This document summarizes a presentation on Cyclic Vomiting Syndrome (CVS). It discusses the clinical manifestations of CVS including stereotypical vomiting episodes, intervals of good health between episodes, and absence of an organic cause. It outlines the diagnostic criteria per Rome IV as having stereotypical episodes of vomiting at least 3 times in the past year, with varying intervals of good health in between. The pathogenesis of CVS is unknown but has been associated with migraines. Treatment involves abortive medications like sumatriptan for mild episodes and prophylactic tricyclic antidepressants for more frequent/severe episodes. An illness script compares CVS to Cannabinoid Hyperemesis Syndrome.

1. Noon Conference
Jessica Rakonza
4/23/2019

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Objectives
Cyclic Vomiting Syndrome
• Clinical manifestations
• Diagnostic criteria
• Pathogenesis
• Treatment
• Review illness script

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Clinical Manifestations
• Four essential clinical features:
– Three or more recurrent discrete episodes of vomiting
» Self-limited
– Varying intervals of baseline health between episodes
– Stereotypical timing of onset, symptoms, and duration
» Stereotypical for the patient
» Tend to start in early AM hours – starts acutely
» Last the same duration each time – hours to days
» Prodrome of pallor, anorexia, nausea, abdominal
pain
– The absence of an organic cause of vomiting
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Diagnostic Criteria
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• Rome IV Criteria:
– Stereotypical episodes of vomiting regarding onset
(acute) and duration (less than one week)
– Three or more discrete episodes in the prior year, and
two episodes in the past six months, occurring at least
one week apart
– Absence of vomiting between episodes, but other
milder symptoms can be present between cycles
– Varying intervals of baseline health between episodes
• Criteria should be fulfilled for at least 3mo with
symptom onset at least 6mo before diagnosis

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With which of these physiologic
processes has CVS been associated?
a. Hypothalamic-pituitary-adrenal
activation
b. Migraines
c. Mitochondrial dysfunction
d. Menses
e. All of the above
f. None of the above
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Pathogenesis
UNKNOWN!
• An association between CVS and
migraines has most consistently been
described
• CVS often progresses to a migraine HA
• Many patients have a strong family history
of migraines
• CVS often responds to antimigraine therapy
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Treatment
• Choice of abortive vs prophylactic
medications depends on the frequency
and severity of the attacks, similar to the
treatment of migraines
• If occurring every 1-2mo and are mild, can
try abortive therapy
• If occurring more frequently and/or are
more severe than this, consider prophylactic
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Treatment
• Abortive – Sumatriptan, ketorolac,
prochlorperazine, and tricyclic
antidepressants
• Prophylactic – Amitriptyline, notrtiptyline,
doxepin
Unfortunately, once vomiting begins, the
episode typically cannot be aborted and
must run its usual course.
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Illness Script
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Cyclic Vomiting Syndrome
Cannabinoid Hyperemesis
Syndrome
Pathophysiology UNKNOWN UNKNOWN
Epidemiology
More common in children (1.9-2.3% prevalence),
but being diagnosed more frequently in adults
Daily cannabis users, usually for at least 1 year
Time course Adults – episodes every 3mo, lasting 3-6 days
Sxs resolve within 1-2d of cessation of cannabis
use
Clinical
presentation
Episodes of spontaneous, intractable
vomiting and abdominal pain with intervals of
normal health in between
Episodic severe n/v and abdominal pain
relieved by exposure to hot water
Diagnostics ROME IV Criteria Clinical
Therapeutics
Abortive – sumatriptan, ketorolac,
prochlorperazine, TC antidepressants
Prophylactic – TC antidepressants
Topical capsaicin?