Cyclic Syndrome

National Digestive Diseases Information Clearinghouse

What is cyclic vomiting What is the gastrointestinal syndrome? (GI) tract? , 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 , 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 hospital during episodes. After an episode, Mouth a person usually experiences symptom- 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. 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.

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Cyclic vomiting syndrome affects the upper GI tract, which includes the mouth, esophagus, stomach, , and duodenum. digests 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. Cyclic vomiting Specific conditions or events may trigger an syndrome affects the upper GI tract, which episode of cyclic vomiting: includes the mouth, esophagus, stomach, small intestine, and duodenum, the first • emotional , , or panic part of the small intestine. The esophagus attacks—for example, in children, is the muscular tube that carries food and common triggers of anticipatory anxiety liquids from the mouth to the stomach. are school exams or events, birthday The stomach slowly pumps the food and parties, holidays, family conflicts, or liquids through the duodenum and into the travel rest of the small intestine, which absorbs • , such as a sinus , a nutrients from food particles. This process respiratory infection, or the flu is automatic and people are usually not aware of it, though people sometimes feel • eating certain , such as chocolate food in their esophagus when they swallow or cheese, or additives such as something too large, try to eat too quickly, or caffeine, nitrites—commonly found drink hot or cold liquids. in cured meats such as hot dogs—and monosodium glutamate, also called What causes cyclic vomiting MSG syndrome? • hot weather The cause of cyclic vomiting syndrome is • menstrual periods unknown. However, some experts believe • that some possible problems with bodily functions may contribute to the cause, such • overeating, fasting, or eating right as the following: before bedtime • gastrointestinal motility—the way food • physical exhaustion or too much moves through the digestive system exercise • function— includes the brain, spinal cord, and How common is cyclic nerves that control bodily responses vomiting syndrome? • function— Cyclic vomiting syndrome is more common nerves that control internal organs such in children than adults, although reports of as the heart the syndrome in adults have increased in recent years.1 Usually, children are about • hormone imbalances—hormones are 5 years old when diagnosed with cyclic a chemical produced in one part of vomiting syndrome, which occurs in every the body and released into the three out of 100,000 children.2 to trigger or regulate particular bodily functions

2 Cyclic Vomiting Syndrome Who is more likely • dizziness to develop cyclic • vomiting syndrome? • sensitivity to light Children who suffer from —severe, Intensity of symptoms will vary as a person throbbing with nausea, vomiting, cycles through four distinct phases of an and sensitivity to light and sound—are more episode: likely to develop cyclic vomiting syndrome. Up to 80 percent of children and 25 percent • phase. During the prodrome of adults who develop cyclic vomiting phase, the person feels that an episode syndrome also get headaches.1 of nausea and vomiting is about to start. People with a family history of migraines may Often marked by intense sweating and be more likely to develop the syndrome. nausea—with or without —this phase can last from a few People with a history of chronic marijuana minutes to several hours. The person use may also be more likely to develop cyclic may appear unusually pale. vomiting syndrome. • Vomiting phase. This phase consists of intense nausea, vomiting, and . What are the symptoms of Periods of vomiting and retching can cyclic vomiting syndrome? last 20 to 30 minutes at a time. The The main symptoms of cyclic vomiting person may be subdued and responsive, syndrome are severe nausea and sudden immobile and unresponsive, or writhing vomiting lasting hours to days. A person may and moaning with intense abdominal also experience one or more of the following pain. An episode can last from hours symptoms: to days. • retching, or making an attempt to vomit • Recovery phase. This phase begins when the vomiting and retching stop • heaving or gagging and the nausea subsides. Improvement • lack of appetite of symptoms during the recovery phase can vary. Healthy color, appetite, and • abdominal pain energy return gradually or right away. • • Well phase. This phase occurs between • fever episodes when no symptoms are present.

3 Cyclic Vomiting Syndrome What are the complications of cyclic vomiting Seek Help for Signs syndrome? or Symptoms of Severe The severe vomiting and retching that define cyclic vomiting syndrome increase the People who have any signs or symptoms chance of developing several complications, of severe dehydration should call or see including dehydration, , a a health care provider right away: Mallory-Weiss tear, and . • excessive thirst • Dehydration may occur when a person does not replace fluids that • dark-colored urine were lost because of vomiting and • infrequent urination diarrhea. When dehydrated, the body lacks enough fluid and — • lethargy, dizziness, or faintness minerals in , including sodium, • dry skin , and chloride—to function properly. Severe dehydration may Infants, children, older adults, and require intravenous (IV) fluids and people with weak immune systems hospitalization. have the greatest chance of becoming dehydrated. People should watch • Esophagitis—inflammation or for the following of the esophagus—can result from the of dehydration in infants, young stomach acid that exits through the children, and people who are unable to esophagus during vomiting. communicate their symptoms: • A Mallory-Weiss tear—a tear in the • dry mouth and tongue lower end of the esophagus—is caused by severe vomiting. A person with • lack of tears when crying bloody vomit and stool should see a • infants with no wet diapers for health care provider right away. 3 hours or more • Tooth decay or corroding • infants with a sunken soft spot is damage caused by stomach acid. • unusually cranky or drowsy behavior • sunken eyes or cheeks • fever If left untreated, severe dehydration can cause serious health problems, such as organ damage, , or coma—a sleeplike state in which a person is not conscious.

