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Cyclic Vomiting Syndrome: Syndrome: What GI Nurses Need to Know

Samantha Kozak Melroy, BS, RN, MSN, APNP

Disclosure of Significant Relationships

ObjectivesUpon completion of this activity, the learner will be able to:--Summarize the relevance of CVS--Describe basic CVS pathophysiology, including main contributing factorsmain contributing factors--Identify signs and symptoms characteristic of CVS disease--Discuss nursing interventions to help in the management/treatment of CVS patients--Review the relationship and effects of marijuana use in CVS patients--List available CVS resources for patients.

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In BriefPatients with episodes of nausea, vomiting and abdominal pain lasting 1 hour to 1 week, often accompanied by migraine headache, anorexia, photophobia, weakness and p pdehydration. Intense vomiting frequently requiring ED visits or hospitalizationComplete return to baseline in between. “AKA” (frequently labeled)

Gastroparesis, Viral illness, pyschologicalcondition, drug seeking, illness of childhood

HistoryStudied by Dr. Samuel Gee in late 19th

CenturyDocumented episodes dating back to Charles Darwin in 1862Charles Darwin in 1862

“Two days ago three officers of the Beagle came here to dinner; I took every possible precaution, but it made me very ill with violent shaking & vomiting til the early morning; & I could not even wish them goodbye next morning” – Charles Darwin to JJohn Lubbock, October 1862A century later, Rome III Criteria

Rome III CriteriaStereotypical episodes of vomiting regarding onset (Acute) and duration (less than 1 week)3 or more discrete episodes in the prior yearAbsence of nausea and vomiting between Absence of nausea and vomiting between episodesNo metabolic, gastrointestinal, central nervous system structural or biochemical disordersCriteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis

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Supportive CriteriaAnxiety/Depression

Chicken or the egg ? Migraine headachesg

Up to 82 % of children and 70 % of adults with CVS have personal or family history of migraines (Talwalkar, Scholand, Doolittle, 2013)

Autonomic dysfunctionMitochondrial dysfunctionNeuroendocrine dysfunction

RelevanceOften Misdiagnosed with delay in initial treatment

Median time to correct diagnosis = 2.5 Median time to correct diagnosis 2.5 years (Li & Williams, 2012)

It’s More Common than we thinkPrevalence rate of 0.04%- 1.9% with female to male predominance of 55:45 (Talwalker, Scholand, Doolittle, 2013).

Psychosocial Issues

CostDisabilityUtilization of Emergency Services Inpatient hospitalizationInpatient hospitalization

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Vomiting Pathophysiology

CVS PathophysiologyFunctional Disorder

Mind/Gut CorrelationDifferential Diagnosis to considerDifferential Diagnosis to consider

Functional Disorders

cyclic vomiting

fibromyalgia

depression

migrainetinnitus

The Functional Symptoms Elephant (Lying Low dt Chronic

Fatigue Syndrome)

Functional

irritable bowel syndromecomplex regional pain syndrome

restless legs syndrome

interstitial cystitis

FunctionalAbdominalpain

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Functional Symptoms

http://www.ijdr.in/article.asp?issn=0970-9290;year=2012;volume=23;issue=4;spage=529;epage=536;aulast=Suma

Functional DisorderAssociated with mtDNA polymorphisms= Maternal inheritance of functional disordersdisorders

In the absense of mutuation, mtDNAsequence is identical in all matrilineal relatives (mothers, siblings, maternal grandmother, aunts uncles etc)

CVS PathophysiologyFunctional DisorderMind/Gut CorrelationDifferential Diagnosis to considerDifferential Diagnosis to consider

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The Mind/Gut CorrelationSympathetic Nervous System

Fight/Flight, increased alertness, increased t b li ti it i d h /b d d metabolic activity, increased hr/bp, decreased

digestion, mobilized glucose reservesParasympathetic Nervous system

Decreased sweating, increased digestive function

** Many of our CVS patient’s have Autonomic Dysfunction

Symptoms of Autonomic Dysfunction

DizzinessLight headednesPOTSPOTSSyncopeNausea rt gastroparesisConstipation and diarrhea

CVS PathophysiologyFunctional DisorderMind/Gut CorrelationDifferential Diagnosis to considerDifferential Diagnosis to consider

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DifferentialsGastroparesis *Gallbladder dysfunction *Recurrent Viral gastroenteritis *GastritisV l lVoluvulusIntoxicationPregnancyNeurological or intracranial processUDThyroid disorderHormone or Metabolic disorderAcute hydronephrosisPancreatitis

Diagnostic Tests/Labsand Procedures

EGDBrain Imaging (CT or MRI)Brain Imaging (CT or MRI)Abdominal USUpper GI seriesGES (Gastric emptying study)HIDA scan

Contributing FactorsDysregulation in the CNS (autonomic dysfunction) which can lead to flushing or gut dysmotilityg y yNeuroendocrine abnormalityMitochondrial metabolism dysfunctionAnxiety/Depression/Bipolor disorderSignificant stress (Trauma, surgery, anesthesia, infection, life event etc.)

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What do these patient’slook like?

Sick as dogs if in an acute episodeTotally normal if not

What do these patient’slook like?

