Cyclic Vomiting Syndrome

Cyclic Vomiting Syndrome is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • An idiopathic chronic functional GI disorder characterized by discrete, recurrent, stereotypical episodes of high-intensity nausea and vomiting lasting hours to days, separated by symptom-free intervals
  • Subsets
    • Cyclic vomiting syndrome (CVS) plus two or more neuromuscular disorders in association
    • Catamenial CVS: associated with menstrual cycle
  • CVS has four distinct phases:
    • Interepisodic: symptom-free period
    • Prodromal: often marked by nausea with or without abdominal pain; able to take oral medications; minutes to hours
    • Vomiting: nausea, vomiting, and retching
    • Recovery: Nausea remits and patient recovers appetite, strength, and energy (1)[B].

Epidemiology

Prevalence
  • 0.04–2% in general population
  • Whites affected more than other races
  • Predominant sex: female > male (55:45)
  • More common in children; mean age of diagnosis is 5 years in children and 35 years in adults.
  • Average of 3 years from symptom onset to diagnosis

Etiology and Pathophysiology

  • Strong link between CVS and migraine, with similar symptoms, frequent family history of migraines, and effectiveness of antimigraine therapy
  • Unknown etiology. One proposed mechanism:
    • Heightened neuronal excitability owing to enhanced ion permeability, mitochondrial deficits, or hormonal state → increased susceptibility to physical or psychological trigger → release of corticotropin-releasing factor (CRF) → vomiting
    • Vomiting perpetuated by altered brainstem regulation → sustained vomiting
  • Possible maternal inheritance, based on family history of migraines and link to mitochondrial DNA (mtDNA) mutations (2)[B]
  • Multiple theories:
    • GI motility dysfunction
    • Autonomic dysfunction: sympathetic (1)[B]
    • Food allergy or intolerance

Genetics
  • Likely matrilineal inheritance, especially with childhood onset
  • A3243G or other mtDNA mutations including mitochondrial dysfunction (2)[B]
  • Ion channel mutations

Risk Factors

  • Family history of migraine headaches
  • Depression and/or anxiety
  • Chronic cannabis use
  • Possibly food allergies or hypothalamic-pituitary-adrenal axis dysfunction

Commonly Associated Conditions

  • Irritable bowel syndrome (67%)
  • Headaches (52%)
  • Motion sickness (46%)
  • Migraines (11–40%)
  • Seizure disorder (5.6%)

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