David R. Fleisher

Cyclic vomiting syndrome in adults

Abstract  Cyclic vomiting syndrome (CVS) was initially described in children but can occur in all age groups. Cyclic vomiting syndrome is increasingly recognized in adults. However, the lack of awareness of CVS in adults has led to small numbers of diagnosed patients and a paucity of published data on the causes, diagnosis and management of CVS in adults. This article is a state‐of‐knowledge overview on CVS in adults and is intended to provide a framework for management and further investigations into CVS in adults.

Cyclic Vomiting Syndrome in 41 adults: the illness, the patients, and problems of management

BackgroundCyclic Vomiting Syndrome (CVS) is a disorder characterized by recurrent, stereotypic episodes of incapacitating nausea, vomiting and other symptoms, separated by intervals of comparative wellness. This report describes the clinical features, co-morbidities and problems encountered in management of 41 adult patients who met the diagnostic criteria for CVS.MethodsThis is a retrospective study of adults with CVS seen between 1994 and 2003. Follow-up data were obtained by mailed questionnaires.ResultsAge of onset ranged from 2 to 49 years. The duration of CVS at the time of consultation ranged from less than 1 year to 49 years. CVS episodes were stereotypic in respect of their hours of onset, symptomatology and length. Ninety-three percent of patients had recognizable prodromes. Half of the patients experienced a constellation of symptoms consisting of CVS episodes, migraine diathesis, inter-episodic dyspeptic nausea and a history of panic attacks. Deterioration in the course of CVS is indicated by coalescence of episodes in time. The prognosis of CVS is favorable in the majority of patients.ConclusionCVS is a disabling disorder affecting adults as well as children. Because its occurrence in adults is little known, patients experience delayed or mis-diagnosis and ineffectual, sometimes inappropriately invasive management.

The Cyclic Vomiting Syndrome: A Report of 71 Cases and Literature Review

This study reviews 71 patients who presented between 1968 and 1988 with recurrent, self-limited episodes of nausea and vomiting separated by symptom-free intervals and were diagnosed with cyclic vomiting syndrome (CVS). The length and symptomatology of episodes tended to be stereotyped and characteristic for each patient over time. The disorder may persist from months to decades. There is a coincident relationship between CVS, migraine, and irritable bowel syndrome. The differential diagnosis includes many diseases which may mimic CVS. Management involves a responsive, collaborative doctor-patient relationship, sensitivity to stresses caused by the illness and to feelings and attitudes that may predispose to attacks, use of antiemetic agents to abort or shorten attacks, treatment of complications, and use of prophylactic agents in patients whose episodes are of sufficient frequency and severity to warrant their trial.

Cyclic Vomiting Syndrome: What a Gastroenterologist Needs to Know

BACKGROUND:CVS (cyclic vomiting syndrome) is a functional disorder that may occur in any age group of patients. In the past the disorder was considered to be fairly uncommon of unknown etiology. Treatment has generally been based on anecdotal reports.METHODS:Literature review was performed based on internet/Medline search as of April 2006.RESULTS:CVS is much more common than previously thought, especially in adults and is commonly associated with migraine headaches and sharing many of its characteristic features. Genetic association with mitochondrial DNA has been recognized with CVS. Prompt diagnosis is essential in order to prevent the significant morbidity associated with CVS. It is mandatory to rule out certain life-threatening disorders that can mimic CVS. Treatment options are based on the particular phase of the syndrome in which a patient is in and carried out in a systematic manner.CONCLUSION:Expert consensus is that CVS is a distinct disorder and is a part of the migraine spectrum (migraine headaches, CVS, and abdominal migraines). Once patients are properly diagnosed, treatment is highly effective. Because of renewed interest in CVS since the 1990s, many more patients in all age groups are being recognized who suffer from this disabling disorder. An increase in basic science and clinical research in CVS will hopefully lead to better patient outcomes.

