Cyclic vomiting syndrome (CVS) is a condition that involves recurrent episodes of vomiting with three main features: sudden onset, stereotypical (similar episodes), and periods of wellness between episodes. There is not a single test to diagnose cyclic vomiting syndrome; diagnosis is often made by history, physical exam, and tests to exclude other diseases. CVS occurs in about 1 in 33,000 children and can often be so severe it keeps the affected person from participating in daily activities.
There is no known cause for the recurrent symptoms and the episodes can last from several hours to a few days. Studies have indicated that cyclic vomiting syndrome is strongly linked to migraines. Theoretical causes include dysautonomia, specific mitochondrial DNA mutations, and heightened stress response that activates the vomiting response system.
Symptoms include vomiting episodes that recur in a cyclical pattern (for example every two weeks or once a month). The vomiting episodes start suddenly, typically with nausea, and progresses to vomiting later. The episodes can sometimes wake the affected person from sleep.
The episodes are “stereotypical” which means that each episode resembles previous episodes. Other symptoms can include stomach pain, diarrhea and headache. The vomiting “attacks” can become so severe that patients become dehydrated and require medical attention in the emergency room.
In between episodes, patients feel completely well. Once an episode resolves, affected children often feel normal within hours.
Many children with CVS also have a diagnosis of migraines or a family history of migraines.
Other causes of recurrent vomiting include:
The diagnosis of CVS is based mostly on the history and symptoms presented. Physicians may often perform tests to exclude other conditions. These may include:
- Upper GI. A patient swallows a contrast agent and a series of X-rays are performed to evaluate the esophagus, stomach, and a portion of the small intestine. Used to evaluate for an abnormal twisting of the intestine called a malrotation.
- Abdominal ultrasound. A diagnostic imaging technique which creates images from the rebound of high-frequency sound waves in the internal organs. Used to evaluate potential diseases in the kidneys or gallbladder.
- MRI of the brain. Magnetic resonance imaging (MRI) is an imaging procedure that uses a powerful magnet, radiofrequencies, and a computer to produce detailed images of the brain. This is to exclude possible neurologic causes of vomiting.
- Blood tests. These tests may be done during an episode to evaluate for infection, inflammation of the pancreas, and metabolic enzyme problems.
- Endoscopy. A test that uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of the digestive tract. Tissue samples from inside may also be taken for examination and testing.
- Abortive therapies (therapies that stop the episode once it starts)
- Anti-nausea medications Anti-anxiety medications
- Anti-migraine treatments
- Prophylactic therapy (daily medication to prevent episodes). These treatments are similar to treatments for migraines. Sometimes anticonvulsants are prescribed.
Some patients may have cyclic vomiting episodes triggered by psychological stress — these can be negative stressors (such as taking a test) or positive (such as vacation or holidays). Additionally, CVS is a stressful illness. Therefore, many patients benefit from counseling to promote relaxation.
Once patients are properly diagnosed and treated, most improve. Additionally, many children “outgrow” the diagnosis before adulthood.
The Suzi and Scott Lustgarten Center for GI Motility has a dedicated group of physicians that treat CVS and work closely with the Division of Neurology and other specialties for a multidisciplinary approach.