Meet Rome III criteriaAdult median age of onset = 35Children median age of onset = 5May Have: May Have:

- maternal or personal hx migraine headache- autonomic dysfunction- Anxiety, depression, IBS- Marijuana use- Chronic opiate use (often rt misdiagnosis)

What else do they look like? May Have (continued):

Carry misdiagnosis of gallbladder dysfunction, gastro paresis or recurrent i f ti infectious processMany have seen multiple providers and are frustrated, depressed, and defeatedRelief of symptoms with hot water bathing, water guzzling, or sleepSymptoms presenting in early morning hours, often waking up vomiting.

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Subgroups of CVS patientsThose with migrainesThose with hypertension during episodeCVS associated with mensesCVS associated with mensesThose with diabetesMorning n/v only Postinfectious subgroup

DemographicsChildren- approx 2 % of the popluationaffected, median age of onset is 5. Most outgrow by early adolescence, but 75 % g y ytransition to migraine headaches. On average 9 episodes per yearAdults: affects females > males, on average 14 episodes yearly, typically longer in duration

Clinical Features of Disease

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Prodromal “Warning”Phase

1st sign of attackSudden onset, lasting 0-1 hourTime for Abortive MedicationsTypical symptomsTypical symptoms

Abdominal pain or discomfortSweatingIrritabilityAnxiety, feeling of impending doomPallorNausea/salivationHeadache/migraine

Clinical Features of Disease

Emetic PhaseIntense abdominal pain, nausea, vomitingOften times migraine headacheAcutely illAcutely illCompulsive hot water bathing or water guzzlingIf prolonged, leads to dehydration, weakness, electrolyte abnormalities, requiring ED visit or hospitalization

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Clinical Features of Disease

Recovery Phase“Turned the Corner” and on the road to recoveryVomiting and acute pain has stoppedVomiting and acute pain has stoppedAble to eat and drinkOften times patients are very fatigued, with tender/sore abdomen from intense vomiting/dry heavesTypically lasts 12-24 hours.

Clinical Features of Disease

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Intra-episodic PhaseIn between – Symptom free phaseThis is an overlooked, but key piece to the picture of CVS picture of CVS. This is the time to focus on maintaining healthy, balanced lifestyle, diet, and emotional state. Routine follow up with HCP team (q 6-8 weeks to q 12 months)

Psychosocial ImpactAnxiety and depression associated with chronic illness and unpredictable, largely unknown nature of disease often triggers CVS episodes. In turn CVS also worsens underlying psych issues In turn, CVS also worsens underlying psych issues (Chicken or the egg)

Key to address/manage both piecesPatient’s often have very involved parents and spouses. Others often struggle to maintain relationships and due to social isolation, embarassment, anxiety about having an attack. etc

Psychosocial ImpactLoss of employmentDelay/ending of higher educationDisability designationDisability designationFinancial hardship

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Treatment/TherapyTrigger AvoidanceProphylactic (Preventative)Abortive (Abort = To Stop)Abortive (Abort = To Stop)Supportive

Trigger AvoidanceSleep deprivationMotion SicknessStress (positive and negative)Stress (positive and negative)Missed or infrequent mealsWeatherFood triggers

Typically highly individual although common culprits are red wine, chocolate, certain cheese

Treatment/TherapyTrigger AvoidanceProphylactic (Preventative)Abortive (Abort = To Stop)Abortive (Abort = To Stop)Supportive

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Prophylactic (Preventative)Pharmacologic (may take weeks to months to take full effect!)

Tricyclic antidepressants (Amitriptyline/Nortriptyline) and/or anti seizure (Amitriptyline/Nortriptyline) and/or anti-seizure drug TopamaxMitochondrial supplements (CO Q10, Riboflavin, L-Carnitine)

Non-pharmacologicSupport! Social, psychological, physical, educational. Nursing team can make a huge impact

Treatment/TherapyTrigger AvoidanceProphylactic (Preventative)Abortive (Abort = To Stop)Abortive (Abort = To Stop)Supportive

AbortivePharmacologic

Anti-emetics Zofran (ondansetron) ODT, Compazine, Phenergan, Emend

SedativesSedativesBenadryl, Benzos

TriptansImitrex, Zomig

Non-pharmacologic Mindful relaxation (easier said that done)Breathing exercisesBiofeedbackSleep!!

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Treatment/TherapyTrigger AvoidanceProphylactic (Preventative)Abortive (Abort = To Stop)Abortive (Abort = To Stop)Supportive

SupportivePharmacologic

IV anti-emetics, sedatives, and pain medicationIVF

Non PharmacologicEmotional support, ability to rest and take time to recoup/listen to body. Collaboration among HCPsContinue with abortive strategies

Alternative TherapyGinger Supplements

As Nurses, what can we doto help?

Continuous, collaborative, empathetic support during all stages of diseaseRemind our patients that meds can take time to work, and not to be discouraged to work, and not to be discouraged Educational reinforcement and support, often via telephone. Primary objective is to manage episodes at home. Provide appropriate options during acute phase if home management has failed – Be aware of Hot Button words that require Immediate attention

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Triage Current symptomsDuration of episodeLast po intakeLast po intakeVerify medsMeds taken in attempt to abort episodeEncourage they keep a diary of symptoms and med list/logAny alarm signs?

