Diagnostic criteria for cyclic vomiting syndrome

Posted by Doctor Mai Vien Phuong - Department of Medical Examination & Internal Medicine - Vinmec Central Park International General Hospital

Adult cyclic vomiting syndrome (CVS) is a disorder characterized by sudden recurrent episodes of nausea, vomiting, and abdominal pain, separated by different periods of normal health. The aim of this paper is to further characterize the clinical presentation and propose new diagnostic criteria for cyclic vomiting syndrome in the adult population.

Cyclic vomiting syndrome is not as uncommon an adult condition as once thought and is essentially a clinical diagnosis based on “classical” patterned cycles of episodes of vomiting and discrete periods of time with no symptoms. It is now more common in adults than children and is diagnosed in 12% of patients referred for evaluation for nausea and vomiting. When cyclic vomiting episodes come together, often because no specific therapy has been given, the patient's symptoms may begin to resemble gastroparesis, a disorder characterized by Chronic nausea and vomiting are more persistent but often less painful.

Cyclic vomiting syndrome is actually a definitive diagnosis of the "classic" history of this disease. Patients often present with nausea, vomiting, and mid-epigastric abdominal pain with a variable frequency per year. In all the adult manifestations were accompanied by severe mid-epigastric abdominal pain, with or shortly after the onset of nausea and vomiting. This history of mid-epigastric abdominal pain tends to attract the need to rule out other sources as it may resemble an acute abdominal pain.
Diagnostic criteria for cyclic vomiting syndrome based on Rome III include the following list:
Must be at least 3 months, with a chronological start of at least 6 months prior to:
Related vomiting episodes to acute time to onset and lasting <1 week. Three or more discrete episodes in the previous year. No feeling of nausea and vomiting between episodes No any organic cause of vomiting. Supporting Criteria: History or family history of migraine.
These criteria were developed when cyclic vomiting syndrome was predominantly recognized only in children and abdominal pain was not a predictable concomitant feature.

The majority of cyclic vomiting syndrome attacks occur without any warning although in retrospect patients report that as many as 60-80% of vomiting syndrome attacks follow Cycles may be related to trigger mechanisms such as infections (chronic sinusitis and upper respiratory tract infections), psychological stress, emotional stress, physical stress (heavy exercise), lack of sleep, diet (chocolate, cheese), motion sickness, and menstruating. Many patients take hot baths or baths during vomiting and report relief of symptoms and therefore exposure to hot water is said to have a "relaxing effect".

As far as contributing factors or etiological “subgroups” are concerned, approximately 24-70% of patients with cyclic vomiting syndrome report a personal or family history of migraine. In adults, however, the migraine subset accounts for more than 30-40% of the cyclic vomiting syndrome population.
Psychiatric disorders, such as anxiety and depression, are common findings in patients with cyclic vomiting syndrome. Anxiety present in patients with cyclic vomiting syndrome, including panic disorder, has been reported to be the cause of attacks in 66% of cases. Anxiety can also be increased by the burden of illness, anticipation of the next episode of vomiting, or trauma, and experienced before the onset of cyclic vomiting syndrome. Sometimes psychological disturbances in patients with cyclic vomiting syndrome including depression are so dominant that co-management with a psychiatrist may be indicated.

Another identifiable subgroup is that diabetes is increased by 15% in cyclic vomiting syndrome populations compared to about 8% in normal population-based studies. The theory proposed here is that high glucose levels, often in the early stages of diabetes, in the context of genetically predisposed CNS chemoreceptors may induce vomiting cycles. .

Review of the current literature on cyclic vomiting syndrome in adult drug users is 42-53%. The predictable scenario is the typical pattern of daily addictive drug consumption starting in adolescence for recreational use. Cyclical episodes of vomiting do not occur until at least 5 years of chronic daily use. A clinical entity known as drug-induced vomiting syndrome has also been described separately and actually presents clinically as cyclic vomiting syndrome. Drug-induced vomiting syndrome is characterized by chronic drug use, recurrent episodes of nausea, vomiting, abdominal pain, and frequent relief with hot baths.

Adult patients often have symptoms for a long time before being diagnosed. Patients often go undiagnosed for some time due to the lack of recognition of this clinical entity with reports showing a delay in diagnosis of approximately 8-21 years after the onset of symptoms.
Over time without proper specific treatment, cycles of cyclic vomiting syndrome slowly begin to "link together" and become closer together and this can disrupt the expression present and further suggest a “chronic” entity such as gastroparesis. Cyclic vomiting syndrome results in a significant morbidity for patients who lose time at work or school, causing significant disruption in personal and professional life as well as economic burden. economic. Cyclical vomiting syndrome in adults can range from a mild illness with infrequent episodes to a severe debilitating illness requiring multiple emergency department visits (emergency) and frequent hospitalization. These patients often undergo many unnecessary diagnostic tests and procedures without any apparent clinical benefit.

References
Venkatesan T, Prieto T, Barboi A, et al. Autonomic nerve function in adults with cyclic vomiting syndrome: a prospective study. Neurogastroenterol Motil. 2010; 22(12):1303-1307,e339. Sarosiek I, Alvarez A, Zamora A, et al. Etiologies of nausea and vomiting in patients referred to a gastroenterology motility clinic. The El Paso Physician. 2014; 37(2):14-18. Lee LY, Abbott L, Moodie S, Anderson S. Cyclic vomiting syndrome in 28 patients: demographics, features and outcomes. EurJ Gastroenterol Hepatol. 2012; 24(8):939-943 Chad J. Cooper, Richard W. McCallum, Cyclic Vomiting Syndrome: Diagnostic Criteria and Insights into Long Term Treatment Outcomes, Gastrointestinal motility and functional bowel disorders, series
5, Practical gastroenterology • january 2015