4 Cyclic Vomiting Syndrome How is cyclic vomiting Medical and Family History syndrome diagnosed? Taking a medical and family history is one of A specific test to diagnose cyclic vomiting the first things a health care provider may do syndrome does not exist; instead, a health to help diagnose cyclic vomiting syndrome. care provider will rule out other conditions He or she will ask the patient to provide a and diagnose the syndrome based upon medical and family history. • a medical and family history Physical Exam • a physical exam A physical exam may help diagnose other conditions besides cyclic vomiting syndrome. • a pattern or cycle of symptoms During a physical exam, a health care • blood tests provider usually • urine tests • examines a patient’s body • imaging tests • taps on specific areas of the patient’s body • upper GI • a gastric emptying test Pattern or Cycle of Symptoms in Children3 Often, it is suspected that one of the following is causing their symptoms: A health care provider will often suspect cyclic vomiting syndrome in a child when • —a disorder that slows or the child stops the movement of food from the stomach to the small intestine • has at least five separate episodes, or at least three separate episodes over • —inflammation of the 6 months lining of the stomach, small intestine, and • has episodes of intense nausea and vomiting lasting 1 hour to 10 days and A diagnosis of cyclic vomiting syndrome may occurring at least 1 week apart be difficult to make until the person sees a health care provider. A health care provider • has episodes that are similar to will suspect cyclic vomiting syndrome if previous ones—they tend to start at the person suffers from repeat episodes of the same time of day, last the same vomiting. length of time, and occur with the same symptoms and level of intensity

5 Cyclic Vomiting Syndrome • vomits during episodes at least four Urine Tests times per hour for at least 1 hour Urinalysis involves testing a urine sample. • vomits and it is not attributed to The patient collects a urine sample in a another disorder special container in a health care provider’s office or a commercial facility. A health • has absence of nausea and vomiting care provider tests the sample in the same between episodes location or sends the sample to a lab for Pattern or Cycle of Symptoms analysis. A urinalysis can rule out in Adults4,5 problems or an infection. A health care provider will often suspect Imaging Tests cyclic vomiting syndrome in adults when the The health care provider decides which test following is present for at least 3 months and to order based on the symptoms, medical the symptoms started more than 6 months history, and physical exam. ago: Upper GI series. A health care provider • Each episode of cyclic vomiting may order an upper GI series to look at the syndrome is usually similar to previous upper GI tract. A radiologist—a doctor who ones, meaning that episodes tend to specializes in medical imaging—performs start at the same time of day and last the this test at a hospital or an outpatient center. same length of time—less than 1 week. This test does not require . The • Three or more separate episodes in the patient should not eat or drink for 8 hours past year. before the procedure, if possible. During the procedure, the patient will stand or sit in • Absence of nausea or vomiting between front of an x-ray machine and drink barium, episodes. a chalky liquid. Infants lie on a table and Blood Tests a health care provider gives them barium through a tiny tube placed in the nose that A nurse or technician will draw blood runs into the stomach. Barium coats the samples at a health care provider’s office or a GI tract, making signs of obstruction or commercial facility and send the samples to other problems that can cause vomiting show a lab for analysis. The blood test can tell the up more clearly on x rays. A patient may health care provider if the patient has any experience and nausea for a short signs of dehydration or other problems. time after the test. The upper GI series can show other problems that may be causing symptoms, such as an ulcer or obstruction.

