NOTE: Dr. David Fleisher is Associate Professor of Pediatrics at the University of Missouri School of Medicine. He has been researching CVS for several years, serves as CVSA's medical advisor, and led the conference held last April in Milwaukee. In the following letter, his clinical and personal observations of CVS are articulated.
Dr. Samuel Gee was a nineteenth century British physician who is remembered for his powers of clinical observation and description. In 1882, he described a series of patients with similar "fits of vomiting which recur at intervals of uncertain length. The intervals themselves are free from sign of disease. The vomiting continues for a few hours or a few days. When it had been severe, the patients are left much exhausted. . .the closest observation fails to discover anything which can be called a cause."
Although more than 100 years have passed since publication of Dr. Gee's paper, there has been almost no research and little discussion of Cyclic Vomiting Syndrome (CVS) in The medical literature. Why? CVS is a rarity in clinical practice. It is almost never life-threatening. It almost always "goes away" in time. And there are as yet no identifiable abnormalities in CVS that can be shown by blood tests, x-rays, biopsies or other diagnostic techniques.
Nevertheless, CVS may cause incredible suffering. Recurrences and fear of recurrences can blight the lives of CVS sufferers and their families for years. Moreover, vomiting is a symptom with more than 100 possible causes: kidney disorders, brain tumors, obstructions or infections of the intestinal tract, ulcers, and diseases of the pancreas, or adrenal glands are a few examples of conditions that may cause CVS-like symptoms. A physician who
encounters a patient with recurrent vomiting must make sure that no underlying disease that can be treated or cured goes undetected. The CVS patient is burdened by the necessity of undergoing sometimes painful, or expensive tests to rule out the presence of such underlying causes. If the possibility of CVS is not considered early enough by the physician, the search for the disease that isn't there may go to unnecessary lengths.
What is CVS like? It can start anytime during childhood or adolescence, ranging from 6 months to 17 years of age. Onset during adulthood has been documented. Vomiting attacks tend to be characteristic over many months or years, although attacks may worsen over time, becoming longer and more frequent. Attacks lasting 12-24 hours and 1-2 days are most common, although
attacks may last less than 6 hours or more than 5 days. The frequency of attacks in our patients range from 1-70 per year, averaging 12 per year. Although the term "cyclic" implies a regular rhythmicity, occurrences were fairly predictable in only about half of our patients. Many patients had characteristic symptoms in addition to nausea and vomiting, that accompanied
attacks, such as loose stooling, headache, and low grade fever. During attacks, patients experience intense misery and may seem unresponsive or withdrawn. They may be unable to swallow their saliva and hold it in their mouths or spit it out. They may complain of abdominal pain, and prefer to rest in a quiet,
dark room to attempt to sleep. Some patients have intense thirst and attempt to drink, only to vomit as soon as they do so. Some have rapid heart beat and mild to moderate high blood pressure during episodes, abnormalities which disappear as soon as the attack is over. If vomiting persists for more than several hours, blood may appear in the vomitus. This is caused by irritation
of the lining of the esophagus due to backwash of irritatingly acid stomach fluid. Such irritation may compound the misery of nausea with intense heartburn.
The vomiting attacks often subside as promptly as they began, at which point the patient feels well, regains appetite and gains back whatever weight was lost during the episode. They are then typically well until the next attack.
The Cyclic Vomiting Syndrome Association (CVSA) has been organized to break through the isolation, hopelessness, and frustration that has burdened patients, their families, and their physicians. In these newsletters, (NOTE: Here Dr. Fleisher was referring to the quarterly Code V newsletter published by the CVSA) we'll discuss what is known about management of this disorder, research in progress, the possible relationship between CVS and migraine headache, emotional factors that may be a part of the predisposition to CVS, and overall management strategies.
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