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EPA Curricular Resources https://www.naspghan.org/content/133/en/training/opportunities/curricular-resources# Common outpatient GI Problems Vomiting (including cyclic vomiting) NASPGHAN Guidelines/Position Statements NASPGHAN Consensus Statement on Evaluation and Management of Cyclic Vomiting in Pediatric Patients Additional Publications/ Podcasts/ Slide Sets Cyclic Vomiting Syndrome Association Empiric Treatment Guidelines Other Resources International Foundation for Functional Gastrointestinal Disorders Common Questions about CVS Vomiting and Nausea Chapter 8. Wyllie, Hyams, and Kay. Pediatric Gastrointestinal and Liver Disease. 5th edition. 2015. Gastroesophageal Reflux Sentinel Articles Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Van der Pol, R. J., Smits, M. J., van Wijk, M. P., Omari, T. I., Tabbers, M. M., & Benninga, M. A. (2011) NASPGHAN Guidelines/ Position Statements Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of NASPGHAN and ESPGHAN. Journal of pediatric gastroenterology and nutrition 49.4 (2009): 498-547 Evidence-based guidelines from ESPGHAN and NASPGHAN for Helicobacter pylori infection in children. Journal of pediatric gastroenterology and nutrition53.2 (2011): 230-243. Pediatric Gastroesophageal Reflux Clinical Practice Guideines A Global, Evidence-based Consensus on the Definition of Gastroesophageal Reflux Disease in the Pediatric Population Additional Guidelines/Position Statements Gastroesophageal Reflux: Management Guidance for the Pediatrician. Lightdale, J. R., Gremse, D. A., Heitlinger, L. A., Cabana, M., Gilger, M. A., Gugig, R., & Hill, I. D. (2013) Pediatrics, 131(5), e1684-e1695. American Gastroenterological Association – Medical Position Statement on Gastroesophageal Reflux – Gastroenterology 2008. America Gastroenterological Association – Technical Review on Gastroesophageal Reflux – Gastroenterology 2008 Additional Publications/Podcasts/Slide Sets NASPGHAN GER Slide Set NASPGHAN PPI Use Slide Set NASPGHAN Resident Teaching Slide Sets - Reflux Other Resources Reflux & GERD Gastroesophageal Relux Chapter 21. Wyllie, Hyams, and Kay. Pediatric Gastrointestinal and Liver Disease. 5th edition. 2015 Diarrhea Sentinel Articles The management of acute diarrhea in children in developed and developing areas: from evidence base to clinical practice. Expert opinion on pharmacotherapy, 13(1), 17-26. Probiotics for treatment of acute diarrhea in children: randomized clinical trial of five different preparations PMID 17690340 Universal recommendations for the management of acute diarrhea in non-malnourished children NASPGHAN Guidelines/Position Statements Clinical Efficacy of Probiotics 2009 ESPGHAN Guidelines for Management of Acute Gastroenteritis in Children in Europe: Update in 2014 ESPGHAN Guidelines for Management of Acute Gastroenteritis in Children in Europe 2008 Additional Guidelines/Position Statements AGA technical review on the evaluation and management of chronic diarrhea Fine KD, Schiller LR. Gastroenterol.1999;116(6):1464–1486 Additional Publications/Podcasts/Slide Sets NASPGHAN Carbohydrate Induced Diarrhea Slide Set NASPGHAN Resident Teaching Slide Set – Acute Diarrhea NASPGHAN Resident Teaching Slide Set – Chronic Diarrhea Other Resources IFFGD Fact Sheet "Diarrhea"– Chapter 10. Wyllie, Hyams, and Kay. Pediatric Gastrointestinal and Liver Disease. 4th edition. 2011. Constipation Sentinel Articles Rome IV Criteria for Functional GI Disorders in Children PMID 27144632 New NASPGHAN/ESPGHAN Guideline 2: ESPGHAN Guidelines for Management of Neurologically Impaired Children Osmotic and stimulant laxatives for the management of childhood constipation (Review) NASPGHAN Guidelines/Position Statements Evaluation and treatment of functional constipation in infants and children: evidence based recommendations from ESPGHAN and NASPGHAN. Tabers MM, Di Lorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA. (2014). JPGN Feb 2014; V58: 258-74. Additional Guidelines/Position Statements American Gastroenterological Association – Medical Position Statement on Constipation Gastroenterology2013 America Gastroenterological Association – Technical Review on constipation Gastroenterology 2013 Additional Publications/Podcasts/Slide Sets NASPGHAN Resident Teaching Slide Set - Constipation Videos Poo in You Other Resources Aboutconstipation.org IFFGD Fact Sheet Constipation – Chapter 11. Wyllie, Hyams, and Kay. Pediatric Gastrointestinal and Liver Disease. 