methods This was a systematic retrospective review of charts from March 1st 2012 till December 31st 2014. Patients diagnosed with CVS and treated with hydroxyzine were included in this study. Demographic criteria as well as response to therapy were reviewed. Results 48 patients were diagnosed with CVS during the period of two years and nine months. Female to male ratio was 2:1. The average age at diagnosis was 10.4 years. Fifteen patients were treated with hydroxyzine. Overall success rate was 86.7%. The rates of complete and partial remission were respectively 61.5% and 38.4%. Only 2 patients failed to respond. Conclusion Hydroxyzine seems to be a safe and effective alternative prophylactic treatment in children with CVS. Further randomized controlled studies are needed to support this specific indication for prescribing hydroxyzine.

Pharmacological interventions on early functional gastrointestinal disorders.

BackgroundFunctional gastrointestinal disorders (FGIDs) are chronic or recurrent gastrointestinal symptoms without structural or biochemical abnormalities. FGIDs are multifactorial conditions with different pathophysiologic mechanisms including altered motility, visceral hyperalgesia, brain-gut disturbance, genetic, environmental and psychological factors.Although in most cases gastrointestinal symptoms are transient and with spontaneous resolution in infancy multiple dietary changes and pharmacological therapy are often started despite a lack of evidence-based data. Our aim was to update and critically review the current literature to assess the effects and the clinical appropriateness of drug treatment in early (occurring in infants and toddlers) FGIDs.MethodsWe systematically searched the Medline and GIMBE (Italian Group on Medicine Based on Evidence) databases, according to the methodology of the Critically Appraised Topics (CATs). We included reviews, clinical studies, and evidence-based guidelines reporting on pharmacological treatments. Systematic reviews and randomized controlled trials (RCTs) concerning pharmacologic therapies in children with early FGIDs were included, and data were extracted on participants, interventions, and outcomes.ResultsWe found no evidence-based guidelines or systematic reviews about the utility of pharmacological therapy in functional regurgitation, infant colic and functional diarrhea. In case of regurgitation associated with marked distress, some evidences support a short trial with alginate when other non pharmacological approach failed (stepped-care approach). In constipated infants younger than 6 months of age Lactulose is recommended, whilst in older ages Polyethylene glycol (PEG) represents the first-line therapy both for fecal disimpaction and maintenance therapy of constipation. Conversely, no evidence supports the use of laxatives for dyschezia. Furthermore, we found no RCTs regarding the pharmacological treatment of cyclic vomiting syndrome, but retrospective studies showed a high percentage of clinical response using cyproheptadine, propanolol and pizotifen.ConclusionThere is some evidence that a pharmacological intervention is necessary for rectal disimpaction in childhood constipation and that PEG is the first line therapy. In contrast, for the other early FGIDs there is a lack of well-designed high-quality RCTs and no evidence on the use of pharmacological therapy was found.

Prevalence of functional gastrointestinal disorders among adolescents in Delhi based on Rome III criteria: A school-based survey.

Functional gastrointestinal diseases (FGIDs) are emerging as an important cause of morbidity in adolescents globally. The prevalence of FGIDs among Indian children or adolescents is not clear. A cross-sectional school-based survey conducted in 1115 children aged 10-17years attending four semi urban government schools of National capital territory (NCT) of Delhi. Rome III questionnaire was translated into Hindi and was filled by the students under supervision. Prevalence of FGIDs was calculated. Ten percent (112) adolescents had FGIDs. Out of 112, 52% (58) were boys, and 48% (54) were girls. 2.7% (30) had functional dyspepsia, 1.3% (15) had irritable bowel syndrome, 1.4% (16) had abdominal migraine, 1.5% (17) had aerophagia, 0.4% (5) had functional abdominal pain syndrome, and 0.3% (4) had functional abdominal pain. Prevalence of functional constipation, adolescent rumination syndrome, cyclical vomiting syndrome, and non-retentive fecal incontinence were 0.5% (6), 0.3% (4), 0.3% (3), 0.4% (5), respectively. Functional abdominal pain-related FGID were present in 6.3% (70) children (35 boys and 35 girls). Functional constipation (4 vs. 2) and functional abdominal pain syndrome (4 vs. 1, p<0.05) were significantly more in females. The prevalence of functional gastrointestinal disorders in our study was 10%. The most frequent FGID noted was functional dyspepsia.

