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Dealing With Cyclic Vomiting Syndrome Given How Little Is Known About The Condition

I have been working as an ER doctor for over a decade, and in that time I have come to recognize that there are certain complaints, and certain patients who bear these complaints, that are very challenging to take care of. I’m trying to be diplomatic here. What I really mean is that there are certain presentations that just make you cringe, drain the life force out of you, and make you wish you’d listened to mother and gone into investment banking instead. Among these, perhaps most prominently, is that of the patient with cyclic vomiting syndrome.

The diagnosis of cyclic vomiting syndrome, or CVS, is something which is only in recent years applied to adult patients.  Previously, it was only described in the pediatric population. It has generally been defined as a disease in which patients will have intermittent severe and prolonged episodes of intractable vomiting separated by asymptomatic intervals, over a period of years, for which no other adequate medical explanation can be found, and for which other causes have been ruled out.

That is not much in the way of good literature about this disease entity, which is surprising, because it is something that I see in the emergency department fairly regularly, and something with which nearly all emergency providers are quite familiar. These patients are familiar to us in part because we see them again and again, in part because they are memorable because they are so challenging to take care of.

Some things about the cyclic vomiting patient that pose particular challenges:

  • The intensity of their vomiting symptoms tends to be very severe, and refractory to most standard antiemetics.
  • The amount of affective distress the patient demonstrates is usually quite disproportionate to the severity of their symptoms, which is actually saying something, since they can at times be fairly ill. This often manifests itself as a patient who is ultra-dramatic, writhing on the gurney, or hyperventilating and sobbing in a knee to chest position, refusing to talk to the care providers. This can create the perception among care providers that the illness is psychogenic, a perception which is reinforced by the fact that there does seem to be significant association between CVS and mental health diagnoses.
  • Patients often will engage in behaviors which seem to be willfully making their symptoms worse, such as compulsively drinking water or being seen to induce vomiting by putting their fingers down their throat.
  • Coexisting with the vomiting is often a fairly severe complaint of abdominal pain, for which no clear diagnosis can be established, requiring in some cases high doses of intravenous narcotics. CVS patients are interesting in that sometimes the only agent that will stop the vomiting is hydromorphone. (For the nonmedical readers, it is worth noting that hydromorphone has no anti-vomiting properties, and in fact causes many people to vomit.) This requirement for narcotic medication supports a perception that the patient is drug addicted or drug seeking, itself reinforced by the fact that patients tend to come back to the emergency room several times in quick succession for recurrent vomiting. (For this reason, some have referred to CVS as an “Abdominal migraine.”)

All of this makes management difficult in the setting where there is fairly little in the way of evidence-based guidelines, or even much in the way of expert recommendations or academic agreement on the definition of the syndrome. My observation, over the years, is that while Zofran and Reglan and Compazine can in some cases be helpful, in most cases they are not. I have however, had very good success with the use of benzodiazepines such as lorazepam or midazolam. Benzodiazepines seem to work in 2 ways: they are well known to have anti-emetic properties, but they are also quite sedating, and the patient does need to be awake to vomit. Interestingly, while use of normal vomiting medications seems to drive patient requests for narcotic medications, when I use the benzodiazepines, I almost never have to co-administer a narcotic. Since I have made these observations and implemented them in my personal standard treatment protocol, I found that CVS patients are much easier to care for, both in the sense that they’re less emotionally draining for me and in the sense that they get better quicker and go home feeling better. It’s not clear to me whether this treatment protocol results in fewer bounce-back presentations to the emergency room, but I would be very interested to find out if that is the case. (Interestingly, the use of hydromorphone seems to increase the likelihood of bounce-back presentations.)

I’m a little curious whether propofol could be used to manage the vomiting of CVS, since it is also known to have anti-emetic properties, but given the demise of poor Mr. Jackson, I suspect such off-label uses of that medication are not going to be encouraged.

One thing which I’ve recently become aware of, in part through our good Aussie friends at Life in the Fast Lane and in part from a journal club that I recently attended, is that there seems to be a fairly strong association with marijuana use and CVS. In fact, there has been proposed a disease entity called cannabinoid hyperemesis syndrome which may possibly represent the same clinical syndrome of CVS, or at least a significant overlap. This is particularly interesting because marijuana is in fact generally perceived to have antiemetic properties. Leon Gussow, a toxicologist who blogs at The Poison Review, has a nice write up over at Emergency Medicine News, where he speculates:

Because cannabinoids are lipophilic and have long half-lives, they may accumulate with chronic heavy use to the point where they start to exert a paradoxical effect. This may be related to their well-described ability to delay gastric emptying and decrease gastrointestinal motility.

However, I would temper that against the observation that in CVS patients gastric motility and gastric emptying is often increased.

Since I have become aware of this association between marijuana use and CVS type presentations it has been my “good fortune” to care for nearly a dozen patients in the emergency department who self-reported diagnosis of CVS. Curiously, of these patients about 10 admitted active marijuana use, and the 2 who denied it had positive urine screenings for marijuana. This does not exactly make a case series, but is certainly another interesting observation. Of course, since the prevalence of marijuana use in our Emergency Department seems to approach 100% sometimes, this also may not be a statistically significant association! Each of these patients was counseled about the possible causal relationship and advised to stop smoking the devil weed. Lord knows whether they will or not, but maybe it will actually do something to reduce their ER visit frequency.

I’d be interested to hear your observations on this matter, whether other ER folks have noticed the same thing.

*This blog post was originally published at Movin' Meat*

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8 Responses to “Dealing With Cyclic Vomiting Syndrome Given How Little Is Known About The Condition”

  1. Will Sargent says:

    Agree with very high association with thc use, though often seen it as a withdrawal phenomenon.

