In this review on functional vomiting, I discuss two functional GI syndromes, gastroparesis and cyclic vomiting syndrome (CVS). Gastroparesis is a type of obstructive vomiting where the normal coordination of gastric emptying of ingested food is delayed. This most commonly occurs with diabetic neuropathy and as an idiopathic gastroparesis syndrome. Other secondary causes include extreme weight loss as with anorexia nervosa, Parkinson’s disease or medications including opioids, anticholinergics or any others that slow gastric motility. Clinically this syndrome is identified by vomiting poorly digested foods rather than on an empty stomach and often the vomitus can contain food ingested many hours prior. The diagnosis of gastroparesis is made by physiological testing showing delay on a 4 hour gastric emptying scintiscan.
Treatment of gastroparesis may begin with identification and treatment of an underlying condition if identified. Patients may also work to adjust their diet with smaller, more frequent meals and also drinking water during meals. Medication options include metoclopramide, erythromycin, and domperidone. New research is exploring the use of botulinum toxin.
Cyclic vomiting syndrome (CVS) is characterized by paroxysmal episodes of vomiting occurring in cycles with intermittent symptom free periods.
Cyclic Vomiting Syndrome has also been defined by the Rome III criteria:
Must include all of the following –
1) Stereotypical episodes of vomiting regarding onset (acute) and duration (less than one week)
2) Three or more discrete episodes in the prior year
3) Absence of nausea and vomiting between episodes
Supportive Criterion – History or family history of migraine headaches
Adults with Cyclic Vomiting Syndrome often experience four distinct phases to the vomiting episodes. Initially, there is a well phase in which patients are without significant symptoms. This then progresses to a pre-emetic phase with increased sweating and severe nausea. A phase of intense vomiting follows and can last multiple days. The final phase is the recovery phase in which the vomiting decreases and the nausea improves. These episodes may be accompanied by abdominal pain in some patients. Infections, psychological stress, lack of sleep, physical exhaustion, certain foods, and menses may be possible triggers for CVS episodes.
Though the cause of CVS is not fully understood, some associations with this syndrome have been identified with abdominal epilepsy, abdominal migraine, and CVS may also be associated with a metabolic disorder called mitochondrial disease (dysfunction). In addition, symptoms can be associated with panic attacks, the frequent use of hot showers or baths to lessen symptoms, and frequent marijuana use (i.e. cannabinoid hyperemesis syndrome) have been associated with CVS.
Treatment during the acute emetic phase of CVS may include supportive care with rest, hydration, anti-emetics (ondansetron or promethazine), anxiolytics (benzodiazepines), analgesics, antimigraine medications (5-HT agonists), and gastric acid suppressants (PPIs or H2 blockers). Prophylactic treatment options to prevent subsequent episodes include lifestyle changes in order to avoid potential triggers and medications including TCAs, SNRI’s, anti-anxiety agents, beta blockers, and most recently, anti-epileptic agents including zonisamide and levetiracetam.
Douglas A. Drossman. M.D.