​Kembara Xtra - Medicine - Cyclic Vomiting Syndrome

​Kembara Xtra - Medicine - Cyclic Vomiting Syndrome 
Cyclic vomiting syndrome is an idiopathic chronic functional gastrointestinal condition that is characterized by discrete, repeated, stereotyped paroxysmal bouts of high-intensity nausea and vomiting that last anywhere from hours to days. Subsets – Cyclic vomiting syndrome (CVS) plus two or more neuromuscular disorders in connection with it. – CVS connected with the catamenial phase of the menstrual cycle – It is important to note that cannabis hyperemesis syndrome (CHS) is not the same as CVS. CVS consists of four separate phases:
– Interepisodic: a period during which there are no symptoms
– Prodromal: nausea lasting from minutes to hours, possibly accompanied by stomach discomfort. – Vomiting lasting from hours to days.
- Recuperation The patient's appetite, strength, and energy return to normal, and they no longer experience nausea.


Epidemiology (Prevalence and Incidence) 

Incidence less than three cases per one hundred thousand children per year; data in adults are limited.

Prevalence

0.04–2% in the general population 1%–2% in children Females more likely to be affected than males (55:45) More common in children; the mean age of diagnosis in adults is 35 years old, while in children it ranges from 3 to 7 years old.
An average of three years between the beginning of symptoms and the diagnosis

Causes and effects: etiology and pathophysiology 

Strong connection between CVS and migraine: comparable symptoms, frequent family history of migraines, and the effectiveness of antimigraine therapy One hypothesized mechanism:
– Increased neuronal excitability due to enhanced ion permeability, mitochondrial deficits, or hormonal state; – increased susceptibility to physical or psychological trigger; – release of corticotropin-releasing factor (CRF); – vomiting; – vomiting perpetuated by altered brainstem regulation; – sustained vomiting; – possible maternal inheritance, based on a family history of migraines and a link to mitochondrial DNA (mtDNA) mutations; – multiple theories
– Dysfunction of the gastrointestinal (GI) motility – Dysfunction of the sympathetic autonomic nervous system – Food allergy or intolerance Genetics – Likely matrilineal inheritance, particularly with childhood onset – A3243G mutation or other mtDNA mutations including mitochondrial dysfunction – Ion channel mutations

A number of different polymorphisms have been discovered. 165119T is more prevalent in children diagnosed with CVS.

factors of danger 

• A history of migraines in the patient's family; • Depression and/or anxiety; • Prolonged use of cannabis; • The possibility of food allergies; • Dysfunction of the hypothalamic-pituitary-adrenal axis


General Preventative methods There are no primary preventative methods available. The secondary prevention of attacks relies on a multidisciplinary approach to the avoidance of triggers, treatment of comorbidities, and the use of prophylactic medicines.

Conditions That Often Occur Together 

Irritable bowel syndrome, which affects 67% of patients
Headaches (52% of Patients)
— Queasiness caused by movement (46%).

● Migraines (11–40%)

● Seizure disorder (5.6%)
The usage of cannabis

History of Presenting Symptoms It is common for children to appear with symptoms including bilious emesis (83%) severe stomach discomfort (80%) and/or hematemesis.
Episodes are frequently brought on by stressors or illnesses that occur simultaneously.
The diagnostic criteria for CVS according to the consensus of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition
– At least five attacks in any interval or more than two attacks within a six-month period – Episodes of extreme nausea and vomiting lasting one hour to ten days, with at least one week in between each episode – Stereotypical symptoms and pattern in each patient – Vomiting at least four times per hour for at least one hour throughout the episode – Patients who have had at least five attacks in any interval or more than two attacks within a six-month period Get back to the starting point between episodes – Unlikely to be the result of some other disease or condition — All six conditions must be met.
● Rome IV criteria for adults
– Episodes of vomiting with a typical start (acute) and length (less than one week) – Fewer than three separate episodes in the previous year and at least two episodes spaced at least one week apart in the most recent six months – A lack of nausea and vomiting in between episodes – At a minimum of three months, each of the three requirements have to be met.
● Adult hallmarks
Normal or rapid gastric emptying Successful suppression of episodes by prolonged amitriptyline medication (1) Prominence of epigastric or diffuse abdominal pain Increased incidence of anxiety and depression Normal or rapid gastric emptying[B]
PHYSICAL EXAM
Check for dehydration, which is present in thirty percent of cases.
Symptoms may include orthostatic hypotension, tachycardia, and dry mucous membranes. 
Routine physical examination, which is typically otherwise normal

