Cyclic Vomiting Syndrome – an overview
written by: Ramón Tormo Carnicé MD
According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIH), Cyclic vomiting syndrome, or CVS, can be defined as a functional gastrointestinal (GI) disorder that causes sudden, repeated attacks -called episodes- of severe nausea and vomiting. Episodes can last from a few hours to several days. The episodes are separated by periods without nausea or vomiting. The time between episodes can be a few weeks to several months. Episodes can happen regularly or at random. Episodes can be so severe that you may have to stay in bed for days, unable to go to school or work. You may need treatment at an emergency room or a hospital during episodes. Cyclic vomiting syndrome can affect you for years or decades.
Nausea and vomiting disappears within a few days of onset. They tend to distress the sick and their families, make it impossible to plan events with the patient for fear of future crisis, and on many occasions causes anxiety and panic, especially in adults, aggravated by the general and habitual ignorance by a large part of the health class of this rare disease that ends up subjecting the patient to the repetition of useless explorations.
It can appear and persist from a few years of life until adulthood; it can also disappear at a certain age.
It usually takes place in 4 phases:
- A first phase, free of episodes, sometimes suffering from migraine.
- A second prodromal phase, in which the patient begins to feel some signs, may last minutes or days; it may retain oral medication.
- A third phase with intense nausea and vomiting, with possible complications due to loss of fluids, glucose, electrolytes.
- A fourth recovery phase, more or less rapid, after which the patient will be free of symptoms, until a new crisis begins within weeks or months.
The mysterious illness that accompanied for 50 years the life of Charles Darwin, father of evolutionary biology, could finally have a name and surname. According to John Hayman, associate professor at Monash University in Australia, it’s called Cyclic Vomiting Syndrome. Everything for the English naturalist began days before he set sail aboard the mythical ship HMS Beagle. It was 1831 and he was already suffering from frequent episodes of vomiting.
The aetiology is not known; it has been suggested that it appears by the release by the hypothalamus of Corticotropin releasing factor, which activates the Locus Ceruleus and induces an increase in the adrenergic tone that stimulates the inhibiting fibres of the Dorsal Motor Nucleus of the Vago; this produces the suppression of gastric motility and as a consequence nausea and vomiting.
Before putting the diagnosis of CVS, other diseases and conditions must be ruled out: Gastroeophageal reflux, hiatal hernia, oesophageal malformations, gastric problems, food allergies and intolerances, liver and pancreatic diseases, metabolic diseases, nervous system diseases, urinary tract diseases, endocrine diseases
The frequence of this disease is difficult to say; the current figure can reach a 3 out of 100,000 people.
Other conditions are found in these patients like, migraines or a family history of migraines, -anxiety and depression, gastroparesis, autonomic nervous, system disorders, high blood pressure, gastroesophageal reflux disease, irritable bowel syndrome.
Due to the intensity and the repetition of vòmits in a short period of time, this syndrome can be the cause of: dehydration, esophagitis, esophageal stenosis, Mallory-Weiss tears, tooth decay or damage to tooth enamel, alkalosis, low iron anemia (1)
It is very diverse and should be established by the treating physician specializing in gastroenterology and nutrition or neurology.
I will mention some of the treatments that can be effective and the diet that I recommend, but I repeat both the treatment and the diet must be established by the treating doctor.
First of all, in the initial prodromal phase, the sick person should rest in a quiet room; sedatives may be used and he should try to sleep (2)
When the second phase or prodromal appears, zofran or ondansetron sublingual can be used at a dose of 4 or 8 mg, depending on weight and age, which can be repeated throughout the day. Ondansetron is an inhibitor of the 5-HT 3 receptor.
Ondansetron can also be used (Setofilm) as an adhesive patch impregnated with 4 to 8 mg of the product.
This authors recommend it as a treatment in different phases and with different doses of amitrypteline, as preventive or as treatment
Another treatment protocol would be a combination of products, including Amitriptyline:
administration of cofactors directed at mitochondria (co-enzyme Q 10 and L-carnitine) together with Amitriptyline or Cyproheptadine in preschoolers under 5 years of age (according to the North American Society for Pediatric Gastroenterology, Hepatology and Nutritin, NASPGHAN), in addition to avoiding fasting and monitoring blood levels.
The protocol is based:
- In taking three normal meals, and also 3 snacks. Avoiding fasting or at least reducing them to the maximum.
- Administration of Coenzyme Q 10 (Ubiquinone) in liquid form or in capsules containing gel, at the initial dose of 10 mg per Kg and day or 200 mg twice a day.
- L- Carnitine: administer the brand name CARNICOR or a generic at the initial dose of 100 mg per kg per day, or 2 g per day, depending on weight without exceeding this dose. If untreated blood levels of carnitine are greater than 30 micromoles, they should not receive carnitine.
- Amitriptyline, over 5 years, dose 0.5 mg per day, to be administered at night. An electrocardiogram should be done before starting this medication and repeat it after several weeks of treatment, assessing the QTc interval.
- Cyproheptadine; to be administered instead of the latter, below the age of 5 years at a dose of 0.25 mg/kg and a day divided into two times.
- Do not exceed the blood levels of 3 mg/l of Co-enzyme Q10.