6 Cyclic Vomiting Syndrome Abdominal ultrasound. A health care mounted on the endoscope transmits a provider may order an ultrasound to look video image to a monitor, allowing close at the organs in the . A technician examination of the intestinal lining. The uses a device, called a transducer, that upper GI endoscopy can show other bounces safe, painless sound waves off problems that may be causing symptoms, organs to create an image of their structure. such as an ulcer. A gastroenterologist may The technician performs the procedure in a obtain a biopsy—a procedure that involves health care provider’s office, an outpatient taking a small piece of tissue for examination center, or a hospital. A radiologist interprets with a microscope—of the small-intestinal the images. A patient does not need lining during an upper GI endoscopy. The anesthesia. The abdominal ultrasound can patient will not feel the biopsy. show other problems that may be causing symptoms, such as . Gastric Emptying Test Also called gastric emptying scintigraphy, Upper Gastrointestinal this test involves eating a bland meal—such Endoscopy as eggs or an egg substitute—that contains This procedure involves using an a small amount of radioactive material. A endoscope—a small, flexible tube with specially trained technician performs the a light—to see the upper GI tract. A test in a radiology center or hospital, and a gastroenterologist—a doctor who specializes radiologist interprets the results; the patient in digestive diseases—performs the test at a does not need anesthesia. An external hospital or an outpatient center. A health camera scans the abdomen to show where care provider may give a patient a liquid the radioactive material is located. The anesthetic to gargle or may spray anesthetic radiologist is then able to measure the rate of on the back of the patient’s throat. A nurse gastric emptying at 1, 2, 3, and 4 hours after or technician will place an IV needle in a the meal. vein in the arm to administer sedation or anesthesia. Sedatives or anesthesia help a patient stay relaxed and comfortable. The gastroenterologist carefully inserts the endoscope into the mouth and feeds the endoscope down the esophagus and into the stomach and duodenum. A small camera

7 Cyclic Vomiting Syndrome How is cyclic vomiting • Vomiting phase treatment. Once vomiting begins, people should call or syndrome treated? see a health care provider as soon as A health care provider may refer patients to possible. Treatment usually requires a gastroenterologist for treatment. the person to stay in bed and sleep People with cyclic vomiting syndrome should in a dark, quiet room. A health care get plenty of rest and take to provider may recommend the following prevent a vomiting episode, stop an episode for both children and adults: in progress, speed up recovery, or relieve –– for pain, nausea, and associated symptoms. reducing stomach acid and anxiety The health care team tailors treatment to the –– anti-migraine medications such as symptoms experienced during each of the sumatriptan to stop symptoms of a four cyclic vomiting syndrome phases: migraine or possibly stop an episode in progress • Prodrome phase treatment. The goal –– hospitalization for severe nausea and during the prodrome phase is to stop vomiting an episode before it progresses. Taking –– IV fluids and medications to prevent medication early in the phase can help dehydration and treat symptoms stop an episode from moving to the vomiting phase or becoming severe; –– IV nutrition if an episode continues however, people do not always realize for several days an episode is coming. For example, a • Recovery phase treatment. During the person may wake up in the morning recovery phase, drinking and eating and begin vomiting. A health care will replace lost electrolytes. A person provider may recommend the following may need IV fluids for a period of medications for both children and time. Some people find their appetite adults: returns to normal right away, while –– (Zofran) or others start by drinking clear liquids (Ativan) for nausea and then moving slowly to other liquids and solid food. A health care provider –– for abdominal pain may prescribe medications during –– ranitidine (Zantac), lansoprazole the recovery phase and well phase to (Prevacid), or omeprazole (Prilosec, prevent future episodes. Zegerid) to control stomach acid production –– sumatriptan (Imitrex)—prescribed as a nasal spray, an injection, or a pill that dissolves under the tongue—for migraines

8 Cyclic Vomiting Syndrome • Well phase treatment. During the A health care provider may refer people with well phase, a health care provider cyclic vomiting syndrome and anxiety to a may use medications to treat people stress management specialist for relaxation whose episodes are frequent and long therapy or other treatments. lasting in an effort to prevent or ease A health care provider may prescribe future episodes. A person may need medications to prevent migraines for people to take a medication daily for 1 to with cyclic vomiting syndrome. 2 months before evaluating whether it helps prevent episodes. A health care provider may prescribe the following Eating, Diet, and Nutrition medications for both children and During the prodrome and vomiting phases adults during the well phase to prevent of cyclic vomiting syndrome, a person will cyclic vomiting syndrome episodes, generally take in little or no nutrition by lessen their severity, and reduce their mouth. During the recovery phase, the frequency: person may be quite hungry as soon as the –– (Elavil) vomiting stops. As eating resumes, a person –– propranolol (Inderal) or his or her family should watch for the return of nausea. In some cases, a person –– cyproheptadine (Periactin) can start with clear liquids and proceed slowly to a regular diet. How can a person prevent During the well phase, a balanced diet cyclic vomiting syndrome? and regular meals are important. People A person should stay away from known should avoid any trigger foods and foods triggers, especially during the well phase, as with additives. Eating small, carbohydrate- well as containing snacks between meals, before exercise, and at bedtime may help prevent • get adequate sleep to prevent future attacks. A health care provider will exhaustion assist with planning a return to a regular diet. • treat sinus problems or • seek help on reducing stress and anxiety • avoid foods that trigger episodes or foods with additives

