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Butt MF, Cefalo F, Sbarigia C, Dhali A, Corsetti M. Impact of Opioid and Cannabis Use on Low-Dose Amitriptyline Efficacy in Cyclical Vomiting Syndrome: A Real-World Study in the United Kingdom. Neurogastroenterol Motil 2025; 37:e70007. [PMID: 40017095 PMCID: PMC12075911 DOI: 10.1111/nmo.70007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2024] [Revised: 01/27/2025] [Accepted: 02/06/2025] [Indexed: 03/01/2025]
Abstract
BACKGROUND Central neuromodulators, specifically tricyclic antidepressants (TCAs), are prescribed as prophylactic treatment for cyclical vomiting syndrome (CVS). It is unclear whether opioids and/or cannabis affect the treatment response to neuromodulators. The aims of this study were to assess: (i) the prevalence of opioid and cannabis use among outpatients with CVS, (ii) clinical characteristics associated with opioid/cannabis use and response to a three-tiered neuromodulator treatment algorithm, and (iii) the effect of opioid/cannabis cessation on response to the treatment algorithm. METHODOLOGY Data from consecutive patients newly diagnosed with Rome IV CVS at a single tertiary care neurogastroenterology outpatient clinic (January 2016-June 2024) were retrospectively collected. Patients were advised to stop consuming opioids and/or cannabis and commenced a low-dose TCA. RESULTS Sixty-one (46/75) percent of outpatients with CVS responded to the three-tiered treatment algorithm. Among responders, 42 (91%) patients responded to TCA alone (1st line therapy), 3 (7%) patients responded to TCA and selective serotonin reuptake inhibitor or serotonin norepinephrine reuptake inhibitor (2nd line therapy), and 1 (2%) patient required topiramate (3rd line therapy). The mean [SD] dosage of TCA among responders was 26.5 [18.3] mg. Twenty-five (33%) patients consumed opioids, 14 (19%) took cannabis, and five (7%) consumed both opioids and cannabis. While opioid cessation was associated with clinical response to the treatment algorithm (p = 0.03), opioid intake at the initial consultation was not (p = 0.2). Irritable bowel syndrome was independently associated with significantly greater odds (OR [95% CI]) of opioid consumption at baseline (6.59 [1.49-29.24], p = 0.01). Heartburn was independently associated with lower odds of response to the treatment algorithm (0.2 [0.05-0.65], p = 0.006). CONCLUSION Low-dose neuromodulators, along with opioid and cannabis cessation, may be important strategies in the management of CVS.
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Affiliation(s)
- Mohsin F. Butt
- NIHR Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of MedicineUniversity of NottinghamNottinghamUK
| | - Francesca Cefalo
- NIHR Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of MedicineUniversity of NottinghamNottinghamUK
| | - Caterina Sbarigia
- NIHR Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of MedicineUniversity of NottinghamNottinghamUK
| | - Arkadeep Dhali
- Academic Department of GastroenterologySheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of MedicineUniversity of NottinghamNottinghamUK
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Gómez-Escudero O, Remes-Troche JM, Coss-Adame E, García-Zermeño KR, Aquino-Matus J, Jiménez-Pavón J, Valdovinos-García LR, Vargas-Martínez MA, Amieva-Balmori M, Arenas-Martínez JS, Félix-Téllez FA, Gómez-Castaños PC, Mejía-Rivas M, Valdovinos-Díaz MA, Vázquez-Elizondo G, Villar-Chávez AS, Gyawali CP. Clinical practice recommendations on the use of neuromodulators in gastroenterology: AMG (Asociación Mexicana de Gastroenterología) - AMNM (Asociación Mexicana de Neurogastroenterología y Motilidad) expert joint review. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2025:S2255-534X(25)00007-6. [PMID: 40374462 DOI: 10.1016/j.rgmxen.2024.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Accepted: 12/20/2024] [Indexed: 05/17/2025]
Abstract
Disorders of gut-brain interaction (DGBI) are characterized by alterations in both central and peripheral gut-brain axis (GBA)-related stimuli, and include esophageal, gastroduodenal, intestinal and anorectal disorders. Despite the fact that several pathophysiologic mechanisms are involved, the mainstay of treatment is neuromodulators, a heterogeneous group of drugs that act on pathways related to central and peripheral pain processing. This expert review by both the AMG (Asociación Mexicana de Gastroenterología) and AMNM (Asociación Mexicana de Neurogastroenterología y Motilidad) summarizes a series of updated clinical recommendations based on an exhaustive review of the literature, regarding the use of neuromodulators for DGBI, and is grouped into six sections: pharmacologic principles, definition, classification, mechanism of action, indications and use in each DGBI subtype, up/downscaling strategies, combination therapy, adverse events, joint use along with psychiatry in the case of comorbidities, and non-pharmacologic neuromodulation. Furthermore, drug selection process tips and dose personalization according to individual groups and sensitivities are provided, and special cases with DGBI-psychiatric comorbidity, as well as overlap with another DGBI, are considered.
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Affiliation(s)
- O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia, Neurogastroenterología y Motilidad Gastrointestinal "Endoneurogastro", Hospital Ángeles Puebla, Puebla, Puebla, Mexico
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico.
| | - E Coss-Adame
- Departamento de Gastroenterología, Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - K R García-Zermeño
- Centro Integral de Gastroenterología y Motilidad Avanzada (CIGMA), Boca del Río, Veracruz, Mexico
| | - J Aquino-Matus
- Departamento de Cirugía Experimental, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - J Jiménez-Pavón
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz - Clínica de Trastornos Afectivos, Hospital Médica Sur, Mexico City, Mexico
| | - L R Valdovinos-García
- Departamento de Cirugía Experimental, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico; Servicio de Gastroenterología, Hospital Médica Sur, Mexico City, Mexico
| | - M A Vargas-Martínez
- Departamento de Neurología y Psiquiatría, Servicio de Psiquiatría de Enlace, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - J S Arenas-Martínez
- Posgrado de Alta Especialidad en Medicina (Neurogastroenterología), Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - F A Félix-Téllez
- Posgrado de Alta Especialidad en Medicina (Neurogastroenterología), Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - P C Gómez-Castaños
- Servicio de Gastroenterología y Endoscopia Gastrointestinal, Centro de Investigación y Docencia en Ciencias de la Salud, Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, Mexico
| | | | | | - G Vázquez-Elizondo
- Centro de Enfermedades Digestivas ONCARE/Gastro Alliance Center, Monterrey, Nuevo León, Mexico
| | | | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, United States
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Hasler WL, Alshaarawy O, Venkatesan T. Cannabis use patterns and association with hyperemesis: A comprehensive review. Neurogastroenterol Motil 2025; 37:e14895. [PMID: 39164887 DOI: 10.1111/nmo.14895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 05/23/2024] [Accepted: 07/31/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Cannabis use in the general population is prevalent and is rising because of increased acceptance of its use, legalization in most US states, and perceived health benefits. Cannabis product potency has dramatically increased with higher delta-9-tetrahydrocannabinol content. Cannabis has documented antiemetic properties and cannabinoid pharmaceuticals are used in disorders like chemotherapy-induced nausea and vomiting. PURPOSE Forty to eighty percent of cyclic vomiting syndrome (CVS) patients use cannabis products, which reportedly reduce stress as well as nausea and vomiting. Cannabinoid hyperemesis syndrome (CHS) has a presentation similar to CVS, but is associated with longstanding, high dose cannabis use, and is thought to be relieved by sustained cannabis abstinence. Most CHS patients have used cannabis on a daily or near-daily basis for more than 2 years. Compulsive hot-water bathing behaviors are reported by most CHS patients, but are not specific for this disorder as they are also noted by about half of CVS patients. Episodic vomiting associated with cannabis use contributes to extensive health resource use, including emergency department visits and inpatient hospitalizations, and impacts patients and their families negatively. Treatment for CHS overlaps with CVS although cannabis abstinence remains the cornerstone of its management. Challenges associated with cannabis use cessation in CHS include patient skepticism of the role of cannabis as a cause of symptoms, perceived benefits of cannabis, and a lack of other effective therapies. In this review, we highlight cannabis use patterns in the US and discuss diagnosis and management of CHS and gaps in knowledge about this disorder.
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Affiliation(s)
- William L Hasler
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Hasler WL, Li BUK, Levinthal DJ, Venkatesan T. Cyclic vomiting syndrome: Future clinical and research priorities for: Special supplement/proceedings of 3rd international symposium. Neurogastroenterol Motil 2025; 37:e14825. [PMID: 38775195 DOI: 10.1111/nmo.14825] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/29/2024] [Accepted: 05/13/2024] [Indexed: 09/21/2024]
Abstract
BACKGROUND An increasing number of studies have explored the clinical features, epidemiology, pathophysiology, and management of cyclic vomiting syndrome (CVS). CVS is common in adults and children and negatively impacts patients, families, and the healthcare system. A related condition, cannabinoid hyperemesis syndrome (CHS), has been a focus of interest in the lay press and published literature. PURPOSE Clinical presentations of CVS have been defined by small series and expert opinion, but recent prospective studies are refining our understanding of the spectrum of emetic episodes and the breadth of comorbid conditions. Large cross-sectional population analyses are clarifying CVS prevalence and factors related to age, ethnicity, and geographic region. CVS pathophysiology is multifactorial with contributions from migraines, dysautonomia, endogenous cannabinoids, mitochondrial dysfunction, genetic abnormalities, and rapid gastric emptying. CVS treatment relies on antiemetics and antimigraine therapies to abort acute episodes coupled with prophylactic regimens employing neuromodulators and antiepileptics. CHS represents a challenge partly because of difficulties in achieving sustained cannabis abstinence. Benefits of other therapies in CHS remain poorly defined. Several areas warrant further scrutiny including better identification of CVS triggers and characterization of different CVS subsets including those with frequent severe episodes, refined description of epidemiology to allow targeting of populations predisposed to CVS development, rigorous definition of pathogenic factors to provide a foundation for exploratory studies of novel therapies, and conduct of controlled trials by multicenter collaborations to confirm benefits of existing and new therapies in development. Progress in these areas will be facilitated by generous governmental and industry support.
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Affiliation(s)
| | - B U K Li
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Chen YJ, Patel M, Venkatesan T. Treatment principles in adults and development of patient-reported outcomes in cyclic vomiting syndrome. Neurogastroenterol Motil 2025; 37:e14910. [PMID: 39552561 PMCID: PMC11911091 DOI: 10.1111/nmo.14910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 08/02/2024] [Accepted: 08/20/2024] [Indexed: 11/19/2024]
Abstract
BACKGROUND Cyclic vomiting syndrome is a chronic disorder of gut-brain interaction that is present in both adults and children. It is characterized by severe nausea, vomiting, abdominal pain, and several non-GI symptoms. It is also associated with several comorbid conditions such as anxiety and depression, which affect overall health care outcomes. METHODS This article delineates treatment principles, encompassing both abortive interventions and prophylactic regimens currently recommended for CVS. However, it underscores a critical concern: the absence of FDA-approved medications for CVS treatment, with existing therapies relying on retrospective and open-labeled trials. KEY RESULTS This article emphasizes the pressing need for the development of CVS-specific outcome assessment tools to facilitate more accurate evaluation and robust data collection for the future studies. In exploring this deficiency, the manuscript also presents the up-to-date data and development that enhances our comprehension of patient-centric concepts, and the challenges faced in creating CVS-specific tools, and presents a roadmap for their development. Addressing this gap is crucial for advancing our understanding of CVS and optimizing patient care. CONCLUSIONS AND INFERENCES This elucidates the current state of CVS management but also advocates for a future where tailored tools enhance our ability to measure and improve the outcomes for individuals with this debilitating disorder.
