Diagnosis Of Cyclic Vomiting Syndrome Research Articles

“It's Not Cyclic Vomiting Syndrome Until Dietl's is Ruled Out: A Case for Point of Care Renal Ultrasound”

BackgroundAbdominal pain and vomiting are frequent complaints for pediatric patients presenting to the Emergency Department (ED). When a diagnosis such as chronic abdominal pain, cyclic vomiting, or abdominal migraine has previously been made, it can lead to diagnostic momentum and confirmation bias on behalf of the treating physician. Dietl's Crisis is a commonly missed diagnosis in the pediatric population that presents with intermittent episodes of pain and vomiting. It can be readily diagnosed at the bedside by the emergency physician (EP) through the employment of point of care ultrasound (POCUS). Case SeriesWe present two cases of pediatric patients with episodic abdominal pain and vomiting who were previously diagnosed with cyclic vomiting syndrome. In both cases, pediatric gastroenterology evaluations had occurred with negative diagnostic testing having been performed. Both patients also presented to their primary pediatrician and the ED multiple times with each encounter resulting in treatment of symptoms and discharge. Each patient eventually presented to the ED when an EP was present who performed a renal point of care ultrasound (POCUS). In each patient, the POCUS revealed severe unilateral hydronephrosis. Subsequent workup confirmed the diagnosis of Dietl's Crisis as the etiology of symptoms. Why Should an Emergency Physician Be Aware of This? In pediatric patients, EPs should be wary of the diagnosis of cyclic vomiting syndrome until ureteral obstruction has been ruled out. A bedside POCUS can rapidly establish this diagnosis and potentially preclude recurrent health care visits, unnecessary diagnostic testing, and permanent loss of renal function.

Epidemiology, Comorbidities, and Treatment of Cyclic Vomiting Syndrome in the United States.

Cyclic vomiting syndrome (CVS) imposes a substantial burden, but epidemiological data are scarce. This study aimed to estimate the incidence and prevalence of CVS, comorbid conditions, and treatment patterns, using administrative databases in the United States. This cross-sectional study used claims data from Merative MarketScan Commercial/Medicare Supplemental and Medicaid databases in all health care settings. Incidence and prevalence rates for 2019 were calculated and stratified by age, sex, region, and race/ethnicity. Patient characteristics were reported among newly diagnosed patients with CVS (i.e., no documented claims for CVS before 2019). CVS was defined as having 1+ inpatient and/or 2+ outpatient CVS claims that were 7+ days apart. The estimated prevalence of CVS was 16.7 (Commercial/Medicare) and 42.9 (Medicaid) per 100,000 individuals. The incidence of CVS was estimated to be 10.6 (Commercial/Medicare) and 26.6 (Medicaid) per 100,000 individuals. Both prevalence and incidence rates were higher among female individuals (for both Commercial/Medicare and Medicaid). Comorbid conditions were common and included abdominal pain (56%-64%), anxiety (32%-39%), depression (26%-34%), cardiac conditions (39%-42%), and gastroesophageal reflux disease (30%-40%). Despite a diagnosis of CVS, only 32%-35% had prescriptions for prophylactic treatment and 47%-55% for acute treatment within the first 30-day period following diagnosis. This study provides the first population-level estimates of CVS incidence and prevalence in the United States. Comorbid conditions are common, and most patients with CVS do not receive adequate treatment. These findings underscore the need for improving disease awareness and developing better screening strategies and effective treatments.

Association of Anxiety and Gastrointestinal Comorbidities in Repeat Hospital Admissions in Pediatric Cyclic Vomiting Syndrome.

Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder with recurrent episodes of intense nausea and vomiting and thus may require frequent hospitalizations. There is paucity of data exploring the association of psychiatric and gastrointestinal comorbidities in repeat hospitalizations among pediatric patients with CVS. We analyzed the Pediatric Health Information System database and included all patients up to 18 years of age with a diagnosis of CVS between 2016 and 2020. We excluded patients with chronic conditions, which mimic CVS. The primary outcome variable was 90-day admission rate, which was defined as a visit to emergency department or admission to observation/inpatient unit with a primary diagnosis of CVS within 90 days after an index CVS hospitalization. We evaluated a total of 2,604 hospitalizations represented by 1,370 unique individuals. The overall 90-day admission rate was 28.5%, which steadily decreased from 35.7% in 2016 to 23% in 2019 ( P < 0.001). Patients in the repeat hospitalization cohort were slightly older and more often men. Patients with repeat admissions had an increased proportion of anxiety and other gastrointestinal disorders. Multivariable logistic regression showed that anxiety, gastroesophageal reflux disease, functional dyspepsia, and abdominal migraine were associated with increased odds of repeat admissions. Ninety-day admission rates in pediatric CVS are decreasing overall, although still contributing to significant healthcare expenditure. Anxiety and gastrointestinal comorbidities were associated with increased risk of repeat admissions. Further prospective studies are needed to better understand the complex interactions of these comorbidities and their management affecting the natural course of CVS.