  2. Jeffery Fields says:

    I know, for me, I womit more often now that I am over 50.Excess acid? Slow digestion? J.

  3. Kate Field says:

    As an ER doc in Oz, we have always been taught the CVS has a high association with marijuana use, in fact I can’t recall a patient who hasn’t been a heavy user. One of things we often see is a need for the patient to have hot showers. They can demand several of these during one ER stay!

    In my arsenal of treatment is the use of largactil (chlorpromazine) – I give 12.5mg IV stat followed by 12.5mg in 1L of saline over an hour. It’s a treatment I often use in treatment of primary headache also. I have had some great results with this for both migraine and CVS.

  4. Carly says:

    Only 40% of patients with CVS also use marjuana. Has anyone stopped to think that maybe because mj is extremely effective treatment for nausea and vomiting many CVS suffers use it?! What about the rest of patients ego don’t use and still ave CVS? What about people like me who have had CVS since childhood?? Obviously marjuana is not what made me sick.

    I understand that working in an ER must make you a completely synical person, but how exactly do you fake symptoms this extreme? If someone just wanted drugs they could get them a lot more easily than faking CVS of all things. Do you have any idea how awful it is the be writhing in real pain while ER doctors look at you like you’re a junky?

    It’s really hurtful to see you paint us suffers with CVS as psychologically disturbed and as dramatic drug seekers. If you lived one day of a CVS episode you would think so differently. Please stop contributing to the ignorance about CVS and start listening to the true voices of the disease. We deserve so much better than this.

  5. Ryan says:

    I’m 27 and I’ve officially had CVS for 6 years now. I have an episode about every 4 months that lasts 3-10 days where I will usually require at least 2 ER visits to get the vomiting to subside. Usual treatment at ER is Zofran, Dilaudid and Ativan injections to basically “reboot”, it will stop the shakes and sweats, help with the pain from non-stop puking for 50 hours which in turn also helps with the nausea and maybe even let me relax enough to get 20 minutes of sleep. Along with the vomiting of course is hot/cold sweats each time I throw up, can happen about every 5-10 minutes and my body is constantly in an uneasy position, I’m constantly moving one leg or the other and twisting from side to side as I concentrate on every single inhale and exhale to delay the puking as long as I can.

    When I finally get to the point when I can no longer stand to keep throwing up bile and my medications, (Zofran Phenergan, nortriptelyene, lorazapam, prilosec, hydrocondone,) and I can actually get myself to an ER, I have to hope I’m going to get the right Dr. or I might as well have not come in at all sometimes, especially if I go 2-3 times in a 3-4 day period. An hour or two puking in the lobby followed by another in triage gets you the same attitude from the DR. regardless of where you might be in the nation. “Oh you have CVS and you admitted to smoking marijuana? Clearly you’re doing this to yourself…” They might give you 1 round of injections you need to stop shaking and vomiting, at least in their presence, but as soon as you appear that you are better than when you came in, the nurse is back in your room with discharge papers basically saying get out of here you junkie. But then an hour after the meds where off and you’re back at home you start to get sick again and within 24-48 hours you are right back in the ER looking for the shots again because you’re back to puking up medications. It would be one thing if a person just showed up with no medical history or documentation but when you have been going to the same ER for 5 years why do they even need to question you at this point? You have my records right in front of your face on the computer, you see that this treatment works even though it has narcotics and yet you make me feel like I’m doing something wrong by being there and seeking help.

  6. Harris says:

    I would like to turn the tables on our first doctor. I am 40, and was diagnosed one year ago after six months of searching. I am we’ll educated with BS in Accounting and business admin and a MA in Higher education and counseling. I have worked three years with severe mentally ill and sex offenders. Since then I am a U.S. Border Patrol Agent for the last seven years protecting our nation.
    I don’t include my background to try to brag merely to show I am just a normal guy who is stuck with this ailment from Hell! By the way the last time I smoked marijuana was in 1990! I don’t think it is still in my system. What I have learned on this journey since my episode is that there are many doctors out there that have no clue! Obviously the doctor that thinks everyone with CVS is mentally ill. I guess we know who the c student was. I have been very fortunate to have some great doctors both in the ER and in my clinic, but I went through some idiots along the way.
    I must say to those naysayers many of us would wish it on you, but we know what it feels like to have the jaws of hell breathing down our necks and wishing that bastard would just get on with it!!
    By the way if you was to try something like samonella and while you are puking have your friend kick in in the stomach for four or five days. It’s a blast!! I wonder why we want relief?

  7. Sunny C says:

    That first doctor’s diatribe is amazingly ignorant and frankly offensive. I have suffered from CVS for 30 years, only recently having a name for the seemingly inexplicable symptoms that send me to ER every other month. Along the way, my gall bladder and appendix were removed which of course did nothing to fix the problem. I stopped smoking “the devil weed” for over 20 years, no better. I started again when my primary care physician recommended it as for it’s anti-nausea properties; no better or worse. Believe me, as noted previously, if drugs were all I wanted there are much easier, less traumatic ways to get them. It is completely frustrating to vomit in intense pain for days in anticipation of encountering just this sort of demeaning treatment from people who have taken an oath to help others. If there is an alternative to hours in the ER to treat CVS I will gladly try it…anyone who has experienced it would surely tell you the same thing. Being jaded and cynical is one thing; dismissing those who are suffering is unacceptable.

  8. Erin says:

    Reading all the comments,I find I’m not alone. Ryan, you and I are the exact same way, right down to the treatment. I require the same meds and I’m treated badly for it. You made a great point about going to the same er for years and years. I am not alone!

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