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Affiliation(s)
| | - Milan Patel
- Medical StudentMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Thangam Venkatesan
- Division of Gastroenterology, Hepatology and NutritionThe Ohio State UniversityColumbusOhioUSA
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Li BUK. Landscape of Cyclic Vomiting Syndrome: From Bedside to Bench, Past to Present. Neurogastroenterol Motil 2025; 37:e14990. [PMID: 39789960 PMCID: PMC11911070 DOI: 10.1111/nmo.14990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2024] [Revised: 11/25/2024] [Accepted: 12/12/2024] [Indexed: 01/12/2025]
Abstract
Investigations into mechanisms of cyclic(al) vomiting syndrome (CVS) began at the bedside more than a century ago. The modern era started with the formation of the Cyclic Vomiting Syndrome Association in 1993 that helped initiate robust efforts in education, advocacy, family physician conferences, scientific symposia, dedicated clinical programs, therapeutic guidelines, and research. Even today, bedside clues continue to emerge with the recent description of cannabinoid hyperemesis syndrome (CHS) and subsequent evidence of a perturbed endocannabinoid system. The clinical picture of CVS has evolved from that of a straightforward emetic disorder related to migraine requiring short-term antiemetics or prophylactic anti-migraine therapy, to a complicated, heterogenous one with multiple comorbid associations (anxiety, dysautonomia) and endophenotypes (migraine, Sato, CHS). This expanded view has important therapeutic implications which necessitate managing the comorbidities which can in turn impact the disease itself and proffered promising evidence that behavioral management (meditation) and vagal neuromodulation appear efficacious with few untoward effects, perhaps by reestablishing autonomic (parasympathetic) balance. The pathophysiologic picture now appears to be inscribed on an autonomic polyvagal design but multiple additional pathways interact, some confirmed (NK1, CB1, HPA axis, PPM1D gene, biological calendar, estrogen), and others, possible (TRPV-1, CGRP, GDF-15, mitochondrial dysfunction, impaired cation transport). CVS and its cousin CHS continue to challenge clinicians and perplex investigators and in the current era require not only a critical mass of specific pathway expertise but also syncretic biopsychosocial thinking to integrate these disparate threads. We may have reached such a tipping point at this Symposium.
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Affiliation(s)
- B U K Li
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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7
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DeVuono MV, Venkatesan T, Hillard CJ. Endocannabinoid signaling in stress, nausea, and vomiting. Neurogastroenterol Motil 2025; 37:e14911. [PMID: 39223918 PMCID: PMC11872018 DOI: 10.1111/nmo.14911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 08/06/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Classical antiemetics that target the serotonin system may not be effective in treating certain nausea and vomiting conditions like cyclic vomiting syndrome (CVS) and cannabinoid hyperemesis syndrome (CHS). As a result, there is a need for better therapies to manage the symptoms of these disorders, including nausea, vomiting, and anxiety. Cannabis is often used for its purported antiemetic and anxiolytic effects, given regulation of these processes by the endocannabinoid system (ECS). However, there is considerable evidence that cannabinoids can also produce nausea and vomiting and increase anxiety in certain instances, especially at higher doses. This paradoxical effect of cannabinoids on nausea, vomiting, and anxiety may be due to the dysregulation of the ECS, altering how it maintains these processes and contributing to the pathophysiology of CVS or CHS. PURPOSE The purpose of this review is to highlight the involvement of the ECS in the regulation of stress, nausea, and vomiting. We discuss how prolonged cannabis use, such as in the case of CHS or heightened stress, can dysregulate the ECS and affect its modulation of these functions. The review also examines the evidence for the roles of ECS and stress systems' dysfunction in CVS and CHS to better understand the underlying mechanisms of these conditions.
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Affiliation(s)
- Marieka V. DeVuono
- Department of Anatomy and Cell BiologySchulich School of Medicine & Dentistry, Western UniversityLondonOntarioCanada
| | - Thangam Venkatesan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal MedicineThe Ohio State University College of MedicineColumbusOhioUSA
| | - Cecilia J. Hillard
- Department of Pharmacology and Toxicology and Neuroscience Research CenterMedical College of WisconsinMilwaukeeWisconsinUSA
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Bujarska M, Bora G, Li BUK, Banda J, Thomas D, Simpson P, Karrento K. Diagnostic characteristics of pediatric cyclic vomiting syndrome. J Pediatr Gastroenterol Nutr 2025; 80:417-425. [PMID: 39737559 DOI: 10.1002/jpn3.12448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 08/29/2024] [Accepted: 10/11/2024] [Indexed: 01/01/2025]
Abstract
OBJECTIVES Cyclic vomiting syndrome (CVS) remains a diagnostic challenge due to its nonspecific presentation despite consensus-based diagnostic criteria. There is a need for improved, evidence-based diagnostic criteria. We hypothesized that symptoms differ quantitatively between children with CVS versus other vomiting conditions and that current diagnostic criteria are not sufficiently sensitive for diagnosing CVS. METHODS Observational, prospective study of children ages 3-18 years with unexplained vomiting episodes evaluated in the outpatient gastroenterology clinic, emergency department, and inpatient units at Children's Wisconsin. Parents completed symptom surveys at 0, 3, and 6 months. Diagnostic workup and treatment response were monitored by chart review. A final diagnosis (CVS vs. non-CVS) was assigned for group comparisons and receiver operating characteristics (ROC) analysis of diagnostic cutoffs. RESULTS Of 108 subjects enrolled, 46 CVS and 54 non-CVS patients were analyzed. The groups reported overall different episode frequencies with more CVS versus non-CVS (81% vs. 55%) having ≥4 episodes/preceding 12 months (p = 0.013). CVS patients also had longer vomiting episodes (p = 0.03). To distinguish CVS from non-CVS, ROC analyses demonstrated the highest sensitivity for a frequency of 4-10 episodes/12 months (p = 0.002) and a duration threshold of >2 h (p < 0.001). CVS patients reported specific episode characteristics: photophobia (p = 0.003), diaphoresis (p = 0.002), multiple emeses/hour (p = 0.001), stereotypical episodes (p = 0.008), and continued retching after gastric emptying (p = 0.008). Less than half of CVS patients met Rome IV and North American Society for Pediatric Gastroenterology, Hepatology & Nutrition diagnostic criteria. CONCLUSIONS Children with CVS display a distinctive vomiting pattern and clinical features compared to other vomiting conditions. Our findings will help improve current diagnostic criteria.
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Affiliation(s)
- Malgorzata Bujarska
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Geetanjali Bora
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's National Hospital, Washington, DC, USA
| | - B U K Li
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Julie Banda
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Danny Thomas
- Division of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pippa Simpson
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Katja Karrento
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Frazier R, Ghoshal UC, Remes-Troche J, Robin D, Shun E, Aravind T. Exploring cyclic vomiting syndrome (CVS) worldwide: Current epidemiological insights and recent developments. Neurogastroenterol Motil 2025; 37:e14932. [PMID: 39370604 DOI: 10.1111/nmo.14932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 08/22/2024] [Accepted: 09/15/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND Cyclic vomiting syndrome (CVS), a disorder of gut-brain interaction, presents with recurrent episodes of severe nausea and vomiting. It is often associated with missed or delayed diagnoses and substantial healthcare utilization. Despite historical recognition dating back to the 19th century, epidemiological insights remain limited, with research predominantly originating from specific regions, such as the US. CVS prevalence and incidence rates vary widely and are hindered by inconsistent methodologies and disease recognition. PURPOSE This review aims to provide a comprehensive overview of CVS prevalence and incidence rates. It reviews the currently available data and identifies gaps in knowledge. Understanding the global epidemiology of CVS, increasing awareness of the disease, and fostering global collaboration are crucial. Other pertinent issues include disparities in outcomes, particularly among African Americans and Hispanics in the United States, underscoring the need to understand the social determinants of health that drive disease outcomes. This understanding can inform targeted interventions to address these barriers and achieve equitable healthcare both in the United States and globally.
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Affiliation(s)
- Rosita Frazier
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jose Remes-Troche
- Digestive Physiology and Motility Lab, Veracruzana University, Xalapa, Mexico
| | - Dover Robin
- Cyclical Vomiting Syndrome Association, Letchworth, UK
| | - Emoto Shun
- Department of Family Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Thavamani Aravind
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, UH Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
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Gandhi JJ, Khlevner J. A step closer to bridging the knowledge gap in pediatric cyclic vomiting syndrome. J Pediatr Gastroenterol Nutr 2025; 80:395-396. [PMID: 39718114 DOI: 10.1002/jpn3.12447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Accepted: 12/01/2024] [Indexed: 12/25/2024]
Affiliation(s)
- Jermie J Gandhi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Irving Medical Center/NewYork Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Irving Medical Center/NewYork Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
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Peles S, Khalife R, Magliocco A. Cannabinoid Hyperemesis Syndrome: A Rising Complication. Cureus 2025; 17:e78958. [PMID: 40091958 PMCID: PMC11910202 DOI: 10.7759/cureus.78958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2025] [Indexed: 03/19/2025] Open
Abstract
Cannabis, commonly known as marijuana, is a psychoactive plant that has been used for both medicinal and recreational purposes for centuries. It contains over 100 biologically active compounds known as cannabinoids, the most notable of which are tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is responsible for the euphoric and hallucinogenic effects associated with cannabis use, while CBD is often utilized for its potential therapeutic benefits, such as pain relief and anti-inflammatory properties. Despite its widespread reputation for alleviating nausea and stimulating appetite, chronic cannabis use has been linked to a paradoxical condition known as cannabinoid hyperemesis syndrome (CHS). CHS is a disorder that paradoxically causes abdominal pain, nausea, and uncontrollable vomiting in long-term cannabis users rather than alleviating pain and reducing nausea. Misdiagnosis of this condition is extremely common, and it is often confused with cyclic vomiting syndrome (CVS). The underlying pathogenesis of CHS is not completely understood, though several mechanisms have been proposed. Although considered rare, there has been a steady increase in CHS diagnoses in the Emergency Department (ED). This article summarizes the symptoms, pathogenesis, treatments for CHS, and differential diagnoses to further increase our understanding of this condition.
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Affiliation(s)
- Saar Peles
- Gastrointestinal Oncology, University of Central Florida College of Medicine, Orlando, USA
| | - Roy Khalife
- Genetics, Protean Biodiagnostics, Orlando, USA
| | - Anthony Magliocco
- Pathology, University of Central Florida College of Medicine, Orlando, USA
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Liu B, Sun H, Liu Y, Yuan ML, Zhu HR, Zhang W. Comprehensive interventions for adult cyclic vomiting syndrome complicated by superior mesenteric artery syndrome: A case report. World J Clin Cases 2024; 12:6327-6334. [PMID: 39417051 PMCID: PMC11372522 DOI: 10.12998/wjcc.v12.i29.6327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/04/2024] [Accepted: 07/23/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Cyclic vomiting syndrome (CVS) is a chronic functional gastrointestinal disorder involving the gut-brain interaction that is characterized by recurring episodes of nausea, vomiting, abdominal pain, and interspersed complete normal periods. Superior mesenteric artery (SMA) syndrome (SMAS) is a vascular condition in which the horizontal portion of the duodenum is compressed due to a reduced angle between the aorta and the SMA. This condition presents with symptoms similar to CVS, posing challenges in distinguishing between the two and often resulting in misdiagnosis or inappropriate treatment. CASE SUMMARY A 20-year-old female patient presented with recurrent episodes of vomiting and experienced a persistent fear of vomiting for the past 2 years. She adopted conscious dietary restrictions, which led to severe malnutrition. Initially, she was diagnosed with SMAS, as revealed by computed tomography angiography. Despite efforts to increase the angle between the aorta and the SMA through weight gain, her vomiting did not improve. Finally, she was diagnosed with comorbidities including CVS, SMAS and anxiety disorder. She underwent comprehensive interventions, including enteral and parenteral nutritional supplementation, administration of antiemetic and anti-anxiety agents, and participation in mindfulness-based cognitive therapy. The patient eventually experienced a notable improvement in both body weight and clinical symptoms. CONCLUSION We present a rare case of CVS in an adult complicated with SMAS and propose additional treatment with nutritional support, pharmacological intervention, and psychotherapy.
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Affiliation(s)
- Bo Liu
- Department of Psychiatry, Zigong Mental Health Center, Zigong 643020, Sichuan Province, China
| | - Hui Sun
- Department of Radiology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yang Liu
- Mental Health Center and Psychiatric Laboratory, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Min-Lan Yuan
- Mental Health Center and Psychiatric Laboratory, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hong-Ru Zhu
- Mental Health Center and Psychiatric Laboratory, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wei Zhang
- Mental Health Center and Psychiatric Laboratory, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
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Levinthal DJ, Staller K, Venkatesan T. AGA Clinical Practice Update on Diagnosis and Management of Cyclic Vomiting Syndrome: Commentary. Gastroenterology 2024; 167:804-811.e1. [PMID: 39023502 DOI: 10.1053/j.gastro.2024.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/12/2024] [Accepted: 05/14/2024] [Indexed: 07/20/2024]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding the diagnosis and management of cyclic vomiting syndrome. METHODS This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are experts in treating patients with cyclic vomiting syndrome.
