What is cyclic vomiting syndrome
(CVS)? CVS is characterized by episodes or cycles of severe
nausea and vomiting that last for hours, or even days, that
alternate with intervals with no symptoms. Although originally
thought to be a pediatric disease, CVS occurs in all age groups.
Each episode of CVS is similar to previous ones, meaning the
episodes tend to start at the same time of day, last the same
length of time, and occur with the same symptoms and level of
intensity. Although CVS can begin at any age, in children it
starts most often between the ages of 3 and 7.
Episodes can be so severe that a person has to stay in bed for
days, unable to go to school or work. The exact number of people
with CVS is unknown, but medical researchers believe more people
may have the disorder than commonly thought. Because other more
common diseases and disorders also cause cycles of vomiting, many
people with CVS are initially misdiagnosed until other disorders
can be ruled out. CVS can be disruptive and frightening not just
to people who have it but to family members as well.
The Four Phases of CVS CVS has four phases:
* Symptom-free interval phase. This phase is the period between
episodes when no symptoms are present.
* Prodrome phase. This phase signals that an episode of nausea and
vomiting is about to begin. Often marked by nausea—with or without
abdominal pain—this phase can last from just a few minutes to
several hours. Sometimes, taking medicine early in the phase can
stop an episode in progress. However, sometimes there is no
warning; a person may simply wake up in the morning and begin
vomiting.
* Vomiting phase. This phase consists of nausea and vomiting; an
inability to eat, drink, or take medicines without vomiting;
paleness; drowsiness; and exhaustion.
* Recovery phase. This phase begins when the nausea and vomiting
stop. Healthy color, appetite, and energy return.
What triggers CVS?
Many people can identify a specific condition or event that
triggered an episode, such as an infection. Common triggers in
children include emotional stress and excitement. Anxiety and
panic attacks are more common triggers in adults. Colds,
allergies, sinus problems, and the flu can also set off episodes
in some people.
Other reported triggers include eating certain foods such as
chocolate or cheese, eating too much, or eating just before going
to bed. Hot weather, physical exhaustion, menstruation, and motion
sickness can also trigger episodes.
What are the symptoms of CVS?
A person who experiences the following symptoms for at least 3
months—with first onset at least 6 months prior—may have CVS:
* vomiting episodes that start with severe vomiting—several times
per hour—and last less than 1 week
* three or more separate episodes of vomiting in the past year
* absence of nausea or vomiting between episodes
A person with CVS may experience abdominal pain, diarrhea, fever,
dizziness, and sensitivity to light during vomiting episodes.
Continued vomiting may cause severe dehydration that can be life
threatening. Symptoms of dehydration include thirst, decreased
urination, paleness, exhaustion, and listlessness. A person with
any symptoms of dehydration should see a health care provider
immediately.
How is CVS diagnosed?
CVS is hard to diagnose because no tests—such as a blood test or x
ray—can establish a diagnosis of CVS. A doctor must look at
symptoms and medical history to rule out other common diseases or
disorders that can cause nausea and vomiting. Making a diagnosis
takes time because the doctor also needs to identify a pattern or
cycle to the vomiting.
CVS and Migraine
The relationship between migraine and CVS is still unclear, but
medical researchers believe the two are related.
* Migraine headaches, which cause severe head pain; abdominal
migraines, which cause stomach pain; and CVS are all marked by
severe symptoms that start and end quickly and are followed by
intervals without pain or other symptoms.
* Many of the situations that trigger CVS also trigger migraines,
including stress and excitement.
* Research has shown that many children with CVS either have a
family history of migraine or develop migraines as they grow
older.
Because of the similarities between migraine and CVS, doctors
treat some people with severe CVS with drugs that are also used
for migraine headaches. The drugs are designed to prevent
episodes, reduce frequency, and lessen severity.
How is CVS treated?
Treatment varies, but people with CVS generally improve after
learning to control their symptoms. People with CVS are advised to
get plenty of rest and sleep and to take medications that prevent
a vomiting episode, stop one in progress, speed up recovery, or
relieve associated symptoms.
