Patients with CVS have four essential clinical features:
Three or more recurrent discrete episodes of vomiting that are self-limited
Intervals of normal, baseline health between episodes
Episodes tend to last longer in adults (approx. 3-6d vs 24-48h for children) and with longer intervals of normal health (approx. 3mo vs 2-4w for children).
NOTE: 40-63% of CVS patients have interictal nausea or low-grade daily vomiting
Stereotypical timing of onset, sxs, and duration – there are some common features, but the most important thing is that these elements are fairly consistent for the individual patient
Tends to start in early AM hours (2-7AM)
Lasts hours todays, depending on the person
Commonly with a prodrome of pallor, anorexia, nausea, and/or abdominal pain
Triggers are sometimes identified, including infectious (URI) or psychological (negative OR positive)
And, of course, this is largely a diagnosis of exclusion
Patients have frequently been seen by multiple doctors with an extensive medical work-up yielding little to no explanation for their sxs, as was the case for our patient
There are two set of diagnostic criteria that have been proposed, but for adults we use the 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 sxs can be present between cycles
Criteria should be fulfilled for at least 3mo with symptom onset at least 6mo before diagnosis
Personal or family history of migraine headaches is also a strong supportive criteria
CVS has been linked to migraines, autonomic abnormalities, hypothalamic-pituitary-adrenal activation, mitochondrial dysfunction, menses, and food allergies
CVS has been linked to migraines, autonomic abnormalities, hypothalamic-pituitary-adrenal activation, mitochondrial dysfunction, menses, and food allergies
NO specific therapy has been proven effective for CVS in controlled trials, but several large open-label trials have shown tricyclic antidepressants to be effective empiric treatment.
Low-dose estrogen or progesterone-only birth control pills can be used in females with CVS that occurs at the time of menses, although sometimes birth control pills can exacerbate sxs in CVS patients (like estrogen-associated migraines)
Traditional anti-emetics do not have strong evidence of effectiveness
Children – 9.6yrs at diagnosis, 5.3yrs at onset of sxs
Adults – 41 at diagnosis, 35 at onset of sxs
Cannabinoid hyperemesis syndrome is very similar to CVS and is a relatively new and rare phenomenon that’s still a bit of a mystery
The problem here is that there can be a lot of phenotypic overlap between the two syndromes, so it would be difficult to determine if a patient was suffering from CVS or CHS if they were a cannabis user, and some CVS patients use cannabis to alleviate their daily nausea. Also CVS patients sometimes use hot showers to help with their sxs as well.
BUT if the person abstains from cannabis use for at least 2 weeks and the emesis stops, then you can be more assured that it was CHS vs CVS