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Affiliation(s)
- David J Levinthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Thangam Venkatesan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio.
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Venkatesan T, Hillard CJ, Ayer L, Arumugam S, Culp S, Vyas M, Gofar K, Petrova A, Palsson OS. Acute and Long-Term Effects of App-Delivered Heartfulness Meditation on Psychological Outcomes and the Endocannabinoid Signaling System in Cyclic Vomiting Syndrome. Clin Transl Gastroenterol 2024; 15:e00711. [PMID: 38713142 PMCID: PMC11272346 DOI: 10.14309/ctg.0000000000000711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/08/2024] Open
Abstract
INTRODUCTION Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction often triggered by stress. Interventions such as meditation may improve psychological outcomes and health-related quality of life (HRQoL), but their efficacy and the underlying mechanism are unknown. METHODS We conducted a 6-week single-arm pilot study to assess the effects of heartfulness meditation (HFM) in CVS using a custom-designed meditation app. Primary outcomes included state and trait anxiety and mood state changes pre vs post-meditation, and secondary outcomes were psychological distress, coping, sleep quality, and HRQoL at baseline and at weeks 3 and 6. Serum concentrations of endocannabinoids N -arachidonylethanolamine and 2-arachidonoylglycerol and related lipids were measured pre- and post-HFM at baseline and week 6. RESULTS In 30 treatment completers, there was a significant improvement in state anxiety ( P < 0.001), total mood disturbance ( P < 0.001), and other mood states (all P values < 0.05) across the 3 time points. Trait anxiety was also improved at week 6. There was a significant improvement in psychological distress (Global Severity Index), sleep quality (daytime dysfunction), coping (using religion/spirituality), and HRQoL (mental and physical) across the 3 time points (all P < 0.05). Significant increases in N -arachidonylethanolamine and related lipids N -oleoylethanolamine and palmitoylethanolamide post vs pre-HFM were observed at week 6 ( P < 0.001, 0.002, 0.003, respectively). No adverse effects were noted. DISCUSSION App-delivered HFM is feasible, safe, and effective and improves psychological outcomes and augments endocannabinoids. This provides insight into the mechanism underlying HFM and has potential for widespread use as a digital therapeutic in CVS and other disorder of gut-brain interaction.
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Affiliation(s)
- Thangam Venkatesan
- Section of Neurogastroenterology and Motility, Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | - Lina Ayer
- University of Michigan, Novi, Michigan, USA
| | - Saranya Arumugam
- Section of Neurogastroenterology and Motility, Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Stacey Culp
- Division of Bioinformatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Mahima Vyas
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kebire Gofar
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Ana Petrova
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Olafur S. Palsson
- Division of Gastroenterology and Hepatology, Centre for Functional GI and Motility Disorders, The University of North Carolina, Chapel Hill, North Carolina, USA
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Jiménez-Castillo RA, Frazier R, Venkatesan T, Remes-Troche JM. Cyclic vomiting syndrome: From pathophysiology to treatment. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:389-403. [PMID: 39034267 DOI: 10.1016/j.rgmxen.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 06/04/2024] [Indexed: 07/23/2024]
Abstract
Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent and unpredictable episodes of intense vomiting, interspersed with periods of apparent wellbeing. This disorder, which primarily affects children and adolescents but can persist into adulthood, has recently been the subject of extensive study and analysis in the medical literature. The aim of the present review is to examine the most important aspects of the epidemiology, pathophysiology, subtypes, diagnostic criteria, and current management of CVS. Even though the exact etiology remains unknown, genetic factors (polymorphisms), nervous system alterations and autonomic dysregulation, and environmental factors (use and abuse of cannabinoids) are postulated as possible triggers. CVS has significant diagnostic challenges, given that there is no specific test for confirming its presence. Thorough evaluation of symptoms and the ruling out of other possible causes of recurrent vomiting are required. Management of CVS typically involves a multidisciplinary approach. Pharmacologic options are explored, such as antiemetics and preventive medications, as well as behavioral and psychologic support therapies. Treatment personalization is essential, adapting it to the individual needs of each patient. Despite advances in the understanding of CVS, it remains a significant clinical challenge. This disorder impacts the quality of life of those affected and their families, underscoring the ongoing need for research and the development of more effective treatment strategies.
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Affiliation(s)
- R A Jiménez-Castillo
- Servicio de Gastroenterología y Endoscopía Digestiva, Hospital Universitario «Dr. José E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - R Frazier
- Servicio de Gastroenterología y Hepatología, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - T Venkatesan
- Servicio de Gastroenterología, Hepatología y Nutrición, The Ohio State University, Columbus, Ohio, USA
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico.
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Narang G, Chen YJ, Wedel N, Wu M, Luo M, Atreja A. Development of a Digital Patient Assistant for the Management of Cyclic Vomiting Syndrome: Patient-Centric Design Study. JMIR Form Res 2024; 8:e52251. [PMID: 38842924 PMCID: PMC11190623 DOI: 10.2196/52251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/27/2024] [Accepted: 03/06/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Cyclic vomiting syndrome (CVS) is an enigmatic and debilitating disorder of gut-brain interaction that is characterized by recurrent episodes of severe vomiting and nausea. It significantly impairs patients' quality of life and can lead to frequent medical visits and substantial health care costs. The diagnosis for CVS is often protracted and complex, primarily due to its exclusionary diagnosis nature and the lack of specific biomarkers. This typically leads to a considerable delay in accurate diagnosis, contributing to increased patient morbidity. Additionally, the absence of approved therapies for CVS worsens patient hardship and reflects the urgent need for innovative, patient-centric solutions to improve CVS management. OBJECTIVE We aim to develop a digital patient assistant (DPA) for patients with CVS to address their unique needs, and iteratively enhance the technical features and user experience on the initial DPA versions. METHODS The development of the DPA for CVS used a design thinking approach, prioritizing user needs. A literature review and Patient Advisory Board shaped the initial prototype, focusing on diagnostic support and symptom tracking. Iterative development, informed by the design thinking approach and feedback from patients with CVS and caregivers through interviews and smartphone testing, led to significant enhancements in user interaction and artificial intelligence integration. The final DPA's effectiveness was validated using the System Usability Scale and feedback questions, ensuring it met the specific needs of the CVS community. RESULTS The DPA developed for CVS integrates an introductory bot, daily and weekly check-in bots, and a knowledge hub, all accessible via a patient dashboard. This multicomponent solution effectively addresses key unmet needs in CVS management: efficient symptom and impacts tracking, access to comprehensive disease information, and a digital health platform for disease management. Significant improvements, based on user feedback, include the implementation of artificial intelligence features like intent recognition and data syncing, enhancing the bot interaction and reducing the burden on patients. The inclusion of the knowledge hub provides educational resources, contributing to better disease understanding and management. The DPA achieved a System Usability Scale score of 80 out of 100, indicating high ease of use and relevance. Patient feedback highlighted the DPA's potential in disease management and suggested further applications, such as integration into health care provider recommendations for patients with suspected or confirmed CVS. This positive response underscores the DPA's role in enhancing patient engagement and disease management through a patient-centered digital solution. CONCLUSIONS The development of this DPA for patients with CVS, via an iterative design thinking approach, offers a patient-centric solution for disease management. The DPA development framework may also serve to guide future patient digital support and research scenarios.
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Affiliation(s)
| | - Yaozhu J Chen
- Takeda Development Center Americas, Inc, Lexington, MA, United States
| | | | - Melody Wu
- Takeda Development Center Americas, Inc, Lexington, MA, United States
| | - Michelle Luo
- Takeda Development Center Americas, Inc, Lexington, MA, United States
| | - Ashish Atreja
- Rx.Health, New York, NY, United States
- UC Davis Health, University of California, Davis, Davis, CA, United States
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Patel M, Partovi O, Karrento K, Garacchi Z, Balasubramanian G, Venkatesan T. Pharmacogenomic testing for CYP2C19 and CYP2D6 in cyclic vomiting syndrome. Neurogastroenterol Motil 2024; 36:e14705. [PMID: 37953495 DOI: 10.1111/nmo.14705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 10/17/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Amitriptyline (AT) is recommended as first-line prophylactic therapy in patients with cyclic vomiting syndrome (CVS). However, significant side effects limit its use and dosing is based on trial and error. Though the Clinical Pharmacogenetic Implementation Consortium (CPIC) Guidelines recommend dosing for AT based on CY2D6 and CYP2C19 genotype profile, this is not followed in clinical practice. METHODS This pilot study determined CYP2C19 and CYP2D6 genotypes and ascertained its association with adverse drug reactions (ADRs), clinical response, and serum concentration of AT and nortriptyline in a well-characterized cohort of adults with CVS. KEY RESULTS Of 46 subjects with CVS, age 33 ± 12 years, 61% female, 85% Caucasian, a third (33%) had normal CYP2C19 metabolizer status, while 4% were poor, and 43% were ultrarapid metabolizers. Most (61%) had normal CYP2D6 genotype while 9% were poor and 2% were ultra-rapid metabolizers. There was no statistically significant association between genotype and ADRs, clinical response or serum drug concentration. There was a trend towards significance between genotype and clinical response, with 64% of responders having normal CYP2D6 metabolism versus 36% of nonresponders (p = 0.06). ADRs were encountered in 46% of patients with 28% discontinuing the medication as a result. CONCLUSIONS AND INFERENCES A subset of patients with CVS have dysfunctional alleles of CYP2C19 and CYP2D6. Larger prospective studies to evaluate the clinical impact of pharmacogenomic testing in CVS are needed. This has the potential to optimize clinical management, predict ADRs and allow for personalized therapy.
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Affiliation(s)
- Milan Patel
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Omeed Partovi
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Thavamani A, Velayuthan S, Patel D, Al-Hammadi N, Sferra TJ, Sankararaman S. Association of Anxiety and Gastrointestinal Comorbidities in Repeat Hospital Admissions in Pediatric Cyclic Vomiting Syndrome. Am J Gastroenterol 2023; 118:1439-1445. [PMID: 37052354 DOI: 10.14309/ajg.0000000000002292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/28/2023] [Indexed: 04/14/2023]
Abstract
INTRODUCTION Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder with recurrent episodes of intense nausea and vomiting and thus may require frequent hospitalizations. There is paucity of data exploring the association of psychiatric and gastrointestinal comorbidities in repeat hospitalizations among pediatric patients with CVS. METHODS We analyzed the Pediatric Health Information System database and included all patients up to 18 years of age with a diagnosis of CVS between 2016 and 2020. We excluded patients with chronic conditions, which mimic CVS. The primary outcome variable was 90-day admission rate, which was defined as a visit to emergency department or admission to observation/inpatient unit with a primary diagnosis of CVS within 90 days after an index CVS hospitalization. RESULTS We evaluated a total of 2,604 hospitalizations represented by 1,370 unique individuals. The overall 90-day admission rate was 28.5%, which steadily decreased from 35.7% in 2016 to 23% in 2019 ( P < 0.001). Patients in the repeat hospitalization cohort were slightly older and more often men. Patients with repeat admissions had an increased proportion of anxiety and other gastrointestinal disorders. Multivariable logistic regression showed that anxiety, gastroesophageal reflux disease, functional dyspepsia, and abdominal migraine were associated with increased odds of repeat admissions. DISCUSSION Ninety-day admission rates in pediatric CVS are decreasing overall, although still contributing to significant healthcare expenditure. Anxiety and gastrointestinal comorbidities were associated with increased risk of repeat admissions. Further prospective studies are needed to better understand the complex interactions of these comorbidities and their management affecting the natural course of CVS.
