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.

The aim of this study was to assess clinical, economic, and epidemiological characteristics of hospitalized patients in the United States with cyclic vomiting syndrome (CVS).

CVS is a poorly understood disorder of gut-brain interaction (DGBI) characterized by recurring episodes of intractable nausea and vomiting.

The study utilized the Healthcare Cost and Utilization Project's National Inpatient Sample between 2016 and 2019. χ2 test and logistic regression were performed to compare the variables. All analyses included sample weights, strata, and clusters to account for the complex survey design.

Admission rates declined from 11,055 in 2016 to 8625 in 2019. Mean age (34.7 y), females (62.5%), and racial distribution (61.8% white) remained stable. Patients were more likely to be 18 to 30 years old (37.2%) and female (62.5%). Comorbidities included anxiety/depression (38.6%) and cannabis use (35.0%). Overall, 90.4% were discharged routinely (ie, to home). Older age (P=0.002) and female gender (P<0.001) had higher length of stay (LOS) and charges. Hispanics incurred higher costs (P<0.001). Depression/anxiety comorbidity (P<0.001) and teaching hospitals (P<0.001) were associated with significantly higher LOS and cost.

The number of hospitalizations declined between 2016 and 2019, with the latter having 8625 hospitalizations costing over $300 million. Young females represent a larger group, African Americans were disproportionally affected, and Hispanics had the highest hospitalization costs. Anxiety and depression are primary comorbidities. The disparities identified can help clinicians identify riskier CVS patients who may become a burden on the healthcare system, stratifying them for closer monitoring with the goal of improved outcomes.

Cyclic vomiting syndrome (CVS) is a disorder characterized by sudden, recurrent episodes of severe nausea and vomiting. The pathophysiology of CVS is not known but genetic factors that regulate emetic neurocircuitry have been proposed. The aim of this study was to investigate whether different variations in genes encoding serotonin receptors (HTRs) are associated with susceptibility to CVS and/or CVS symptoms.

This case-control study included 70 patients with CVS:16 male and 54 female, and 2504 healthy controls from the 1000 Genomes Project database. Single-nucleotide polymorphisms (SNPs) in genes encoding serotonin receptors (HTR1B, HTR1D, HTR3B and HTR3C) and correlations between SNPs and the symptoms of CVS were determined.

Our study discovered that patients with GG, AA and GG genotypes of HTR1B/D rs6296, rs6298 and rs6300, respectively, as well as the CC genotype of HTR3B rs176744 are associated with an increased risk (p < 0.001), whereas allele C in rs3788987 (HTR3B, p < 0.01) and allele A in rs6766410 (HTR3C, p < 0.05) were associated with a decreased risk of CVS. In addition, statistical analysis indicated that CVS patients with GA or AA genotypes of HTR1D rs676643 gene have a seven-fold increase in risk of depression compared to patients with GG genotype (p < 0.01).

Our study revealed for the first time that variations in 5-HTR genes may contribute to CVS susceptibility and CVS-related symptoms.

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.

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.

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.

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.

Cyclic vomiting syndrome (CVS) and cannabinoid hyperemesis syndrome (CHS) are both characterized by episodic, acute transitions from asymptomatic states to highly symptomatic states of nausea, repetitive vomiting, and often severe abdominal pain. Patients with CVS and CHS face significant challenges to abort or mitigate episodes at home and often require emergency department (ED)-based care.

This paper reviews the current treatment approach to abort acute CVS and CHS episodes at home and in ED settings. Multiple pharmacologic and nonpharmacologic interventions have been demonstrated to potentially abort CVS or CHS episodes. Systemic pharmacologic agents often used as abortive therapy include triptans, antiemetics, anxiolytics, NK-1 receptor antagonists, antipsychotics, sedatives in general, and various analgesic / anti-inflammatory medications. Nonsystemic, nonpharmacologic approaches include reducing external stimuli (quiet room, dim lights, etc.), and hot water bathing or the application of topical capsaicin cream. More research is needed to develop evidence-based, individualized abortive treatment plans, as well as to determine whether the abortive treatment for CVS requires a fundamentally different approach than for CHS. When home-based approaches fail, all patients with CVS or CHS should receive nonjudgmental, informed, and compassionate care in the ED to abort their episode. Patients with more severe forms of CVS/CHS who require more frequent ED utilization should develop care plans with their ED to assure predictable and effective treatment.