Cyclic Vomiting Syndrome: An underdiagnosed entity. Report of a case

Cyclic vomiting syndrome is a benign, chronic, functional gastrointestinal pathology that manifests clinically with intense nausea and vomiting interspersed with asymptomatic periods. Its diagnosis is made according to the Rome IV criteria, which require the presence of at least 2 episodes of vomiting in the past 6 months or 3 or more episodes in the past year, with the corresponding exclusion of secondary causes that can explain the vomiting. We present the case of a 44-year-old man who consulted for intermittent nausea and vomiting of 1 year evolution with hydroelectrolytic repercussion and multiple emergency consultations. The diagnosis of cyclic vomiting syndrome was made and treatment with amitriptyline was started due to odulatory effect to prevent the recurrence of episodes. After 6 months of establishing it, the patient is asymptomatic.

Cyclic Vomiting Syndrome in the Emergency Department: A 10-Year Review of Clinical Presentation and Management.

The aims of the study were (1) to determine how frequently patients with cyclic vomiting syndrome (CVS) present to the pediatric emergency department (ED) with CVS-related symptoms, (2) to identify variables in clinical presentation that occur frequently in patients with multiple ED visits, and (3) to compare ED management of CVS with recommended guidelines. This study is a retrospective chart review of all ED visits for CVS between April 1, 2008, and April 1, 2018, at a single center. Patients were identified from a master list of patients diagnosed with CVS in a pediatric gastroenterology clinic at the same center between June 1, 2004, and June 19, 2018. Of the 181 CVS clinic patients identified, 65 had visited to the ED (35.9%). Two hundred twenty-eight visits met inclusion criteria. A total of 42.5% of these visits were made by a small number of high-intensity patients (n = 6) who had an average of 16.1 visits each. These patients represented less than 10% of the total patient group. Patients with frequent visits had longer visits (536.52 vs 380.55 minutes), more frequent hospital admissions (57.73% vs 29.01%), and more visits to the ED before a formal diagnosis of CVS was made (5.83 vs 1.22), but few other distinguishing characteristics. Only 27% of eligible visits were managed with an available order set, and management varied from recommended guidelines. An ambiguous presentation makes the identification and consistent management of CVS in the ED difficult. Physicians should consider CVS for patients who present multiple times with unremitting vomiting to ensure appropriate referral for diagnosis and prophylactic treatment. Future studies are warranted to evaluate anticipatory processing and treatment of the "high-intensity patients" who account for much of the clinical morbidity and resource utilization.

Cyclic Vomiting

The novel corona virus disease (COVID-19) has caused a great pandemic since the end of 2019. A variety of symptoms has been identified for this disease. In this case series we report 5 patients in different age groups who presented with cyclic vomiting as a late complication of COVID-19. All patients have gone through complete diagnostic process for cyclic vomiting syndrome (CVS) including endoscopy. However, they all showed normal findings. The diagnosis of cyclic vomiting syndrome was made based on the symptoms and normal endoscopic and laboratory findings. We treated all of the patients applying the guideline we previously published regarding treatment of CVS patients. According to the results of the present study, CVS might be a late complication of COVID-19 infection. So, it is necessary for physicians to consider it as a differential diagnosis in patients with recent COVID-19 infection and to be aware of its management in each phase.

