Cyclic Vomiting Syndrome (CVS) has been known for hundreds of years, first being recorded in 1802 (1). It is a long-term gastrointestinal condition most commonly diagnosed in children but also affecting adults. CVS often occurs along with other conditions such as migraines (~60-70% of patients are diagnosed with both), anxiety disorders (84%) and depression (78%) (2, 3, 4).
What is CVS and how is it diagnosed?
As the name would suggest, it involves recurrent bouts of intense nausea and vomiting, separated by periods of wellness. Other common symptoms include abdominal pain, pallor, excessive sweating, diarrhoea, photophobia, sound sensitivity, lethargy, disorientation and agitation (5). Patients can experience a prodromal phase before nausea starts with feelings of doom, panic, temperature changes and fatigue, sometimes lasting for several hours (2).
The psychological and emotional aspects can be severe, with patients anecdotally reporting feeling suicidal, referring to CVS as an “evil disorder” or a “puke monster” and saying “It’s been a decade or more of that hell” (6). The long-term effects of the condition are not just limited to the core symptoms; patients have been disabled and suffered delays to education, unemployment or social disruption (7).
Many individuals end up in emergency care departments due to the severity of their symptoms and secondary effects, like dehydration and electrolyte imbalance. Unfortunately, many do not receive sufficient care. This is due to undergoing excessive testing during diagnosis, a lack of CVS awareness by healthcare professionals, and stigmatisation of patients as having substance misuse or other such disorders. Around 20% of individuals even undergo hysterectomy or cholecystectomy before being correctly diagnosed with CVS (8, 9).
In the absence of a biochemical test, it is diagnosed by matching a set number of diagnostic symptoms as defined by the Rome IV Criteria or the NASPHAGN Criteria (North American Society of Paediatric Gastroenterology, Hepatology, and Nutrition) (10). However, it can be difficult to diagnose as the symptoms overlap with many other conditions and it can take years to get an accurate diagnosis (5, 11).
It is not known exactly how or why CVS occurs. It is classified as a disorder of gut-brain interaction (DGBI), which means there is likely some changes in how the brain and stomach send, receive and respond to signals between them. There have also been various genetic markers suggested, but more research is needed to characterise these (2). It is also not known what causes a CVS episode, although the majority of patients have known CVS triggers, such as stress (even positive stress or excitement), movement, tiredness, fasting or hormonal changes (12, 13).
How is CVS treated?
Treatment is focused on symptom management and prolonging the periods of wellness between episodes. A combination of pharmacological, psychological and lifestyle care is recommended to improve quality of life and reduce triggers. Drugs used to treat CVS, either prophylactically or during an episode, include tricyclic antidepressants, anticonvulsants, mitochondrial supplements, NK1 receptor antagonists, antiemetics, triptans, analgesics and sedatives. Some of the medicines used, however, are off-label or lack evidence and rigorous studies to confirm their wide-spread efficacy and they may be used on a case-by-case basis (2).
Medicinal cannabis use has shown to improve nausea, lack of appetite and associated stress in some patients, although the success rate varies greatly. However, excessive cannabis use is also known to cause Cannabinoid Hyperemesis Syndrome, which has periods of intense vomiting and nausea like CVS. As cannabis can both help and cause excessive vomiting, its use in CVS management is under debate (14, 15, 16, 17).
Non-invasive painless auricular neuromodulation (electrical stimulation delivered by electrodes on the outside of the head) has been effective with other DGBIs and gastrointestinal disorders. It has recently been tested for CVS management in children and has shown promising results (ClinicalTrials.gov ID NCT03434652) (18).
Key Points
- Cyclic Vomiting Syndrome (CVS) involves repeated periods of excessive vomiting and nausea, separated by periods of wellness.
- Causes are unknown but linked to both genetic and environmental factors.
- It significantly impacts quality of life, made worse by a lack of awareness and a difficult pathway to diagnosis.
- It affects both children and adults.
- Treatment focuses on preventing triggers, improving quality of life and managing vomiting episodes.
References
Heberden, W., (1802). Commentaries on the history and cure of diseases. London: T. Payne.
Frazier, R., and Venkatesan, T., 2022. Current understanding of the etiology of cyclic vomiting syndrome and therapeutic strategies in its management. Expert Review of Clinical Pharmacology: 15 (11): 1305-1316
Namin, F. et al., 2007. Clinical, psychiatric and manometric profile of cyclic vomiting syndrome in adults and response to tricyclic therapy. Neurogastroenterology and Motility: 19 (3): 196-202
Tarbell, S. and Li, B.U.K., 2008. Psychiatric symptoms in children and adolescents with cyclic vomiting syndrome and their parents. Headache: 48 (2): 259-266
Abell, T.L., et al., 2008. Cyclic vomiting syndrome in adults. Neurogastroenterology and Motility: 20 (4): 269–284
Khalil, C., et al., 2024. Perspectives, experiences, and concerns with cyclical vomiting syndrome: Insights from online targeted-disease forums. Neurogastroenterology and Motility: 36 (2): e14712
Kumar, N., et al., 2012. Cyclic Vomiting Syndrome (CVS): is there a difference based on onset of symptoms – pediatric versus adult? BMC Gastroenterology: 12 (1): 52
Fleisher, D.R., et al., 2005. Cyclic Vomiting Syndrome in 41 adults: the illness, the patients, and problems of management. BMC Medicine: 3 (1): 20
Venkatesan, T., et al., 2010. A survey of emergency department use in patients with cyclic vomiting syndrome. BMC Emergency Medicine: 10 (1): 4
Li, B.U.K., et al., 2008. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition consensus statement on the diagnosis and management of cyclic vomiting syndrome. Journal of Pediatric Gastroenterology and Nutrition: 47 (3): 379–393
Haghighat. M., et al., 2007. Cyclic vomiting syndrome in children: experience with 181 cases from southern Iran. World Journal of Gastroenterology: 13 (12): 1833-1836
Kovacic, K., et al., 2018. Cyclic Vomiting Syndrome in children and adults: what is new in 2018? Current Gastroenterology Reports: 20 (10): 46
Li, B.U.K., 2018. Managing cyclic vomiting syndrome in children: beyond the guidelines. European Journal of Pediatrics: 177 (10): 1435–1442
Venkatesan, T., et al., 2019. Role of chronic cannabis use: cyclic vomiting syndrome vs cannabinoid hyper-emesis syndrome. Neurogastroenterology and Motility: 31 (2): e13606
Allen, J., et al., 2004. Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse. Gut: 53 (11): 1566–1570
Habboushe, J., et al., 2018. The prevalence of cannabinoid hyperemesis syndrome among regular marijuana smokers in an urban public hospital. Basic and Clinical Pharmacology and Toxicology: 122 (6): 660–662
Nicolson, S.E., et al., 2012. Cannabinoid hyperemesis syndrome: a case series and review of previous reports. Psychosomatics: 53 (3): 212–219
Karrento, K., et al., 2023. Percutaneous electrical nerve field stimulation improves comorbidities in children with cyclic vomiting syndrome. Frontiers in Pain Research (Lausanne): 4: 1203541
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