Functional Gastrointestinal Disorders Dominate Pediatric Gastroenterology Outpatient Practice.

Symptom-based diagnostic criteria have improved recognition and standardization of pediatric functional gastrointestinal disorders (FGIDs). We used Rome 3 diagnostic criteria to determine the prevalence of FGIDs in pediatric gastroenterology clinic. In the process, we developed a diagnostic questionnaire for infants and toddlers. We enrolled new patients ≤18 years referred during 19 months to a pediatric gastroenterology clinic. Subjects or parents completed a demographic survey and a the Questionnaire on Pediatric Gastrointestinal symptoms, Rome 3 Version (if ≥4 years, or a new infant-toddler questionnaire) before their appointment. We acquired data from 976 subjects: 476 boys, 592 white. Of 332 subjects <4 years, 172 (52%) met diagnostic criteria for ≥1 FGIDs. Of 644 subjects ≥4 years, 486 (75%) met diagnostic criteria for ≥1 FGIDs. Thirty one (9%) subjects <4 years and 170 (26%) subjects ≥4 years met the criteria for ≥2 FGIDs. Of the total sample of subjects <4 years, common FGIDs included functional constipation (29%), infant regurgitation (13%), and cyclic vomiting syndrome (10%). Of the total sample of subjects ≥4 years, common FGIDs included irritable bowel syndrome (36%), abdominal migraine (19%), functional constipation (17%), cyclic vomiting syndrome (8%), functional abdominal pain syndrome (7%), aerophagia (7%), and functional dyspepsia (7%). More than half of new pediatric gastrointestinal clinic patients met the Rome 3 criteria for ≥1 FGIDs. Satisfying the criteria may facilitate diagnosis on the first visit.

Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction

Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction

Welcome Interns: May I Have Your Attention?

Welcome Interns: May I Have Your Attention?

Endocannabinoid-related lipids are increased during an episode of cyclic vomiting syndrome.

The endocannabinoid system and the hypothalamic-pituitary-adrenal axis are important neuromodulators of nausea and vomiting. This led us to hypothesize that patients with cyclic vomiting syndrome (CVS) have lower serum endocannabinoids (eCBs) and higher salivary cortisol and alpha amylase. Serum eCBs and related lipids, N-oleoylethanolamine (OEA) and N-palmitoylethanolamide (PEA), and salivary cortisol, and alpha amylase (index of sympathetic nervous system activity) were measured in 22 CVS patients (age 40 ± 11, female = 17) in the well and sick phases and 12 matched controls (age 37 ± 12, female = 10). Contrary to our hypothesis, serum concentrations of the eCBs were not different among the study groups. However, serum concentrations of OEA and PEA were significantly higher during the sick than well phase in CVS patients (p = 0.001 and p = 0.04). There were positive correlations between serum PEA and nausea scores in the sick phase (Pearson's rho = 0.48, p = 0.036) and between serum OEA and poor sleep quality in patients (Pearson's rho = 0.7, p = 0.0005). Salivary cortisol and alpha amylase were not different between patients and controls, but subgroup analysis revealed that both were significantly higher in marijuana users compared to non-users during the sick phase (p = 0.04 and 0.03, respectively). These data demonstrate that eCB-related lipids, OEA and PEA, are mobilized in the sick phase of CVS and are positively correlated with several of the symptoms of a CVS episode. These data also suggest the hypothesis that chronic marijuana use results in enhanced stress responses during CVS.