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Jiménez-Castillo RA, Frazier R, Venkatesan T, Remes-Troche JM. Cyclic vomiting syndrome: From pathophysiology to treatment. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:389-403. [PMID: 39034267 DOI: 10.1016/j.rgmxen.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 06/04/2024] [Indexed: 07/23/2024]
Abstract
Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent and unpredictable episodes of intense vomiting, interspersed with periods of apparent wellbeing. This disorder, which primarily affects children and adolescents but can persist into adulthood, has recently been the subject of extensive study and analysis in the medical literature. The aim of the present review is to examine the most important aspects of the epidemiology, pathophysiology, subtypes, diagnostic criteria, and current management of CVS. Even though the exact etiology remains unknown, genetic factors (polymorphisms), nervous system alterations and autonomic dysregulation, and environmental factors (use and abuse of cannabinoids) are postulated as possible triggers. CVS has significant diagnostic challenges, given that there is no specific test for confirming its presence. Thorough evaluation of symptoms and the ruling out of other possible causes of recurrent vomiting are required. Management of CVS typically involves a multidisciplinary approach. Pharmacologic options are explored, such as antiemetics and preventive medications, as well as behavioral and psychologic support therapies. Treatment personalization is essential, adapting it to the individual needs of each patient. Despite advances in the understanding of CVS, it remains a significant clinical challenge. This disorder impacts the quality of life of those affected and their families, underscoring the ongoing need for research and the development of more effective treatment strategies.
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Affiliation(s)
- R A Jiménez-Castillo
- Servicio de Gastroenterología y Endoscopía Digestiva, Hospital Universitario «Dr. José E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - R Frazier
- Servicio de Gastroenterología y Hepatología, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - T Venkatesan
- Servicio de Gastroenterología, Hepatología y Nutrición, The Ohio State University, Columbus, Ohio, USA
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico.
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Kuroda H, Kaneko R, Katagiri N, Kagawa K, Saito N, Sasaki Y, Kuroda-Ohgi K, Kuroda Y, Kuroda S, Tsukimoto S, Ishikawa N, Abe T, Sanuki T. General Anesthesia for Patients With Cyclic Vomiting Syndrome and Obesity: A Case Report. Cureus 2024; 16:e65130. [PMID: 39171030 PMCID: PMC11338629 DOI: 10.7759/cureus.65130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/23/2024] Open
Abstract
Cyclic vomiting syndrome (CVS) is a chronic digestive disorder characterized by recurrent episodes of severe nausea and vomiting. The perioperative management of patients with CVS undergoing general anesthesia is challenging, especially when combined with obesity. This case report describes the successful management of a patient with CVS and obesity who underwent dental surgery under general anesthesia. A 21-year-old woman with CVS, obesity (body mass index, 35), and intellectual disability was scheduled for tooth extraction and composite resin restoration under general anesthesia. The patient was diagnosed with CVS at the age of 20 years with frequent vomiting attacks requiring hospitalization. Surgery was scheduled during the CVS remission to reduce the risk of perioperative vomiting. Preoperative laboratory test results were normal, including serum adrenocorticotropic hormone (ACTH), anti-diuretic hormone (ADH), and cortisol levels. General anesthesia was induced using remifentanil and propofol. Nasal endotracheal intubation was performed after rocuronium administration. Local anesthesia (2% lidocaine with 1:80,000 epinephrine) was used for all dental procedures. Postoperatively, midazolam was administered to control agitation. No postoperative vomiting occurred. Serum ACTH, ADH, and cortisol levels showed no significant changes before and after anesthesia, suggesting that hypothalamic-pituitary-adrenal (HPA) axis activation due to surgical stress did not occur. This case highlights the importance of careful perioperative planning and monitoring stress-related hormone levels in patients with CVS or obesity. An anesthetic approach using midazolam may effectively suppress HPA axis activation and prevent postoperative vomiting.
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Affiliation(s)
- Hidetaka Kuroda
- Department of Dental Anesthesiology, Kanagawa Dental University, Kanagawa, JPN
| | - Rumi Kaneko
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Center, Saitama, JPN
| | - Norika Katagiri
- Department of Dental Anesthesiology, Kanagawa Dental University, Kanagawa, JPN
| | - Keita Kagawa
- Department of Dental Anesthesiology, Kanagawa Dental University, Kanagawa, JPN
| | - Natsuki Saito
- Department of Dental Anesthesiology, Tokyo Dental College, Tokyo, JPN
| | - Yoko Sasaki
- Department of Anesthesiology, Saitama Medical University International Medical Center, Saitama, JPN
| | | | - Yukiko Kuroda
- Pediatric Dentistry, White Dental Clinic, Gunma, JPN
| | | | - Shota Tsukimoto
- Department of Dental Anesthesiology, Kanagawa Dental University, Kanagawa, JPN
| | - Noboru Ishikawa
- Department of Forensic Odontology and Anthropology, Tokyo Dental College, Tokyo, JPN
| | - Takahiro Abe
- Department of Oral and Maxillofacial Surgery, Kanagawa Dental University, Kanagawa, JPN
| | - Takuro Sanuki
- Department of Dental Anesthesiology, Kanagawa Dental University, Kanagawa, JPN
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Kilani Y, Aljabiri Y, Arshad I, Alsakarneh S, Aldiabat M, Castro Puello P, Vahanyan A, Vikash F, Kumar V, Numan L, Thor S. Cannabis use and cyclical vomiting syndrome: An open debate. Dig Liver Dis 2024; 56:272-280. [PMID: 37880016 DOI: 10.1016/j.dld.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/06/2023] [Accepted: 10/01/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Cyclical vomiting syndrome (CVS) carries a significant financial burden on the U.S. healthcare system due to the recurrent emergency department visits and inpatient hospitalizations. We aimed to update the literature on the predictors of hospital utilization and readmission among individuals admitted with CVS. METHODS This is a retrospective nationwide study of patients hospitalized with a primary diagnosis of CVS. Using weighted data from the National Inpatient Sample (NIS) and the National Readmission Database (NRD), we conducted a multivariate regression analysis to assess predictors of length of stay (LOS), and 30-day readmission. RESULTS Primary admissions for CVS totaled 35,055 in the NIS, and 31,240 in the NRD. 2012 patients (6.4%) were readmitted within 30 days. On multivariate regression, cannabis use was associated with reduced LOS (adjusted Mean Difference (aMD) = -0.53 days, 95% CI: -0.68 to -0.38), and 30-day readmissions (adjusted Hazard Ratio (aHR) = 0.63, 95% CI: 0.54-0.73). DISCUSSION Cannabis use among CVS admissions was associated with reduced LOS and 30-day readmissions; these results could be in fact driven by Cannabis Hyperemesis Syndrome (CHS)-related hospitalizations and the effect of cannabis cessation on decreased symptomatology. ICD-10 coding for CHS should be transitioned to specific codes to improve the differentiation between CVS and CHS-related hospitalizations.
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Affiliation(s)
- Yassine Kilani
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medical College, New York, USA.
| | - Yazan Aljabiri
- Department of Medicine, Washington University in St. Louis, Saint Louis, USA
| | - Iqra Arshad
- Department of Medicine, Saint Louis University School of Medicine, Saint Louis, USA
| | - Saqr Alsakarneh
- Department of Medicine, University of Missouri-Kansas City, Kansas City, USA
| | - Mohammad Aldiabat
- Department of Medicine, Washington University in St. Louis, Saint Louis, USA
| | - Priscila Castro Puello
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medical College, New York, USA
| | - Anush Vahanyan
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medical College, New York, USA
| | - Fnu Vikash
- Department of Medicine, Jacobi Medical Center, New York, NY
| | - Vikash Kumar
- Department of Medicine, Brooklyn Hospital Center, New York, USA
| | - Laith Numan
- Department of Gastroenterology & Hepatology, Saint Louis University, Saint Louis, USA
| | - Savanna Thor
- Division of Gastroenterology & Hepatology, SUNY Downstate Health Sciences University, New York, USA
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Thavamani A, Velayuthan S, Patel D, Al-Hammadi N, Sferra TJ, Sankararaman S. Association of Anxiety and Gastrointestinal Comorbidities in Repeat Hospital Admissions in Pediatric Cyclic Vomiting Syndrome. Am J Gastroenterol 2023; 118:1439-1445. [PMID: 37052354 DOI: 10.14309/ajg.0000000000002292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/28/2023] [Indexed: 04/14/2023]
Abstract
INTRODUCTION 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. METHODS 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. RESULTS 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. DISCUSSION 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.