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Affiliation(s)
- Aravind Thavamani
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sujithra Velayuthan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Dhiren Patel
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, SSM Health Cardinal Glennon Children's Medical Center, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Noor Al-Hammadi
- The Advanced HEAlth Data (AHEAD) Research Institute, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Thomas J Sferra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Lathrop JR, Rosen SN, Heitkemper MM, Buchanan DT. Cyclic Vomiting Syndrome and Cannabis Hyperemesis Syndrome: The State of the Science. Gastroenterol Nurs 2023; 46:208-224. [PMID: 37074964 DOI: 10.1097/sga.0000000000000730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/10/2022] [Indexed: 04/20/2023] Open
Abstract
This article provides a narrative review of the state of the science for both cyclic vomiting syndrome and cannabis hyperemesis syndrome along with a discussion of the relationship between these 2 conditions. The scope of this review includes the historical context of these conditions as well as the prevalence, diagnostic criteria, pathogenesis, and treatment strategies for both conditions. A synopsis of the endocannabinoid system provides a basis for the hypothesis that a lack of cannabidiol in modern high-potency Δ 9 -tetrahydrocannabinol cannabis may be contributory to cannabis hyperemesis syndrome and possibly other cannabis use disorders. In concluding assessment, though the publications addressing both adult cyclic vomiting syndrome and cannabis hyperemesis syndrome are steadily increasing overall, the state of the science supporting the treatments, prognosis, etiology, and confounding factors (including cannabis use) is of moderate quality. Much of the literature portrays these conditions separately and as such sometimes fails to account for the confounding of adult cyclic vomiting syndrome with cannabis hyperemesis syndrome. The diagnostic and therapeutic approaches are, at present, based generally on case series publications and expert opinion, with a very limited number of randomized controlled trials and a complete absence of Level 1 evidence within the cyclic vomiting literature overall as well as for cannabis hyperemesis syndrome specifically.
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Affiliation(s)
- James R Lathrop
- James R. Lathrop, DNP, FNP, ARNP, is a PhD student under the Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Sheldon N. Rosen, MD, is Clinical Associate Professor, Division of Gastroenterology, School of Medicine, University of Washington, Seattle
- Margaret M. Heitkemper, PhD, RN, FAAN, is Professor and Elizabeth Sterling Soule Endowed Chair in Nursing, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Diana Taibi Buchanan, PhD, RN, is Associate Professor and Mary S. Tschudin Endowed Professor of Nursing Education, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
| | - Sheldon N Rosen
- James R. Lathrop, DNP, FNP, ARNP, is a PhD student under the Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Sheldon N. Rosen, MD, is Clinical Associate Professor, Division of Gastroenterology, School of Medicine, University of Washington, Seattle
- Margaret M. Heitkemper, PhD, RN, FAAN, is Professor and Elizabeth Sterling Soule Endowed Chair in Nursing, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Diana Taibi Buchanan, PhD, RN, is Associate Professor and Mary S. Tschudin Endowed Professor of Nursing Education, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
| | - Margaret M Heitkemper
- James R. Lathrop, DNP, FNP, ARNP, is a PhD student under the Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Sheldon N. Rosen, MD, is Clinical Associate Professor, Division of Gastroenterology, School of Medicine, University of Washington, Seattle
- Margaret M. Heitkemper, PhD, RN, FAAN, is Professor and Elizabeth Sterling Soule Endowed Chair in Nursing, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Diana Taibi Buchanan, PhD, RN, is Associate Professor and Mary S. Tschudin Endowed Professor of Nursing Education, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
| | - Diana Taibi Buchanan
- James R. Lathrop, DNP, FNP, ARNP, is a PhD student under the Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Sheldon N. Rosen, MD, is Clinical Associate Professor, Division of Gastroenterology, School of Medicine, University of Washington, Seattle
- Margaret M. Heitkemper, PhD, RN, FAAN, is Professor and Elizabeth Sterling Soule Endowed Chair in Nursing, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
- Diana Taibi Buchanan, PhD, RN, is Associate Professor and Mary S. Tschudin Endowed Professor of Nursing Education, Department of Biobehavioral Nursing & Health Informatics, School of Nursing, University of Washington, Seattle
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Patel M, Partovi O, Mooers H, Kovacic K, Garacchi Z, Venkatesan T. Efficacy of aprepitant as a prophylactic medication in adults with cyclic vomiting syndrome. Neurogastroenterol Motil 2023; 35:e14530. [PMID: 36740813 DOI: 10.1111/nmo.14530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/20/2022] [Accepted: 12/20/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Aprepitant is a neurokinin-1 receptor antagonist, and recent guidelines by the American Neurogastoenterology and Motility Society recommend its use as prophylaxis in moderate-to severe cyclic vomiting syndrome (CVS). Data are limited to small studies in children. We aimed to determine its efficacy in adults with CVS. METHODS A retrospective review of CVS patients diagnosed using Rome criteria at a tertiary referral center was conducted. Drug response was defined as >50% reduction in symptoms and/or healthcare utilization. An intent-to-treat (ITT) analysis was conducted. KEY RESULTS Of 96 patients prescribed aprepitant, 26 (27%) were unable to start due to cost/lack of insurance coverage. Of 70 receiving therapy, mean age was 33 ± 11 years; 51 (73%) were female and 56 (80%) Caucasian. The majority (93%) were refractory to other prophylactic medications. Aprepitant was taken thrice weekly in 51 (73%), daily in 16 (23%) and a few times a month in 3 (4%) due to cost. Fifty (71.4%) had a global symptom response to aprepitant. There was significant reduction in the number of CVS episodes (14.5 ± 11.7 to 6.2 ± 8.0, p < 0.0001), emergency department visits (4.2 ± 7.7 to 1.8 ± 3.4, p = 0.006), and hospital admissions (1.6 ± 3.9 to 0.8 ± 2.1, p = 0.02) in patients treated with aprepitant. Seven (10%) discontinued the drug due to minor side effects. CONCLUSIONS AND INFERENCES Aprepitant is a safe and effective prophylactic medication in adults with refractory CVS. Adequate insurance coverage is a major barrier preventing its use.
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Affiliation(s)
- Milan Patel
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Omeed Partovi
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Harrison Mooers
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Katja Kovacic
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Zhuping Garacchi
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Partovi O, Patel M, Kovacic K, Petrova A, Garacchi Z, Venkatesan T. Clinical characteristics and long-term outcomes in patients with cyclic vomiting syndrome: A 15-year experience at a tertiary referral center. Neurogastroenterol Motil 2023:e14571. [PMID: 36989184 DOI: 10.1111/nmo.14571] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/29/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction (DGBI) characterized by recurrent episodes of nausea and vomiting. Most children outgrow their CVS symptoms and develop migraine headaches, but there are limited data in adults. We thus sought to determine the natural history of CVS in adults. METHODS We conducted a retrospective analysis of patients at a specialized tertiary care clinic. Frequency of CVS episodes, emergency department (ED) visits, and hospitalizations were recorded at the index visit and at follow-up. KEY RESULTS Of 455 CVS patients with complete data, mean age was 33 ± 13 years, 294 (65%) were female, and 392 (86%) were Caucasian. Mean duration of follow-up was 47.4 ± 37.2 months. There was a significant reduction in frequency of CVS episodes/year (18 to 6.8), ED visits (6.1 to 2), and hospitalizations (2.3 to 0.7) (all p-values < 0.001) but only 88 (19%) of patients had complete resolution of episodes at follow-up. On multivariable regression analysis, non-white race [0.33 (0.11-0.98) p = 0.01], comorbidity count [0.77 (0.62-0.95) p = 0.01], cannabis use [0.36 (0.2-0.65) p = 0.0007], and aprepitant use [0.2 (0.08-0.005) p < 0.001] were associated with a reduced odds of complete resolution of CVS episodes. Of note, 19 patients (4%) died. CONCLUSIONS AND INFERENCES While most adults with CVS improved with specialized care, in contrast to children, only a small subset (~1 in 5) had complete resolution of symptoms. Reasons for the effects of race, cannabis use, and comorbidity burden on outcomes in CVS are unclear and warrant further investigation.
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Affiliation(s)
- Omeed Partovi
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, Wisconsin, 53226, USA
| | - Milan Patel
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, Wisconsin, 53226, USA
| | - Katja Kovacic
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, Wisconsin, 53226, USA
| | - Ana Petrova
- The Ohio State University, 395, W 12th St., Columbus, Ohio, 43210, USA
| | - Zhuping Garacchi
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, Wisconsin, 53226, USA
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Frazier R, Li BUK, Venkatesan T. Diagnosis and Management of Cyclic Vomiting Syndrome: A Critical Review. Am J Gastroenterol 2023:00000434-990000000-00677. [PMID: 36791365 DOI: 10.14309/ajg.0000000000002216] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/10/2023] [Indexed: 02/17/2023]
Abstract
Cyclic vomiting syndrome (CVS) is a chronic disorder of gut-brain interaction characterized by recurrent disabling episodes of nausea, vomiting, and abdominal pain. CVS affects both children and adults with a prevalence of approximately 2% in the United States. CVS is more common in female individuals and affects all races. The pathophysiology of CVS is unknown and a combination of genetic, environmental, autonomic, and neurohormonal factors is believed to play a role. CVS is also closely associated with migraine headaches and likely have a shared pathophysiology. The diagnosis of CVS is based on the Rome criteria, and minimal recommended testing includes an upper endoscopy and imaging studies of the abdomen. CVS is frequently associated with anxiety, depression, and autonomic dysfunction. Patients with CVS commonly use cannabis therapeutically for symptom relief. By contrast, cannabinoid hyperemesis syndrome is believed to be a subset of CVS with chronic heavy cannabis use leading to hyperemesis. Due to the recalcitrant nature of the illness, patients often visit the emergency department and are hospitalized for acute CVS flares. Guidelines on the management of CVS recommend a biopsychosocial approach. Prophylactic therapy consists of tricyclic antidepressants (amitriptyline), antiepileptics (topiramate), and aprepitant in refractory patients. Abortive therapy consists of triptans, antiemetics (ondansetron), and sedation. Treatment of comorbid conditions is extremely important to improve overall patient outcomes. CVS has a significant negative impact on patients, families, and the healthcare system, and future research to understand its pathophysiology and develop targeted therapies is needed.
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Affiliation(s)
- Rosita Frazier
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - B U K Li
- Division of Gastroenterology, Hepatology & Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Thangam Venkatesan
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Columbus, Ohio, USA
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Prevalence and incidence of cyclic vomiting syndrome in Japan: A study using Japanese claims data. PLoS One 2022; 17:e0279502. [PMID: 36548340 PMCID: PMC9778604 DOI: 10.1371/journal.pone.0279502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
Cyclic vomiting syndrome (CVS) is a gastrointestinal disorder that is characterized by recurrent episodes of vomiting. Previous studies have provided reliable data on the prevalence of CVS among children in Japan; however, neither prevalence data nor incidence of CVS is available for adults. Hence, we obtained detailed prevalence and incidence data for CVS and estimated the total number of CVS cases in Japan. This retrospective cross-sectional study was conducted using the JMDC (JMDC, Inc.; formerly known as Japan Medical Data Center Co., Ltd.,) database, which is a de-identified Japanese claims database. Individuals enrolled between January 2017 and December 2017 were included in this study. Longitudinal data for eligible populations were used to identify patients who displayed CVS symptoms throughout the follow-up period. Due to the lack of a specific diagnosis code for CVS in 2017, the Rome IV criteria were applied to identify CVS cases in the pediatric and adult populations. The prevalence was standardized to the 2017 Japanese census and extrapolated to estimate the number of CVS cases. A total of 2,093 patients with CVS were identified from 3,506,144 individuals. The overall age-and-sex-standardized prevalence was 0.32 per 1,000 population (95% confidence interval [CI]: 0.30-0.34), projected to approximately 49,000 patients with CVS across Japan. The pediatric age-and-sex-standardized prevalence was 2.10 per 1,000 population (95% CI: 2.01-2.19), and the adult prevalence was 0.05 per 1,000 population (95% CI: 0.04-0.06). Marked sex differences were observed before and after 12 years of age. Thus our study provides the first large-population-based estimates of CVS prevalence and incidence in Japan, and currently, the only estimates for adult CVS in Japan.