Cyclic vomiting syndrome (CVS) is identified as one of the "episodic syndromes that may be associated with migraine," along with benign paroxysmal torticollis, benign paroxysmal vertigo, and abdominal migraine. It has been proposed that CVS and migraine may share pathophysiologic mechanisms of hypothalamic activation and altered dopaminergic signaling, and impaired sensorimotor intrinsic connectivity. The past decade has brought groundbreaking advances in the treatment of migraine and other headache disorders. While many of these therapies have yet to be studied in episodic syndromes associated with migraine including CVS and abdominal migraine, the potential shared pathophysiology among these conditions suggests that use of migraine-specific treatments may have a beneficial role even in those for whom headache is not the primary symptom.

This manuscript highlights newer therapies in migraine. Calcitonin gene-related peptide (CGRP) and its relation to migraine pathophysiology and the therapies that target the CGRP pathway, as well as a 5HT1F receptor agonist and neuromodulation devices used to treat migraine are briefly discussed as they may potentially prove to be useful in the future treatment of CVS.

Cyclic vomiting syndrome (CVS) is a phasic disorder of gut-brain interaction characterized by episodes of severe nausea and vomiting. In-depth qualitative research on phase-specific CVS symptoms and impacts is lacking. The study objectives were to explore the experience of patients with CVS in the United States and to identify CVS symptoms and impacts on adults, adolescents, and caregivers.

Qualitative, cross-sectional, semi-structured concept elicitation interviews were conducted with adults and adolescents with CVS and with adolescents' caregivers. Adolescents either participated alone or in a dyad format with their caregiver. Interview data were analyzed using an open coding approach.

Concept elicitation interviews were conducted with 13 adults (mean age 45.3 years [standard deviation (SD) 13.1]) and 15 adolescents (mean age 14.6 years [SD 1.8]). The most frequently reported prodrome phase symptoms were nausea (n = 12, 92.3%), anxiety (n = 10, 76.9%), and abdominal pain (n = 9, 69.2%) in adults, and nausea (n = 15, 100%), abdominal pain (n = 11, 73.3%), and headache (n = 11, 73.3%) in adolescents. All adults reported nausea, tiredness, and dry heaves in the emetic phase, and 12 (92.3%) reported vomiting and retching. The remaining patient said they no longer vomited due to abortive medications. All adolescents reported nausea and vomiting in the emetic phase; other common emetic phase symptoms were abdominal pain (n = 14, 93.3%), dehydration (n = 13, 86.7%), and tiredness (n = 13, 86.7%). The leading most bothersome impact reported by adults was anxiety associated with impending vomiting (n = 5, 38.5%). Among adolescents, the leading most bothersome impact was on school (n = 7/13 asked, 53.8%), and among their caregivers, it was seeing their child suffer (n = 6/11 asked, 54.5%).

Patients with CVS experience considerable gastrointestinal and extra-intestinal symptoms. CVS impacts the activities of daily life of patients and their caregivers, with patients reporting negative effects of CVS on their emotional status and their ability to maintain a normal school or work routine.

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.

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.

We present a rare case of CVS in an adult complicated with SMAS and propose additional treatment with nutritional support, pharmacological intervention, and psychotherapy.

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.

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.

The endocannabinoid system (ECs) is composed of multiple signaling compounds and receptors within the central and peripheral nervous system along with various organs, including the gut, liver, and skeletal muscle. The ECs has been implicated in metabolism, gut motility, and eating behaviors. The ECs is altered in disease states such as obesity. Recent studies have clarified the role of the gut microbiome and nutrition on the ECs. Exogenous cannabinoid (CB) use, either organic or synthetic, stimulates the ECs through CB1 and CB2 receptors. However, the role of CBs is unclear in regard to nutrition optimization or to treat disease states. This review briefly summarizes the effect of the ECs and exogenous CBs on metabolism and nutrition. With the increased legalization of cannabis, there is a corresponding increased use in the United States. Therefore, nutrition clinicians need to be aware of both the benefits and harm of cannabis use on overall nutrition status, as well as the gaps in knowledge for future research and guideline development.