Epistemic injustice in a case of cyclic vomiting syndrome. A case report

IntroductionWe present the case of a 19-year-old female patient treated in our hospital due to an outburst of persistent vomiting. The patient had a diagnosis of Cyclic Vomiting Syndrome (CVS), a year before the diagnosis the patient had been labeled as a somatizer and admitted into the department of psychiatry. Given her psychiatric record and the fact that CVS is a rare diagnosis we were consulted on arrival.ObjectivesCVS is an infrequent disorder of unknown etiology which shares similarities with migraine headaches. It is characterized by episodes of vomiting followed by periods of remission without active symptomatology with no organic pathology to account for the symptoms. Epistemic injustice (EI) is defined by Miranda Fricker as “a damage done to someone in their capacity as a knower”. She defined two forms of EI: testimonial and hermeneutical injustice.MethodsA case report is presented alongside a review of the relevant literature regarding CVS and epistemic injustice.ResultsOn arrival at the emergency department she tried explaining her condition, but her testimony was disregarded on the basis of her psychiatric record. It was only after the on-call psychiatrist explained the condition when she received the appropriate abortive treatment, after which she was admitted to the internal medicine department where she was followed by the liaison psychiatrist.ConclusionsCVS is a disabling disease still unknown to most clinicians in spite of the increasing quality evidence about its identification and treatment. The case highlight how cases of newly identified disease can suffer from testimonial and hermeneutical injustice.

Assessment of Gastric Emptying Times Between Pediatrics and Adults With Cyclic Vomiting Syndrome.

Cyclic vomiting syndrome (CVS) is characterized by episodes of nausea and vomiting separated by symptom-free intervals. Rome IV guidelines have now distinguished CVS from other disorders such as cannabinoid hyperemesis. The pathogenesis of CVS, however, is poorly understood. Limited data exist on gastric emptying (GE) in patients with CVS. Therefore, the authors aim to measure the GE profile in pediatrics and adults with CVS. Patients with the diagnosis of CVS (per NASPGHAN and Rome IV) between December 1998 and March 2017 who underwent gastric emptying study (GES) and without documented cannabis use were included. Clinical features including demographics, medication use, and comorbidities were also recorded. Frequency of rapid, normal, and delayed emptying was reported, and multinomial univariate logistic regression was used to identify factors associated with each type of emptying. Sixty-seven subjects were included (50.7% female individuals, pediatrics n=15, adults n=52). At 2-hour retention, 40% of pediatric patients met criteria for rapid, 33.3% for normal, and 26.7% for delayed GE. In adults, 50% met criteria for rapid, 46.2% for normal, and 3.8% for delayed GE. For every 5-year increase in age, odds of rapid emptying on GES increased. (1) GE is predominantly rapid at 2 hours in pediatrics and adults with CVS. (2) Rapid GE seems to increase with age. (3) Current guidelines do not recommend GE in the initial management, however, further studies may play a role to help differentiate CVS from other functional gastric disorders.

Prevalence of cannabis use has significantly increased in patients with cyclic vomiting syndrome.

Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder which leads to multiple hospitalizations and causes significant impairment of quality of life. Cannabis use is common in patients with CVS, and there are limited data on the national trends in the prevalence of its use in the United States. We used the National Inpatient Sample (NIS) database from 2005 to 2014 and identified hospitalizations with a primary diagnosis of CVS by utilizing the International Classification of Diseases, 9th revision Clinical Modification (ICD-9 CM) coding system. The primary objective of the study was to analyze the prevalence and trends in cannabis use in CVS patients. We also assessed healthcare resource utilization associated with cannabis use. A total of 129090 hospitalizations with a primary diagnosis of CVS were identified and included in the study. In the United States, the overall rate of cannabis use among these patients was 104 per 1000 hospitalizations (N=13460). Over the last decade, the prevalence of cannabis use increased by 10-fold, from 2.2% in 2005 to 21.2% in 2014. Our analysis of the national database suggests that nearly 1 in 5 CVS hospitalizations have concurrent cannabis use. This prevalence is significantly rising over the last decade, perhaps due to changing legislation and increased utilization of cannabis. Age younger than 35, male gender, African American and Native American race, personal history of alcohol abuse and tobacco use were some of the strongest predictors of cannabis use.