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Affiliation(s)
- Aravind Thavamani
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sujithra Velayuthan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Dhiren Patel
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, SSM Health Cardinal Glennon Children's Medical Center, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Noor Al-Hammadi
- The Advanced HEAlth Data (AHEAD) Research Institute, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Thomas J Sferra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Bar O, Ebenau L, Weiner K, Mintz M, Boles RG. Whole exome/genome sequencing in cyclic vomiting syndrome reveals multiple candidate genes, suggesting a model of elevated intracellular cations and mitochondrial dysfunction. Front Neurol 2023; 14:1151835. [PMID: 37234784 PMCID: PMC10208274 DOI: 10.3389/fneur.2023.1151835] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/03/2023] [Indexed: 05/28/2023] Open
Abstract
Objective To utilize whole exome or genome sequencing and the scientific literature for identifying candidate genes for cyclic vomiting syndrome (CVS), an idiopathic migraine variant with paroxysmal nausea and vomiting. Methods A retrospective chart review of 80 unrelated participants, ascertained by a quaternary care CVS specialist, was conducted. Genes associated with paroxysmal symptoms were identified querying the literature for genes associated with dominant cases of intermittent vomiting or both discomfort and disability; among which the raw genetic sequence was reviewed. "Qualifying" variants were defined as coding, rare, and conserved. Additionally, "Key Qualifying" variants were Pathogenic/Likely Pathogenic, or "Clinical" based upon the presence of a corresponding diagnosis. Candidate association to CVS was based on a point system. Results Thirty-five paroxysmal genes were identified per the literature review. Among these, 12 genes were scored as "Highly likely" (SCN4A, CACNA1A, CACNA1S, RYR2, TRAP1, MEFV) or "Likely" (SCN9A, TNFRSF1A, POLG, SCN10A, POGZ, TRPA1) CVS related. Nine additional genes (OTC, ATP1A3, ATP1A2, GFAP, SLC2A1, TUBB3, PPM1D, CHAMP1, HMBS) had sufficient evidence in the literature but not from our study participants. Candidate status for mitochondrial DNA was confirmed by the literature and our study data. Among the above-listed 22 CVS candidate genes, a Key Qualifying variant was identified in 31/80 (34%), and any Qualifying variant was present in 61/80 (76%) of participants. These findings were highly statistically significant (p < 0.0001, p = 0.004, respectively) compared to an alternative hypothesis/control group regarding brain neurotransmitter receptor genes. Additional, post-analyses, less-intensive review of all genes (exome) outside our paroxysmal genes identified 13 additional genes as "Possibly" CVS related. Conclusion All 22 CVS candidate genes are associated with either cation transport or energy metabolism (14 directly, 8 indirectly). Our findings suggest a cellular model in which aberrant ion gradients lead to mitochondrial dysfunction, or vice versa, in a pathogenic vicious cycle of cellular hyperexcitability. Among the non-paroxysmal genes identified, 5 are known causes of peripheral neuropathy. Our model is consistent with multiple current hypotheses of CVS.
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Affiliation(s)
- Omri Bar
- NeurAbilities Healthcare, Voorhees, NJ, United States
| | - Laurie Ebenau
- NeurAbilities Healthcare, Voorhees, NJ, United States
| | - Kellee Weiner
- NeurAbilities Healthcare, Voorhees, NJ, United States
| | - Mark Mintz
- NeurAbilities Healthcare, Voorhees, NJ, United States
| | - Richard G. Boles
- NeurAbilities Healthcare, Voorhees, NJ, United States
- NeuroNeeds, Old Lyme, CT, United States
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Collins AB, Beaudoin FL, Metrik J, Wightman RS. "I still partly think this is bullshit": A qualitative analysis of cannabinoid hyperemesis syndrome perceptions among people with chronic cannabis use and cyclic vomiting. Drug Alcohol Depend 2023; 246:109853. [PMID: 36996524 PMCID: PMC10121940 DOI: 10.1016/j.drugalcdep.2023.109853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/17/2023] [Accepted: 03/18/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Cannabis is the most widely used psychoactive substance in the United States (US), with reported use patterns increasing among adults in recent years. Cannabinoid hyperemesis syndrome (CHS) has been one concern related to increased cannabis use patterns. US emergency departments have reported an increase of CHS cases over the last decade, yet little is known about CHS. This study explores the experiences of people with chronic cannabis use and cyclic vomiting and their perceptions of CHS. METHODS Semi-structured interviews were conducted with 24 people recruited from a prospective cohort of patients presenting to Rhode Island emergency departments with symptomatic cyclic vomiting and chronic cannabis use. Data were analyzed thematically using NVivo. FINDINGS Participants characterized their cyclic vomiting as related to food and alcohol consumption patterns, stress, and existing gastrointestinal issues. Despite recurrent episodes of cyclic vomiting, nausea, and abdominal pain, many participants remained uncertain whether their symptoms were driven by cannabis. Many participants relied on at-home research to assess their symptoms and seek out management approaches. Clinical treatment recommendations focused on cannabis cessation. However, most participants felt clinical recommendations failed to consider the complexity and challenge of stopping cannabis use given the chronicity of use and therapeutic benefits some perceived cannabis to have. CONCLUSIONS Although cannabis cessation is the only reported CHS cure to date, additional clinical and non-clinical treatment approaches are needed to better support people with chronic cannabis use and cyclic vomiting to meet their ongoing needs.
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Affiliation(s)
- Alexandra B Collins
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA.
| | - Francesca L Beaudoin
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA
| | - Jane Metrik
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, 02903, USA; Providence VA Medical Center, Providence, RI, 02908, USA
| | - Rachel S Wightman
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
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Cheng S, Yu E, Garacci Z, Erwin AL, Venkatesan T. Prevalence of Undiagnosed Acute Hepatic Porphyria in Cyclic Vomiting Syndrome and Overlap in Clinical Symptoms. Dig Dis Sci 2022; 68:2107-2114. [PMID: 36380150 DOI: 10.1007/s10620-022-07756-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 10/27/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Acute hepatic porphyria (AHP) presents with nausea and vomiting and can mimic cyclic vomiting syndrome (CVS). The prevalence of AHP in CVS and overlap in clinical symptomatology is not known. We thus sought to determine the prevalence of pathogenic variants for AHP and characterize symptom overlap between CVS and AHP. METHODS We conducted a cross-sectional study of 234 CVS patients using Rome criteria. Patients were eligible for AHP genetic testing if they had recurrent episodes of severe, diffuse abdominal pain with ≥ 2 of the following-peripheral nervous system (muscle weakness/aching, numbness, tingling), central nervous system (confusion, anxiety, seizures, hallucinations), autonomic nervous system (hyponatremia, tachycardia, hypertension, constipation) symptoms, red/brownish urine, or blistering skin lesions on sun-exposed areas. A family history of AHP or elevated urinary porphobilinogen (PBG)/aminolaevulinic acid (ALA) were also criteria for genetic testing and was performed using a 4-gene panel. RESULTS Mean age was 38.7 ± 14.5 years, 180 (76.9%) were female and 200 (85.5%) were Caucasian. During a CVS attack, 173 (92%) reported abdominal pain, 166 (87.2%) had peripheral nervous system, 164 (86.8%) had central nervous system and 173 (92) % had autonomic symptoms. Ninety-one eligible patients completed genetic testing. None were positive for AHP but two had variants of uncertain significance (VUS) in the HMBS gene. CONCLUSIONS There is a high prevalence of non-gastrointestinal symptoms in CVS, like AHP, which is important for clinicians to recognize. AHP was not detected in this study and larger studies are warranted to ascertain its prevalence.
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Affiliation(s)
- Shanna Cheng
- Department of Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Elliot Yu
- Gastroenterology and Hepatology Fellow, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Zhuping Garacci
- Center for Advancing Population Science, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Angelika L Erwin
- Department of Pediatrics, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Center for Personalized Genetic Healthcare, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Thangam Venkatesan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University College of Medicine, 395 W 12th Avenue, Columbus, OH, 43210, USA.
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von Both I, Santos B. Death of a young woman with cyclic vomiting: a case report. Forensic Sci Med Pathol 2021; 17:715-722. [PMID: 34735682 DOI: 10.1007/s12024-021-00410-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 01/19/2023]
Abstract
We report the death of a 22-year-old woman, with a 3½ year history of cyclic vomiting and cannabis use since age 14, who developed torsades de pointes cardiac arrythmia while being treated in the emergency room for nausea and vomiting. Resuscitation restored spontaneous cardiac circulation, however, due to post-cardiac arrest anoxic brain injury, she never regained consciousness and was declared brain dead 4 days later. Postmortem examination confirmed hypoxic-ischemic encephalopathy, in keeping with the in-hospital diagnosis of brain death. The heart was anatomically normal but showed signs of acute post-cardiopulmonary arrest reperfusion injury. As a consequence of limited survival in hospital in a neuro-vegetative state, early bronchopneumonia and isolated pulmonary thromboemboli were seen. Toxicological studies confirmed cannabis use, in addition to the presence of haloperidol and ondansetron. Genetic studies were performed to rule out a possible channelopathy and revealed a mutation in the MYBPC3 and RYR2 genes. Death in this woman with cannabinoid hyperemesis syndrome was attributed to a fatal cardiac arrhythmia complicating vomiting-induced hypokalemia and treatment with QT interval prolonging and potentially arrhythmogenic medications, with the identified cardiac genetic mutations listed as contributing factors. The emphasis of this report is a) to raise awareness that death can occur due to cyclic vomiting, b) provide a brief but practical overview of cannabinoid hyperemesis syndrome, c) describe the findings from our postmortem examination and come to the most reasonable cause and mechanism of death, d) comment on the risk factors associated with torsades de pointes cardiac arrythmia, and e) conclude that a complete postmortem examination is needed to exclude an anatomical or toxicological cause of death in cannabinoid hyperemesis syndrome, a disabling but preventable disorder.