5th edition.2015. Abdominal Pain/Functional GI Diseases Sentinel Articles Rome IV Criteria for Functional GI Disorders in Children PMID 27144632 Childhood Functional Gastrointestinal Disorders Gut 1999 Chronic abdominal pain in children: a technical report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition: AAP Subcommittee and NASPGHAN Committee on Chronic Abdominal Pain. Di Lorenzo, C., Colletti, R. B., Lehmann, H. P., Boyle, J. T., Gerson, W. T., Hyams, J. S., & Kanda, P. T. (2005). Journal of pediatric gastroenterology and nutrition, 40(3), 249-261. Chronic Abdominal Pain in Children: A Clinical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition: American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain and NASPGHAN Committee on Abdominal Pain. Di Lorenzo, C., Colletti, R. B., Lehmann, H. P., Boyle, J. T., Gerson, W. T., Hyams, J. S., & Kanda, P. T. (2005). Journal of pediatric gastroenterology and nutrition, 40(3), 245-248. A comprehensive review of randomized placebo-controlled pharmacological clinical trials in children with functional abdominal pain disorders. Saps M, Biring HS, Pusatcioglu CK, Mintjens S, Rzeznikiewiz D. (2015) JPGN 60 (5): 645-53. Gut-directed hypnotherapy for functional abdominal pain or irritable bowel syndrome in children: a systematic review. Rutten JM, Reitsma JB, Vlieger AM, Benninga MA. (2013). Arch Dis Child 98 (4): 252-7. High prevalence of nausea in children with pain-associated functional gastrointestinal disorders: are Rome criteria applicable? Kovacic, Katja, et al. Journal of pediatric gastroenterology and nutrition 57.3 (2013): 311-315 Pharmacologic Management for Pediatric Functional Abdominal Pain PMID 15381890 NASPGHAN Guidelines/Position Statements Functional Abdominal Pain 2008 NASPGHAN Medical Position Paper Abdominal Pain 2005 NASPGHAN Technical Report Additional Publications/Podcasts/Slide Sets Functional Abdominal Pain NASPGHAN Resident Teaching Slide Set Other Resources International Foundation for Functional GI Disorders 10th International Symposium on Functional GI Disorders Plenary Audio Recordings (2013) About GI Motility About Irritable Bowel Syndrome Chronic Abdominal Pain of Childhood and Adolescence Chapter 6. Wyllie, Hyams, and Kay. Pediatric Gastrointestinal and Liver Disease. 5th edition (2015). Approach to the Child with a Functional Gastrointestinal Disorder Chapter 7. Wyllie, Hyams, and Kay. Pediatric Gastrointestinal and Liver Disease. 5th edition (2015). Failure to Thrive Sentinel Articles Failure to thrive: an update. Cole SZ, Lanham JS. Am Fam Physician 2011 April 1, 83 (2): 829-34. Weight faltering and failure to thrive in infancy and early childhood Shields, B., Wacogne, I., & Wright, C. M. (2012) BMJ: British Medical Journal, 345. Failure to Thrive as a Manifestation of Child Neglect Block, Robert W., Krebs, Nancy F. 2005; Pediatrics 116;1234 Additional Guidelines/Position Statements Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. Mehta NM, et al. JPEN J Parenter Enteral Nutr. 37(4):460-81. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition). Becker PJ, et al. Acad Nutr Diet. 2014;114(12):1988-2000. Pediatric Malnutrition: Putting the new Definition and Standards into Practice. Nutr Clin Pract October 20015: 609-624. Additional Publications/Podcasts/Slide Sets Failure to thrive NASPGHAN Resident Teaching Slide Set FTT as a Manifestation of Child Neglect AAP 2005 Videos NASPGHAN Nutrition University Failure to Thrive Module Other Resources Failure to Thrive Chapter 12. Wyllie, Hyams, and Kay. Pediatric Gastrointestinal and Liver Disease. 5th edition. 2015. Common Liver Issues in Pediatric GI Refer to Liver and Liver Transplant Curricular Resources Inflammatory Bowel Disease Adult Sentinel Articles SONIC: Infliximab, Azathioprine, or Combination Therapy for Crohn's Disease Colombel JF, Sandborn WJ, Reinisch W, Mantzaris GJ, Kornbluth A, Rachmilewitz D, Lichtiger S, D'Haens G, Diamond RH, Broussard DL, Tang KL, van der Woude CJ, Rutgeerts P; SONIC Study Group. N Engl J Med. 2010 Apr 15;362(15):1383-95. doi: 10.1056/NEJMoa0904492. PMID:20393175 CLASSIC 1: Human Anti–Tumor Necrosis Factor Monoclonal Antibody (Adalimumab) in Crohn's Disease: the CLASSIC-I Trial Hanauer S, Sandborn WJ, Rutgeerts P, Fedorak RN, Lukas M, Macintosh D, Panaccione R, Wolf D, Pollack P. Gastro. 2006 Feb;130(2):323-33. PMID:16472588 ACCENT 1: Maintenance Infliximab for Crohn's Disease: The ACCENT I Randomised Trial Hanauer SB, Feagan BG, Lichtenstein GR, Mayer LF, Schreiber S, Colombel JF, Rachmilewitz D, Wolf DC, Olson A, Bao W, Rutgeerts
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    Childhood Functional Gastrointestinal Disorders: Child/Adolescent