- L-carnitine: free carnitine in blood: not above 40 micromoles
- Amitriptyline*: amitriptyline + nortriptyline blood levels not exceeding 150 ng/ml
In children refractory to ciates treatments, Dr. Richard G Boles recommends administration of Topiramate 25 mg twice daily (3) It is difficult to know until trying to which medicine each patient will respond well.
Diet can play an important role in the treatment of CVS, according the results in 21 children affected by CVS, on the favourable effect of a special diet. (4) The authors considered that this syndrome is like a variant of migraine in children, due to a disorder of the brain-intestine axis.The authors said that migraine/jaqueca, is associated with the intake of foods such as cheese, chocolate, citrus, caffeine, yeast extract, pork, peas, dried beans, game, seafood, beef, meat sauces, caffeine, cola drinks and alcohol. Many of these foods are rich in histamine, so it may justify the study of the enzyme DIAMINO-OXIDASA in these patients.
These 21 children affected by CVC were subjected to a diet without these foods and also low in protein (LAC). Of the 21 children studied, 18 had a complete remission of vomiting, two continued with abdominal pain, and one later had a migraine.
Based on this work by Siba Prosad Paul et al, and lacking another proven explanation of the aetiology of CVS, we consider that patients affected by CVS would behave as heterozygote of urea cycle disorder affecting protein metabolism or heterozygote of fat oxidation disorders. For this reason and following in part the work of Siba Prosad Paul, to my patients I apply a diet low in fat and low in protein, which I expose below:
LOW-FAT, LOW-PROTEIN DIET
BREAKFAST: Low-fat, semi-skimmed milk…200ml or 250ml, plus normal bread with ham or serrano, about 20 gr, without fat, or cereals without fat or chocolate type Corn Flakes, or Rice Krispis simple (simple cereals), or Special K, or Simple biscuits, low fat.
HALF MORNING: a skimmed yogurt and/or bread with about 10- 20 gr of fat-free cheese or fruit
MIDDLE MEAL: First course: Potatoes, vegetables, legumes, pastas (noodles, macaroni, spaghetti… with a minimum of sautéed onion, tomato or some oil, no garlic…or rice all boiled, without fat or oil or butter (as rice has arsenic, although in small quantity, if taken more than twice a week, you have to wash it, put it to boil with plenty of water about 7′ or more, discard that water and pass, to another container with clean boiling water and finish there boiling; this culinary practice applied by the Chinese for 3,000 years) … or vegetable broths without fat, with them to make soups of bread or pasta.
SECOND COURSE: All types of grilled meat except lamb and pork, but only 50 gr.. or grilled white fish, only 50 gr. of blue fish once every 15 days.
AT TEA TIME: a skimmed yogurt and/or bread with about 10- 20 gr. of fat-free cheese or a fruit or a few fat-free biscuits.
DINNER: similar to midday, but instead of meat or fish take up to 3 eggs per week without oil or a minimum. Two days white fish, 50 gr,
Fruit dessert or a lactic dessert such as flan or low-fat custard
It is possible to descend to the contribution of meat or fish depending on the age.
AT ANYTIME: Low-fat milk and low-fat biscuits, fresh defatted cheese, flam, custard, rice pudding, bread with de-fatted ham, low-fat yogurt,
Absolutely no sausages or foods like hamburgers with a lot of fat or that can soak up fat or oil such as meat balls. Do not give, or a little, oily fish or seafood.
In adults, no alcohol, no tobacco and little coffee.
Some people induced by chinese medicine are in favor of acupuncture chinese medicine
Stimulation of the acupuncture point: no more vomiting:
The Association No More Vomits proposes a complementary and/or alternative therapy that consists in the stimulation of the acupuncture point 6 Master of Heart, located in the forearm, by means of the topical application of silicon discs, using hypoallergenic paper tape for its fixation in the skin. In this way, they assure, a balance of the energetic circulation in the body is achieved, making unpleasant episodes of nausea and/or vomiting disappear.
They claim that it is a 100% natural therapy to prevent and treat nausea and vomiting from dizziness during travel, vertigo, pregnancy, anaesthesia, chemotherapy and cyclic vomiting syndrome.
According our results, on occasion it seems to have helped some sick people. If any reader is interested please contact them (5).
- Bhandari S, Venkatesan T. Clinical characteristics, comorbidities and hospital outcomes in hospitalizations with cyclic vomiting syndrome: a nationwide analysis. Digestive Diseases and Sciences. 2017;62(8):2035–2044.
- Proceedimngs of the 46 Annual Meeting, London, European Society for Paediatric Gasstroenterology, Hepatology and Nutrition (ESPGHAN), AUTHORS: Cristofori F, Kumaraguru N, Saliakiellis E et als. Department of Gastroenterology, Great Ormond Street Hospital, London).
- Richard G Boles1,2 1 Division of Medical Genetics and the Saban Research Institute, Childrens Hospital Los Angeles, California, USA 2 Department of Pediatrics, Keck School of Medicine at the University of Southern California, Los Angeles, California, USA. BMC Neurology 2011, 11:102doi:10.1186/1471-2377-11-102).
- Antimigraine (Low-Amine) Diet May Be Helpful in Children With Cyclic Vomiting Syndrome. Paul, Siba Prosad*; Barnard, Penny†; Soondrum, Krishna*; Candy, David C.A.*Journal of Pediatric Gastroenterology and Nutrition: May 2012 – Volume 54 – Issue 5 – p 698–699.
- Alternative treatment for cyclic vomiting síndrome.:. email@example.com.