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Affiliation(s)
- Ingo von Both
- Provincial Forensic Pathology Unit, Department of Laboratory Medicine & Pathobiology, Ontario Forensic Pathology Service, University of Toronto, 25 Morton Shulman Avenue, Toronto, ON, M3M 0B1, Canada. .,Office of the Chief Medical Examiner, Department of Laboratory Medicine & Pathology, University of Alberta, 7007 - 116 Street NW, Edmonton, AB T6H 5R8, Canada.
| | - Brittini Santos
- Provincial Forensic Pathology Unit, Department of Laboratory Medicine & Pathobiology, Ontario Forensic Pathology Service, University of Toronto, 25 Morton Shulman Avenue, Toronto, ON, M3M 0B1, Canada
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Nivatsi M, Aslanidou I, Mantadakis E. Highly effective use of aprepitant in an adolescent girl with severe cyclic vomiting syndrome. BMJ Case Rep 2021; 14:e241132. [PMID: 33664041 PMCID: PMC7934711 DOI: 10.1136/bcr-2020-241132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2021] [Indexed: 01/16/2023] Open
Abstract
Cyclic vomiting syndrome (CVS) is a debilitating functional gastrointestinal disorder. Diagnosis is based on the Rome III criteria. There are no evidence-based guidelines for the management of paediatric CVS, although ondansetron and antimigraine medications are frequently tried. We describe a 13-year-old adolescent girl with severe CVS and numerous hospital admissions for dehydration because of cyclic vomiting. She had failed oral ondansetron therapy. Oral aprepitant (125 mg in the first, and 85 mg on the second and third days), a neurokinin 1 receptor antagonist that has been approved for preventing chemotherapy-induced vomiting or postoperative emesis, was tried in our patient at home during the first prodromal signs of an upset stomach. She had a dramatic response to it, with no further episodes of vomiting since its start. There is an urgent need for randomised clinical studies to assess the efficacy of available treatment options, including aprepitant in patients with severe CVS.
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Affiliation(s)
- Maria Nivatsi
- Department of Paediatrics, University General Hospital of Alexandroupolis, Alexandroupolis, Thrace, Greece
| | - Ilona Aslanidou
- Department of Paediatrics, University General Hospital of Alexandroupolis, Alexandroupolis, Thrace, Greece
| | - Elpis Mantadakis
- Department of Paediatrics, Democritus University of Thrace Faculty of Medicine, Alexandroupolis, Thrace, Greece
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Raucci U, Borrelli O, Di Nardo G, Tambucci R, Pavone P, Salvatore S, Baldassarre ME, Cordelli DM, Falsaperla R, Felici E, Ferilli MAN, Grosso S, Mallardo S, Martinelli D, Quitadamo P, Pensabene L, Romano C, Savasta S, Spalice A, Strisciuglio C, Suppiej A, Valeriani M, Zenzeri L, Verrotti A, Staiano A, Villa MP, Ruggieri M, Striano P, Parisi P. Cyclic Vomiting Syndrome in Children. Front Neurol 2020; 11:583425. [PMID: 33224097 PMCID: PMC7667239 DOI: 10.3389/fneur.2020.583425] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022] Open
Abstract
Cyclic Vomiting Syndrome (CVS) is an underdiagnosed episodic syndrome characterized by frequent hospitalizations, multiple comorbidities, and poor quality of life. It is often misdiagnosed due to the unappreciated pattern of recurrence and lack of confirmatory testing. CVS mainly occurs in pre-school or early school-age, but infants and elderly onset have been also described. The etiopathogenesis is largely unknown, but it is likely to be multifactorial. Recent evidence suggests that aberrant brain-gut pathways, mitochondrial enzymopathies, gastrointestinal motility disorders, calcium channel abnormalities, and hyperactivity of the hypothalamic-pituitary-adrenal axis in response to a triggering environmental stimulus are involved. CVS is characterized by acute, stereotyped and recurrent episodes of intense nausea and incoercible vomiting with predictable periodicity and return to baseline health between episodes. A distinction with other differential diagnoses is a challenge for clinicians. Although extensive and invasive investigations should be avoided, baseline testing toward identifying organic causes is recommended in all children with CVS. The management of CVS requires an individually tailored therapy. Management of acute phase is mainly based on supportive and symptomatic care. Early intervention with abortive agents during the brief prodromal phase can be used to attempt to terminate the attack. During the interictal period, non-pharmacologic measures as lifestyle changes and the use of reassurance and anticipatory guidance seem to be effective as a preventive treatment. The indication for prophylactic pharmacotherapy depends on attack intensity and severity, the impairment of the QoL and if attack treatments are ineffective or cause side effects. When children remain refractory to acute or prophylactic treatment, or the episode differs from previous ones, the clinician should consider the possibility of an underlying disease and further mono- or combination therapy and psychotherapy can be guided by accompanying comorbidities and specific sub-phenotype. This review was developed by a joint task force of the Italian Society of Pediatric Gastroenterology Hepatology and Nutrition (SIGENP) and Italian Society of Pediatric Neurology (SINP) to identify relevant current issues and to propose future research directions on pediatric CVS.
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Affiliation(s)
- Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Pediatric Gastroenterology, University College London (UCL) Institute of Child Health and Great Ormond Street Hospital, London, United Kingdom
| | - Giovanni Di Nardo
- Chair of Pediatrics, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Faculty of Medicine & Psychology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Piero Pavone
- Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale “F. Del Ponte,” University of Insubria, Varese, Italy
| | | | | | - Raffaele Falsaperla
- Neonatal Intensive Care and Pediatric Units, S. Marco Hospital, Vittorio Emanuele Hospital, Catania, Italy
| | - Enrico Felici
- Unit of Pediatrics, The Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Michela Ada Noris Ferilli
- Division of Neurology, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Salvatore Grosso
- Clinical Pediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Saverio Mallardo
- Pediatric Department, Santa Maria Goretti Hospital, Sapienza University of Rome, Latina, Italy
| | - Diego Martinelli
- Division of Metabolism, Department of Pediatric Specialties, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Paolo Quitadamo
- Department of Pediatrics, A.O.R.N. Santobono-Pausilipon, Naples, Italy
| | - Licia Pensabene
- Pediatric Unit, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Claudio Romano
- Pediatric Gastroenterology Unit, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina, Messina, Italy
| | | | - Alberto Spalice
- Child Neurology Division, Department of Pediatrics, “Sapienza,” University of Rome, Rome, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child, General and Specialistic Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Agnese Suppiej
- Pediatric Section, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Massimiliano Valeriani
- Division of Neurology, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Letizia Zenzeri
- Emergency Pediatric Department, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Annamaria Staiano
- Section of Pediatrics, Department of Translational Medical Science, “Federico II” University of Naples, Naples, Italy
| | - Maria Pia Villa
- Chair of Pediatrics, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Faculty of Medicine & Psychology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
- Institute for Research, Hospitalization and Health Care (IRCCS) “G. Gaslini” Institute, Genova, Italy
| | - Pasquale Parisi
- Chair of Pediatrics, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Faculty of Medicine & Psychology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Siddiqui MT, Bilal M, Singh A, Olivier-Cabrera S, Lebovics E, Schorr-Lesnick B, Dworkin B, Kirby DF. Prevalence of cannabis use has significantly increased in patients with cyclic vomiting syndrome. Neurogastroenterol Motil 2020; 32:e13806. [PMID: 31990435 PMCID: PMC9206874 DOI: 10.1111/nmo.13806] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION 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. METHODS 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. RESULTS A total of 129 090 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 = 13 460). Over the last decade, the prevalence of cannabis use increased by 10-fold, from 2.2% in 2005 to 21.2% in 2014. CONCLUSION 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.
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Affiliation(s)
- Mohamed Tausif Siddiqui
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mohammad Bilal
- Department of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sarah Olivier-Cabrera
- Department of Medicine, Division of Gastroenterology and Hepatology, New York Medical College, Valhalla, New York
| | - Edward Lebovics
- Department of Medicine, Division of Gastroenterology and Hepatology, New York Medical College, Valhalla, New York
| | - Beth Schorr-Lesnick
- Department of Medicine, Division of Gastroenterology and Hepatology, New York Medical College, Valhalla, New York
| | - Brad Dworkin
- Department of Medicine, Division of Gastroenterology and Hepatology, New York Medical College, Valhalla, New York
| | - Donald F Kirby
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Abstract
INTRODUCTION Cyclic vomiting syndrome (CVS) is a potentially exhausting disorder and has an adverse impact on quality of life, but it is poorly recognized and is always misdiagnosed leading to a diagnostic delay of several years, especially in adults. PATIENT CONCERNS We report a case of a 32-year-old woman with recurrent severe nausea, vomiting, and abdominal pain, and repeated visits to the emergency department or the outpatient department for 4 years. Each time she was diagnosed with gastroenteritis or gastritis, and recovered after supportive treatment including antiemetics, maintenance of water and electrolyte balance, and a proton pump inhibitor. DIAGNOSIS Laboratory examinations, gastroenteroscopy, chest and abdominal computed tomography, and brain magnetic resonance imaging all failed to reveal abnormalities that would explain her symptoms. Based on typical symptoms and the exclusion of other diseases associated with repeated vomiting, the diagnosis was made as CVS. INTERVENTIONS She was given orally amitriptyline, 50 mg per night, and olanzapine, 1.25 mg per night. OUTCOMES The treatment was effective in inducing remission, and symptoms did not recur after treatment. The treatment lasted for 2 months and stopped. Her symptoms did not recur over the 10-month follow up. CONCLUSION CVS is not rare in adults, but its diagnosis is usually delayed due to poor recognition of the condition. Clinician awareness of CVS should be enhanced to improve early diagnosis.Core tip: Cyclic vomiting syndrome has a tremendous impact on the quality of life, but it is poorly recognized and is always misdiagnosed leading to a diagnostic delay of several years, especially in adults. The article presented a case report of cyclic vomiting syndrome of adult; we hope the article will attribute to increased awareness of physician and reduce delayed diagnosis.
