Cyclic Vomiting Syndrome (CVS): is there a difference based on onset of symptoms - pediatric versus adult?

Abstract

BackgroundCyclic Vomiting Syndrome (CVS) is a well-recognized functional gastrointestinal disorder in children but its presentation is poorly understood in adults. Genetic differences in pediatric-onset (presentation before age 18) and adult-onset CVS have been reported recently but their clinical features and possible differences in response to therapy have not been well studied.MethodsThis was a retrospective review of 101 CVS patients seen at the Medical College of Wisconsin between 2006 and 2008. Rome III criteria were utilized to make the diagnosis of CVS.ResultsOur study population comprised of 29(29%) pediatric-onset and 72 (71%) adult-onset CVS patients. Pediatric-onset CVS patients were more likely to be female (86% vs. 57%, p = 0.005) and had a higher prevalence of CVS plus (CVS + neurocognitive disorders) as compared to adult-onset CVS patients (14% vs. 3%, p = 0.05). There was a longer delay in diagnosis (10 ± 7 years) in the pediatric-onset group when compared to (5 ± 7 years) adult-onset CVS group (p = 0.001). Chronic opiate use was less frequent in the pediatric-onset group compared to adult-onset patients (0% vs. 23%, p = 0.004). Aside from these differences, the two groups were similar with regards to their clinical features and the time of onset of symptoms did not predict response to standard treatment. The majority of patients (86%) responded to treatment with tricyclic antidepressants, anticonvulsants (topiramate), coenzyme Q-10, and L-carnitine. Non-response to therapy was associated with coalescence of symptoms, chronic opiate use and more severe disease as characterized by longer episodes, greater number of emergency department visits in the year prior to presentation, presence of disability and non-compliance on univariate analysis. On multivariate analysis, only compliance to therapy was associated with a response. (88% vs. 38%, Odds Ratio, OR 9.6; 95% Confidence Interval [CI], 1.18-77.05).ConclusionDespite reported genetic differences, the clinical features and response to standard therapy in pediatric- and adult-onset CVS were mostly similar. Most patients (86%) responded to therapy and compliance was the only factor associated with a response.

A New Approach to the Prophylaxis of Cyclic Vomiting: Topiramate

“…In our study, the response rate for topiramate was 94%. Our results were inconsistent with the findings of Kumar et al 17 .…”

“…The most frequently reported adverse effects related to propranolol or topiramate included restlessness, sleep disturbance, asthenia, dizziness, somnolence, ataxia, tremors, dysarthria, blurred vision, gastrointestinal symptoms, and weight loss. 16,17,22 In the present study, the most commonly observed side effects in both groups included drowsiness, nervousness and dizziness. Weight loss due to appetite decrease is a frequent side effect of topiramate.…”

“…21 Among few studies investigating the effects of topiramate in CVS, Ölmez et al 16 reported a child having CVS with generalized epileptiform discharges who responded to topiramate therapy. In a last large single center study, Kumar et al 17 retrospectivly reviewed the clinical features of 101 pediatric-onset and adult-onset patients with CVS. In their study, the responder rate was reported to be 60% with topiramate.…”

Challenges With Acute Care and Response to Treatment Among Adult Patients With Cyclic Vomiting Syndrome

“…Cyclic vomiting syndrome symptoms and frequent use of medical services cause social and work-related issues. For instance, 29%-57% report losing their jobs and 32% are completely disabled by the time they are diagnosed ( Fleisher et al, 2005 ;Kumar et al, 2012 ). Those who are still employed (55%) report missing as many as 20 work days per year ( Fleisher et al, 2005 ).…”

“…Lying in a dark, quiet room, and using cold packs have been reported as beneficial strategies to alleviate symptoms and to promote sleep ( Fleisher et al, 2005 ;Lee et al, 2012 ). Individualized treatment for CVS is based on the phase of illness, effectiveness of medications, and the ability to tolerate side effects ( Boles, 2011 ;Boles et al, 2010 ;Fleisher et al, 2005 ;Kumar et al, 2012 ;Namin et al, 2007 ) (see Table 1 ).…”