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Cyclic vomiting syndrome is underrecognized: can be partially alleviated.

MONTREAL -- The prolonged arracks of severe nausea, vomiting, and exhaustion characteristic of cyclic vomiting syndrome can sometimes be partially alleviated with prompt antiemetic medication, followed by migraine prophylaxis.

However, because cyclic vomiting syndrome (CVS) is poorly recognized among health care providers, the condition is often not ideally managed or is misdiagnosed altogether, said Dr. Sonny Chong, consultant pediatrician and gastroenterologist at Queen Mary's Hospital in London, and medical advisor to the Cyclic Vomiting Syndrome Association (CVSA).

Dr. Chong presented his audit of CVS in the United Kingdom as a poster at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Better recognition of the disorder by primary care providers is essential for better management, he said.

"Many people don't realize it exists, and consequently it is underdiagnosed because many practitioners don't know where to refer these patients. It starts in school-age children, and both the physical examination and the investigations are usually normal."

"But because the symptoms can go on for a few days, and then patients may be well for weeks between episodes, it is often put down to some viral infection. And if they continue to have recurrent symptoms, it is often be attributed to psycho logical factors," he said in an interview.

Dr. Chong's audit consisted of 106 questionnaires completed by parents of children in the U.K. chapter of the CVSA. The age range of patients was 3-21 years, with a mean age of 8.8 years.

The mean age when symptoms started was 6.9 years; 84% of patients were diagnosed with CVS by their respective doctors, whereas 16% were not diagnosed.

The most frequent symptoms were vomiting (94%), nausea (93%), tiredness (91%), vomiting bile (88.7%), abdominal pain (67%), fever (37%), and headache (36%).

The frequency of episodes over the last 12 months was 0-3 episodes (39%), 4-7 episodes (21%), 8-11 episodes (12%), 12-15 episodes (5%), 16-20 episodes (7%), and more than 20 episodes (16%).

During an episode, vomiting persisted at frequent intervals for hours to 10 days; the most common duration was 1-4 days.

Dr. Chong said 63% of children were completely symptom free between episodes, while the remainder had nausea and abdominal pain, but no vomiting.

"For those who are not completely symptom free between episodes, I suspect that this may be a subgroup who may have some other pathology, like esophagitis, reflux disease, or something else as well," he said.

CVS is a diagnosis of exclusion, and Dr. Chong said he has seen other medical conditions missed because they mimic CVS.

"It is important to exclude relevant medical conditions such as recurrent gastroenteritis; a problem in the bowel, such as malrotation; hydronephrosis due to an obstruction; a neurological condition such as a brain tumor or a space-occupying lesion; and even simple things such a urinary tract infection or allergies," he said.

A useful clue for physicians is that many patients (68%) have a strong family history of migraine, although they themselves infrequently report headache.

Whether the children are too young to identify migraine--or they grow older and then develop migraine--are two areas that need more investigation, he said.

Seventy-three percent of the children reported triggers for their vomiting episodes, such as infections, exhaustion, menstruation, specific foods, or anesthesia. Emotional stress or excitement may also trigger attacks in some patients.

Jodie Jonas, a CVS sufferer and a member of the board of directors for the North American chapter of the CVSA, said emergency room personnel may often be the ones who see cases of CVS, when patients are suffering from dehydration and electrolyte imbalance.

Some unusual behaviors that these patients may exhibit include hypersalivation and refusal to swallow (inhibiting speech), unusual postures as a means of reducing nausea, a state of confusion and exhaustion sometimes referred to as a "conscious coma," or compulsive water drinking in an attempt to alleviate retching and also reduce the acidity of vomit.

Patients need immediate hydration, antiemetics, and pain relief by intravenous drip because a delay could prolong the episode. In addition, they need a dark, quiet place to sleep in between vomiting episodes.

Prophylaxis with antimigraine medication often can reduce the frequency of vomiting episodes: A good way to start is with propranolol (Inderal), a [beta]-blocker. The children with cyclic vomiting who have asthma or who do not tolerate [beta]-blockers are started on an antihistamine such as cyproheptadine (Periactin), or an antidepressant such as amitriptyline, in the U.K. Antiepileptic medication such as carbamazepine is used if there are EEG findings to support a diagnosis of abdominal epilepsy.

During the acute phase, ondansetron (Zofran) is used for 48-72 hours 3-4 times per day, he said.
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Title Annotation:Clinical Rounds
Author:Johnson, Kate
Publication:Pediatric News
Geographic Code:1USA
Date:Apr 1, 2004
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