Cyclic Vomiting Syndrome

Cyclic vomiting syndrome is a condition in which there are episodes of severe vomiting without any noticeable cause. As the name suggests, the episodes occur in a cycle. Each episode resembles the previous in terms of duration, intensity, symptoms and time of initiation. You or your child may experience the symptoms for hours in a day followed by a symptom-free episode on the next day. It was originally believed to affect children only, but it can affect people of any age.

The incidence of cyclic vomiting syndrome in adults is rising and study suggests almost 2% of school going kids are affected by this. A link between cyclic vomiting syndrome and migraines has been proposed. Often, you may have to take complete bed rest for days due to severe vomiting.

Diagnosis is difficult as vomiting is a non-specific symptom that could be indicative of a variety of disorders. Treatment focuses on symptom management and lifestyle modifications to avoid the triggering factors. Symptoms can also be managed by anti-vomiting medications and migraine therapies.

The symptoms of cyclic vomiting syndrome are: 

• Severe vomiting occurring frequently and lasting for less than seven days 
• Three or more separate vomiting episodes in the past year, which cannot be connected to any cause

Other symptoms during a vomiting episode may include: 

• Stomachache 
• Diarrhea 
• Fever 
• Dizziness 
• Sensitivity to light 

Usually, a vomiting episode is succeeded by a symptom-free episode while in some people, mild to moderate nausea or pain in stomach or extremities is reported between episodes. Vomiting that last longer can cause severe loss of fluids and electrolytes resulting in fatal dehydration. Some common symptoms of dehydration are: 

• Thirst 
• Reduced urination 
• Unusually light skin (paleness) 
• Tiredness and lack of vigor

It’s not clear what causes cyclic vomiting syndrome but it may be triggered by: 

• Colds, allergies or sinus problems 
• Emotional stress or excitement, especially in children 
• Anxiety or panic attacks, especially in adults 
• Foods, such as chocolate or cheese 
• Excessive eating or eating right before going to bed 
• Hot weather 
• Fatigue
• Menstruation 
• Motion sickness 

Diagnosis of cyclic vomiting syndrome is often difficult due to absence of specific symptoms.

After you visit your primary care doctor or your child's pediatrician, you may be referred immediately to a gastroenterologist (a specialist in digestive disorders). If you have continuous severe vomiting, seek immediate medical care. 

How to prepare yourself for the visit?

Getting prepared for the visit can optimize the therapy and help make the visit more fruitful.

List out all the symptoms. Mention duration, frequency of vomiting and triggering factors

Write down your key medical information. 

Write down the names of all your medications, vitamins or supplements. 

Make a list of the questions to ask your doctor. Some typical questions can be: 

• What could be the most likely cause of these symptoms? 
• Are any tests needed? 
• Is this condition temporary or long lasting? 
• What are the treatment options? 
• Can any medication help? 
• Is it necessary to follow any dietary restrictions? 

What your doctor wants to know?

A clear talk with your doctor can optimize the therapy and improve the outcomes. Prepare yourself to answer some essential questions from your doctor. Your doctor might ask you typical questions like: 

• When did the symptoms start appearing? 
• Can you tell me about the frequency of vomiting and duration of an episode? 
• Is vomiting accompanied by abdominal pain? 
• Is your episode preceded by any warning signs, such as loss of appetite or feeling unusually tired, or any triggering factors, such as intense emotions, illness or menstruation? 
• Is there a history of any other medical problems, including mental health conditions? 
• What treatments (over-the-counter medications and home remedies) are being administered for other conditions? 
• Does anything improve the symptoms or reduce the duration of an episode? 
• Is there a history of severe headaches? 
• Has anyone in your family suffered from cyclic vomiting syndrome or of migraines? 

What you can do in the meantime? 

The doctor will observe the episode of vomiting, if possible. But if it’s over, s/he may recommend increased fluid intake, proper rest and an easily digestible diet to promote recovery. You may also avoid or ask your child to avoid caffeine. 

No test can confirm the diagnosis but tests can be performed to rule out other possible causes of vomiting. Diagnosis starts with review of your or your child’s medical history followed by a physical exam. The doctor may also recommend: 

• Imaging studies such as endoscopy, CT scan or magnetic resonance enterography to determine if there are other digestive problems. 
• Motility tests to assess how the food you or your child takes moves along the gastrointestinal tract. 
• Laboratory tests to detect problems with thyroid and other metabolic conditions, if any 
• MRI to determine if a brain tumor and other central nervous system disorders are present

Like the cause, cure has not been discovered yet and the treatment of cyclic vomiting syndrome is aimed at managing the the signs and symptoms. Following medications may be prescribed: 

• Drugs to prevent vomiting or nausea 
• Drugs to reduce excitement (sedatives) 
• Stomach acid suppressing medications 
• Depression medications (antidepressants) 
• Migraine medications: If the vomiting episodes are frequent and persistent, migraine medications may be prescribed to control, or less commonly to prevent episodes of cyclic vomiting.
• Behavioral therapy: Studies suggest that depression or anxiety occur in approximately half of the victims of cyclic vomiting syndrome. However, there is no clear link between depression or anxiety and cyclic vomiting episodes as the cause and effect of each other. Behavioral therapy may help you or your child manage depression or anxiety.

The best way to prevent cyclic vomiting syndrome episodes is to avoid personal triggers, which vary from person to person. People with this syndrome are aware of the triggers that initiate vomiting episodes. In cases when episodes are severe requiring hospitalization or frequent (occur more than once a month), you may need to take preventive medications as prescribed by the doctor. You may follow these lifestyle modification tips: 

• Get enough sleep 
• Keep calm and keep your excitements under control
• Avoid trigger foods, such as cheese and chocolate 
• Have three small meals and three snacks in a day at almost same times every day

A few alternative remedies exist for preventin symptoms of cyclic vomiting syndrome.

Though there are few studies to back their effectiveness, you may try following alternative and complementary treatments to prevent vomiting episodes: 

• Biofeedback training: It may help you to effectively manage stress.
• L-carnitine: A naturally occurring substance in your body, it is available as a supplement and may help to burn your body fat to generate energy. 
• Coenzyme Q10 (ubiquinone), another naturally occurring substance in your body, it is available as a supplement. 

Both L-carnitine and coenzyme Q10 are said to assist in converting food into energy. Problems with such conversion (mitochondrial dysfunction) may cause vomiting syndrome and migraine. 

DO NOT take any supplement without consulting your doctor.

Making certain changes in your lifestyle may help to control the signs and symptoms of cyclic vomiting syndrome. Here are some tips:

• Get enough sleep. 
• Stay in silence and dark for some time while vomiting
• Replace lost fluid and electrolytes with water and electrolyte supplements.
• Once vomiting is over, start with liquid and gradually upgrade to solid foods
• Avoid triggers
• Try stress management 
• Have three small meals and three snacks daily
• Cyclic vomiting syndrome can cause significant stress to you and your family. Stay close and support each other. 
• Join a support group

There are several risks and complications associated with cyclic vomiting syndrome.

Risks

• Migraine: Though there is no established link between migraine and cyclic vomiting syndrome, they seem to occur together in many children. 
• Chronic use of marijuana (cannabis sativa) can also cause cyclic vomiting syndrome.

Complications

• Dehydration: Loss of fluid and electrolytes due to excessive vomiting can cause dehydration. 
• Injury to the food pipe: The food pipe (esophagus) is exposed to stomach acid during vomiting causing damages to the lining of the food pipe. Sometimes, bleeding may occur in the esophagus. 
• Tooth decay: Exposure to acid during vomiting may initiate tooth decay.