Differential Diagnosis 

disorders of the digestive tract include gastroesophageal reflux disease, Helicobacter pylori infection, peptic ulcer disease, cholelithiasis, pancreatitis, appendicitis, blockage, and gastroparesis. problems of the nervous system include migraine headaches, Chiari malformation, and intracranial tumor. 
nephrolithiasis and blockage are examples of renal diseases. 
Diseases of the metabolic system and the endocrine system, include porphyria, Addison disease, diabetic ketoacidosis, hyperemesis gravidarum, and pheochromocytoma 
Münchausen by proxy, anxiety, bulimia nervosa, depression, and panic disorder are included in the category of behavioral disorders.r ● Pregnancx Cannabinoid abuse—also known as cannabinoid hyperemesis syndrome (CHS): This condition is characterized by recurrent bouts of nausea and vomiting, as well as abdominal pain and a compulsive need to bathe in hot water. It is associated with high-dose (almost daily) cannabis use.e Any kid with a probable case of CVS should be investigated for a possible metabolic or neurologic etiology if the following conditions are met: – The child is younger than 2 years old- Episodes of vomiting are linked to a previous state of fasting or to an increase in the amount of protein consumed- Any specific findings on the neurologic examination.m - Hypoglycemia, anion gap metabolic acidosis, hyperammonemia, or other symptoms that point to the presence of a metabolic disease.s 

Results From the Laboratory 

The diagnosis of CVS is one of exclusion. Laboratory testing and imaging are essential for determining and ruling out other diagnosis and consequences.
First Examinations (laboratory and imaging): Electrolytes: hypokalemia
CBC with hemoconcentration and leukocytosis; amylase and lipase; erythrocyte sedimentation rate

hepatitis or biliary illness, as shown by hepatic transaminases 
Urinalysis: granular casts, ketones; Urine drug screen: THC (false positives can occur, especially after IV PPI administration); Pregnancy test; Lactate, ammonia, amino acids, urine organic acids, and adrenocorticotropic hormone—particularly for acute episodes in children to exclude metabolic disease;  
GI referral and esophagogastroduodenoscopy (EGD) in adults and patients with alarm symptoms (hematemesis, dysphagia, etc.) 

Additional Assessments, as well as Other Important Factors
Behavioral health counseling for the management of anxiety, depression, eating problems, or cannabis misuse (if applicable) Computed tomography (CT) or magnetic resonance imaging (MRI) of the head to evaluate for structural lesions of the brain or reasons of high intracranial pressure (ICP)
Computed tomography of the abdomen and pelvis, with evaluation of the biliary and urinary tracts to rule out the possibility of structural reasons 

Diagnostic Procedures/Other

EGD: to evaluate for clinical suspicion of peptic ulcer disease or evidence of hematemesis Electroencephalogram: to evaluate for seizure disorder clinical suspicion of peptic ulcer disease or signs of hematemesis

Studies on the emptying of the stomach should rule out gastroparesis. Autonomic testing.

psychiatric and neurological evaluations

Management ● Patient reassurance

● Avoid triggers (stress, sleep deprivation, chocolate, cheese, monosodium glutamate, red wine).
- An setting that does not stimulate you; - Relaxation techniques and psychological tests; - Staying away from recreational drugs like marijuana.

The First Line Of Defense Is Medication
Early therapy with antiemetics for patients who present themselves to the emergency department has the potential to reduce the need for hospitalization.
Medications that cause miscarriage to end (they should be given in the prodrome or shortly after the first sign of vomiting): – Sumatriptan is a selective serotonin agonist (5-HT1B, 5-HT1D); for patients weighing more than 40 kilograms, the recommended dosage is three to six milligrams (mg) when administered subcutaneously. – Aprepitant: neurokinin 1 antagonist; 30 min before vomiting, days 2 and 3—if <15 kg = 80 mg/40 mg/40 mg; if 15 to 20 kg = 80 mg/80 mg/80 mg; if >20 kg = 125 mg/80 mg/80 mg 
Medications used for prevention (reduce the incidence or severity by more than 50 percent): – A significant number of antiviral drugs used to prevent CVS fall into pregnancy risk categories C or higher. Therefore, it is vital to have a conversation about the risks and benefits of receiving treatment while pregnant.
Amitriptyline (67–82%): first-line in adults and children over the age of 5 years: 0.2 to 2.0 mg/kg/day; not advised for children under the age of 5 years; careful titration over the course of two to three weeks to avoid side effects Cyproheptadine (39–66%): medication for use in pediatrics Appetite stimulant; recommended as a first-line treatment for children under 5 years old; especially if combined with migraines; dosage: 0.25 to 0.50 mg/kg/day divided BID–TID for children aged 2 to 5 years old  Propranolol (57%): for infants, 0.5 mg/kg/day divided BID–TID; for adults, 10 to 20 mg/day BID–TID, particularly if associated with migraines Medications used to provide support:
(1) Anticonvulsants, supplements for the mitochondria (coenzyme Q10 and riboflavin), and calcium channel blockers  Topiramate: people with CVS and chronic headaches should take 20 to 100 mg daily, or 2 mg/kg/day, divided BID.
Ondansetron: children: 0.3 to 0.4 mg/kg/dose (16 mg) q6h; adults: 4 mg IV/PO q6–8h. Lorazepam: children: 0.05 to 0.10 mg/kg/dose IV (not to exceed 4 mg/dose); adults: 1 mg PO QID for the treatment of anxiety.