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Cheng S, Yu E, Garacci Z, Erwin AL, Venkatesan T. Prevalence of Undiagnosed Acute Hepatic Porphyria in Cyclic Vomiting Syndrome and Overlap in Clinical Symptoms. Dig Dis Sci 2022; 68:2107-2114. [PMID: 36380150 DOI: 10.1007/s10620-022-07756-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 10/27/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Acute hepatic porphyria (AHP) presents with nausea and vomiting and can mimic cyclic vomiting syndrome (CVS). The prevalence of AHP in CVS and overlap in clinical symptomatology is not known. We thus sought to determine the prevalence of pathogenic variants for AHP and characterize symptom overlap between CVS and AHP. METHODS We conducted a cross-sectional study of 234 CVS patients using Rome criteria. Patients were eligible for AHP genetic testing if they had recurrent episodes of severe, diffuse abdominal pain with ≥ 2 of the following-peripheral nervous system (muscle weakness/aching, numbness, tingling), central nervous system (confusion, anxiety, seizures, hallucinations), autonomic nervous system (hyponatremia, tachycardia, hypertension, constipation) symptoms, red/brownish urine, or blistering skin lesions on sun-exposed areas. A family history of AHP or elevated urinary porphobilinogen (PBG)/aminolaevulinic acid (ALA) were also criteria for genetic testing and was performed using a 4-gene panel. RESULTS Mean age was 38.7 ± 14.5 years, 180 (76.9%) were female and 200 (85.5%) were Caucasian. During a CVS attack, 173 (92%) reported abdominal pain, 166 (87.2%) had peripheral nervous system, 164 (86.8%) had central nervous system and 173 (92) % had autonomic symptoms. Ninety-one eligible patients completed genetic testing. None were positive for AHP but two had variants of uncertain significance (VUS) in the HMBS gene. CONCLUSIONS There is a high prevalence of non-gastrointestinal symptoms in CVS, like AHP, which is important for clinicians to recognize. AHP was not detected in this study and larger studies are warranted to ascertain its prevalence.
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Affiliation(s)
- Shanna Cheng
- Department of Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Elliot Yu
- Gastroenterology and Hepatology Fellow, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Zhuping Garacci
- Center for Advancing Population Science, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Angelika L Erwin
- Department of Pediatrics, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Center for Personalized Genetic Healthcare, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Thangam Venkatesan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University College of Medicine, 395 W 12th Avenue, Columbus, OH, 43210, USA.
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Frazier R, Venkatesan T. Current understanding of the etiology of cyclic vomiting syndrome and therapeutic strategies in its management. Expert Rev Clin Pharmacol 2022; 15:1305-1316. [PMID: 36259482 DOI: 10.1080/17512433.2022.2138341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Cyclic vomiting syndrome is a chronic debilitating disorder of the gut-brain interaction and is characterized by recurrent episodes of nausea and vomiting.Recent studies indicate that it is common and affects 2% of the US population. Unfortunately, there is significant heterogeneity in the management of these patients in the medical community. This review article aims to bridge this gap and will review the epidemiology and etiology with a focus on management of CVS. AREAS COVERED This article reviews the epidemiology, and pathophysiology of CVS and impact on patients. It also discusses management based on recent guidelines based on which is intended for the busy clinician. A literature search was done using PubMed and key words "cyclic vomiting", "management", "etiology", and pathophysiology were used to identify articles of importance. EXPERT OPINION CVS is a complex, poorly understood disorder of gut-brain interaction (DGBI) and has a significant negative impact on patients, families and the healthcare system. Recent guidelines recommend a multidisciplinary approach to management using prophylactic therapy in moderate-severe CVS and abortive medication for acute flares. However more research is needed to better understand the pathophysiology and develop targeted therapies for CVS.
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Affiliation(s)
- Rosita Frazier
- Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Thangam Venkatesan
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Columbus, OH
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Masri G, Barq A. Elevated Serum Pancreatic Enzymes in a Patient With Acute Epigastric Pain and End-Stage Renal Disease. Cureus 2022; 14:e24315. [PMID: 35607554 PMCID: PMC9122236 DOI: 10.7759/cureus.24315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/08/2022] [Indexed: 11/05/2022] Open
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Redon S. Episodic syndromes that may be associated with migraine: What adult neurologists need to know. Rev Neurol (Paris) 2021; 177:773-778. [PMID: 34366172 DOI: 10.1016/j.neurol.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 11/24/2022]
Abstract
Four episodic syndromes are recognized in the current version of the International Classification of Headache Disorders (ICHD): cyclic vomiting syndrome (CVS); abdominal migraine; benign paroxysmal vertigo; benign paroxysmal torticollis. Previously called childhood periodic syndromes, they are thought to be early expressions of a migrainous spectrum. They usually occur in childhood or adolescence and some of these patients will develop migraine later in childhood or in adulthood. More rarely, some of these disorders, in particular CVS and abdominal migraine, can persist or even begin at adulthood. The concept of episodic syndromes associated with migraine in adults is relatively recent, recognized for the first time in the version III-beta of the ICHD (2013). It is important for the adult neurologist to recognize the clinical pattern of these disorders. Lack of knowledge of these disorders often leads to delayed diagnosis, and a large number of complementary tests. Treatments are often borrowed from migraine abortive and preventive treatments. This review summarizes the characteristics of episodic syndromes and is particularly focused on data in adults.
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Affiliation(s)
- S Redon
- Department of Evaluation and Treatment of Pain, FHU INOVPAIN, la Timone Hospital, AP-HM, Marseille, France.
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Mooers H, Srivastava S, Venkatesan T. Editorial: topiramate for cyclic vomiting syndrome-for refractory patients only? Authors' reply. Aliment Pharmacol Ther 2021; 54:502-503. [PMID: 34331799 DOI: 10.1111/apt.16516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Harrison Mooers
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sonali Srivastava
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Mooers H, Srivastava S, Garacci E, Venkatesan T. Retrospective review of patients treated for cyclic vomiting syndrome with topiramate. Aliment Pharmacol Ther 2021; 54:153-159. [PMID: 34114666 DOI: 10.1111/apt.16457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/20/2021] [Accepted: 05/17/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Practice guidelines recommend topiramate as second-line treatment for the prevention of moderate-severe cyclic vomiting syndrome (CVS) in adults. However, data are limited to small studies in children. AIM To characterise the response to topiramate as prophylactic therapy in adults with CVS. METHODS We conducted a retrospective review of patients with CVS. Clinical characteristics, number of CVS episodes, emergency department (ED) visits, and hospitalisations the year before and after initiating topiramate were recorded. Response was defined as a global improvement in symptoms or >50% reduction in the number of CVS episodes, ED visits or hospitalisations. RESULTS Sixty-five percent (88/136) of patients responded to topiramate in an intent-to-treat analysis. There was a significant decrease in the annual number of CVS episodes (18.1 vs 6.2, P < 0.0001), CVS-related ED visits (4.3 vs 1.6, P = 0.0029), and CVS-related hospitalisations (2.0 vs 1.0, P = 0.035). Logistic regression revealed that higher doses of topiramate, longer use of topiramate (≥12 months) and topiramate as monotherapy were associated with a response to treatment. Anxiety was associated with non-response to topiramate. Fifty-five percent of patients experienced side effects, and 32% discontinued the medication as a result. The most common side effects were cognitive impairment (13%), fatigue (11%) and paresthesia (10%). This represented a refractory group with topiramate being initiated in patients (92%) who had failed treatment with tricyclic antidepressants (TCAs). CONCLUSIONS Topiramate may be an effective second-line prophylaxis for patients with moderate-severe CVS, but its use is limited by side effects. Efforts to develop better-tolerated therapies for CVS are warranted.
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Affiliation(s)
- Harrison Mooers
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sonali Srivastava
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Emma Garacci
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Cheung F, Doherty SM, Tatara AW. Ketamine in Refractory Cyclic Vomiting Syndrome: A Case Report and Review of Literature. J Pharm Pract 2021; 35:805-810. [PMID: 33813940 DOI: 10.1177/08971900211000684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To describe the use of ketamine in an adult patient in aborting a cyclic vomiting syndrome (CVS) episode. SUMMARY A 40-year-old man with a history of CVS was admitted after several days of nausea and vomiting. He was given parenteral doses of lorazepam and ondansetron but was unable to remain emesis-free. Ketamine was recommended by Gastroenterology as a therapeutic option after exhausting all first- and second-line agents. Ketamine is a noncompetitive N-methyl-D-aspartate receptor antagonist that is widely used for its analgesic and sedative effects. While there is some data to support its use in CVS, most of the published literature has been limited to the Emergency Department setting and no specific therapeutic dose has been established. We will review our institution's experience with low dose ketamine in an adult patient with a CVS episode that is refractory to first-line agents. CONCLUSION In the case described, ketamine at a low sub-anesthetic dose successfully aborted a CVS episode with no appreciable side effects. As much of ketamine's full effects remain relatively unknown, additional studies are needed to determine optimal strategies for ketamine use in patients with a CVS episode.
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Affiliation(s)
- Fiona Cheung
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Stephanie M Doherty
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
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Rosen S, Diaz R, Garacci Z, Kumar VCS, Thyarala SR, Hillard CJ, Venkatesan T. Hot-Water Bathing Improves Symptoms in Patients with Cyclic Vomiting Syndrome and Is Modulated by Chronic Cannabis Use. Dig Dis Sci 2021; 66:1153-1161. [PMID: 32472256 DOI: 10.1007/s10620-020-06343-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 05/12/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cyclic vomiting syndrome (CVS) is a chronic functional GI disorder; a characteristic compulsive "hot-water bathing" pattern is reported to alleviate symptoms during an acute episode. There is limited data on this bathing pattern: proposed mechanisms include core temperature increase via effects on cannabinoid type 1 receptors in the brain, skin transient receptor potential vanilloid 1 receptor stimulation, and blood flow shift from viscera to skin. AIMS We thus sought to characterize the hot-water bathing pattern in patients with CVS and identify differences between heavy cannabis users in comparison to occasional and non-users. METHODS We conducted a cross-sectional study of 111 patients with CVS at a single tertiary referral center. Questionnaires regarding clinical characteristics, hot-water bathing, and cannabis use were administered. Patients were classified based on cannabis usage into regular cannabis users (≥ 4 times/week), and occasional + non-users (< 4 times/week and no current use). RESULTS A total of 81 (73%) respondents reported the hot-water bathing behavior during an episode. The majority (> 80%) noted a marked improvement in nausea, vomiting, abdominal pain and symptoms associated with panic. Regular cannabis users were more likely to use "very-hot" water (50% vs. 16%, p = 0.01) and time to relief of symptoms was longer (> 10 min) in this group, compared to the rest of the cohort. CONCLUSIONS Hot-water bathing relieves both GI and symptoms related to panic in most patients which appear to be modulated by chronic cannabis use. These findings can help inform future physiologic studies in CVS pathogenesis.
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Affiliation(s)
- Sheldon Rosen
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA, USA
| | - Robert Diaz
- Pharmacology and Toxicology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Zhuping Garacci
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Vishnu Charan Suresh Kumar
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Shashank R Thyarala
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Cecilia J Hillard
- Pharmacology and Toxicology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
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Aurora SK, Shrewsbury SB, Ray S, Hindiyeh N, Nguyen L. A link between gastrointestinal disorders and migraine: Insights into the gut-brain connection. Headache 2021; 61:576-589. [PMID: 33793965 PMCID: PMC8251535 DOI: 10.1111/head.14099] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/03/2021] [Accepted: 02/15/2021] [Indexed: 12/12/2022]
Abstract
Background Migraine is a complex, multifaceted, and disabling headache disease that is often complicated by gastrointestinal (GI) conditions, such as gastroparesis, functional dyspepsia, and cyclic vomiting syndrome (CVS). Functional dyspepsia and CVS are part of a spectrum of disorders newly classified as disorders of gut–brain interaction (DGBI). Gastroparesis and functional dyspepsia are both associated with delayed gastric emptying, while nausea and vomiting are prominent in CVS, which are also symptoms that commonly occur with migraine attacks. Furthermore, these gastric disorders are comorbidities frequently reported by patients with migraine. While very few studies assessing GI disorders in patients with migraine have been performed, they do demonstrate a physiological link between these conditions. Objective To summarize the available studies supporting a link between GI comorbidities and migraine, including historical and current scientific evidence, as well as provide evidence that symptoms of GI disorders are also observed outside of migraine attacks during the interictal period. Additionally, the importance of route of administration and formulation of migraine therapies for patients with GI symptoms will be discussed. Methods A literature search of PubMed for articles relating to the relationship between the gut and the brain with no restriction on the publication year was performed. Studies providing scientific support for associations of gastroparesis, functional dyspepsia, and CVS with migraine and the impact these associations may have on migraine treatment were the primary focus. This is a narrative review of identified studies. Results Although the association between migraine and GI disorders has received very little attention in the literature, the existing evidence suggests that they may share a common etiology. In particular, the relationship between migraine, gastric motility, and vomiting has important clinical implications in the treatment of migraine, as delayed gastric emptying and vomiting may affect oral dosing compliance, and thus, the absorption and efficacy of oral migraine treatments. Conclusions There is evidence of a link between migraine and GI comorbidities, including those under the DGBI classification. Many patients do not find adequate relief with oral migraine therapies, which further necessitates increased recognition of GI disorders in patients with migraine by the headache community.