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Affiliation(s)
- Cuilan Tang
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou 310009
| | - Ning Dai
- Department of Digestive Diseases, Sir Run Run Shaw Hospital (SRRSH), affiliated with the Zhejiang University School of Medicine, No. 3 East Qingchun Road, Hangzhou 310006, Zhejiang, China
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13
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Spiller TR, Künzler K, Caduff B. Cyclic vomiting syndrome: an important differential diagnosis of cannabinoid hyperemesis syndrome. BMJ 2019; 366:l5615. [PMID: 31548258 DOI: 10.1136/bmj.l5615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Tobias R Spiller
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Katarina Künzler
- Department of Internal Medicine, Limmattal Hospital, Urdorferstrasse 100, 8952 Schlieren, Switzerland
| | - Basil Caduff
- Department of Internal Medicine, Limmattal Hospital, Urdorferstrasse 100, 8952 Schlieren, Switzerland
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Hassani MEME, Saad B, Mounir M, Kouach J, Rahali DM. Catamenial cyclic vomiting syndrome responding to oestrogen therapy: an adolescent case report. Pan Afr Med J 2019; 33:286. [PMID: 31692884 PMCID: PMC6815497 DOI: 10.11604/pamj.2019.33.286.17978] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 07/07/2019] [Indexed: 01/20/2023] Open
Abstract
Cyclic vomiting syndrome (CVS) is defined by episodes of vomiting lasting from a few hours to several days, alternating with periods of no symptoms. Various symptoms can be associated with vomiting such as nausea, migraine or abdominal pain. Common triggers of CVS include infection, psychological stress and menstruation. CVS's diagnosis requires exclusion of alternative diseases particularly neurological and gastrointestinal. CVS shares many common features with catamenial migraine including treatment. We herein report a case of CVS in a 16 years old girl characterized by stereotypical vomiting attacks occurring in every menstrual period. Recurrent vomiting episodes began 2 years before admission. Given the negativity of paraclinical exams and the absence of response to different therapeutic approaches as well as the similarity with catamenial migraine, we treated our patient with permenstrual percutaneous oestrogen for six months. The evolution was marked by the disappearance of symptoms within the first month and the absence of their recurrence after treatment cessation during a follow-up of 6 years.
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Affiliation(s)
| | - Benali Saad
- Service Gynécologie Obstétrique, Hôpital Militaire d'Instruction Mohamed V, Rabat, Maroc
| | - Moukit Mounir
- Service Gynécologie Obstétrique, Hôpital Militaire d'Instruction Mohamed V, Rabat, Maroc
| | - Jaouad Kouach
- Service Gynécologie Obstétrique, Hôpital Militaire d'Instruction Mohamed V, Rabat, Maroc
| | - Driss Moussaoui Rahali
- Service Gynécologie Obstétrique, Hôpital Militaire d'Instruction Mohamed V, Rabat, Maroc
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15
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Burlen J, Runnels M, Mehta M, Andersson S, Ducrotte P, Gourcerol G, Lindberg G, Fullarton G, Abrahamsson H, Al-Juburi A, Lahr C, Rashed H, Abell T. Efficacy of Gastric Electrical Stimulation for Gastroparesis: US/European Comparison. Gastroenterology Res 2018; 11:349-354. [PMID: 30344806 PMCID: PMC6188037 DOI: 10.14740/gr1061w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 07/26/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Gastric electrical stimulation (GES) is used in both the US and Europe, but little research has investigated the demographics of gastroparesis patients receiving GES by geographic location. METHODS We compared data from 380 patients, 296 female and 84 males, mean age 42 years, 246 idiopathic (ID), 107 diabetic (DM), and 27 post-surgical (PS). The statistical significance was calculated by Chi-square test and a P-value obtained for ID, DM, and PS. The statistical significance was calculated by Fischer exact test and a P-value obtained comparing male vs. female. RESULTS European centers had 61 GES patients compared to 319 from the US. In Europe, 100% of patients had gastric emptying test (GET) values available; in the US, it was 75% of patients. European centers had more DM patients (59%) than the US (22%), and a smaller proportion of ID patients (25%) than the US (72%). There was a statistical difference between the causes of gastroparesis in the patients receiving GES (P-value < 0.00001). There was also significant difference in the gender of the patients receiving GES, with a greater proportion of women in the US (P value = 0.0023). CONCLUSIONS Comparing GES in US vs. Europe demonstrated significant differences in gastroparesis demographics and percentage of patients with GET data. After analyzing the previously discussed results and reviewing recent updates in evidence-based medicine guidelines, the discrepancy and variance in patient populations in the US and Europe emphasizes the need for a database that allows better analysis and treatment of gastroparesis patients worldwide including stimulation therapies.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Amar Al-Juburi
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Chris Lahr
- Medical University of South Carolina, Charleston, SC, USA
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Hayes WJ, VanGilder D, Berendse J, Lemon MD, Kappes JA. Cyclic vomiting syndrome: diagnostic approach and current management strategies. Clin Exp Gastroenterol 2018; 11:77-84. [PMID: 29520160 PMCID: PMC5833754 DOI: 10.2147/ceg.s136420] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Cyclic vomiting syndrome (CVS) is a disorder characterized by episodes of nausea and vomiting lasting for 1-5 days followed by asymptomatic periods. The etiology of CVS is unknown, but it shares similar characteristics to migraine headaches. CVS is generally classified as having four phases: prodromal, acute/vomiting/hyperemesis, recovery, and remission/interepisodic. Current management strategies include trigger avoidance, abortive and prophylactic medication therapies, and supportive care. The goal of therapy for the remission phase is prophylaxis of further episodes. Antidepressant, antiepileptic, and antimigraine medications show an overall reduction or remission of CVS symptoms in more than 70% of patients. This article provides a summary of diagnostic strategies and reviews current management strategies for CVS.
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Affiliation(s)
- William J Hayes
- Department of Pharmacy Practice, South Dakota State University, Regional Health Medical Clinic, Rapid City, SD, USA
| | - Deidra VanGilder
- South Dakota State University, College of Pharmacy and Allied Health Professions, Brown Clinic, Watertown, SD, USA
| | - Joseph Berendse
- Department of Pharmacy Practice, South Dakota State University, College of Pharmacy and Allied Health Professions, VA Black Hills Health Care System, Fort Meade, SD, USA
| | - Michael D Lemon
- Department of Pharmacy Practice, South Dakota State University, College of Pharmacy and Allied Health Professions, VA Black Hills Health Care System, Fort Meade, SD, USA
| | - John A Kappes
- Department of Pharmacy Practice, South Dakota State University, College of Pharmacy and Allied Health Professions, Rapid City Regional Hospital, Rapid City, SD, USA
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Bhandari S, Jha P, Thakur A, Kar A, Gerdes H, Venkatesan T. Cyclic vomiting syndrome: epidemiology, diagnosis, and treatment. Clin Auton Res 2018; 28:203-209. [PMID: 29442203 DOI: 10.1007/s10286-018-0506-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 01/19/2018] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Sanjay Bhandari
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA. .,Division of General Internal Medicine, Clinical Cancer Center, Medical College of Wisconsin, 9200 W Wisconsin Ave, 5th Floor, Milwaukee, WI, 53226, USA.
| | - Pinky Jha
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Abhishek Thakur
- Quinnipiac University Frank H. Netter MD School of Medicine, North Haven, CT, USA
| | - Abhipsa Kar
- Medical College of Wisconsin, Wisconsin, WI, USA
| | | | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Affiliation(s)
| | - Tammy Camp
- Texas Tech University Health Sciences Center, Lubbock, TX
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19
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Haghighat M, Memari H, Honar N, Dehghani SM, Imanieh MH, Injoo SJ, Javaherizadeh H. The efficacy and duration of treatment with propranolol in children with cyclic vomiting syndrome in southern Iran. PRZEGLAD GASTROENTEROLOGICZNY 2017; 12:291-295. [PMID: 29358999 PMCID: PMC5771454 DOI: 10.5114/pg.2017.72105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/18/2016] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Cyclic vomiting syndrome is a functional disorder characterised by repeated episodes of nausea and vomiting with symptom-free intervals between the attacks. Cyclic vomiting syndrome is a migraine equivalent; therefore, anti-migraine medications are effective for cyclic vomiting syndrome prophylaxis, but duration of treatment is not clear. AIM To determine the efficacy and duration of drug therapy in cyclic vomiting syndrome. MATERIAL AND METHODS This study was conducted on 206 cases of cyclic vomiting syndrome, who were treated with propranolol as prophylaxis. After they were symptom-free for at least 9 months, propranolol was tapered and discontinued and then they were followed for at least 6 months after drug withdrawal for evaluation of recurrence. RESULTS The study subjects included 127 boys and 79 girls. The mean age of symptom onset was 3.4 years (range: 3 months to 14.5 years) and the mean age at the time of diagnosis was 5.7 years (range: 8.4 months to 18 years). Among the 206 patients in whom propranolol was discontinued, only 16 (7.8%) subjects developed recurrence of symptoms in the 6-month follow-up period. CONCLUSIONS There is no need to continue prophylaxis of cyclic vomiting syndrome for a long time. It is also possible to make the duration of drug therapy shorter, which is useful for the convenience of the patients and prevention of drug side effects.