9 Cyclic Vomiting Syndrome Hope through Research Points to Remember The National Institute of Diabetes and • Cyclic vomiting syndrome, Digestive and Kidney Diseases’ (NIDDK’s) sometimes referred to as CVS, is Division of Digestive Diseases and Nutrition an increasingly recognized disorder conducts and supports basic and clinical with sudden, repeated attacks— research into many digestive disorders, also called episodes—of severe including cyclic vomiting syndrome. nausea, vomiting, and physical Clinical trials are research studies involving exhaustion that occur with no people. Clinical trials look at safe and apparent cause. effective new ways to prevent, detect, or • The disorder can affect a person treat disease. Researchers also use clinical for months, years, or decades. trials to look at other aspects of care, such as improving the quality of life for people • The cause of cyclic vomiting with chronic illnesses. To learn more about syndrome is unknown. clinical trials, why they matter, and how to • The severe vomiting and retching participate, visit the NIH Clinical Research that define cyclic vomiting Trials and You website at www.nih.gov/health/ syndrome increase the chance of clinicaltrials. For information about current developing several complications, studies, visit www.ClinicalTrials.gov. including dehydration, esophagitis, a Mallory-Weiss tear, and tooth decay. References 1. Hejazi, RA, McCallum RW. Review • Intensity of symptoms will vary as a article: cyclic vomiting syndrome in person cycles through four distinct adults—rediscovering and redefining an phases of an episode. old entity. Alimentary Pharmacology & • The main symptoms of cyclic Therapeutics. 2011;34(3):263–273. vomiting syndrome are severe 2. Drumm BR, Bourke B, Drummond nausea and sudden vomiting lasting J, et al. Cyclical vomiting syndrome hours to days. in children: a prospective study. • People with cyclic vomiting Neurogastroenterology & Motility. syndrome should get plenty of rest 2012;24(10):922–927. and take medications to prevent a 3. Li B U.K., Lefevre F, Chelimsky GG, vomiting episode, stop an episode et al. North American Society for in progress, speed up recovery, or Pediatric , Hepatology, relieve associated symptoms. and Nutrition consensus statement • During the well phase, a balanced on the diagnosis and management of diet and regular meals are cyclic vomiting syndrome. Journal of important. A health care provider Pediatric Gastroenterology and Nutrition. will assist with planning a return to 2008;47(3):379–393. a regular diet.

10 Cyclic Vomiting Syndrome 4. Functional gastroduodenal disorders. Office of Rare Diseases Research In: Drossman D, ed. Rome III: The National Center for Advancing Functional Gastrointestinal Disorders. Translational Sciences 3rd ed. McLean, VA: Degnon National Institutes of Health Associates, Inc.; 2006: 419–486. 6701 Democracy Boulevard, Suite 1001, MSC 4874 5. Abell TL, Adams KA, Boles RG, et al. Bethesda, MD 20892 Cyclic vomiting syndrome in adults. For courier, use Bethesda, MD 20817 Neurogastroenterology & Motility. Phone: 301–402–4336 2008;20(4):269–284. Fax: 301–480–9655 Email: [email protected] For More Information Internet: www.rarediseases.info.nih.gov American Neurogastroenterology and Motility Society Acknowledgments 45685 Harmony Lane Publications produced by the Clearinghouse Belleville, MI 48111 are carefully reviewed by both NIDDK Phone: 734−699−1130 scientists and outside experts. This Fax: 734−699−1136 publication was originally reviewed by David Email: [email protected] R. Fleisher, M.D., Children’s Hospital, Internet: www.motilitysociety.org University of Missouri Health Care. Henry Cyclic Vomiting Syndrome Association P. Parkman, M.D., Temple University School 10520 West Bluemound Road, Suite 106 of Medicine, reviewed the updated version of Milwaukee, WI 53226 the publication. Phone: 414–342–7880 Fax: 414–342–8980 Email: [email protected] You may also find additional information about this Internet: www.cvsaonline.org topic by visiting MedlinePlus at www.medlineplus.gov. This publication may contain information about International Foundation for Functional medications and, when taken as prescribed, the conditions they treat. When prepared, this Gastrointestinal Disorders publication included the most current information 700 West Virginia Street, Suite 201 available. For updates or for questions about Milwaukee, WI 53204 any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA Phone: 1–888–964–2001 or 414–964–1799 (1–888–463–6332) or visit www.fda.gov. Consult your Fax: 414–964–7176 health care provider for more information. Email: [email protected] Internet: www.iffgd.org

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11 Cyclic Vomiting Syndrome National Digestive Diseases Information Clearinghouse 2 Information Way Bethesda, MD 20892–3570 Phone: 1–800–891–5389 TTY: 1–866–569–1162 Fax: 703–738–4929 Email: [email protected] Internet: www.digestive.niddk.nih.gov The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

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NIH Publication No. 14–4548 February 2014

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