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Affiliation(s)
- Sheena K Aurora
- Medical Affairs, Impel NeuroPharma, Seattle, WA, USA.,Department of Neurology, Stanford University, Stanford, CA, USA
| | | | - Sutapa Ray
- Medical Affairs, Impel NeuroPharma, Seattle, WA, USA
| | - Nada Hindiyeh
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Linda Nguyen
- Department of Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
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Nivatsi M, Aslanidou I, Mantadakis E. Highly effective use of aprepitant in an adolescent girl with severe cyclic vomiting syndrome. BMJ Case Rep 2021; 14:e241132. [PMID: 33664041 PMCID: PMC7934711 DOI: 10.1136/bcr-2020-241132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2021] [Indexed: 01/16/2023] Open
Abstract
Cyclic vomiting syndrome (CVS) is a debilitating functional gastrointestinal disorder. Diagnosis is based on the Rome III criteria. There are no evidence-based guidelines for the management of paediatric CVS, although ondansetron and antimigraine medications are frequently tried. We describe a 13-year-old adolescent girl with severe CVS and numerous hospital admissions for dehydration because of cyclic vomiting. She had failed oral ondansetron therapy. Oral aprepitant (125 mg in the first, and 85 mg on the second and third days), a neurokinin 1 receptor antagonist that has been approved for preventing chemotherapy-induced vomiting or postoperative emesis, was tried in our patient at home during the first prodromal signs of an upset stomach. She had a dramatic response to it, with no further episodes of vomiting since its start. There is an urgent need for randomised clinical studies to assess the efficacy of available treatment options, including aprepitant in patients with severe CVS.
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Affiliation(s)
- Maria Nivatsi
- Department of Paediatrics, University General Hospital of Alexandroupolis, Alexandroupolis, Thrace, Greece
| | - Ilona Aslanidou
- Department of Paediatrics, University General Hospital of Alexandroupolis, Alexandroupolis, Thrace, Greece
| | - Elpis Mantadakis
- Department of Paediatrics, Democritus University of Thrace Faculty of Medicine, Alexandroupolis, Thrace, Greece
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Kovacic K, Li BUK. Cyclic vomiting syndrome: A narrative review and guide to management. Headache 2021; 61:231-243. [PMID: 33619730 DOI: 10.1111/head.14073] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/03/2021] [Accepted: 01/06/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/BACKGROUND Cyclic vomiting syndrome (CVS) is a disabling disorder of gut-brain interaction manifested by stereotypical and severe episodes of nausea and vomiting. Prevalence data indicate that CVS affects 1-2% of children and there has been a recent dramatic rise in diagnosed adults. METHODS This narrative review summarizes relevant literature pertaining to pediatric and adult CVS and provides a guide to management based on extensive clinical experience. RESULTS More timely diagnosis is facilitated by an expert consensus diagnostic approach and limited testing. Some diagnostic tests of exclusion remain essential. These include an upper gastrointestinal (GI) contrast study to exclude intestinal malrotation and basic laboratory screening. An abdominal ultrasound is recommended to exclude renal hydronephrosis in children and biliary disease in adults. Exclusion of metabolic/genetic conditions is warranted in those with specific warning signs, presentation in infants/toddler age, and in those with refractory disease. In the absence of chronic GI symptoms, referral to a GI specialist for upper endoscopy is generally not necessary in children but recommended in adults. A large subset termed migraine-equivalent CVS display strong clinical and genetic features of migraine. A unifying pathophysiologic core concept involves neuronal hyperexcitability and aberrant central modulation of autonomic signals. This is coupled with multiple susceptibility factors including mitochondrial dysfunction/cellular energy deficits, a hyper-responsive hypothalamic-pituitary-adrenal axis and many comorbidities that increase vulnerability to triggering events. CVS episodes are frequently triggered by stressors and intercurrent illnesses. Lifestyle and non-pharmacological interventions thus play a pivotal role in successful management. Pharmacological therapies are categorized into abortive, supportive/rescue, and prophylactic treatments. The majority respond particularly well to migraine-focused treatment strategies. CONCLUSION Despite improved characterization and understanding, CVS remains classified as a functional disorder of brain-gut interaction that is often disjointly managed by generalists and subspecialists. Early recognition, evaluation, and management will facilitate care and improve outcomes. Further research into its natural history with common progression to migraine headaches, neuroendocrine mechanisms, and the pathophysiologic relation to migraine diathesis is much needed.
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Affiliation(s)
- Katja Kovacic
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B U K Li
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
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Raucci U, Borrelli O, Di Nardo G, Tambucci R, Pavone P, Salvatore S, Baldassarre ME, Cordelli DM, Falsaperla R, Felici E, Ferilli MAN, Grosso S, Mallardo S, Martinelli D, Quitadamo P, Pensabene L, Romano C, Savasta S, Spalice A, Strisciuglio C, Suppiej A, Valeriani M, Zenzeri L, Verrotti A, Staiano A, Villa MP, Ruggieri M, Striano P, Parisi P. Cyclic Vomiting Syndrome in Children. Front Neurol 2020; 11:583425. [PMID: 33224097 PMCID: PMC7667239 DOI: 10.3389/fneur.2020.583425] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022] Open
Abstract
Cyclic Vomiting Syndrome (CVS) is an underdiagnosed episodic syndrome characterized by frequent hospitalizations, multiple comorbidities, and poor quality of life. It is often misdiagnosed due to the unappreciated pattern of recurrence and lack of confirmatory testing. CVS mainly occurs in pre-school or early school-age, but infants and elderly onset have been also described. The etiopathogenesis is largely unknown, but it is likely to be multifactorial. Recent evidence suggests that aberrant brain-gut pathways, mitochondrial enzymopathies, gastrointestinal motility disorders, calcium channel abnormalities, and hyperactivity of the hypothalamic-pituitary-adrenal axis in response to a triggering environmental stimulus are involved. CVS is characterized by acute, stereotyped and recurrent episodes of intense nausea and incoercible vomiting with predictable periodicity and return to baseline health between episodes. A distinction with other differential diagnoses is a challenge for clinicians. Although extensive and invasive investigations should be avoided, baseline testing toward identifying organic causes is recommended in all children with CVS. The management of CVS requires an individually tailored therapy. Management of acute phase is mainly based on supportive and symptomatic care. Early intervention with abortive agents during the brief prodromal phase can be used to attempt to terminate the attack. During the interictal period, non-pharmacologic measures as lifestyle changes and the use of reassurance and anticipatory guidance seem to be effective as a preventive treatment. The indication for prophylactic pharmacotherapy depends on attack intensity and severity, the impairment of the QoL and if attack treatments are ineffective or cause side effects. When children remain refractory to acute or prophylactic treatment, or the episode differs from previous ones, the clinician should consider the possibility of an underlying disease and further mono- or combination therapy and psychotherapy can be guided by accompanying comorbidities and specific sub-phenotype. This review was developed by a joint task force of the Italian Society of Pediatric Gastroenterology Hepatology and Nutrition (SIGENP) and Italian Society of Pediatric Neurology (SINP) to identify relevant current issues and to propose future research directions on pediatric CVS.
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Affiliation(s)
- Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Pediatric Gastroenterology, University College London (UCL) Institute of Child Health and Great Ormond Street Hospital, London, United Kingdom
| | - Giovanni Di Nardo
- Chair of Pediatrics, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Faculty of Medicine & Psychology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Piero Pavone
- Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale “F. Del Ponte,” University of Insubria, Varese, Italy
| | | | | | - Raffaele Falsaperla
- Neonatal Intensive Care and Pediatric Units, S. Marco Hospital, Vittorio Emanuele Hospital, Catania, Italy
| | - Enrico Felici
- Unit of Pediatrics, The Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Michela Ada Noris Ferilli
- Division of Neurology, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Salvatore Grosso
- Clinical Pediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Saverio Mallardo
- Pediatric Department, Santa Maria Goretti Hospital, Sapienza University of Rome, Latina, Italy
| | - Diego Martinelli
- Division of Metabolism, Department of Pediatric Specialties, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Paolo Quitadamo
- Department of Pediatrics, A.O.R.N. Santobono-Pausilipon, Naples, Italy
| | - Licia Pensabene
- Pediatric Unit, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Claudio Romano
- Pediatric Gastroenterology Unit, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina, Messina, Italy
| | | | - Alberto Spalice
- Child Neurology Division, Department of Pediatrics, “Sapienza,” University of Rome, Rome, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child, General and Specialistic Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Agnese Suppiej
- Pediatric Section, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Massimiliano Valeriani
- Division of Neurology, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Letizia Zenzeri
- Emergency Pediatric Department, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Annamaria Staiano
- Section of Pediatrics, Department of Translational Medical Science, “Federico II” University of Naples, Naples, Italy
| | - Maria Pia Villa
- Chair of Pediatrics, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Faculty of Medicine & Psychology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
- Institute for Research, Hospitalization and Health Care (IRCCS) “G. Gaslini” Institute, Genova, Italy
| | - Pasquale Parisi
- Chair of Pediatrics, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Faculty of Medicine & Psychology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Venkatesan T, Hillard CJ, Rein L, Banerjee A, Lisdahl K. Patterns of Cannabis Use in Patients With Cyclic Vomiting Syndrome. Clin Gastroenterol Hepatol 2020; 18:1082-1090.e2. [PMID: 31352091 DOI: 10.1016/j.cgh.2019.07.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 07/12/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Some patients with cyclic vomiting syndrome (CVS) use cannabis to relieve stress and for its antiemetic properties. However, chronic cannabis use has been associated paradoxically with cannabinoid hyperemesis syndrome (CHS) and some patients with CVS are thought to have CHS. We sought to characterize patterns of cannabis use by patients with CVS and identify those who could be reclassified as having CHS. METHODS We performed a cross-sectional study of 140 patients with CVS (72% female; mean age, 37 ± 13 y) seen at a specialized clinic. Patients were screened for cannabis use with the cannabis use disorder identification test. Patients were classified as regular (use ≥4 times/wk) or occasional users (<4 times/wk). RESULTS Forty-one percent of patients were current cannabis users, with 21% reporting regular use. Regular users were more likely to be male and to report an anxiety diagnosis, and smoked cannabis with higher tetrahydrocannabinol content and for a longer duration. Most users reported that cannabis helped control CVS symptoms. Among all cannabis users, 50 of 57 (88%) reported that they had abstained for longer than 1 month, but only 1 user reported resolution of CVS episodes during the abstinence period. This patient subsequently resumed using cannabis but remains free of symptoms. CONCLUSIONS Cannabis is used commonly among patients with CVS-patients report relief of symptoms with use. We found 21% of patients with CVS to be regular users, but only 1 met the Rome IV criteria for CHS. Longitudinal studies are needed to determine the relationships among cannabis use, hyperemesis, and mood symptoms.
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Affiliation(s)
- Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Cecilia J Hillard
- Pharmacology and Toxicology, Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lisa Rein
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anjishnu Banerjee
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Krista Lisdahl
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin
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Bhandari S, Jha P, Lisdahl KM, Hillard CJ, Venkatesan T. Recent trends in cyclic vomiting syndrome-associated hospitalisations with liberalisation of cannabis use in the state of Colorado. Intern Med J 2020; 49:649-655. [PMID: 30426628 DOI: 10.1111/imj.14164] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 10/25/2018] [Accepted: 11/08/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Currently, 33 states in the United States along with the District of Columbia have legalised cannabis in some forms. There is a paucity of data on the impact of legalisation of cannabis use on hospitalisations due to cyclic vomiting syndrome (CVS). AIM To study the trends in CVS-related hospitalisations and cannabis use in CVS in relation to legalisation of recreational cannabis use in Colorado. METHODS All hospital admissions in Colorado between 2010 and 2014 with the diagnosis of CVS were identified using the Colorado State Inpatient Database. Five-year trends in CVS-related hospitalisations along with the cannabis use were analysed. Multivariate logistic regression analysis was performed to determine predictors of cannabis use in CVS. RESULTS There was a significant increase in CVS-related hospitalisations by 46% from 806 in 2010 to 1180 in 2014 when CVS was included as all-listed diagnoses (P < 0.001). The overall prevalence of cannabis use in CVS (13% with CVS as primary diagnosis and 17% with CVS as all-listed diagnoses) was much higher than non-CVS-related hospitalisations (1.7%) (P < 0.001 for both comparisons). Cannabis use increased dramatically in both CVS and non-CVS-related hospitalisations following legalisation of cannabis for recreational use in 2012. CONCLUSION Our study shows a significant increase in CVS-related hospitalisations concomitant with an increase in cannabis use with its liberalisation in Colorado. Future studies on the relationship between cannabis use and hyperemesis are warranted, especially with its ongoing legalisation in the United States.
