Diagnosis of cyclic vomiting syndrome and related diseases

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

Alternating presentation of disease and disease-free phase distinguishes cyclic vomiting syndrome (CVS) from other nausea and vomiting disorders. This pathology is increasingly recognized in adults and leads to significant morbidity and poor quality of life. Recent referral models suggest prevalence up to 0.2% in the adult population and an explanation for nausea and vomiting in 12% of the referral population to a teaching academic center . In this article, we discuss the diagnostic criteria of this pathology.

Cyclic vomiting syndrome is not as uncommon an adult condition as once thought and is essentially a clinical diagnosis based on the “classic” patterned cycles 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 is given, a patient's symptoms can begin to resemble gastroparesis, a disorder characterized by Chronic nausea and vomiting are more persistent but usually less painful.
However, a small number of patients with diabetic gastroparesis may have recurrent “cycles” superimposed on this chronic disease and this is for example when distinguishing from vomiting syndrome by cycle becomes very difficult. In general, epigastric pain is a more common complaint in patients with cyclic vomiting syndrome, which is not common in gastroparesis. However, rapid or normal gastric emptying in cyclic vomiting syndrome may be the final "binding factor" that distinguishes it from delayed gastric emptying in gastritis.

In the authors' experience at a center specializing in the treatment of gastrointestinal disorders, we recently reviewed a total of 48 patients diagnosed with cyclic vomiting syndrome, 37 female and 11 male with a mean age of 34.8 years. Most patients report episodes of illness occurring in cycles about every 2-3 months. Five (10%) patients experienced relief of symptoms with hot baths or showers and 11 (23%) had relief of symptoms with stress, menstruation or insomnia.
Comorbidities include diabetes (31%), hypertension (23%), hyperlipidemia (15%), anxiety (48%), depression (25%), migraine (40) %), family history of headache/migraine (31%), panic disorder (11%), and chronic daily substance use (23%) for more than 5 years. 11 (23%) of the patients were smokers, 7 (15%) had a history of alcohol use and 15 (33). 3%) were given drugs at some point during their clinical visit. Six (20%) patients reported significant disruption in their professional and/or personal social life. Fifteen (19%) patients underwent cholecystectomy. 25 (52%) visited the emergency department regularly before being diagnosed and treated.
>> See also: Cyclical vomiting syndrome - Article by Doctor Mai Vien Phuong - Department of Medical Examination & Internal Medicine - Vinmec Central Park International General Hospital

Although cyclic vomiting syndrome is increasingly recognized in adults, there is a lack of data on gastric emptying patterns (gastric emptying capacity). Using standard 4-hour spheroscopy, normal gastric emptying was defined as <90% retention at 1 hour, <60% at 2 hours, and <10% at 4 hours. Rapid gastric emptying was defined as isotope retention <35% at the first hour and/or <20% at the second. Intragastric delay was defined as a delay greater than 90% at 1 hour, 60% at 2 hours, and 10% at 4 hours based on established normal data for gastric emptying capacity. this standard.
Using these criteria for rapid gastric emptying, we found that 30% met these criteria while 70% had a normal S gastric emptying capacity. Testing for gastric emptying is performed during the remission phase of cyclic vomiting syndrome. Delayed gastric emptying was not identified. Our group also published the criteria for rapid gastric emptying as isotope retention rate <50% at 1 hour and the majority of our adult patients (65%) with the following vomiting syndrome. cycle has a rapid gastric emptying capacity and 35% has a normal gastric emptying capacity.
Thus, rapid or normal gastric emptying can be used as confirmatory evidence of cyclic vomiting syndrome so that the clinician can confidently rule out the difference between gastroparesis thick. Gastric emptying studies should be performed during the remission period when there are few or no symptoms and no anesthetic is used. Gastric emptying studies while in hospital are not recommended. Narcotic drugs inhibit gastric emptying thereby producing delayed gastric emptying resulting in these patients being mislabeled as having gastroparesis. In addition, previous use of narcotics may delay gastric emptying. An interpretation of the role of rapid gastric emptying during non-vomiting has led to speculation and support for underlying autonomic dysfunction in these patients as well as evidence of hypergrelinemia. Bar is another factor in accelerating gastric emptying.

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. Pareek N, Fleisher D, Abell T. Cyclic vomiting syndrome: what a gastroenterologist needs to know. AmJ Gastroenterol. 2007; 102(12):2832-2840. Duckett A, Pride P. Cyclic vomiting syndrome in an adult patient. J Hosp Med. 2010; 5(4):251–252. 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