Once a vomiting episode begins, treatment usually requires the
person to stay in bed and sleep in a dark, quiet room. Severe
nausea and vomiting may require hospitalization and intravenous
fluids to prevent dehydration. Sedatives may help if the nausea
continues.
Sometimes, during the prodrome phase, it is possible to stop an
episode from happening. For example, people with nausea or
abdominal pain before an episode can ask their doctor about taking
ondansetron (Zofran) or lorazepam (Ativan) for nausea or ibuprofen
(Advil, Motrin) for pain. Other medications that may be helpful
are ranitidine (Zantac) or omeprazole (Prilosec), which help calm
the stomach by lowering the amount of acid it makes.
During the recovery phase, drinking water and replacing lost
electrolytes are important. Electrolytes are salts the body needs
to function and stay healthy. Symptoms during the recovery phase
can vary. Some people find their appetite returns to normal
immediately, while others need to begin by drinking clear liquids
and then move slowly to solid food.
People whose episodes are frequent and long-lasting may be treated
during the symptom-free intervals in an effort to prevent or ease
future episodes. Medications that help people with migraine
headaches, such as propranolol (Inderal), cyproheptadine (Periactin),
and amitriptyline (Elavil), are sometimes used during this phase,
but they do not work for everyone. Taking the medicine daily for 1
to 2 months may be necessary before one can tell if it helps.
The symptom-free interval phase is a good time to eliminate
anything known to trigger an episode. For example, if episodes are
brought on by stress or excitement, a symptom-free interval phase
is the time to find ways to reduce stress and stay calm. If sinus
problems or allergies cause episodes, those conditions should be
treated.
During an episode, anti-migraine drugs such as sumatriptan (Imitrex)
may be prescribed to stop symptoms of migraine headache. However,
these agents have not been studied for use in children.
What are the complications of CVS?
The severe vomiting that defines CVS is a risk factor for several
complications:
* Dehydration. Vomiting causes the body to lose water quickly.
Dehydration can be severe and should be treated immediately.
* Electrolyte imbalance. Vomiting causes the body to lose
important salts it needs to keep working properly.
* Peptic esophagitis. The esophagus—the tube that connects the
mouth to the stomach—becomes injured from stomach acid moving
through it while vomiting.
* Hematemesis. The esophagus becomes irritated and bleeds, so
blood mixes with vomit.
* Mallory-Weiss tear. The lower end of the esophagus may tear open
or the stomach may bruise from vomiting or retching.
* Tooth decay. The acid in vomit can hurt teeth by corroding tooth
enamel.
Points to Remember
* People with CVS have severe nausea and vomiting that come in
cycles.
* CVS occurs in all age groups.
* Medical researchers believe CVS and migraine headaches are
related.
* CVS has four phases: symptom-free interval phase, prodrome
phase, vomiting phase, and recovery phase.
* Many people can identify a condition or event that triggers an
episode of nausea and vomiting. Infections and emotional stress
are two common triggers.
* The main symptoms of CVS are episodes of nausea and vomiting
that come and go. Vomiting can lead to severe dehydration that can
be life threatening.
* Symptoms of dehydration include thirst, decreased urination,
paleness, exhaustion, and listlessness. A person with any symptoms
of dehydration should see a health care provider immediately.
* The only way a doctor can diagnose CVS is by looking at symptoms
and medical history to rule out any other possible causes for the
nausea and vomiting. Then the doctor must identify a pattern or
cycle to the symptoms.
* Treatment varies by person, but people with CVS generally
improve after learning to control their symptoms. They may also be
given medications that prevent a vomiting episode, stop one in
progress, speed up recovery, or relieve associated symptoms.
* Complications include dehydration, which can be severe;
electrolyte imbalance; peptic esophagitis; hematemesis;
Mallory-Weiss tear; and tooth decay.
Global Health
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