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.

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.

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.

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.

Cyclic vomiting syndrome (CVS) is a chronic digestive disorder characterized by recurrent episodes of severe nausea and vomiting. The perioperative management of patients with CVS undergoing general anesthesia is challenging, especially when combined with obesity. This case report describes the successful management of a patient with CVS and obesity who underwent dental surgery under general anesthesia. A 21-year-old woman with CVS, obesity (body mass index, 35), and intellectual disability was scheduled for tooth extraction and composite resin restoration under general anesthesia. The patient was diagnosed with CVS at the age of 20 years with frequent vomiting attacks requiring hospitalization. Surgery was scheduled during the CVS remission to reduce the risk of perioperative vomiting. Preoperative laboratory test results were normal, including serum adrenocorticotropic hormone (ACTH), anti-diuretic hormone (ADH), and cortisol levels. General anesthesia was induced using remifentanil and propofol. Nasal endotracheal intubation was performed after rocuronium administration. Local anesthesia (2% lidocaine with 1:80,000 epinephrine) was used for all dental procedures. Postoperatively, midazolam was administered to control agitation. No postoperative vomiting occurred. Serum ACTH, ADH, and cortisol levels showed no significant changes before and after anesthesia, suggesting that hypothalamic-pituitary-adrenal (HPA) axis activation due to surgical stress did not occur. This case highlights the importance of careful perioperative planning and monitoring stress-related hormone levels in patients with CVS or obesity. An anesthetic approach using midazolam may effectively suppress HPA axis activation and prevent postoperative vomiting.

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding diagnosis and management of cannabinoid hyperemesis syndrome.

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.

The synthesis and degradation of endocannabinoids, location of cannabinoid (CB) receptors, and cannabinoid mechanisms of action on immune/inflammatory, neuromuscular, and sensory functions in digestive organs are well documented. CB2 mechanisms are particularly relevant in immune and sensory functions. Increasing use of cannabinoids in the United States is impacted by social determinants of health including racial discrimination, which is associated with tobacco and cannabis co-use, and combined use disorders. Several conditions associated with emesis are related to cannabinoid use, including cannabinoid hyperemesis or withdrawal, cyclic vomiting syndrome, and nausea and vomiting of pregnancy. Cannabinoids generally inhibit gastrointestinal motor function; yet they relieve symptoms in patients with gastroparesis and diverse nausea syndromes. Cannabinoid effects on inflammatory mechanisms have shown promise in relatively small placebo-controlled studies in reducing disease activity and abdominal pain in patients with inflammatory bowel disease. Cannabinoids have been studied in disorders of motility, pain, and disorders of gut-brain interaction. The CB2-receptor agonist, cannabidiol, reduced the total Gastroparesis Cardinal Symptom Index and increases the ability to tolerate a meal in patients with gastroparesis appraised over 4 weeks of treatment. In contrast, predominant-pain end points in functional dyspepsia with normal gastric emptying were not improved significantly with cannabidiol. The CB2 agonist, olorinab, reduced abdominal pain in inflammatory bowel disease in an open-label trial and in constipation-predominant irritable bowel syndrome in a placebo-controlled trial. Cannabinoid mechanisms alter inflammation in pancreatic and liver diseases. In conclusion, cannabinoids, particularly agents affecting CB2 mechanisms, have potential for inflammatory, gastroparesis, and pain disorders; however, the trials require replication and further understanding of risk-benefit to enhance use of cannabinoids in gastrointestinal diseases.

The author reports a 19-year-old woman suffering from repeated episodes of non-bloody vomiting for 18 months. All routine and special investigations were normal. She was labeled as a case of cyclic vomiting syndrome (CVS), and she developed insomnia after the initiation of amitriptyline as a prophylactic treatment. The case was reported to increase awareness regarding the importance of monitoring medication side effects among clinicians when using different classes of medications to treat CVS.