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Affiliation(s)
- Mahmoud Haghighat
- Gastroenterohepatology Research Center, Nemazee Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hajar Memari
- Gastroenterohepatology Research Center, Nemazee Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Naser Honar
- Gastroenterohepatology Research Center, Nemazee Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Mohsen Dehghani
- Gastroenterohepatology Research Center, Nemazee Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad-Hadi Imanieh
- Gastroenterohepatology Research Center, Nemazee Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed-Javad Injoo
- Gastroenterohepatology Research Center, Nemazee Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hazhir Javaherizadeh
- Research Center for Infectious Diseases of Digestive System [Alimentary Tract Research Center], Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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20
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[Cyclic vomiting syndrome in children]. Arch Pediatr 2017; 24:1129-1136. [PMID: 28947248 DOI: 10.1016/j.arcped.2017.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 04/14/2017] [Accepted: 08/15/2017] [Indexed: 12/23/2022]
Abstract
Cyclic vomiting syndrome (CVS) is a misrecognized and probably underdiagnosed disease that can affect up to 1.9% of the pediatric population and can occupy 15% of these children's time. It is characterized by acute attacks of vomiting, occurring with such a strict frequency that some parents can predict the date of their child's next attack. The pathophysiology of CVS is unclear, although the literature recognizes a common origin with migraine headaches, which has the same acute and prophylactic treatment. CVS is now included in the larger group of diseases called "episodic symptoms related to migraine" previously known as "childhood periodic syndromes." To distinguish between real CVS and other differential diagnoses can challenge the clinician. Additional investigations must be considered in accordance with the clinical presentation. Appropriate management of CVS should lead to an improvement in quality of life and school attendance.
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21
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Bhandari S, Venkatesan T. Clinical Characteristics, Comorbidities and Hospital Outcomes in Hospitalizations with Cyclic Vomiting Syndrome: A Nationwide Analysis. Dig Dis Sci 2017; 62:2035-2044. [PMID: 28050780 DOI: 10.1007/s10620-016-4432-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/21/2016] [Indexed: 12/09/2022]
Abstract
BACKGROUND 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. AIM To study the clinical characteristics, comorbidities, and hospital outcomes in patients hospitalized with CVS using a nationwide database. METHODS 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 18-55 years. 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. RESULTS 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 2 years. CONCLUSIONS 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.
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Affiliation(s)
- Sanjay Bhandari
- Division of General Internal Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA.
| | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Ellingsen DM, Garcia RG, Lee J, Lin RL, Kim J, Thurler AH, Castel S, Dimisko L, Rosen BR, Hadjikhani N, Kuo B, Napadow V. Cyclic Vomiting Syndrome is characterized by altered functional brain connectivity of the insular cortex: A cross-comparison with migraine and healthy adults. Neurogastroenterol Motil 2017; 29:10.1111/nmo.13004. [PMID: 27910222 PMCID: PMC5423835 DOI: 10.1111/nmo.13004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/07/2016] [Indexed: 02/03/2023]
Abstract
Cyclic Vomiting Syndrome (CVS) has been linked to episodic migraine, yet little is known about the precise brain-based mechanisms underpinning CVS, and whether these associated conditions share similar pathophysiology. We investigated the functional integrity of salience (SLN) and sensorimotor (SMN) intrinsic connectivity networks in CVS, migraine and healthy controls using brain functional Magnetic Resonance Imaging. CVS, relative to both migraine and controls, showed increased SLN connectivity to middle/posterior insula, a key brain region for nausea and viscerosensory processing. In contrast, this same region showed diminished SMN connectivity in both CVS and migraine. These results highlight both unique and potentially shared pathophysiology between these conditions, and suggest a potential target for therapeutics in future studies.
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Affiliation(s)
- Dan-Mikael Ellingsen
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Ronald G. Garcia
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Neuroscience Group, School of Medicine, Universidad de Santander (UDES), Bucaramanga, Colombia
- Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeungchan Lee
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard L. Lin
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jieun Kim
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Korean Institute for Oriental Medicine, Daejeon, Korea
| | - Andrea H Thurler
- Department of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shahar Castel
- Department of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Laurie Dimisko
- Department of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Bruce R. Rosen
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nouchine Hadjikhani
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden Kuo
- Department of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vitaly Napadow
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Grover I, Kim R, Spree DC, Lahr CJ, Kedar A, Kothari S, Fleisher D, Abell TL. Gastric Electrical Stimulation Is an Option for Patients with Refractory Cyclic Vomiting Syndrome. J Neurogastroenterol Motil 2016; 22:643-649. [PMID: 27241799 PMCID: PMC5056573 DOI: 10.5056/jnm15135] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 03/09/2016] [Accepted: 03/14/2016] [Indexed: 12/27/2022] Open
Abstract
Background/Aims Cyclic 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. Methods A 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. Results Total 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. Conclusions In 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.
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Affiliation(s)
- Inderpreet Grover
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Richard Kim
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, KY, USA
| | - Danielle C Spree
- Division of Digestive Diseases, University of Mississippi Medical Center, Jackson, MS, USA
| | - Christopher J Lahr
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Archana Kedar
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, KY, USA
| | - Shivangi Kothari
- Division of Digestive Diseases, University of Mississippi Medical Center, Jackson, MS, USA
| | - David Fleisher
- Department of Pediatric Gastroenterology, University of Missouri Health Care, Columbia, MO, USA
| | - Thomas L Abell
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, KY, USA
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Venkatesan T, Zadvornova Y, Raff H, Hillard CJ. Endocannabinoid-related lipids are increased during an episode of cyclic vomiting syndrome. Neurogastroenterol Motil 2016; 28:1409-18. [PMID: 27098832 PMCID: PMC5002231 DOI: 10.1111/nmo.12843] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 03/24/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND 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. METHODS 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). KEY RESULTS 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). CONCLUSIONS & INFERENCES 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.
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Affiliation(s)
- Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Department of Medicine, 9200 W. Wisconsin Ave., Milwaukee, WI 53226
| | - Yelena Zadvornova
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee WI 53226, Telephone: 414-955-7095,
| | - Hershel Raff
- Departments of Medicine, Surgery, and Physiology, Medical College of Wisconsin, Director, Endocrine Research Laboratory, Aurora St. Luke's Medical Center - Aurora Research Institute, 2801 W KK River Pkwy. Suite 245, Milwaukee WI 53215, Telephone: (414) 649-6411
- Fax: (414) 649-5747, or
| | - Cecilia J. Hillard
- Director of the Neuroscience Research Center and Professor of Pharmacology and Toxicology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, Telephone: (414) 955-8493 Phone / Fax: (414) 955-6057,
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Lebron D, Vasconcellos E. The Episodic Syndromes That Maybe Associated with Migraines. Semin Pediatr Neurol 2016; 23:6-10. [PMID: 27017014 DOI: 10.1016/j.spen.2016.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The "childhood periodic syndromes" have been renamed "the episodic syndromes that maybe associated with migraines". These syndromes were initially considered precursors of migraines that only occurred in childhood; however recent literature suggests that the episodic syndromes can occur in adults with known migraine and does not necessarily present as a precursor. This review article discusses the recent literature regarding the episodic syndromes and potential treatments. These disorders are seen by multiple subspecialists, therefore it is important to recognize and use the same definitions, criteria and nomenclature. A collaborative and multidisciplinary approach is critical to characterize, manage and potentially improve outcomes.
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Affiliation(s)
- Diana Lebron
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN.
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Tarbell SE, Li BUK. Anxiety Measures Predict Health-Related Quality of Life in Children and Adolescents with Cyclic Vomiting Syndrome. J Pediatr 2015; 167:633-8.e1. [PMID: 26095286 DOI: 10.1016/j.jpeds.2015.05.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/15/2015] [Accepted: 05/19/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the relationship between anxiety and health-related quality of life (HRQoL) in children and adolescents with cyclic vomiting syndrome (CVS). STUDY DESIGN Forty children aged 8-18 years diagnosed with CVS and 40 parents completed the Screen for Child Anxiety Related Emotional Disorders (SCARED) and the child and parent forms of the Pediatric Quality of Life Generic Core Scale, a measure of HRQoL. RESULTS Eleven of the 40 children (27%) by self-report and 6 of 40 (15%) by parent-proxy report met the clinical cutoff for an anxiety disorder on the SCARED. Parent and child SCARED ratings were moderately correlated (intraclass correlation coefficient 0.68; P < .001). Child-rated HRQoL (mean ± SD, 74.3 ± 15.2) and parent-rated HRQoL (mean, 72.1 ± 14.6) were lower than healthy norms (P < .001). Disease severity (mean duration of CVS episodes, 3 ± 2.4 days), annual frequency of CVS episodes (mean, 8.2 ± 15.3), chronicity of CVS (mean, 5.8 ± 3.4 years), and delay in diagnosis (mean, 2.4 ± 1.9 years) were not associated with child-reported HRQoL; however, child SCARED scores accounted for approximately 50% of the variance in child-reported HRQoL (adjusted R(2) = 0.49; df = 1, 38; P < .001). CONCLUSION Children and adolescents with CVS appear to be at increased risk for anxiety. Anxiety symptoms are a stronger predictor of HRQoL than disease characteristics in children and adolescents with CVS. Assessment and treatment of anxiety in children and adolescents with CVS may have a positive impact on HRQoL.
