Cyclic Vomiting Syndrome in 41 adults: the illness, the patients, and problems of management

Abstract

Background: Cyclic Vomiting Syndrome (CVS) is a disorder characterized by recurrent, stereotypic episodes of incapacitating nausea, vomiting and other symptoms, separated by intervals of comparative wellness. This report describes the clinical features, co-morbidities and problems encountered in management of 41 adult patients who met the diagnostic criteria for CVS.

Methods: This is a retrospective study of adults with CVS seen between 1994 and 2003. Follow-up data were obtained by mailed questionnaires.

Results: Age of onset ranged from 2 to 49 years. The duration of CVS at the time of consultation ranged from less than 1 year to 49 years. CVS episodes were stereotypic in respect of their hours of onset, symptomatology and length. Ninety-three percent of patients had recognizable prodromes. Half of the patients experienced a constellation of symptoms consisting of CVS episodes, migraine diathesis, inter-episodic dyspeptic nausea and a history of panic attacks. Deterioration in the course of CVS is indicated by coalescence of episodes in time. The prognosis of CVS is favorable in the majority of patients.

Conclusion: CVS is a disabling disorder affecting adults as well as children. Because its occurrence in adults is little known, patients experience delayed or mis-diagnosis and ineffectual, sometimes inappropriately invasive management.

Figure 1

Schematic representation of the four phases of Cyclic Vomiting Syndrome and their therapeutic goals.

Figure 2

Duration of typical cyclic vomiting episodes in 39 patients.

Figure 3

The ranges of times of onset of cyclic vomiting episodes in 29 adults who reported typical hours of onset. Morning hours predominate.

Figure 4

Panic symptoms in 21 men and 7 women during prodromal and emetic phases of cyclic vomiting episodes. The abrupt onset of intense fear or discomfort reaching a peak within 10 minutes, accompanied by four or more of the 13 symptoms listed on the left, are the diagnostic criteria for panic attacks [35].

Figure 5

Twenty six CVS patients (63%) experienced dyspeptic nausea between episodes. Dyspeptic patients were more likely to have migraine diathesis and/or a history of panic attacks. Almost two-thirds of dyspeptic CVS patients had both migraine and panic.

Figure 6

Comparison of the cumulative duration of cyclic vomiting episodes per year at the time of the initial consultation and at the time of follow-up in 29 patients. Data points are the products of the estimated number of episodes per year multiplied by the average duration of episodes and are expressed as 24-hour units of time. The intervals between initial consultations and follow-up ranged from 1 to 10 years and averaged 3.8 years.