Функциональные нарушения пищеварения у детей раннего возраста. Результаты онлайн-анкетирования

Aim: to study the possibilities of online surveys for mothers using a questionnaire on the basis of the Rome IV criteria (2016) as a screening for functional gastrointestinal disorders (FGID) in infants and toddlers. Patients and Methods: an anonymous online survey of 477 mothers was conducted regarding the health condition of their children under the age of 4 years. The survey consisted of 2 question pools. The first pool included general questions regarding the age of the mother at the time of delivery, obstetric and gynecological history, feeding of an infant/toddler at the time of the survey. The second pool included questions regarding FGID in infants and toddlers on three separate topics: functional disorders of the first year of life; diagnosis of cyclic vomiting syndrome; bowel movement disorder. Results: among 130 infants, regurgitation was in 50% of cases (at the age of 6 months — in 75%, at the age of 6 to 12 months — in 35%), baby colic — in 49%. The incidence of functional constipation in children under 6 months was 5.8%, from 6 to 12 months — 7.6%, gradually increasing by 3–4 years to 21.5%. Toilet skills were taught to 15 (12%) children aged 1 year — 1 year 11 months, 58 (59%) — at the age of 2 years — 2 years 11 months, and 119 (98%) — at the age of 3 years — 3 years 11 months. Mothers who were unaware of their child’s physical development and/or defecation problems accounted for 20.1% of those who took part in the survey. Conclusion: online survey results of mothers coincide with modern statistical data on FGID disorder. The survey results generally reflect the anatomical and physiological patterns of the child’s GI development. Online survey on the detection of FGID in infants/toddlers allows to make a preliminary diagnosis, identify existing problems and determine further patient management tactics. KEYWORDS: functional gastrointestinal disorders, infant, toddler, Rome IV criteria, questionnaire for parents, functional constipation, online survey, baby colic, regurgitation, toilet skills. FOR CITATION: Dubrovskaya M.I., Gryaznova E.I. Functional gastrointestinal disorders in infants and toddlers. Online survey results. Russian Medical Inquiry. 2020;4(5):274–281. DOI: 10.32364/2587-6821-2020-4-5-274-281.

Recent trends in cyclic vomiting syndrome-associated hospitalisations with liberalisation of cannabis use in the state of Colorado.

Currently, 33 states in the United States along with the District of Columbia have legalised cannabis in some forms. There is a paucity of data on the impact of legalisation of cannabis use on hospitalisations due to cyclic vomiting syndrome (CVS). To study the trends in CVS-related hospitalisations and cannabis use in CVS in relation to legalisation of recreational cannabis use in Colorado. All hospital admissions in Colorado between 2010 and 2014 with the diagnosis of CVS were identified using the Colorado State Inpatient Database. Five-year trends in CVS-related hospitalisations along with the cannabis use were analysed. Multivariate logistic regression analysis was performed to determine predictors of cannabis use in CVS. There was a significant increase in CVS-related hospitalisations by 46% from 806 in 2010 to 1180 in 2014 when CVS was included as all-listed diagnoses (P < 0.001). The overall prevalence of cannabis use in CVS (13% with CVS as primary diagnosis and 17% with CVS as all-listed diagnoses) was much higher than non-CVS-related hospitalisations (1.7%) (P < 0.001 for both comparisons). Cannabis use increased dramatically in both CVS and non-CVS-related hospitalisations following legalisation of cannabis for recreational use in 2012. Our study shows a significant increase in CVS-related hospitalisations concomitant with an increase in cannabis use with its liberalisation in Colorado. Future studies on the relationship between cannabis use and hyperemesis are warranted, especially with its ongoing legalisation in the United States.

Cyclic vomiting syndrome and benign paroxysmal torticollis are associated with a high risk of developing primary headache: A longitudinal study.

Episodic syndromes that may be associated with migraine are a group of disorders affecting patients with migraine or with an increased risk of presenting it, and likely represent an early life expression of migraine. Cyclic vomiting syndrome and benign paroxysmal torticollis are well characterized and represent a frequent cause of request for specialist consultations. The aim of this study is to longitudinally assess the rate of headache in patients presenting with cyclic vomiting syndrome and benign paroxysmal torticollis during infancy, and to define the main clinical features of the disorder. We administered a questionnaire to the parents of all our pediatric patients with previous diagnosis of cyclic vomiting syndrome and/or benign paroxysmal torticollis according to ICHD-3; questions were focused on the main clinical features of the disorder as well as the prognosis, with particular emphasis on the development of headache. For the final analysis we considered 82 patients with cyclic vomiting syndrome and 33 with benign paroxysmal torticollis. Seventy-nine percent of patients with cyclic vomiting syndrome presented with headache during the follow-up, with a mean age at onset of 6 years; 67% of patients with benign paroxysmal torticollis suffered from headache during the follow-up, with a mean age at onset of 5 years. Cyclic vomiting syndrome and benign paroxysmal torticollis are associated with a very high risk of developing headache, mostly migraine, later in life. In both groups of patients, the vast majority presented with different episodic syndromes that may be associated with migraine at different ages, thus suggesting an age-dependent evolution of migraine-like symptoms before the onset of clear migrainous headache.

