Treatment of cyclic vomiting syndrome

Cyclic vomiting syndrome (CVS) is a relatively rare but highly incapacitating disorder. It is seen both in children and adults, although classically it has been perceived as a pediatric gastrointestinal disorder. Recent studies have demonstrated that this disorder indeed can be seen in adults and is highly disabling. Although classically associated with migraine headaches in the pediatric form, this relationship is less well established in adults. This has major implications for management in that traditionally, one of the major avenues for treatment of pediatric CVS has been antimigraine drugs. An additional factor that obscures a review of CVS treatment is the fact that because of its relative rarity, no randomized controlled trials (RCTs) have been performed. In the absence of RCTs, it is difficult to make definitive recommendations regarding treatment. The literature to date consists of case reports and open-ended case series. However, despite these limitations, it is the goal of this article to present in a comprehensive manner the options available for the treatment of CVS. Recognizing the limitations in the literature, it is clear that a number of treatment strategies that can often prove effective for the treatment of these complicated and often-challenging patients are available. Treatment is divided between acute intervention, when a patient is actively and severely vomiting, and prophylactic treatment for patients in their "interictal" phase, the goal of which is reducing frequency and intensity of subsequent episodes. Finally, we are beginning to identify possible mechanisms of the cause of CVS. Once these are better understood, this will provide the basis for further improvement in treatment.     

Human taste bud density across adult age groups

Some of the subjective variability attributed to taste experience could be related to wide variations of taste bud density. Studies of taste perception show a direct relationship between sensation and the number of receptors. Taste bud densities are quantified in this study using light microscopy to reconstruct two regions of 18 human cadaver tongues. Specimens came from male and female cadavers representing three age groups: young adults, middle-aged adults, and older adults. The results show a range of more than 100-fold in taste bud density that is evenly distributed among age groups and sexes. The disparity is not attributable to the state of health of the adults prior to death, and it is corroborated in the literature. Differences in taste bud density that extend across age groups probably confound some inferences about the effects of aging on taste sensitivity that are derived from cross-sectional studies of human populations. It is not clear from the data whether or not human taste bud density in individuals and in populations is stable or changing with time.     

The incidence of cyclic vomiting syndrome in children: population-based study

OBJECTIVE: Cyclic vomiting syndrome (CVS) is characterized by severe recurrent episodes of vomiting in an otherwise healthy child. Currently, there is no population data on the incidence of CVS. The aim of this study was to determine the incidence of CVS and to define the clinical characteristics of the condition at diagnosis.
METHODS: Each pediatrician on the island of Ireland was surveyed on a monthly basis from January 1, 2005 to December 31, 2005 by the Irish Pediatric Surveillance Unit (IPSU) and was asked to report any incident cases of CVS according to the criteria outlined by the First International Symposium on CVS. Subsequently, data on demographics and clinical features were collected anonymously from the reporting pediatricians.
RESULTS: Eighty-nine percent (1,647 of 1,848) of the surveillance cards were returned, reporting 41 valid cases of CVS. The incidence of CVS in Ireland was 3.15/100,000 children per annum for 2005 (95% confidence interval [CI] 2.19–4.11). The median age at diagnosis of CVS was 7.42 yr (range 1.8–15 yr). The median age at onset of CVS was 4 yr (range 0.5–14 yr) with 46% (19 of 41) of children having an onset at or before the age of 3 yr. The median number of episodes of CVS per child per year was eight (range 3–52); the median duration of an episode was 24 h (range 1 h to 5 days). Of school-age children, 85% (22 of 26) had missed school in the previous year due to CVS and 44% (18 of 41) were admitted to hospital for supportive treatment or investigation of CVS.
CONCLUSION: CVS is a relatively common condition in pediatric patients, with an incidence comparable to other major gastrointestinal diseases of childhood, such as Crohn's disease. The onset of pediatric CVS is generally early in childhood and this disease causes significant morbidity in the majority of those affected.     