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  • Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment—A Systematic Review

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  • Nutritional Approaches to Chronic Nausea and Vomiting

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  • Cyclical Vomiting Syndrome (CVS) Is a Rare Condition Affecting ~3 in 100,000 Children, with Caucasian but No Sex Predominance

    Cyclical Vomiting Syndrome (CVS) Is a Rare Condition Affecting ~3 in 100,000 Children, with Caucasian but No Sex Predominance

    orphananesthesia Anaesthesia recommendations for patients suffering from Cyclical (or cyclic) vomiting syndrome Disease name: Cyclical (or cyclic) vomiting syndrome ICD 10: G43.A0 Synonyms: Cyclical vomiting, not intractable; persistent vomiting, cyclical; cyclic vomiting, psychogenic Cyclical vomiting syndrome (CVS) is a rare condition affecting ~3 in 100,000 children, with Caucasian but no sex predominance. It is generally a disorder of childhood with symptom onset in pre or early school age. Adult cases (onset in 3rd to 4th decade) are also reported. As patients are well in between episodes, there is usually a delay in diagnosis (2-3 years in children, longer in adults), with frequent emergency department presentations. It is a diagnosis of exclusion. Diagnostic criteria have been published by various bodies including the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, the Rome Foundation (Rome IV 2016 under functional gastrointestinal disorders) and also the International Classification of Headache Disorders (3rd edition beta version). This reflects the uncertainty about the pathophysiology of the syndrome, described variously as functional, psychiatric, neurological either epileptogenic or autonomic dysfunction, association with or triggered by cannabis use versus a migraine variant or as episodic symptoms associated with migraine. Medicine in progress Perhaps new knowledge Every patient is unique Perhaps the diagnostic is wrong Find more information on the disease, its centres of reference and patient organisations on Orphanet: www.orpha.net 1 Disease summary The pattern experienced by an individual is stereotypical: a prodrome including nausea, a hyperemesis/vomiting phase (typically 6-8 episodes per hour for a few days; associated with continuing nausea, headache and abdominal pain), recovery phase and an asymptomatic phase of a few to several weeks.
  • Recurrent Abdominal Pain and Vomiting

    Recurrent Abdominal Pain and Vomiting

    A SELF-TEST IM BOARD REVIEW ON A CME EDUCATIONAL OBJECTIVE: Readers will be aware of narcotic bowel syndrome as a consequence CLINICAL CREDIT of prolonged narcotic use. CASE MARKUS AGITO, MD MAGED RIZK, MD Department of Internal Medicine, Quality Improvement Officer, Digestive Akron General Medical Center, Disease Institute, Cleveland Clinic; Assistant Akron, OH Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH Recurrent abdominal pain and vomiting 32-year-old man presents to the emer- Based on the information available, which A gency department with excruciating is the least likely cause of his symptoms? abdominal pain associated with multiple epi- 1 sodes of vomiting for the past 2 days. He re- □ Acute pancreatitis ports no fevers, headaches, diarrhea, constipa- □ Cyclic vomiting syndrome tion, hematochezia, melena, musculoskeletal □ Acute intermittent porphyria symptoms, or weight loss. His abdominal pain □ Gastroparesis is generalized and crampy. It does not radiate Acute pancreatitis and has no precipitating factors. The pain is Acute pancreatitis is the least likely cause of relieved only with intravenous narcotics. his symptoms. It is commonly caused by gall- stones, alcohol, hypertriglyceridemia, and cer- See related editorial, page 441 tain drugs.1 The associated abdominal pain is usually epigastric, radiates to the back, and is He does not smoke, drink alcohol, or use accompanied by nausea or vomiting, or both. illicit drugs. He has no known drug or food The onset of pain is sudden and rapidly increas- allergies. He says that his current condition es in severity within 30 minutes. CT shows en- causes him emotional stress that affects his largement of the pancreas with diffuse edema, A year ago, performance at work.
  • Status of Brain Imaging in Gastroparesis