A case series of cyclic vomiting syndrome in paediatric patients at a tertiary care hospital in Chennai, Tamil Nadu, India

Background: Cyclic vomiting syndrome is an increasingly recognized disorder with sudden, repeated episodes of severe nausea, vomiting, and physical exhaustion that occur with no apparent cause. It is more common in children than adults. However, we don’t often see a diagnosis of cyclic vomiting syndrome being made. Hereby we report 7 cases of cyclical vomiting.Methods: This is a retrospective study. Medical records of 5 years were review and consecutive paediatric patients discharged with a diagnosis of cyclic vomiting syndrome were identified, data collected and analysed.Results: Total of 7 cases were found, all of which were adolescents. The mean age was 13.28. 57.14% (4) were females and 42.86% (3) were boys. 42.86% (3) presented with complications. 14.28% (1) had an association with menstrual cycles and 14.28% (1) had an association with psychological stress.Conclusions: Cyclic vomiting syndrome should be kept in mind when a child presents with multiple episodes of vomiting, especially when repeated admissions have been made for the same. Early diagnosis and treatment can improve the quality of life.

Yield and Costs of Evaluating Children With Cyclic Vomiting Syndrome.

Cyclic vomiting syndrome (CVS) clinical guidelines recommend an algorithm of basic testing for standard patients, and more targeted testing, including laboratory and imaging studies, in the presence of specific red flags. The cost-effectiveness of this screening of children with suspected CVS is lacking. The objectives of this study are to determine whether screening studies in CVS patients results in diagnostic change and to estimate their healthcare cost. Charts of patients (1-18 years) with suspected CVS were retrospectively reviewed at a single center. Results and cost of laboratory and imaging studies were analyzed. A total of 503 charts were reviewed from electronic medical records with the International Classification of Diseases-9 (ICD-9) code 536.2 or search terms "CVS, cyclic vomiting, persistent emesis/vomiting, hyperemesis, or intractable/ periodic vomiting." Of these, 165 (33%) had a diagnosis of CVS and 135 (82%) children (mean age 7.7 ± 4.3; 73 (54%) girls) met CVS criteria based on North American Society for Pediatric Gastroenterology, Hepatology and Nutrition diagnostic criteria. Of those meeting CVS criteria, 6 (4%) had a change in management based on the CVS screening evaluation. The mean cost of screening per patient that met CVS criteria was $6125.02 and the estimated total cost for all patients who met CVS criteria was $826,877.88. The screening metabolic laboratory results, pelvic ultrasound, magnetic resonance imaging, and upper endoscopy resulted in a diagnosis change in few patients screened for CVS. Most children who met criteria for CVS did not benefit from screening evaluation as results did not change clinical diagnosis or management, and were associated with higher cost.

Family Health-related Quality of Life in Pediatric Cyclic Vomiting Syndrome.

The aim of the study was to evaluate the relationship of disease characteristics and child anxiety symptoms to family health-related quality of life (FHRQoL) in youth with cyclic vomiting syndrome (CVS). Forty-two parents of youth ages 8 to 18 years diagnosed with CVS completed the Family Impact Module of the PedsQL, a measure of the impact of the child's illness on the family. We evaluated the relationship of disease characteristics and child and parent proxy reports of anxiety symptoms on the Screen for Childhood Anxiety and Related Emotional Disorders to FHRQoL. Parent report of child anxiety symptoms and missed school days (mean = 11.93, standard deviation = 14.62) were the strongest predictors of FHRQoL (r = 0.33, df = 1.39, F = 8.51, P = 0.006). Other disease characteristics, including frequency, duration, chronicity of CVS episodes, and delay in initial CVS diagnosis were not significantly associated with the FHRQoL total score. Child anxiety symptoms by either parent and/or child report were associated with subscales of the FHRQoL, including family physical functioning, family communication, and family daily activities. HRQoL for the families assessed in this study was associated with anxiety symptoms to a greater extent than disease characteristics, indexing the importance of a biopsychosocial approach to CVS management. Screening for anxiety symptoms and support for school absences due to illness are indicated to help lessen the impact of CVS on the family as a whole.