The management of cyclic vomiting syndrome: a systematic review

Cyclic vomiting syndrome (CVS) is a rare abnormality of the neuroendocrine system that affects 2% of children. It is a frequently missed diagnosis in the emergency department and may require a number of emergency department visits before the diagnosis is made. The objectives of this review are to identify the clinical features that suggest a diagnosis of CVS and to review the literature on its management. The MEDLINE and EMBASE databases were searched from January 1948 to October 2011 using the keywords 'Cyclic' or 'Vomiting'. Papers were excluded if they did not follow the consensus guidelines or if they were case reports. This review analysed 1093 cases of cyclic vomiting in 25 papers that fulfilled the inclusion criteria. All except one paper were retrospective studies. The size of these cohort studies ranged from three to 181 patients, with a mean patient size of 29. This review found that over 40% of patients have headaches/migraines, with associated anxiety and depression in ≈ 30% of cases. There is a family history of headaches/migraines in 38.9%, and this association was much stronger in the adult CVS cohort compared with the paediatric cohort. Compared with paediatric CVS, adults have a longer duration of attacks and they occur more frequently (5.9 vs. 3.4 days, 14.4 vs. 9.6 episodes/year). Limited data are available on the treatment of the acute phase of CVS, but in adults, sumatriptan has been shown to be effective. For prophylactic treatment, tricyclics are effective in both adult and paediatric CVS, with a clinical response in 75.5 and 67.6% of patients, respectively, in nonplacebo-controlled cohort studies. Furthermore, propranolol has been shown to be useful in children. CVS is an intractable illness with a major impact on the patient's quality of life. There is a long duration between the onset of symptoms and the diagnosis of the condition. There is a high association with headaches/migraines and anxiety/depression. The symptoms are more severe in adult-onset CVS. Tricyclic antidepressants have good efficacy in reducing the frequency/duration or the intensity of attacks. There is limited evidence on the acute management of CVS.     

The clinical profile of cyclic vomiting syndrome in a regional hospital, Saudi Arabia.

BACKGROUND: Cyclic-vomiting syndrome is an uncommon disorder in adults. The aim was to determine the frequency and define the clinical characteristics of the syndrome among Saudi patients. METHODS: The subjects were patients with recurrent vomiting who were evaluated and treated in a regional referral centre in Saudi Arabia. RESULTS: Of 4290 patients who had endoscopic examinations during a period of 7 years (1995-2001), 13 patients (11 females and 2 males, mean age = 18.4 years) were diagnosed as cyclic vomiting. Precipitating factors were rarely identified and none of the cases was associated with migraine. Responses to therapy, which comprised reassurance, tricyclic drugs and prokinetic drugs were variable. CONCLUSIONS: The study indicated that the syndrome is relatively rare among Saudi patients with a frequency of 2.6 per 1000. The delay in the referral of these patients to a specialized unit was striking. It is probable that the syndrome is under-diagnosed and under-reported, in general. This report may stimulate more awareness of this disorder among health care givers in Saudi Arabia and may avoid unnecessary and protracted investigations.     

Cyclic vomiting syndrome

Opinion statement For the last century, empiric therapy has been used to treat the relentless vomiting and resulting dehydration associated with cyclic vomiting syndrome. Despite its unknown pathogenesis, in the last decade, uncontrolled trials of various antimigraine and antiemetic agents have demonstrated rates of efficacy of 40% to 90%. Antimigraine agents are used to prevent or abort episodes, whereas antiemetic agents are used to attenuate symptoms during episodes. A positive family history of migraine headaches renders the patient more likely to respond to antimigraine therapy. In addition to antimigraine therapy, antiemetic ± sedative/anxiolytic, neuroleptic and gastroinestinal prokinetic agents may be useful.     

Prevalence of cyclic vomiting syndrome in a sample of Turkish school children in an urban area

OBJECTIVES: Cyclic vomiting syndrome (CVS) is characterized by recurrent, explosive bouts of vomiting punctuating periods of normal health. Its prevalence is unclear in the world, and is unknown in Turkey. This study was designed to investigate its prevalence in Turkish school children. METHODS: The study was performed on 1263 children, aged 6 to 17 years old, who were selected by systematic sampling method before, for the celiac disease prevalence study. The population was asked the questions relating to CVS. Children whose answers fulfilled CVS criteria were invited for clinical interview and physical examination at the hospital. RESULTS: Of 1263 children, 24 (1.9%) fulfilled the criteria of CVS. Of them, 33.3% were male, 66.6% were female; the age ranged from 7 to 14 years old (mean age 10.5). The mean onset age was 7+/-3.4 years (5 to 12 years). The duration of attack ranged from 3 to 10 days (median: 5 days). Prodromal symptoms were reported in 25% of children with CVS. The episodes were accompanied by pallor, anorexia, feeling unwell, headache, abdominal pain, and photophobia in 100%, 100%, 83.3%, 66.7%, 58.3%, and 16.6%, respectively. Precipitating factors were reported by 20.8% of the children. Six children (25%) had migraine. A positive family history for migraine was noted in 7 (29.2%). Seven children (29.2%) suffered from travel sickness. CONCLUSIONS: In this first CVS prevalence study in Turkey, we found that CVS is highly prevalent in school children. For this reason, we emphasize that clinicians should be aware of this syndrome and consider it in the differential diagnosis of recurrent vomiting.     