    Status of Brain Imaging in Gastroparesis

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  • ORIGINAL ARTICLE Non-Caucasian Race, Chronic Opioid Use and Lack

    ORIGINAL ARTICLE Non-Caucasian Race, Chronic Opioid Use and Lack

    AJHM Volume 5 Issue 1 (Jan-March 2021) ORIGINAL ARTICLE ORIGINAL ARTICLE Non-Caucasian Race, Chronic Opioid Use and Lack of Insurance or Public Insurance were Predictors of Hospitalizations in Cyclic Vomiting Syndrome Vikram Kanagala, MD1; Sanjay Bhandari, MD2; Tatyana Taranukha, MD1; Lisa Rein, PhD3; Ruta Brazauskas, PhD3; Thangam Venkatesan, MD1 1Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI 2Division of General Internal Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI 3Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI. Corresponding author: Thangam Venkatesan, MD. 8701 Watertown Plank Rd. Medical Education Building. ([email protected]) Received: April 24, 2020. Revised: January 2, 2021. Accepted: March 3, 2021. Published: March 31, 2021. Am j Hosp Med 2021 Jan;5(1):2021. DOI: https://doi.org/10.24150/ajhm/2021.001 Introduction: Cyclic vomiting syndrome (CVS) is associated with frequent hospitalizations; risk factors for this are unknown. We sought to determine predictors of increased hospitalizations and length of hospital stay (LOS). Methods: We performed a retrospective review of patients with CVS at a tertiary referral center. Clinical characteristics and details about yearly hospitalizations and LOS were assessed; follow- up was divided into two one-year periods before and after the initial clinic visit. Negative binomial regression was used to assess predictors of hospital admission and total length of stay for each time period; the regression results are presented as ratio ratios (RRs). Results: Of 118 patients (70% female, 73% Caucasian), mean follow up was 3.4 2 years. During the first year of follow up, chronic opioid use (Rate Ratio [RR] 2.22) and being uninsured or having public health insurance (RR, 2.39) were associated with higher rates of hospitalization.
  • Cyclic Vomiting Syndrome

    Cyclic Vomiting Syndrome

    Cyclic Vomiting Syndrome National Digestive Diseases Information Clearinghouse What is cyclic vomiting What is the gastrointestinal syndrome? (GI) tract? Cyclic vomiting syndrome, sometimes The GI tract is a series of hollow organs referred to as CVS, is an increasingly joined in a long, twisting tube from the recognized disorder with sudden, repeated mouth to the anus—the opening through attacks—also called episodes—of severe which stool leaves the body. The body nausea, vomiting, and physical exhaustion that occur with no apparent cause. The episodes can last from a few hours to several days. Episodes can be so severe that a person has to stay in bed for days, unable to go to school or work. A person may need treatment at an emergency room or a Esophagus hospital during episodes. After an episode, Mouth a person usually experiences symptom- Stomach free periods lasting a few weeks to several months. To people who have the disorder, as well as their family members and friends, cyclic vomiting syndrome can be disruptive and frightening. Duodenum The disorder can affect a person for months, years, or decades. Each episode of cyclic vomiting syndrome is usually similar to previous ones, meaning that episodes tend to start at the same time of day, last the same Small length of time, and occur with the same intestine symptoms and level of intensity. Anus Cyclic vomiting syndrome affects the upper GI tract, which includes the mouth, esophagus, stomach, small intestine, and duodenum. digests food using the movement of muscles • in children, an abnormal inherited gene in the GI tract, along with the release of may also contribute to the condition hormones and enzymes.
  • Diagnosis, Pathophysiology, and Treatment—A Systematic Review