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Affiliation(s)
- Sally E Tarbell
- Department of Psychiatry and Behavioral Sciences, Children's Hospital Colorado, Aurora, CO; Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO.
| | - B U K Li
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
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Felton D, Zitomersky N, Manzi S, Lightdale JR. 13-year-old girl with recurrent, episodic, persistent vomiting: out of the pot and into the fire. Pediatrics 2015; 135:e1060-3. [PMID: 25733759 DOI: 10.1542/peds.2014-2116] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2014] [Indexed: 11/24/2022] Open
Abstract
Cyclic vomiting syndrome (CVS) is a well-established cause of recurrent vomiting in the pediatric population. Severe vomiting with chronic cannabis use, known as cannabinoid hyperemesis syndrome, has recently been more widely recognized as an etiology of persistent episodic vomiting. In turn, patients presenting with frequent episodes of CVS are now increasingly being screened for cannabinoid use. Because patients with persistent vomiting are also frequently prescribed a proton pump inhibitor (PPI) for their gastrointestinal symptoms, it is important to be aware of the potential for a PPI to cause an interaction that can lead to false-positive urine cannabinoid screening. We describe a case of a false-positive urine cannabinoid screen in a patient with CVS who received a dose of intravenous pantoprazole. The primary reference regarding drug screen interference from PPIs can be found in the pantoprazole package insert that refers to pre-Food and Drug Administration approval data. Although multiple sources on the Internet report the possibility of positive cannabinoid screens from pantoprazole, there are no known published reports of the phenomenon in the medical literature.
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Affiliation(s)
| | | | - Shannon Manzi
- Department of Pharmacy, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts Genetics and Genomics, and
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Hayes WJ, Weisensee LA, Kappes JA, Dalton SM, Lemon MD. OnabotulinumtoxinA Injections for the Treatment of Cyclic Vomiting Syndrome. Pharmacotherapy 2015; 35:e51-5. [PMID: 25823714 DOI: 10.1002/phar.1570] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cyclic vomiting syndrome (CVS) is a disorder characterized by episodes of nausea and vomiting lasting 1 to 5 days, followed by asymptomatic periods. The etiology and pathophysiology of CVS are unknown, but CVS shares similar characteristics to those of migraine headaches. Tricyclic antidepressants have the most evidence and are generally effective for prophylaxis of further episodes in patients with CVS. Second-line pharmacotherapies typically target specific comorbid symptoms or conditions and may include antiepileptic or antimigraine drugs, benzodiazepines, antispasmodics, proton pump inhibitors, antiemetics, and analgesics. OnabotulinumtoxinA (ONABoNT-A) injections have not been studied in the population with CVS but are regarded as a pharmacotherapeutic option for migraine headaches. We describe a 45-year-old woman with a 5-year history of CVS who had failed previous typical prophylactic migraine and CVS pharmacotherapies and was referred to the neurology clinic for management of both of these conditions. On review, the neurologist noted a correlation of the patient's headaches with her CVS symptoms. ONABoNT-A injections were started at 155 units intramuscularly every 12 weeks for her migraine headaches, which also dramatically improved her CVS. The main adverse effect reported by the patient was numbness and weakness in her left shoulder after the injections, which are symptoms consistent with ONABoNT-A injection use; however, these symptoms typically resolved a few days later. Regarded as a pharmacotherapeutic option for migraine headache prophylaxis, ONABoNT-A injections have demonstrated modest efficacy in preventing migraine headaches. Clinicians should be aware that ONABoNT-A injections may also have a role in the prophylaxis of CVS.
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Affiliation(s)
- William J Hayes
- College of Pharmacy, VA Black Hills Health Care System, South Dakota State University, Fort Meade, South Dakota
| | - Laurie A Weisensee
- VA Black Hills Health Care System, Sanford School of Medicine at the University of South Dakota, Fort Meade, South Dakota
| | - John A Kappes
- College of Pharmacy, Rapid City Regional Hospital, South Dakota State University, Rapid City, South Dakota
| | - Shawn M Dalton
- College of Pharmacy, VA Black Hills Health Care System, South Dakota State University, Hot Springs, South Dakota
| | - Michael D Lemon
- College of Pharmacy, VA Black Hills Health Care System, South Dakota State University, Fort Meade, South Dakota
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Headache prevalence and related symptoms, family history, and treatment habits in a representative population of children in Alba, Italy. Pediatr Neurol 2014; 51:348-53. [PMID: 24993247 DOI: 10.1016/j.pediatrneurol.2014.05.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/16/2014] [Accepted: 05/21/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Headache is a widespread disorder in children, but little is known about the headache prevalence in northwest Italy, on less frequent migraine equivalents, family history, and treatment habits in children. METHOD This is an epidemiologic population-based study of a representative sample of children aged 3 to 11 years, conducted in Alba, Italy. We used a self-administered questionnaire to acquire information on gender, age, headache, possible migraine equivalents, family history for various diseases, and treatment habits. RESULTS We distributed the questionnaire to 1152 children, and a total of 649 questionnaires were successfully completed. In the preschool age, 10.3% (seven boys and nine girls) of children suffered from headache. In school-age children, the prevalence of headache was 31.4% (75 boys and 80 girls; 27% in 6 year olds and 41% at age 9 years). We found a significant correlation between headache and abdominal pain in the entire sample and with cyclic vomiting syndrome and dizziness in school-age children only. Headache correlated significantly with a family history of headache, thyroid diseases, diabetes, hypertension, and vascular diseases. Headache was treated with drugs, primarily paracetamol, in 60 of the 171 (35%) children who reported headache and in 61% of the children with migraine; no subjects were treated with triptans. CONCLUSIONS Headache is widespread in children, with a high prevalence of associated symptoms and family history for many other headache-related disorders.
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Evans RW, Whyte C. Cyclic vomiting syndrome and abdominal migraine in adults and children. Headache 2014; 53:984-93. [PMID: 23721241 DOI: 10.1111/head.12124] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2013] [Indexed: 11/30/2022]
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Cooper CJ, Said S, Bizet J, Alkahateeb H, Sarosiek I, McCallum RW. Rapid or normal gastric emptying as new supportive criteria for diagnosing cyclic vomiting syndrome in adults. Med Sci Monit 2014; 20:1491-5. [PMID: 25145650 PMCID: PMC4152253 DOI: 10.12659/msm.890547] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Cyclic 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/Methods This 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. Results Of 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.
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Affiliation(s)
- Chad J Cooper
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Sarmad Said
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Jorge Bizet
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Haider Alkahateeb
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Irene Sarosiek
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Richard W McCallum
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
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Abstract
The adverse effects of marijuana are well documented, as well as its positive therapeutic uses. Cannabis has traditionally been associated with an antiemetic action following acute ingestion and synthetic cannabinoids have an established use as antiemetics for chemotherapy induced nausea. However, there has been limited recognition of chronic cannabis use as a cause of cyclic vomiting syndrome. Cannabinoid hyperemesis was first identified by Allen er al in 2004. Compulsive bathing was also described as part of the clinical picture. This same syndrome has been confirmed a number of times in the medical literature in the interim. The condition has, to our knowledge, never been reported, in a psychiatric patient.
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Approach to the diagnosis and treatment of cyclic vomiting syndrome: a large single-center experience with 106 patients. Pediatr Neurol 2014; 50:569-73. [PMID: 24842256 DOI: 10.1016/j.pediatrneurol.2014.02.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 02/05/2014] [Accepted: 02/12/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cyclic vomiting syndrome is characterized by repeated, stereotypical vomiting episodes. The diagnosis is made by exclusion of other organic diseases, which can lead to extensive testing. It has been suggested that these patients can have mitochondrial dysfunction. The aim of the study was to examine the evaluation of our cyclic vomiting patients and to determine whether they had associated, undiagnosed metabolic abnormalities. METHODS This retrospective study included 106 patients aged <21 years at diagnosis. Information regarding medical history, laboratory, and imaging studies were collected. Metabolic studies in plasma and urine were obtained when patients were well and when patients were in a vomiting cycle, including plasma amino acids, acylcarnitines, and urine organic acids. RESULTS The mean age at diagnosis was 8.9 ± 5.0 years. Neuroimaging revealed previously unknown intracranial abnormalities in <10% of patients, none of whom explained the vomiting signs. Abdominal ultrasounds revealed abnormalities in 15% of patients during an acute episode and 7% of patients when well. Sixty-one patients had an upper gastrointestinal series, all of which were normal. A total of 92% of patients had laboratory testing with 38% indicating abnormalities possibly suggesting mitochondrial dysfunction. CONCLUSIONS This large, single-center study further evaluated the need for more focused evaluation in patients with suspected cyclic vomiting syndrome. Thirty-eight percent of our patients had abnormalities in blood and/or urine suggesting mitochondrial dysfunction, which requires more detailed investigation in the future.
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Vidula MK, Wadhwani A, Roberts K, Berkowitz LL. Use of a once-daily NSAID in treatment of cyclic vomiting syndrome. J Gen Intern Med 2014; 29:543-6. [PMID: 24129856 PMCID: PMC3930795 DOI: 10.1007/s11606-013-2624-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 05/15/2013] [Accepted: 08/30/2013] [Indexed: 10/26/2022]
Abstract
Cyclic vomiting syndrome (CVS) is a rare disorder characterized by episodes of intense vomiting and nausea separated by symptom-free periods. We report the case of a 71-year-old man who presented with a long history of poorly controlled CVS whose symptoms resolved with the addition of a once-daily dose of meloxicam, a semi-selective non-steroidal anti-inflammatory drug (NSAID). This is the first report of symptom alleviation in a CVS patient using a once-daily NSAID, as well as one with selectivity to COX-2 inhibition. This is important due to both the increased compliance seen with once-daily medications, as well as the decreased gastrointestinal effects seen with selective COX-2 inhibitors compared to nonselective NSAIDS.