Two-Thirds Line
Abortive: In an effort to reduce the number of times you have to throw up, try medicating yourself intravenously, rectal, or topically.
Children should take 1.25 milligrams per kilogram per dosage every six hours, with a daily maximum of 300 milligrams; adults should take 25 to 50 milligrams every four to six hours as needed.
– Metoclopramide: 0.1 mg/kg/dose q6h – Chlorpromazine + diphenhydramine: 0.5 to 1.0 mg/kg q8h – Ketorolac: 0.5 to 1.0 mg/kg/dose <10 mg q8h – Hydromorphone: children: 0.015 mg/kg/dose IV for 1 dose; adults: 2 to 4 mg PO PRN or 0.5 to 2.0 mg IM/SC for 1 dose Prophylactic – Phenobarbital (79%): 2 to 3 mg/kg/day – Erythromycin (75%): 20 mg/kg/day divided BID Hydromorphone: children: 0.015 mg/kg/dose IV for 1 dose; adults: 2 to 4 mg PO–TID
- The recommended dose of valproic acid is 10–40 mg/kg/day (this medication should be avoided if at all feasible; adjunctive mitochondrial supplements should be used instead). - Levetiracetam: adults should take between 500 and 3,000 mg per day
- Zonisamide: 100 to 700 mg daily adults
- Pizotifen: 0.25 mg BID–TID
– Flunarizine: 5 mg once a day – Mirtazapine: 7.5 to 15 mg once at night – Aprepitant: twice weekly—<40 kg = 40 mg; 40 to 60 kg = 80 mg; >60 kg = 125 mg – Rescue therapy: sedative drugs Most episodes (72%) conclude with premonitory sleep; as a result, induced sleep can give symptomatic relief and may abbreviate an episode. – Erythromycin dosage: 20 milligrams per kilogram of body weight per day, to be taken four times during the day.


Considerations Necessary Before Proceeding 
Appointments with a behavioral health professional on a consistent basis, as well as consultations with gastroenterologists, have been shown to reduce the number of episodes of CVS and the need for inappropriate medication. Patients who have symptoms that may be consistent with CVS should initially be referred to a gastroenterologist.
Referral to the most appropriate allied health specialist (psychologist, psychiatrist, neurologist, sleep, or drug use specialist) as warranted by the patient's condition.

Extra Medical Interventions 
Breathing exercises, biofeedback, and guided imagery are examples of relaxation techniques.


Alternative and Complementary Treatments 

L-carnitine 50 to 100 mg/kg/day divided BID for prevention up to 3 g daily Riboflavin 10 mg/kg/day divided BID for prevention While marijuana is a potential treatment for intractable vomiting, regular use may cause cannabinoid hyperemesis syndrome (CHS).

Admission 

● Admission criteria/initial stabilization Increased anion gap that is reflective of severe dehydration or metabolic decompensation IV fluids or IV medicines
- One to two milligrams of lorazepam administered intravenously every three hours is the most efficient method for inducing sleep in acute emergencies. 
Intravenous fluids: replenishment of continuous losses; fluids containing 5–10% dextrose or normal saline with additional potassium to mitigate any metabolic crisis that may occur 
When nursing, reduce stimulation; stay away from loud and strong light and sounds.
- Encourage relaxing practices.
Attempt to sleep uninterrupted by any activities that aren't absolutely necessary.
Discharge criteria - Vomiting and electrolyte imbalances have been corrected. Pain has been controlled with oral analgesics. Euvolemia has been achieved. Appropriate oral intake has occurred.

Continued Patient Observation and Monitoring
Appointments on a weekly basis for severe cases
  In the case of persistent vomiting, be on the lookout for hypokalemia, acid–base abnormalities, and ketosis.
● Regular outpatient appointments for support


Nutritional Intake 
Dietary sources that are high in carbs, vitamin and mineral content 
A diet that is low in amines might be helpful for youngsters.
Reduce your intake of fatty and hot foods.
Stay away from items that set off your allergic reactions, such as chocolate, cheese, and monosodium glutamate.
Regularly scheduled times for meals


A vomiting diary can identify probable triggers in 75% of children. Managing stress. Practicing good sleep hygiene. Regularly engaging in moderate exercise.



The condition typically lasts between 2.5 and 5.5 years, and 70% of children will no longer experience vomiting after treatment. Many people nevertheless suffer from somatic symptoms such as headaches and stomach pain.
35% of people will experience headaches that are chronic or migraine-like.
Between fifty and seventy five percent of patients who were given a preventative treatment are symptom-free after one year.

13% of patients do not respond favorably to treatment. Marijuana usage and persistent narcotic use are two of the risk variables that contribute to nonresponse. Other risk factors include poorly managed migraines and psychiatric problems.


Complications 

The following conditions can manifest themselves during the vomiting phase: esophagitis, Mallory-Weiss tear, and weight loss