The cyclic vomiting syndrome described

Summary: Cyclic vomiting syndrome (CVS) consists of discrete episodes of nausea and vomiting lasting hours or days, separated by symptom‐free intervals of similar or varying lengths. The disorder is not caused by underlying organic disease. The episodes tend to be similar in time of onset, duration, and symptomatology specific for each patient and are self‐limited. The majority of patients can identify experiences or conditions that may precipitate episodes, the commonest being heightened emotional states and infections. The onset of CVS most often occurs during preschool or early school years, although it may begin at any age, from infancy to mature adulthood. CVS episodes can recur for months or decades, and their subsidence cannot be predicted.

Management of cyclic vomiting syndrome.

Summary: The general goals of treatment of cyclic vomiting syndrome (CVS) are: interruption of established episodes, amelioration of symptoms in patients whose episodes cannot be interrupted, aborting episodes during prodromal symptoms, prophylaxis to abolish or lessen the frequency of episodes, and recovery. Complications of cyclic vomiting episodes include esophagitis, hematemesis, depletion of intracellular electrolytes, hypertension, and secretion of inappropriate antidiuretic hormone.

Adenoviral transduction of enterocytes and M-cells using in vitro models based on Caco-2 cells: the coxsackievirus and adenovirus receptor (CAR) mediates both apical and basolateral transduction.

Understanding virus-cell interaction is a key to the design of successful gene delivery vectors. In the present study we investigated Ad5 transduction of enterocytes and M-cells utilizing differentiated Caco-2 cells and cocultures of Caco-2 cells with lymphocytes. Transduction inhibition studies showed that CAR is the major receptor mediating apical and basolateral virus entry in differentiated Caco-2 cells. Integrins and heparan sulfate glycosaminoglycans do not appear to play a significant role. Immunofluorescence localized CAR to sites of cell-cell contact, with staining mostly observed on the cell perimeter. Staining was observed even in nonpermeabilized monolayers, suggesting apical accessibility of the receptor. Cocultures with mouse Peyers patch lymphocytes or Raji B human lymphocytes were more susceptible to transduction than Caco-2 cells, and the effects were dose-dependent. Similar to Caco-2 cells, CAR and not integrins mediated apical transduction. In conclusion, contrary to other epithelial cell lines, both apical and basolateral transduction of absorptive enterocytes and M-cells is mediated by binding to CAR. The coculture system can be used to study the interactions between M-cells and gene delivery vectors.

Anticipatory nausea in cyclical vomiting.

BackgroundCyclical Vomiting Syndrome (CVS) is characterised by discrete, unexplained episodes of intense nausea and vomiting, and mainly affects children and adolescents. Comprehending Cyclical Vomiting Syndrome requires awareness of the severity of nausea experienced by patients. As a subjective symptom, nausea is easily overlooked, yet is the most distressing symptom for patients and causes many behavioural changes during attacks.Case presentationThis first-hand account of one patients experience of Cyclical Vomiting Syndrome shows how severe nausea contributed to the development of anticipatory nausea and vomiting (ANV), a conditioned response frequently observed in chemotherapy patients. This conditioning apparently worsened the course of the patients disease. Anticipatory nausea and vomiting has not previously been recognised in Cyclical Vomiting Syndrome, however predictors of its occurrence in oncology patients indicate that it could complicate many cases.ConclusionWe suggest a model whereby untreated severe and prolonged nausea provokes anxiety about further cyclical vomiting attacks. This anxiety facilitates conditioning, thus increasing the range of triggers in a self-perpetuating manner. Effective management of the nausea-anxiety feedback loop can reduce the likelihood of anticipatory nausea and vomiting developing in other patients.

Pediatric Functional Gastrointestinal Disorders

Many of the childhood functional gastrointestinal disorders are extremely common. Using symptom-based diagnostic criteria for pediatric functional gastrointestinal disorders will improve patient care, enhance family satisfaction, and reduce costs. Using symptom-based diagnoses, the emphasis shifts from evaluations to rule out rare diseases to family education and symptom management. Well-meaning clinicians may co-create disability by failure to recognize and appropriately manage functional pediatric gastrointestinal disorders.

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

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.