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The second International Scientific Symposium on Cyclic Vomiting Syndrome (CVS) was held in Milwaukee, Wisconsin, on April 17th and 18th 1998. This conference brought together clinicians and scientists interested in the problem of vomiting in order to enhance understanding of the knowledge of the possible causes and potential treatments of CVS. One of the major conclusions of the meeting was the recognition of the close relationship between CVS and migraine. Dr. David Symon, of the United Kingdom, reported his experience with a large group of children with migraine and a much smaller group with CVS, some of whom have evolved to classic migraine. One of the important differences between his groups is the age of onset of CVS, suggesting that this may be something that CVS may be specifically related to particular of brain development. Work from Perth was presented confirming the relationship of migraine to CVS through demonstration of the much higher rate of occurrence of migraine in family members of patients with CVS compared with healthy children in the community. Dr. Pierro Rinaldo and Richard Boles, both from the United States, presented information about newly recognised genetic disorders which may appear very similar to CVS, and discussed ways in which these may be recognised. Professor Louis Ptacek talked in general about conditions which may be suddenly switched on after nutritional or environmental changes and discussed how his research group had recognised that some of these conditions can be caused by abnormalities of the "gates" that allow salts such as calcium, sodium or potassium into and out of cells. It is possible that these sorts of disorders may be related to migraine, some forms of epilepsy and possibly to CVS, although this is quite unproven. There is increased understanding of the way in which anxiety and stress may work to produce cyclic vomiting. Quite extensive work in animals and limited studies in humans have shown that stress causes release of corticotrophic releasing hormone and other brain chemicals which in turn stimulate the vomiting centre of the brain. The types of drugs available for the treatment of cyclic vomiting are likely to change over the next five years. A new class of drugs called tachykinin receptor antagonists appear to be extremely potent in preventing vomiting in animals. Studies have already shown that these drugs are capable of blocking vomiting that is initiated by a whole range of stimulants, including cancer chemotherapy, radiotherapy and motion. The companies involved in the development of these drugs are about to initiate clinical trials and it is anticipated that these drugs will be ready for marketing in four to five years. In the meantime a number of issues which may be important in general treatment were emphasised. The first of these is the importance of recognising that stress may be an important precipitant of vomiting for some children, and the role that psychological assessment and treatment may have in helping children and families deal with this. "Stress" may be positive, that is pleasant, as well as negative or unpleasant. During treatment of an acute episode of vomiting it is emphasised that it is important not to give too much fluid as this can, in fact, stimulate some of the chemicals which will perpetuate vomiting. It is important to ensure a good supply of sugar during this process. One of the interesting aspects of treatment that has emerged is the importance of placebo effect in treating migraine and cyclic vomiting. It is recognised that in migraine up to 40% of patients will respond to a placebo, reminding us of the importance of the mind, stress and anticipation in producing changes in how the body works. A clinical research trial in the use of Ondansetron (which has been used effectively in Perth) has not made much progress because many patients have got better and stopped having attacks once the Ondansetron has been used a few times and, it appears, that the patients become more confident that they can be helped. The 2nd International Scientific Symposium on CVS highlighted the important advances made in understanding the brain and bowel mechanisms involved in vomiting and in particular, the effect that stress can have in producing vomiting. The conference emphasised that in many, though perhaps not all children with cyclic vomiting, the underlying problem is of migraine. A few individuals will have very rare biochemical disorders which need careful assessment in order for them to be recognised. While there are no immediate breakthroughs in treatment, there are exciting prospects of new agents which appear to be very effective and safe in the treatment of vomiting. Reprinted from the Australian CVS Association newsletter. |
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