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Affiliation(s)
- Mahesh K. Vidula
- />Feinberg School of Medicine, Northwestern University, 1913 W. North Ave, Chicago, IL 60622 USA
| | - Anil Wadhwani
- />Feinberg School of Medicine, Northwestern University, 1913 W. North Ave, Chicago, IL 60622 USA
| | - Kaleigh Roberts
- />Feinberg School of Medicine, Northwestern University, 1913 W. North Ave, Chicago, IL 60622 USA
| | - Lyle L. Berkowitz
- />Feinberg School of Medicine, Northwestern University, 1913 W. North Ave, Chicago, IL 60622 USA
- />Northwestern Memorial Hospital, 1913 W. North Ave, Chicago, IL 60622 USA
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Abstract
BACKGROUND The purpose of this review is to describe cannabinoid hyperemesis syndrome (CHS), which is thought to be induced by long-term cannabis use, and provide clinical pharmacists with information to manage the hyperemetic phase of CHS. METHOD Published literature was searched and reviewed using PubMed. RESULTS CHS is characterized by intractable nausea and vomiting without an obvious organic cause and associated learned compulsive hot water bathing behavior. Patients often seek care in the emergency department (ED) for symptomatic relief. CONCLUSION CHS is potentially underrecognized and underdiagnosed in the ED, and it should be considered in the differential diagnosis in long-term cannabis use patients with CHS symptoms to avoid unnecessary extensive diagnostic workup including invasive radiologic imaging. Pharmacists have an important role in CHS recognition, education, and symptom management.
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Affiliation(s)
| | - Anthony E Zimmermann
- Clinical Professor and Chair, Department of Pharmacy Practice, College of Pharmacy, Western New England University, Springfield, Massachusetts. Corresponding author: Shusen Sun, PharmD, BCPS, Department of Pharmacy Practice, College of Pharmacy, Western New England University, 1215 Wilbraham Road, Springfield, MA 01119; phone: 413-796-2424; e-mail:
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Abstract
BACKGROUND Charles Darwin (CD), "father of modern biology," suffered from multisystem illness from early adulthood. The most disabling manifestation was cyclic vomiting syndrome (CVS). This study aims at finding the possible cause of CVS in CD. METHODS A literature search using the PubMed database was carried out, and CD's complaints, as reported in his personal writings and those of his relatives, friends, colleagues, biographers, were compared with various manifestations of mitochondrial disorders (MIDs), known to cause CVS, described in the literature. RESULTS Organ tissues involved in CD's disease were brain, nerves, muscles, vestibular apparatus, heart, gut, and skin. Cerebral manifestations included episodic headache, visual disturbance, episodic memory loss, periodic paralysis, hysterical crying, panic attacks, and episodes of depression. Manifestations of polyneuropathy included numbness, paresthesias, increased sweating, temperature sensitivity, and arterial hypotension. Muscular manifestations included periods of exhaustion, easy fatigability, myalgia, and muscle twitching. Cardiac manifestations included episodes of palpitations and chest pain. Gastrointestinal manifestations were CVS, dental problems, abnormal seasickness, eructation, belching, and flatulence. Dermatological manifestations included painful lips, dermatitis, eczema, and facial edema. Treatments with beneficial effects to his complaints were rest, relaxation, heat, and hydrotherapy. CONCLUSION CVS in CD was most likely due to a multisystem, nonsyndromic MID. This diagnosis is based upon the multisystem nature of his disease, the fact that CVS is most frequently the manifestation of a MID, the family history, the variable phenotypic expression between affected family members, the fact that symptoms were triggered by stress, and that only few symptoms could not be explained by a MID.
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Affiliation(s)
| | - John Hayman
- Department of pathology, University of Melbourne, Victoria, Australia
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Morris R, Fisher M. Cannabinoid hyperemesis syndrome: a specific cause of cyclical vomiting. Int J Adolesc Med Health 2014; 26:153-156. [PMID: 23370905 DOI: 10.1515/ijamh-2012-0113] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 11/22/2012] [Indexed: 06/01/2023]
Abstract
Cyclical vomiting syndrome (CVS) is a disorder that occurs mostly in children, adolescents and young adults in which episodes of nausea and vomiting occur up to six to 12 times per year. In the past decade, one specific cause of cyclical vomiting syndrome, referred to as cannabinoid hyperemesis syndrome (CHS), has been described in a subset of patients who report chronic marijuana use. Of interest, almost all of these patients report compulsive bathing in hot water as part of the syndrome. In this report, we present the case of a 20-year-old female with CHS, review the issues generally encountered in CVS and discuss the known details of CHS. This is an important syndrome that needs to be considered as a potential diagnosis when patients present with cyclical vomiting.
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Cyclic vomiting syndrome in adults. Wien Med Wochenschr 2013; 163:514-6. [DOI: 10.1007/s10354-013-0250-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 10/25/2013] [Indexed: 12/17/2022]
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Abstract
Cyclic vomiting syndrome (CVS) is an idiopathic functional gastrointestinal disorder that has been underrecognized in the adult population. Nausea, vomiting, and abdominal pain are common presentations to gastrointestinal nursing. There are multiple differential diagnoses the clinician must consider prior to a diagnosis of CVS to recognize the disorder. CVS occurs in 4 phases: (a) interepisodic, (b) prodromal, (c) vomiting, and (d) recovery. Each phase has specific treatment guidelines. There is no specific "cure" for CVS; proper management is key. Increasing awareness of CVS is paramount to its detection. CVS has been examined in the pediatric population and has often been considered a pediatric disorder. More recently, it has come to be recognized in the adult population. Proper care and management of these patients allow for better support for patients and their families who are often on the primary caregivers. Nurses are often on the front lines of care and knowledge of CVS from the beginning should lead to shortened hospital stays and optimal patient care.
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Affiliation(s)
- Andrea H Thurler
- Andrea H. Thurler, DNP, RN, FNP-BC, is Nurse Practitioner, Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts. Braden Kuo, MD, is Attending Physician, Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
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Brown Tonore T, Spree DC, Abell T. Cyclic vomiting syndrome: a common, underrecognized disorder. J Am Assoc Nurse Pract 2013; 26:340-7. [PMID: 24170626 DOI: 10.1002/2327-6924.12068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE To increase recognition and present symptom assessment strategies for treating cyclic vomiting syndrome (CVS). DATA SOURCES Clinical experience, a range of pediatric, gastroenterological, emergency medicine research, survey, and literature review reports on CVS. CONCLUSIONS Improved efforts to recognize, diagnose, and treat CVS will help patients manage their symptoms and may reduce both the morbidity and costs of hospitalizations associated with this illness. IMPLICATIONS FOR PRACTICE If promptly diagnosed and appropriately treated, CVS episodes can be aborted. Patients inappropriately treated must often be hospitalized because of complications associated with symptoms. Lifestyle changes, prophylactic and abortive migraine therapy, and supportive care are important to prevention.
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Affiliation(s)
- Thais Brown Tonore
- Department of Family Medicine, University of Mississippi Medical Center, Jackson, Mississippi; Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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Bashashati M, McCallum RW. Neurochemical mechanisms and pharmacologic strategies in managing nausea and vomiting related to cyclic vomiting syndrome and other gastrointestinal disorders. Eur J Pharmacol 2013; 722:79-94. [PMID: 24161560 DOI: 10.1016/j.ejphar.2013.09.075] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 09/24/2013] [Accepted: 09/27/2013] [Indexed: 12/18/2022]
Abstract
Nausea and vomiting are common gastrointestinal complaints which could be triggered by stimuli in both the peripheral and central nervous systems. They may be considered as defense mechanisms when threatening toxins/agents enter the gastrointestinal tract or there is excessive retention of gastrointestinal contents due to obstruction. The pathophysiology of nausea and vomiting is complex and much still remains unknown. Therefore, treatments are restricted or ineffective in many cases. Nausea and vomiting with functional etiologies including cyclic vomiting syndrome are challenging in gastroenterology. In this article, we review potential pathways, neurochemical transmitters, and their receptors which are possibly involved in the pathophysiology of nausea and vomiting including the entity cyclic vomiting syndrome.
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Affiliation(s)
- Mohammad Bashashati
- Hotchkiss Brain Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | - Richard W McCallum
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA.
