What is cyclic vomiting syndrome (CVS)?

Cyclic vomiting syndrome (CVS) is a condition where you experience sudden, repeated attacks of severe nausea, vomiting and exhaustion. These symptoms come with no apparent cause. Each attack can last from a few hours to several days. Attacks may be so severe that you’re bedridden or must go to the emergency room or hospital. Often, the symptoms start early in the morning. Following an episode, you’re free of symptoms and return to normal health.

All sexes of any age may be affected. CVS may last for months, years or decades. However, symptoms don’t occur each day. The attacks generally occur several times a year, but could be up to once or twice a month. If you’re having daily symptoms for weeks or a month, these are due to something other than cyclic vomiting syndrome.

The symptoms, time of day, frequency, severity and length of each episode of CVS are usually the same for any one person. However, these may be different from person to person.

Who is affected by cyclic vomiting syndrome (CVS)?

CVS is more common in children than adults. As a generalization, 3 of every 100,000 children are diagnosed with CVS. In most cases in children, CVS starts to occur between the ages of 3 and 7. However, the disorder can begin at any age from infancy through old age.

What causes cyclic vomiting syndrome (CVS)?

There isn’t a known cause of CVS, but there’s some suggestion that mitochondria in your cells may have a role. Mitochondria act as the engine of the cell, taking in nutrients and then breaking them down and forming energy that can be used by the cells. Mitochondrial DNA can become abnormal because of illness, a genetic condition inherited from your mother, or exposure to certain drugs or toxins. Often, tests suggest subtle changes in the mitochondrial function and an exact diagnosis isn’t found. Cyclic vomiting may also occur more commonly in someone who has a parent with migraines.

The following also could play a role in CVS:

• Migraine headaches, which appear in up to 80% of children and 25% of adults with CVS.
• Changes or imbalances in your autonomic nervous system.
• Issues with brain, spinal cord or nervous system control over your body’s gastrointestinal tract responses — your brain gut axis.
• Hormone imbalances.

What can trigger an episode of cyclic vomiting syndrome (CVS)?

Anxiety, a panic attack or something that’s emotionally upsetting may bring on your CVS. Also, the following may trigger CVS:

• Respiratory or sinus infections or the flu.
• Reactions to certain foods such as chocolate or cheese, caffeine or the food additive MSG (monosodium glutamate).
• Changes of season (symptoms are more common in fall and winter).
• Menstrual periods.
• Motion sickness.
• Stress and anxiety.
• Prolonged fasting.
• Physical exhaustion.

What are the symptoms of cyclic vomiting syndrome (CVS)?

Some of the symptoms of CVS include:

• Repeated episodes of severe nausea, retching (attempting to vomit) and vomiting.
• Heaving or gagging.
• Lack of appetite.
• Sensitivity to light.
• Pain in your abdomen.
• Pale appearance to your skin.
• Severe fatigue.
• Severe headaches.
• Not wanting to talk.
• Drooling or spitting.
• Extreme thirst.
• Low-grade fever (up to 101 degrees Fahrenheit or 38.33 degrees Celsius).
• Diarrhea.

How is cyclic vomiting syndrome (CVS) diagnosed?

Providers diagnose CVS by ruling out other conditions that may have similar symptoms. These include:

• Pancreatitis (inflammation of your pancreas).
• Volvulus or malrotation (twisting of your intestine).
• UPJ obstruction (a urinary blockage at the point where one of your kidneys attaches to one of the tubes to your bladder [the ureters]).
• A number of different tests to rule out metabolic disorders.

For the diagnosis of CVS, a provider will ask questions about your medical and family history. They’ll do an exam to check your digestive system and nervous system. They may order metabolic and liver function tests in addition to running tests on your blood and urine. They also may order any of the following:

• Abdominal ultrasound.
• Upper (GI) X-ray series.
• Brain magnetic resonance imaging (MRI).
• Upper GI endoscopy.
• Gastric emptying test.

If an upper endoscopy is ordered, a physician inserts a small, flexible tube through your throat and into your stomach in order to view the interior of your upper GI tract utilizing sedation or anesthesia. If a gastric emptying test is ordered in radiology, you’ll eat a meal containing a marker that’s tracked by a radiologist to see how well your digestive system is working. The physician will determine which if any of the above tests are required based on your history and physical examination findings, as well as lab work if performed.

How is cyclic vomiting syndrome (CVS) treated?

CVS is treated with abortive therapy and preventive therapy. Abortive therapy is given at the time of an episode and is meant to lessen the intensity or stop (abort) your attack after it starts. Preventive therapy is used to stop attacks from happening or to decrease the severity, duration (how long), or frequency (how often) of the attacks.

Providers try to prevent CVS early on in the attack. The treatment for CVS depends on the stage. In the prodrome (early symptom) phase, when symptoms of a CVS episode first start, healthcare providers use medications to manage nausea, reduce stomach acid production, and relieve migraine symptoms and abdominal pain.

In the vomiting phase, they use medicines to manage migraine pain and to reduce your stomach acid and anxiety. A healthcare provider should be seen as soon as possible. In cases of severe vomiting, it may be necessary to go to a hospital. Intravenous (IV) fluids may be required to prevent dehydration. In episodes lasting several days, IV fluids and nutrition may be needed. In the recovery phase, you continue to receive IV fluids as needed. Gradually, you may begin to have clear liquids and food as tolerated. Medicines can help prevent future episodes.

In the well phase, preventive medicines such as amitriptyline (Elavil®) or cyproheptadine (Periactin®) can help to manage your future episodes. A trial period of a daily dose for one or two months is needed to see how effective the treatment is. There may also be a benefit in taking coenzyme Q10 and L-carnitine to treat abnormalities in mitochondria at doses recommended by your physician if appropriate. More research on this topic is still needed.

What complications can result from cyclic vomiting syndrome (CVS)?

• Dehydration: Dehydration happens when fluids lost due to vomiting and diarrhea aren’t replaced.
• Esophagitis: Inflammation of your esophagus (the tube that connects your mouth to your stomach) due to frequent exposure to vomit, which is very acidic.
• Mallory-Weiss tear: A tear in the lower end of your esophagus caused by the muscular contractions of severe vomiting.

How can cyclic vomiting syndrome (CVS) be prevented?

• Avoid known triggers such as certain foods or food additives.
• Get the right amount of sleep.
• Treat sinus problems and allergies right away.
• Reduce stress and anxiety.
• Use medications as prescribed by a doctor.