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Affiliation(s)
- Sanjay Bhandari
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pinky Jha
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Krista M Lisdahl
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Cecilia J Hillard
- Department of Pharmacology and Toxicology, and Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Abstract
INTRODUCTION Cyclic vomiting syndrome (CVS) is a potentially exhausting disorder and has an adverse impact on quality of life, but it is poorly recognized and is always misdiagnosed leading to a diagnostic delay of several years, especially in adults. PATIENT CONCERNS We report a case of a 32-year-old woman with recurrent severe nausea, vomiting, and abdominal pain, and repeated visits to the emergency department or the outpatient department for 4 years. Each time she was diagnosed with gastroenteritis or gastritis, and recovered after supportive treatment including antiemetics, maintenance of water and electrolyte balance, and a proton pump inhibitor. DIAGNOSIS Laboratory examinations, gastroenteroscopy, chest and abdominal computed tomography, and brain magnetic resonance imaging all failed to reveal abnormalities that would explain her symptoms. Based on typical symptoms and the exclusion of other diseases associated with repeated vomiting, the diagnosis was made as CVS. INTERVENTIONS She was given orally amitriptyline, 50 mg per night, and olanzapine, 1.25 mg per night. OUTCOMES The treatment was effective in inducing remission, and symptoms did not recur after treatment. The treatment lasted for 2 months and stopped. Her symptoms did not recur over the 10-month follow up. CONCLUSION CVS is not rare in adults, but its diagnosis is usually delayed due to poor recognition of the condition. Clinician awareness of CVS should be enhanced to improve early diagnosis.Core tip: Cyclic vomiting syndrome has a tremendous impact on the quality of life, but it is poorly recognized and is always misdiagnosed leading to a diagnostic delay of several years, especially in adults. The article presented a case report of cyclic vomiting syndrome of adult; we hope the article will attribute to increased awareness of physician and reduce delayed diagnosis.
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Affiliation(s)
- Cuilan Tang
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou 310009
| | - Ning Dai
- Department of Digestive Diseases, Sir Run Run Shaw Hospital (SRRSH), affiliated with the Zhejiang University School of Medicine, No. 3 East Qingchun Road, Hangzhou 310006, Zhejiang, China
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Venkatesan T, Levinthal DJ, Li BUK, Tarbell SE, Adams KA, Issenman RM, Sarosiek I, Jaradeh SS, Sharaf RN, Sultan S, Stave CD, Monte AA, Hasler WL. Role of chronic cannabis use: Cyclic vomiting syndrome vs cannabinoid hyperemesis syndrome. Neurogastroenterol Motil 2019; 31 Suppl 2:e13606. [PMID: 31241817 PMCID: PMC6788295 DOI: 10.1111/nmo.13606] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 03/17/2019] [Accepted: 03/25/2019] [Indexed: 12/13/2022]
Abstract
Cannabis is commonly used in cyclic vomiting syndrome (CVS) due to its antiemetic and anxiolytic properties. Paradoxically, chronic cannabis use in the context of cyclic vomiting has led to the recognition of a putative new disorder called cannabinoid hyperemesis syndrome (CHS). Since its first description in 2004, numerous case series and case reports have emerged describing this phenomenon. Although not pathognomonic, a patient behavior called "compulsive hot water bathing" has been associated with CHS. There is considerable controversy about how CHS is defined. Most of the data remain heterogenous with limited follow-up, making it difficult to ascertain whether chronic cannabis use is causal, merely a clinical association with CVS, or unmasks or triggers symptoms in patients inherently predisposed to develop CVS. This article will discuss the role of cannabis in the regulation of nausea and vomiting, specifically focusing on both CVS and CHS, in order to address controversies in this context. To this objective, we have collated and analyzed published case series and case reports on CHS in order to determine the number of reported cases that meet current Rome IV criteria for CHS. We have also identified limitations in the existing diagnostic framework and propose revised criteria to diagnose CHS. Future research in this area should improve our understanding of the role of cannabis use in cyclic vomiting and help us better understand and manage this disorder.
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Affiliation(s)
- Thangam Venkatesan
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsin
| | - David J. Levinthal
- Division of Gastroenterology, Hepatology, and NutritionUniversity of Pittsburgh Medical CenterPittsburghPennsylvania
| | - B U. K. Li
- Department of PediatricsMedical College of WisconsinMilwaukeeWisconsin
| | - Sally E. Tarbell
- Department of Psychiatry and Behavioral SciencesNorthwestern Feinberg School of MedicineChicagoIllinois
| | | | - Robert M. Issenman
- Division of Pediatric GastroenterologyMcMaster UniversityHamiltonOntarioCanada
| | - Irene Sarosiek
- Division of GastroenterologyTexas Tech University Health Sciences CenterEl PasoTexas
| | | | - Ravi N. Sharaf
- Division of GastroenterologyDepartment of Medicine and Department of Healthcare Policy and ResearchWeill Cornell Medical CenterNew YorkNew York
| | | | | | - Andrew A. Monte
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColorado
| | - William L. Hasler
- Division of GastroenterologyUniversity of Michigan Health SystemAnn ArborMichigan
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Sharaf RN, Venkatesan T, Shah R, Levinthal DJ, Tarbell SE, Jaradeh SS, Hasler WL, Issenman RM, Adams KA, Sarosiek I, Stave CD, Li BUK, Sultan S. Management of cyclic vomiting syndrome in adults: Evidence review. Neurogastroenterol Motil 2019; 31 Suppl 2:e13605. [PMID: 31241818 PMCID: PMC6899798 DOI: 10.1111/nmo.13605] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND This evidence review was conducted to inform the accompanying clinical practice guideline on the management of cyclic vomiting syndrome (CVS) in adults. METHODS We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and focused on interventions aimed at prophylactic management and abortive treatment of adults with CVS. Specifically, this evidence review addresses the following clinical questions: (a) Should the following pharmacologic agents be used for prophylaxis of CVS: amitriptyline, topiramate, aprepitant, zonisamide/levetiracetam, or mitochondrial supplements? (b) Should the following pharmacologic agents be used for abortive treatment: triptans or aprepitant? RESULTS We found very low-quality evidence to support the use of the following agents for prophylactic and abortive treatment of CVS: amitriptyline, topiramate, aprepitant, zonisamide/levetiracetam, and mitochondrial supplements. We have moderate certainty of evidence for the use of triptans as abortive therapy. We found limited evidence to support the use of ondansetron and the treatment of co-morbid conditions and complementary therapies. CONCLUSIONS This evidence review helps inform the accompanying guideline for the management of adults with CVS which is aimed at helping clinicians, patients, and policymakers, and should improve patient outcomes.
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Affiliation(s)
- Ravi N. Sharaf
- Division of GastroenterologyDepartment of MedicineWeill Cornell Medical CenterNew YorkNew York
| | - Thangam Venkatesan
- Division of GastroenterologyDepartment of MedicineMedical College of WisconsinMilwaukeeWisconsin
| | - Raj Shah
- Division of Gastroenterology and Liver DiseaseDepartment of Internal MedicineCase Western Reserve University School of MedicineClevelandOhio
| | - David J. Levinthal
- Department of MedicineDivision of Gastroenterology, Hepatology, and NutritionUniversity of Pittsburgh Medical CenterPittsburgPennsylvania
| | - Sally E. Tarbell
- Department of Psychiatry and Behavioral SciencesNorthwestern Feinberg University School of MedicineChicagoIllinois
| | - Safwan S. Jaradeh
- Department of Neurology and Neurological SciencesStanford University Medical CenterStanfordCalifornia
| | - William L. Hasler
- Division of GastroenterologyDepartment of MedicineUniversity of Michigan Medical SchoolAnn ArborMichigan
| | - Robert M. Issenman
- Division of Pediatric GastroenterologyDepartment of PediatricsMcMaster UniversityHamiltonOntario
| | | | - Irene Sarosiek
- Division of GastroenterologyDepartment of Internal MedicineTexas Tech University Health Sciences CenterLubbockTexas
| | | | - B U. K. Li
- Division of Pediatric Gastroenterology, Hepatology and NutritionDepartment of PediatricsMedical College of WisconsinMilwaukeeWisconsin
| | - Shahnaz Sultan
- Division of GastroenterologyDepartment of MedicineUniversity of MinnesotaMinneapolis Veterans Affairs Healthcare SystemMinneapolisMinnesota
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Venkatesan T, Levinthal DJ, Tarbell SE, Jaradeh SS, Hasler WL, Issenman RM, Adams KA, Sarosiek I, Stave CD, Sharaf RN, Sultan S, Li BUK. Guidelines on management of cyclic vomiting syndrome in adults by the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association. Neurogastroenterol Motil 2019; 31 Suppl 2:e13604. [PMID: 31241819 PMCID: PMC6899751 DOI: 10.1111/nmo.13604] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 12/15/2022]
Abstract
The increasing recognition of cyclic vomiting syndrome (CVS) in adults prompted the development of these evidence-based guidelines on the management of CVS in adults, which was sponsored by the American Neurogastroenterology and Motility Society (ANMS) and the Cyclic Vomiting Syndrome Association (CVSA). GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework was used and a professional librarian performed the literature search. The expert committee included the President of the CVSA who brought a patient perspective into the deliberations. The committee makes recommendations for the prophylaxis of CVS, treatment of acute attacks, diagnosis, and overall management of CVS. The committee strongly recommends that adults with moderate-to-severe CVS receive a tricyclic antidepressant (TCA), such as amitriptyline, as a first-line prophylactic medication and receive topiramate or aprepitant as alternate prophylactic medications. Zonisamide or levetiracetam and mitochondrial supplements (Coenzyme Q10, L-carnitine, and riboflavin) are conditionally recommended as alternate prophylactic medications, either alone or concurrently with other prophylactic medications. For acute attacks, the committee conditionally recommends using serotonin antagonists, such as ondansetron, and/or triptans, such as sumatriptan or aprepitant to abort symptoms. Emergency department treatment is best achieved with the use of an individualized treatment protocol and shared with the care team (example provided). The committee recommended screening and treatment for comorbid conditions such as anxiety, depression, migraine headache, autonomic dysfunction, sleep disorders, and substance use with referral to appropriate allied health services as indicated. Techniques like meditation, relaxation, and biofeedback may be offered as complementary therapy to improve overall well-being and patient care outcomes.
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Affiliation(s)
- Thangam Venkatesan
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsin
| | - David J. Levinthal
- Division of Gastroenterology, Hepatology and NutritionUniversity of Pittsburgh Medical CenterPittsburghPennsylvania
| | - Sally E. Tarbell
- Department of Psychiatry and Behavioral SciencesNorthwestern Feinberg School of MedicineChicagoIllinois
| | | | | | - Robert M. Issenman
- Division of Pediatric GastroenterologyMcMaster UniversityHamiltonOntarioCanada
| | | | - Irene Sarosiek
- Division of GastroenterologyTexas Tech University Health Sciences CenterEl PasoTexas
| | | | - Ravi N. Sharaf
- Division of GastroenterologyDepartment of Healthcare Policy and ResearchWeill Cornell Medical CenterNew YorkNew York
| | | | - B U. K. Li
- Division of GastroenterologyDepartment of PediatricsMedical College of WisconsinMilwaukeeWisconsin
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BAGHERIAN Z, YAGHINI O, SANEIAN H, BADIHIAN S. Comparison of the Efficacy of Amitriptyline and Topiramate in Prophylaxis of Cyclic Vomiting Syndrome. IRANIAN JOURNAL OF CHILD NEUROLOGY 2019; 13:37-44. [PMID: 30613204 PMCID: PMC6296701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 12/16/2017] [Accepted: 12/27/2017] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Cyclic vomiting syndrome (CVS) is a chronic functional gastrointestinal disorder with no certain treatment. We aimed to compare the efficacy of amitriptyline and topiramate on prophylactic therapy of CVS. MATERIALS & METHODS This randomized clinical trial (registration number: IRCT2015102316844N2) was conducted during 2016 in Isfahan, central Iran. The inclusion criteria were CVS patients (based on Rome III) aging 3-15 yr with normal physical examination, no metabolic disorder, and no gastrointestinal obstruction or renal impairment. Recruited patients were divided into two groups of amitriptyline (1 mg/kg/d) and topiramate (1-2 mg/kg/d) and were followed for 3-months. The outcome was evaluated by comparing severity of attacks (monthly frequency and duration of attacks) before and after intervention. RESULTS Thirty-six children entered each group and two patients left the amitriptyline group. Patients and disease characteristics were similar between groups before intervention (P>0.05). The frequency of attacks (standard deviation) after intervention in amitriptyline and topiramate group was 0.91 (0.40) and 1.07 (0.55), respectively (P=0.368) and the duration of attacks (SD) after intervention were 3.43 (2.46) and 4.90 (3.03), respectively (P=0.017). Twenty-three patients (68%) in amitriptyline group and 14 patients (39%) in topiramate group stopped having attacks after intervention (P=0.016). CONCLUSION Amitriptyline is a better choice to reduce severity of CVS attacks compared to topiramate, in a short-term evaluation. Studies with longer follow-up are required to investigate these findings in a longer period.