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Mohammed F, Panchoo K, Bartholemew M, Maharaj D. Compulsive showering and marijuana use - the cannabis hyperemisis syndrome. AMERICAN JOURNAL OF CASE REPORTS 2013; 14:326-8. [PMID: 23997851 PMCID: PMC3757911 DOI: 10.12659/ajcr.884001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 02/08/2013] [Indexed: 11/25/2022]
Abstract
Patient: Male, 26 Final Diagnosis: Marihuana addiction Symptoms: Compulsive showering • nausea • vomiting Medication: — Clinical Procedure: — Specialty: Toxicology
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Affiliation(s)
- Fawwaz Mohammed
- Department of Surgery, San Fernando General Hospital, West Indies
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Tarbell SE, Li BUK. Health-related quality of life in children and adolescents with cyclic vomiting syndrome: a comparison with published data on youth with irritable bowel syndrome and organic gastrointestinal disorders. J Pediatr 2013; 163:493-7. [PMID: 23485030 DOI: 10.1016/j.jpeds.2013.01.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 12/26/2012] [Accepted: 01/10/2013] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate health-related quality of life (HRQoL) in children with cyclic vomiting syndrome (CVS) and to compare child self-reports with those of their parents and with published reports of children with irritable bowel syndrome (IBS), children with organic gastrointestinal disorders, and a healthy control group. STUDY DESIGN Sixty-eight children aged 5-18 years with CVS confirmed in a gastroenterology clinic completed the Pediatric Quality of Life Inventory (PedsQL). Eighty-two parents completed the parent-proxy PedsQL for children aged 2-18 years. These results were compared with published data for children with IBS, organic gastrointestinal disorders, and a healthy control group using ANOVA. Intraclass correlation was used to evaluate concordance between child and parent reports of HRQoL. RESULTS HRQoL reported on the PedsQL by children with CVS was lower than that reported by children with IBS (P < .01) and healthy controls (P < .001), but did not differ from that reported by children with organic gastrointestinal disorders. Children with CVS also had lower HRQoL compared with healthy controls by parent-proxy report on the PedsQL (P < .001). Correlations between HRQoL reports by parents and children were moderate to good (intraclass correlation coefficients, 0.504-0.805; P < .01). Duration of CVS episodes, delay in CVS diagnosis, and number of school days missed due to CVS were associated with lower parent-rated HRQoL (P = .01). CONCLUSION Children with CVS reported lower HRQoL compared with those with IBS, and both parents and children reported lower HRQoL compared with healthy controls. Parent and child ratings of HRQoL converged. Improved recognition of CVS and school support might help mitigate the impact of CVS on HRQoL.
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Affiliation(s)
- Sally E Tarbell
- Department of Psychiatry and Behavioral Sciences, Children's Hospital Colorado, Aurora, CO 80045, USA.
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Aurora SK, Papapetropoulos S, Kori SH, Kedar A, Abell TL. Gastric stasis in migraineurs: etiology, characteristics, and clinical and therapeutic implications. Cephalalgia 2013; 33:408-15. [PMID: 23463252 DOI: 10.1177/0333102412473371] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Migraine is a disabling neurological disorder often complicated by gastrointestinal conditions such as gastric stasis. The association between migraine and gastric stasis has received very little attention in the literature, but the existing evidence suggests that they may share a common etiology. RESULTS Patients with migraine and those with gastric stasis exhibit abnormal autonomic nervous system function. Furthermore, empirical studies demonstrate that migraineurs experience significant delays in gastric emptying, both during and outside of attacks, when compared to non-migrainous controls. CONCLUSION More research is needed to establish the relationship between gastric stasis and migraine burden and to determine the impact of gastric stasis on migraine treatment.
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Patel A, Sayuk GS, Kushnir VM, Gyawali CP. Sensory neuromodulators in functional nausea and vomiting: predictors of response. Postgrad Med J 2012; 89:131-6. [PMID: 23112216 DOI: 10.1136/postgradmedj-2012-131284] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Tricyclic antidepressants (TCAs) are known to benefit subjects with functional nausea and vomiting (FNV), but it is not known if alternate neuromodulators are also beneficial. We retrospectively evaluated outcomes and clinical predictors of response in FNV subjects treated with any neuromodulator, including TCAs. METHODS We identified 94 subjects (43.8±1.4 year, 79 F) with FNV (Rome III criteria) over a 12 year period, treated with neuromodulators and followed up for 8.5±1.1 months. Clinical presentation, demographics and gastric emptying study (GES) findings (when available) were extracted. Likert scales determined symptom severity at baseline and symptom response or remission at follow-up. Outcomes and predictors of response were evaluated using univariate and multivariate analyses. RESULTS At least moderate symptom improvement was reported by 72.3%, and 22.3% had symptom remission. Proportions achieving moderate improvement and remission, and mean outcome Likert scores were similar regardless of neuromodulator agent used or GES status. On univariate and multivariate logistic regression analysis, baseline symptom severity affected symptom response, and pain negatively impacted symptom remission to treatment (p≤0.04 for each); GES status failed to predict treatment response or remission. CONCLUSIONS Symptom improvement with neuromodulators may be seen in over two-thirds of subjects with FNV regardless of the specific agent administered. Response may be suboptimal in pain predominant presentations.
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Affiliation(s)
- Amit Patel
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
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Feillet F. Les vomissements cycliques de l'enfant, le point du vue du métabolicien. Arch Pediatr 2012. [DOI: 10.1016/s0929-693x(12)71204-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kumar N, Bashar Q, Reddy N, Sengupta J, Ananthakrishnan A, Schroeder A, Hogan WJ, Venkatesan T. Cyclic Vomiting Syndrome (CVS): is there a difference based on onset of symptoms--pediatric versus adult? BMC Gastroenterol 2012; 12:52. [PMID: 22639867 PMCID: PMC3443054 DOI: 10.1186/1471-230x-12-52] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Accepted: 05/28/2012] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND Cyclic Vomiting Syndrome (CVS) is a well-recognized functional gastrointestinal disorder in children but its presentation is poorly understood in adults. Genetic differences in pediatric-onset (presentation before age 18) and adult-onset CVS have been reported recently but their clinical features and possible differences in response to therapy have not been well studied. METHODS This was a retrospective review of 101 CVS patients seen at the Medical College of Wisconsin between 2006 and 2008. Rome III criteria were utilized to make the diagnosis of CVS. RESULTS Our study population comprised of 29(29%) pediatric-onset and 72 (71%) adult-onset CVS patients. Pediatric-onset CVS patients were more likely to be female (86% vs. 57%, p = 0.005) and had a higher prevalence of CVS plus (CVS + neurocognitive disorders) as compared to adult-onset CVS patients (14% vs. 3%, p = 0.05). There was a longer delay in diagnosis (10 ± 7 years) in the pediatric-onset group when compared to (5 ± 7 years) adult-onset CVS group (p = 0.001). Chronic opiate use was less frequent in the pediatric-onset group compared to adult-onset patients (0% vs. 23%, p = 0.004). Aside from these differences, the two groups were similar with regards to their clinical features and the time of onset of symptoms did not predict response to standard treatment. The majority of patients (86%) responded to treatment with tricyclic antidepressants, anticonvulsants (topiramate), coenzyme Q-10, and L-carnitine. Non-response to therapy was associated with coalescence of symptoms, chronic opiate use and more severe disease as characterized by longer episodes, greater number of emergency department visits in the year prior to presentation, presence of disability and non-compliance on univariate analysis. On multivariate analysis, only compliance to therapy was associated with a response. (88% vs. 38%, Odds Ratio, OR 9.6; 95% Confidence Interval [CI], 1.18-77.05). CONCLUSION Despite reported genetic differences, the clinical features and response to standard therapy in pediatric- and adult-onset CVS were mostly similar. Most patients (86%) responded to therapy and compliance was the only factor associated with a response.
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Affiliation(s)
- Nilay Kumar
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin, 4th Floor, Froedtert East Building, 9200 W Wisconsin Avenue, Milwaukee, WI 53226, USA
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Cannabinoid hyperemesis syndrome: case report of a paradoxical reaction with heavy marijuana use. Case Rep Med 2012; 2012:757696. [PMID: 22685471 PMCID: PMC3368238 DOI: 10.1155/2012/757696] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 03/22/2012] [Accepted: 04/02/2012] [Indexed: 11/18/2022] Open
Abstract
Cannabinoid hyperemesis syndrome (CHS) is a rare constellation of clinical findings that includes a history of chronic heavy marijuana use, severe abdominal pain, unrelenting nausea, and intractable vomiting. A striking component of this history includes the use of hot showers or long baths that help to alleviate these symptoms. This is an underrecognized syndrome that can lead to expensive and unrevealing workups and can leave patients self-medicating their nausea and vomiting with the very substance that is causing their symptoms. Long-term treatment of CHS is abstinence from marijuana use-but the acute symptomatic treatment of CHS has been a struggle for many clinicians. Many standard medications used for the symptomatic treatment of CHS (including ondansetron, promethazine, and morphine) have repeatedly been shown to be ineffective. Here we present the use of lorazepam as an agent that successfully and safely treats the tenacious symptoms of CHS. Additionally, we build upon existing hypotheses for the pathogenesis of CHS to try to explain why a substance that has been used for thousands of years is only now beginning to cause this paradoxical hyperemesis syndrome.
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Lee KL, Shin JI. Cyclic vomiting syndrome developed after stroke. Ann Rehabil Med 2012; 36:141-3. [PMID: 22506247 PMCID: PMC3309328 DOI: 10.5535/arm.2012.36.1.141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 02/10/2011] [Indexed: 11/16/2022] Open
Abstract
Cyclic vomiting syndrome is characterized by recurrent episodes of stereotyped vomiting separated by regular symptom-free periods. We describe a case of cyclic vomiting syndrome developed after stroke, which has not been reported to date. A 69-year-old woman experienced recurrent vomiting following left cerebral infarct. The patient's vomiting pattern was consistent with cyclic vomiting syndrome, and the diagnosis of cyclic vomiting syndrome was established by exclusion of other known disorders which could have resulted in vomiting. She was treated with imipramine hydrochloride and her symptom was well controlled.
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Affiliation(s)
- Kwang Lae Lee
- Department of Rehabilitation Medicine, National Rehabilitation Hospital, Seoul 142-884, Korea
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Shanahan F. Darwinian dyspepsia: an extraordinary scientist, an ordinary illness, great dignity. Am J Gastroenterol 2012; 107:161-4. [PMID: 22306938 DOI: 10.1038/ajg.2011.351] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Fergus Shanahan
- Department of Medicine and Alimentary Pharmabiotic Centre, University College Cork, National University of Ireland, Cork, Ireland.
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