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marijuana, cannabinoid hyperemesis syndrome: marijuana, cannabinoid hyperemesis syndromeFigureFigureFigureA 28-year-old man presented to the ED with diffuse abdominal pain, nausea, and more than 15 episodes of non-bilious, non-bloody emesis over the previous 48 hours. His pain was worst in the morning, but improved after a hot shower. Of note, the patient had used products similar to this on a daily basis. (Photo.) This was his fourth visit to the ED for abdominal pain over the past year. Previous visits have included an extensive workup, including unremarkable abdominal CTs, labs, and upper endoscopy. What is the most appropriate diagnosis, and what are the treatment options? Find the diagnosis and case discussion on p. 16. Diagnosis: Cannabinoid Hyperemesis Syndrome Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclic episodes of moderate to severe diffuse abdominal pain, nausea, and emesis in patients endorsing frequent marijuana use. Many patients present repeatedly, and undergo multiple rounds of costly, nondiagnostic tests. The diagnosis of CHS is becoming increasingly common, and is likely due to an increase in the THC content of marijuana, the prevalence of marijuana use, and the availability of commercial marijuana. Shifts in laws and stigma about marijuana use may also be influencing the frequency with which patients report marijuana use to physicians. CHS can be separated into three phases: prodromal, hyperemetic, and recovery. The prodromal phase may last months to years, and involves low-level abdominal discomfort from frequent marijuana use. The hyperemetic phase typically lasts up to 48 hours, and involves intense episodes of non-bilious, non-bloody emesis, sometimes more than five times per hour. Episodes occur cyclically at an interval of weeks to months, and asymptomatic periods may or may not involve marijuana use. (Curr Drug Abuse Rev 2011;4[4]:241.) The pathophysiology of CHS is still an active area of investigation, but may involve CB1 receptors in the gastrointestinal tract and central nervous system. (Pharmaceuticals [Basel] 2010;3[7]:2163.) Initial use of marijuana may provide a therapeutic effect to the patient with decreased nausea and abdominal pain, while chronic use eventually tips the scale toward nausea, pain, and emesis. The recovery phase, which almost invariably coincides with marijuana cessation, is characterized chiefly by a lack of hyperemetic episodes. Confidently diagnosing CHS can be challenging. Excluding the diagnosis of cyclic vomiting syndrome is difficult because both conditions involve cyclic episodes of abdominal pain, nausea, and emesis. Some studies indicated that the only way to discriminate between the syndromes is whether marijuana cessation causes remission. (Ger Med Sci 2017;15:Doc06.) CHS is also more often associated with frequent marijuana use and symptomatic relief via hot showers. (Curr Drug Abuse Rev 2011;4[4]:241.) Up to 92 percent of patients diagnosed with CHS endorse symptomatic relief when taking hot showers. (J Med Toxicol 2017;13[1]:71.) It is important in the ED to exclude acute diagnoses such as pancreatitis, bowel obstruction, or cholecystitis while not repeating prior negative workups. Chronic diagnoses, such as irritable bowel syndrome, Crohn's, or celiac should be investigated by the primary care physician. Treatment in the ED consists primarily of IV fluids and antiemetic medications. Haloperidol (5-10 mg IV) may be beneficial because of the dopamine antagonism and interactions between CB1 and dopamine pathways. (Am J Ther 2017;24[1]:e64.) Recent research suggests that capsaicin creams applied in the ED can also provide quick symptomatic relief. A suggested mechanism of action involves TRPV1 receptors in nociceptive pathways. (Clin Toxicol [Phila] 2017;55[8]:908.) No long-term pharmacologic interventions have been shown to reduce the intensity or frequency of episodes, and cessation of marijuana use is the only intervention that has consistently demonstrated efficacy. (J Med Toxicol 2017;13[1]:71.) Broaching the topic of marijuana as a causative agent while the patient is in the ED is challenging. Many patients resist the idea that marijuana use may be causing their symptoms. Discussion of CHS should be reserved for the end of the visit when symptoms have significantly resolved. It is useful to engage the patient in a conversation on the paradoxical causative role of marijuana. Admitting that cannabis can provide nausea relief in many situations and elaborating on CHS may help reduce resistance to the diagnosis. Engaging patients in the idea that marijuana, like many other medications and remedies, may have side effects is also useful. These conversations help reduce return visits, which are common for CHS patients. This patient received treatment in the ED with IV normal saline and haloperidol with significant improvement. After engaging him in a thoughtful discussion about his cannabis use, he acknowledged that cannabis may have side effects in some patients and agreed to a trial of cannabis cessation to see if his symptoms would resolve.