Effects of revised diagnostic recommendations on malaria treatment practices across age groups in Kenya

Objective The recent change of treatment policy for uncomplicated malaria from sulfadoxine‐pyrime‐thamine to artemether‐lumefantrine (AL) in Kenya was accompanied by revised malaria diagnosis recommendations promoting presumptive antimalarial treatment in young children and parasitological diagnosis in patients 5 years and older. We evaluated the impact of these age‐specific recommendations on routine malaria treatment practices 4–6 months after AL treatment was implemented. Methods Cross‐sectional, cluster sample survey using quality‐of‐care assessment methods in all government facilities in four Kenyan districts. Analysis was restricted to the 64 facilities with malaria diagnostics and AL available on the survey day. Main outcome measures were antimalarial treatment practices for febrile patients stratified by age, use of malaria diagnostic tests, and test result. Results Treatment practices for 706 febrile patients (401 young children and 305 patients ≥5 years) were evaluated. 43.0% of patients ≥5 years and 25.9% of children underwent parasitological malaria testing (87% by microscopy). AL was prescribed for 79.7% of patients ≥5 years with positive test results, for 9.7% with negative results and for 10.9% without a test. 84.6% of children with positive tests, 19.2% with negative tests, and 21.6% without tests were treated with AL. At least one antimalarial drug was prescribed for 75.0% of children and for 61.3% of patients ≥5 years with a negative test result. Conclusions Despite different recommendations for patients below and above 5 years of age, malaria diagnosis and treatment practices were similar in the two age groups. Parasitological diagnosis was under‐used in older children and adults, and young children were still tested. Use of AL was low overall and alternative antimalarials were commonly prescribed; but AL prescribing largely followed the results of malaria tests. Malaria diagnosis recommendations differing between age groups appear complex to implement; further strengthening of diagnosis and treatment practices under AL policy is required.     

Subjective well-being and its domains across different age groups: an Israeli sample

Subjective well-being (SWB) across the life span was studied in a representative Israeli sample by a national survey of 1183 subjects, ranging from 18 to 80 years of age. Subjects were given "life scales", on which they rated their SWB in their present life, as well as their satisfaction regarding health, relations with friends, family, work, economic status, sense of personal achievement, and sense of control. The results indicate that: (a) SWB is negatively correlated with chronological age; (b) the relative strength of most of SWB domains changes in the different age groups; (c) SWB is best explained by different sets of domains in different age groups; and (d) economic status is the strongest domain, accounting for SWB in 6 out of 8 age groups. Explanations for these results confronted the developmental view of changing tasks across the life span vs cohort-based differences between the age groups. The decreasing number of domains that account for SWB variance with progressing age, as well as some unexpected findings with regard to the oldest age group (71-80) are also discussed.     

Resolution of cyclic vomiting after appendectomy in a girl

Cyclic vomiting syndrome is a disorder characterized by recurrent, discrete, stereotypical episodes of nausea and vomiting. Although chronic or recurrent appendicitis may be a cause of recurrent abdominal pain, it rarely meets the diagnostic criteria for cyclic vomiting syndrome. Furthermore, mast cell counts are histologically high in chronic appendicitis. We report a 10-year-old Japanese girl with a cyclic pattern of vomiting that met the stringent diagnostic criteria for cyclic vomiting syndrome, and which was resolved after appendectomy. Histopathologic examination of the resected appendix showed not only acute mucosal inflammation but also chronic inflammatory changes. Because we speculated that recurrent or chronic appendicitis may have been related to the patient's vomiting bouts, we also immunohistochemically investigated the density of mast cells in the specimen. We found that the mast cell density was markedly high in the lamina propria of the appendix. In our patient, a type I hypersensitivity reaction with release of mediators by mast cells could have been the initial factor triggering the recurrent appendicitis, and this stressor could have initiated the vomiting cascade. In conclusion, chronic or recurrent appendicitis could be one of the causes of cyclic vomiting, and must be considered in the differential diagnosis of cyclic vomiting syndrome.     

Colorectal carcinoma in different age groups

Purpose  

Although colorectal cancer is typical in the older population, tumor onset before age 40 is not infrequent. However, the behavior, characteristics, and prognosis of this disease in young patients are unclear when compared to the older population. It is believed that young patients have a poor prognosis. We hypothesized that young patients have a poor prognosis because they have advanced-stage cancer with more aggressive pathologic features.