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Affiliation(s)
- Zahra BAGHERIAN
- Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid YAGHINI
- Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein SANEIAN
- Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shervin BADIHIAN
- Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Yu ES, Priyadharsini S S Y, Venkatesan T. Migraine, Cyclic Vomiting Syndrome, and Other Gastrointestinal Disorders. ACTA ACUST UNITED AC 2018; 16:511-527. [PMID: 30361855 DOI: 10.1007/s11938-018-0202-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Cyclic vomiting syndrome (CVS) is a chronic functional gastrointestinal disorder characterized by episodic nausea and vomiting and is diagnosed using Rome IV criteria. CVS is being recognized more frequently in adults with a prevalence of 2%. It is associated with several functional disorders like autonomic dysfunction, anxiety, and depression, but the strongest association is with migraine. We will elucidate the close relationship between migraine and CVS and briefly discuss its association with other gastrointestinal disorders. RECENT FINDINGS We highlight similarities in pathophysiology, clinical presentation, and response to medications between CVS and migraine (tricyclic antidepressants, triptans, antiepileptics). We also discuss novel therapies like CGRP inhibitors which are effective in migraine and have potential for adaptation in patients with CVS. Using migraine as a template should enable investigators to elucidate the mechanisms underlying this disorder, develop novel therapies, and direct future research in CVS.
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Affiliation(s)
- Elliot S Yu
- Department of Internal Medicine, The Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Yasodara Priyadharsini S S
- Division of Gastroenterology and Hepatology, The Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, The Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
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Kovacic K, Sood M, Venkatesan T. Cyclic Vomiting Syndrome in Children and Adults: What Is New in 2018? Curr Gastroenterol Rep 2018; 20:46. [PMID: 30159612 DOI: 10.1007/s11894-018-0654-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE OF REVIEW Cyclic vomiting syndrome (CVS) is a disabling functional gastrointestinal disorder characterized by severe vomiting episodes that alternate with symptom-free periods. The purpose of this review is to summarize current knowledge and highlight most recent data on prevalence, diagnosis, management, and impact of CVS in children and adults. RECENT FINDINGS Originally thought to be a pediatric disorder, the past decade has witnessed a considerable increase in CVS diagnosed in adults. Despite improved recognition of CVS, without a delineated pathophysiology and specific biomarker, it remains classified as a functional gastrointestinal disorder. Migraines and CVS share a common pathway based on several studies and response to migraine therapy. Recent work has begun to expand the list of comorbidities and identify plausible mechanisms and new therapeutic avenues. This review seeks to highlight best practices and novel therapies for CVS based on expert consensus and review of available literature.
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Affiliation(s)
- Katja Kovacic
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, 9000 W. Wisconsin Avenue, Milwaukee, WI, 53226, USA.
| | - Manu Sood
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, 9000 W. Wisconsin Avenue, Milwaukee, WI, 53226, USA
| | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Taranukha T, Kumar VCS, Seamon A, Sahr N, Szabo A, Venkatesan T. Depression, young age, chronic marijuana use, and interepisodic symptoms predict psychological distress in patients with cyclic vomiting syndrome. Neurogastroenterol Motil 2018; 30:e13245. [PMID: 29152814 PMCID: PMC5878695 DOI: 10.1111/nmo.13245] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 10/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cyclic vomiting syndrome (CVS) is often triggered by stress. Patients report high degrees of psychological distress due to CVS, but there is limited data on factors associated with psychological distress. We sought to determine the degree of psychological distress and its correlation with clinical characteristics in CVS. METHODS The Brief Symptom Inventory (BSI), a validated tool to determine psychological distress, was administered prospectively to patients. The control population consisted of 719 normal subjects. Student's t test was used to compare means, and logistic regression analysis was performed to identify predictors of a GSI score ≥63, indicating high degrees of psychological distress. Scores for the regression predictors were calculated using the maximum likelihood estimate for the logistic regression model and was called the DAME score (depression, age 25-35, chronic marijuana use, and interepisodic GI symptoms). KEY RESULTS Of 87 patients, 60% were female, 92% were caucasian, and mean age was 37 years. Forty-one percent of patients had high degrees of psychological distress with the highest scores for somatization. Independent predictors of psychological distress included depression, young age (25-35 years), chronic marijuana use, and interepisodic dyspepsia (called the DAME score). A score of ≥7 accurately predicted psychological distress in >88% of patients. CONCLUSIONS & INFERENCES Psychological distress is common in CVS and can be predicted accurately using our proposed DAME score. Whether psychological distress is a cause or an effect of CVS needs to be determined. Addressing psychological distress can potentially improve overall healthcare outcomes in CVS.
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Affiliation(s)
- Tatyana Taranukha
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin
| | | | - Alex Seamon
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin
| | - Natasha Sahr
- Division of Biostatistics, Medical College of Wisconsin
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin
| | - Thangam Venkatesan
- Professor of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, 9200 West Wisconsin Avenue, Milwaukee, Wisconsin 53226
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Hayes WJ, VanGilder D, Berendse J, Lemon MD, Kappes JA. Cyclic vomiting syndrome: diagnostic approach and current management strategies. Clin Exp Gastroenterol 2018; 11:77-84. [PMID: 29520160 PMCID: PMC5833754 DOI: 10.2147/ceg.s136420] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Cyclic vomiting syndrome (CVS) is a disorder characterized by episodes of nausea and vomiting lasting for 1-5 days followed by asymptomatic periods. The etiology of CVS is unknown, but it shares similar characteristics to migraine headaches. CVS is generally classified as having four phases: prodromal, acute/vomiting/hyperemesis, recovery, and remission/interepisodic. Current management strategies include trigger avoidance, abortive and prophylactic medication therapies, and supportive care. The goal of therapy for the remission phase is prophylaxis of further episodes. Antidepressant, antiepileptic, and antimigraine medications show an overall reduction or remission of CVS symptoms in more than 70% of patients. This article provides a summary of diagnostic strategies and reviews current management strategies for CVS.
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Affiliation(s)
- William J Hayes
- Department of Pharmacy Practice, South Dakota State University, Regional Health Medical Clinic, Rapid City, SD, USA
| | - Deidra VanGilder
- South Dakota State University, College of Pharmacy and Allied Health Professions, Brown Clinic, Watertown, SD, USA
| | - Joseph Berendse
- Department of Pharmacy Practice, South Dakota State University, College of Pharmacy and Allied Health Professions, VA Black Hills Health Care System, Fort Meade, SD, USA
| | - Michael D Lemon
- Department of Pharmacy Practice, South Dakota State University, College of Pharmacy and Allied Health Professions, VA Black Hills Health Care System, Fort Meade, SD, USA
| | - John A Kappes
- Department of Pharmacy Practice, South Dakota State University, College of Pharmacy and Allied Health Professions, Rapid City Regional Hospital, Rapid City, SD, USA
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Bhandari S, Jha P, Thakur A, Kar A, Gerdes H, Venkatesan T. Cyclic vomiting syndrome: epidemiology, diagnosis, and treatment. Clin Auton Res 2018; 28:203-209. [PMID: 29442203 DOI: 10.1007/s10286-018-0506-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 01/19/2018] [Indexed: 12/19/2022]
Abstract
Cyclic-vomiting syndrome (CVS) is a chronic functional gastrointestinal disorder characterized by recurrent episodes of nausea and vomiting. Although once thought to be a pediatric disorder, there has been a considerable increase in recognition of CVS in adults. The exact pathogenesis is unknown and several theories have been proposed. Migraine and CVS share a similar pathophysiology as suggested by several studies. Since there are no specific biomarkers available for this disorder, physicians should rely on Rome criteria for the diagnosis. Due to the lack of randomized control trials, the treatment of CVS is primarily empirical.
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Affiliation(s)
- Sanjay Bhandari
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA. .,Division of General Internal Medicine, Clinical Cancer Center, Medical College of Wisconsin, 9200 W Wisconsin Ave, 5th Floor, Milwaukee, WI, 53226, USA.
| | - Pinky Jha
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Abhishek Thakur
- Quinnipiac University Frank H. Netter MD School of Medicine, North Haven, CT, USA
| | - Abhipsa Kar
- Medical College of Wisconsin, Wisconsin, WI, USA
| | | | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Bhandari S, Venkatesan T. Clinical Characteristics, Comorbidities and Hospital Outcomes in Hospitalizations with Cyclic Vomiting Syndrome: A Nationwide Analysis. Dig Dis Sci 2017; 62:2035-2044. [PMID: 28050780 DOI: 10.1007/s10620-016-4432-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/21/2016] [Indexed: 12/09/2022]
Abstract
BACKGROUND Data on cyclic vomiting syndrome (CVS) are limited to studies from tertiary care centers. There is a paucity of information about CVS on a national scale. AIM To study the clinical characteristics, comorbidities, and hospital outcomes in patients hospitalized with CVS using a nationwide database. METHODS We identified all hospitalizations associated with a primary diagnosis of CVS in 2010 and 2011 using the Nationwide Inpatient Sample with an age category of 18-55 years. A 1:2 random sample of non-CVS hospitalizations with the same age category was obtained, and comparisons between groups were made. Multivariate logistic regression analysis was used to determine comorbidities independently associated with CVS. RESULTS Our study included 20,952 CVS and 44,262 non-CVS patients. CVS patients tended to be younger, male, and white compared to non-CVS patients. On multivariate analysis, CVS was significantly associated with comorbidities including dysautonomia, migraine, anxiety, marijuana use, irritable bowel syndrome, gastroparesis, gastroesophageal reflux disease, asthma, cigarette smoking, and hypertension. CVS patients underwent esophagogastroduodenoscopy, colonoscopy, and gastric emptying tests more frequently. They had more favorable hospital outcomes like more routine discharges (discharge to home/self-care), lower mortality, and shorter length of stay but tended to leave against medical advice more frequently. CVS patients incurred total hospital charges of about $400 million over the 2 years. CONCLUSIONS Our study showed that CVS is associated with several comorbidities and incurred substantial health care costs despite benign outcomes. Efforts to optimize therapy of CVS, manage comorbid conditions and reduce healthcare utilization are warranted.
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Affiliation(s)
- Sanjay Bhandari
- Division of General Internal Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA.
| | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Redon S, Mareau C, Guedj E, Donnet A. Cyclic Vomiting Syndrome in Adults and Children: A Hypothesis. Headache 2017; 57:943-951. [DOI: 10.1111/head.13108] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 03/14/2017] [Accepted: 03/14/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Sylvain Redon
- Department of Evaluation and Treatment of Pain; La Timone Hospital; Marseille France
| | - Cécile Mareau
- Department of Evaluation and Treatment of Pain; La Timone Hospital; Marseille France
| | - Eric Guedj
- Service Central de Biophysique et de Médecine Nucléaire, Assistance Publique des Hôpitaux de Marseille; Centre Hospitalo-Universitaire de la Timone; Marseille France
| | - Anne Donnet
- Department of Evaluation and Treatment of Pain; La Timone Hospital; Marseille France
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Recurrent Gastrointestinal Disturbance: Abdominal Migraine and Cyclic Vomiting Syndrome. Curr Neurol Neurosci Rep 2017; 17:21. [DOI: 10.1007/s11910-017-0731-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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