Cyclic vomiting syndrome is a prevalent and under-recognized condition in the gastroenterology outpatient clinic.

Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder (FGID) characterized by intermittent episodes of nausea and vomiting. Our aim was to report its prevalence and associated features. Data concerning demographics, symptoms, and psychiatric comorbidity were collected. Symptoms compatible with CVS were classified as per Rome III criteria. We recorded whether a diagnosis of CVS was considered in patients after negative investigation. We compared demographics and association with other FGIDs in patients with and without CVS. 920 of 1002 patients provided data. Of the 920 patients, 112 (12.2%) had symptoms compatible with CVS. Thirteen (11.6%) of these had an organic cause for their symptoms, but 99 patients (88.4%) were deemed to have CVS (prevalence=10.8%). Organic causes for symptoms compatible with CVS included gastroparesis, large hiatus hernia, achalasia, and small bowel obstruction. Only 39.4% of patients with CVS were asked about vomiting symptoms at their initial consultation, and a diagnosis of CVS was considered in only four (4.0%) of the 99 patients. CVS was associated with younger age, tobacco smoking, never having married, psychiatric comorbidity, and presence of symptoms compatible with other FGIDs (P≤.01). Prevalence of CVS in this outpatient gastroenterology adult population was 10.8%. Identified associations included younger age, tobacco smoking, psychiatric comorbidity, and symptoms compatible with other FGIDs. The condition was considered as a possible diagnosis in <5% of patients who met the diagnostic criteria.

Clinical Characteristics, Comorbidities and Hospital Outcomes in Hospitalizations with Cyclic Vomiting Syndrome: A Nationwide Analysis.

Data on cyclic vomiting syndrome (CVS) are limited to studies from tertiary care centers. There is a paucity of information about CVS on a national scale. To study the clinical characteristics, comorbidities, and hospital outcomes in patients hospitalized with CVS using a nationwide database. We identified all hospitalizations associated with a primary diagnosis of CVS in 2010 and 2011 using the Nationwide Inpatient Sample with an age category of 18-55years. A 1:2 random sample of non-CVS hospitalizations with the same age category was obtained, and comparisons between groups were made. Multivariate logistic regression analysis was used to determine comorbidities independently associated with CVS. Our study included 20,952 CVS and 44,262 non-CVS patients. CVS patients tended to be younger, male, and white compared to non-CVS patients. On multivariate analysis, CVS was significantly associated with comorbidities including dysautonomia, migraine, anxiety, marijuana use, irritable bowel syndrome, gastroparesis, gastroesophageal reflux disease, asthma, cigarette smoking, and hypertension. CVS patients underwent esophagogastroduodenoscopy, colonoscopy, and gastric emptying tests more frequently. They had more favorable hospital outcomes like more routine discharges (discharge to home/self-care), lower mortality, and shorter length of stay but tended to leave against medical advice more frequently. CVS patients incurred total hospital charges of about $400 million over the 2years. Our study showed that CVS is associated with several comorbidities and incurred substantial health care costs despite benign outcomes. Efforts to optimize therapy of CVS, manage comorbid conditions and reduce healthcare utilization are warranted.

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.

Combination of erythromycin and propranolol for treatment of childhood cyclic vomiting syndrome: a novel regimen.

This study aimed to evaluate the erythromycin efficacy in childhood cyclic vomiting syndrome. Cyclic vomiting syndrome (CVS) is an unusual cause of episodic emesis in children and erythromycin is an effective treatment. In this prospective study, 301 patients with a final diagnosis of CVS enrolled in two separated groups. The first group received erythromycin for 7 days and propranolol for at least 9 months (n=155). The second group was treated with propranolol alone for at least 9 months (n=146). These two groups were compared for response to the treatment and the recurrence of symptoms after treatment completion. Relationship of response, recurrence, and characteristics of the disease was assessed. Both groups showed a significant difference in terms of response to treatment (P=0.002), however the recurrence after treatment completion had no considerable difference (P=0.563). There was no relationship between CVS characteristics and these two items (response and recurrence). In our point of view, the addition of erythromycin to standard propranolol treatment can improve the response to treatment, although it has no significant effect on recurrence of CVS symptoms. We suggest the use of erythromycin for 7 days in addition to CVS standard therapy.