    Diagnosis, Pathophysiology, and Treatment—A Systematic Review

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  • Cyclic Vomiting Syndrome

    Cyclic Vomiting Syndrome

    Cyclic vomiting syndrome Description Cyclic vomiting syndrome is a disorder that causes recurrent episodes of nausea, vomiting, and tiredness (lethargy). This condition is diagnosed most often in young children, but it can affect people of any age. The episodes of nausea, vomiting, and lethargy last anywhere from an hour to 10 days. An affected person may vomit several times per hour, potentially leading to a dangerous loss of fluids (dehydration). Additional symptoms can include unusually pale skin (pallor), abdominal pain, diarrhea, headache, fever, and an increased sensitivity to light ( photophobia) or to sound (phonophobia). In most affected people, the signs and symptoms of each attack are quite similar. These attacks can be debilitating, making it difficult for an affected person to go to work or school. Episodes of nausea, vomiting, and lethargy can occur regularly or apparently at random, or can be triggered by a variety of factors. The most common triggers are emotional excitement and infections. Other triggers can include periods without eating (fasting), temperature extremes, lack of sleep, overexertion, allergies, ingesting certain foods or alcohol, and menstruation. If the condition is not treated, episodes usually occur four to 12 times per year. Between attacks, vomiting is absent, and nausea is either absent or much reduced. However, many affected people experience other symptoms during and between episodes, including pain, lethargy, digestive disorders such as gastroesophageal reflux and irritable bowel syndrome, and fainting spells (syncope). People with cyclic vomiting syndrome are also more likely than people without the disorder to experience depression, anxiety, and panic disorder. It is unclear whether these health conditions are directly related to nausea and vomiting.
  • Cyclical Vomiting Syndrome in Children: a Prospective Study

    Cyclical Vomiting Syndrome in Children: a Prospective Study

    Cyclic Vomiting Syndrome Definitions & Facts What is cyclic vomiting syndrome? Cyclic vomiting syndrome, or CVS, is 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. CVS is not chronic vomiting that lasts weeks without stopping. CVS is not a condition that has a definite cause, such as chemotherapy . How common is cyclic vomiting syndrome? Experts don’t know how common cyclic vomiting syndrome is in adults. However, experts believe that cyclic vomiting syndrome may be just as common in adults as in children. Doctors diagnose about 3 out of 100,000 children with cyclic vomiting syndrome every year.1 Who is more likely to get cyclic vomiting syndrome? You may be more likely to get cyclic vomiting syndrome if you have migraines or a family history of migraines a history of long-term marijuana use a tendency to get motion sickness Among adults with cyclic vomiting syndrome, about 6 out of 10 are Caucasian.2 What other health problems do people with cyclic vomiting syndrome have? People with cyclic vomiting
  • Cyclic Vomiting Syndrome: a Functional Disorder

    Cyclic Vomiting Syndrome: a Functional Disorder

    pISSN: 2234-8646 eISSN: 2234-8840 http://dx.doi.org/10.5223/pghn.2015.18.4.224 Pediatr Gastroenterol Hepatol Nutr 2015 December 18(4):224-229 Review Article PGHN Cyclic Vomiting Syndrome: A Functional Disorder Ajay Kaul and Kanwar K. Kaul* Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA, *Department of Pediatrics, NSCB Medical College, Jabalpur, India Cyclic vomiting syndrome (CVS) is a functional disorder characterized by stereotypical episodes of intense vomiting separated by weeks to months. Although it can occur at any age, the most common age at presentation is 3-7 years. There is no gender predominance. The precise pathophysiology of CVS is not known but a strong association with migraine headaches, in the patient as well as the mother indicates that it may represent a mitochondriopathy. Studies have also suggested the role of an underlying autonomic neuropathy involving the sympathetic nervous system in its pathogenesis. CVS has known triggers in many individuals and avoiding these triggers can help prevent the onset of the episodes. It typically presents in four phases: a prodrome, vomiting phase, recovery phase and an asympto- matic phase until the next episode. Complications such as dehydration and hematemesis from Mallory Wise tear of the esophageal mucosa may occur in more severe cases. Blood and urine tests and abdominal imaging may be indicated depending upon the severity of symptoms. Brain magnetic resonance imaging and upper gastrointestinal endoscopy may also be indicated in certain circumstances. Management of an episode after it has started (‘abortive treatment’) includes keeping the patient in a dark and quiet room, intravenous hydration, ondansetron, sumatriptan, clonidine, and benzodiazepines.