Alarm SignsLikely needs immediate attention and urgent evaluation in ED

Atypical or “different than usual CVS symptoms”Ss dehydration (dizziness, weakness, confusion)Prolonged period without po intakeHematemesis

Management Optionsfor Patient’s

If management at home is not effective and they do not require emergent ED attention, can consider

Treatment in outpatient infusion clinicDirect admission

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As Nurses, what can we doto help?

Be aware of side effects of medication, and action to take

Increased risk of kidney stones with Topamax (BMP q 6 months). Drink plenty of waterPotential for QTc interval prolongation with TCAs and many anti-emetics.

Ensure pt has had serial EKGs every 2-3 weeks while titrating and one 1 week after reaching target dose

Recommended EKG scheduleBaselineEvery 2-3 weeks while titrating TCA (Amitrip/Nortrip) (Amitrip/Nortrip)

About 55 mg, 85 mg1 Week After Target Dose

Ideally 100 mg

ED ProtocolPatients often triaged behind those with other more common ailmentsHowever the sooner the better in the However, the sooner the better in the initiation of protocol and treatment

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ED Protocol ExampleIf an ER visit becomes necessary, once the blood work is drawn and a bolus of saline is given as indicated, we recommend initially administering IV D5NS. The 5% dextrose is designed to provide a source of energy, stimulate insulin secretion and rapidly terminate ketosis if present.

To provide the optimal antiemetic effect, we recommend administering Zofran 8 mg q 4-6 hours IV with Ativan 1-2 mg q 6 hours IV, and Benadryl 25-50 mg q 6 hours IV PRN. Droperidol 0.625mg IV is also an option and may be given once on a scheduled basis over the first 24 hours, then proceeding to a prn basis. If Droperidol is given and EKG is recommended to monitor the QTc.

This regimen provides both antiemetic and sedative effects to provide symptomatic relief and this combination can occasionally shorten the episode much like sleeping off a migraine. In light of recent warning from FDA that Zofran prolongs QTc, would recommend checking EKG/QTc when giving Zofran.

If necessary Dilaudid may be given for pain control. This should be given at the discretion of the admitting physician and vitals should be monitored accordingly.

We have provided extensive counseling and coordination relate to the acute management of this disorder and provided the above recommendations in written form. The patient has been instructed to share this with the Emergency Department Physicians when seeking treatment there.

We have emphasized that CVS is not a psychogenic disorder. However, psychologic stressors such as excitement and negative stressors can act as triggers of an episode.

In the face of this difficult and disruptive illness, partnering with you and your colleagues, the Emergency Department, a Psychologist and our team is essential to reassure them that responsive medical care is available- this reassurance can be immensely helpful by lowering levels of anxiety and frustration.

The role of Marijuana40 % of CVS patients use, more commonly white malesStudies have shown that users were 2.4 times more likely to have CVS vs functional vomiting (Deb -Where did this come from?, in outline)Anecdotally – pt’s that use marijuana and do poorly, stop using and symptoms are much better controlled.

Self reported effects of marijuana in patients with CVS

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Overallsymptoms

Nausea Vomiting Appetite Generalwell‐being

Stress level Vertigo

Percen

tages Made a lot

betterNo difference

Made a lotworse

Venkatesan et al, International Conference of Nausea & Vomiting,Pittsburgh,2013

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Why Is This? Cannabinoids!Cannabinoids (CB): chemical compounds that work on CB receptors in the brain that affect mood, appetite and weight gainExamples

Endocannabinoids – naturally occurring in humans and animalshumans and animalsPhytocannabinoids – found in cannabis and other plants

THC – psychoactive component in cannabis

Synthetic cannabinoids

Receptors CB1 and CB2Receptor Agonists that promote mood, appetite, and promote weight gain

It Makes Sense…People use marijuana because it works on the same receptors as the naturally occurring feel-good receptors in our g g pbrains!

However…

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Side Effects of Heavy Marijuana Use

Risk factor for schizophreniaWorse outcomes

Frequent longer periods of hospitalizationFrequent, longer periods of hospitalizationHigher relapse rateElevated rates of extrapyramidal motor symptoms (EPS)Lower Medication compliance

(Barnett et al. 2007), (Verdoux and Tournier, 2004) (Stefanis et al. 2004).

Canabidiol (CBD)One of at least 85 different cannabinoids isolated from Cannabisisolated from CannabisRepresents approximately 40% of extract from plant resinNot psychoactiveReceptor 5-HT1A agonist- antidepressant and anxiolytic properties, neuroprotective effects, relief from convulsions, inflammation, nausea, moderate painOils, capsules, Gum, Tincture, Cream, lotion, vaporizers

Current ResearchApproach to DiagnosisCharacteristics of the Disease

Hot Showers Marijuana useHot Showers, Marijuana useNeurochemical MechanismsPharmacologic Management StrategiesPhysiological Components

Anatomical changes in the brainGenetic (Mitochondrial) anomalies

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ResourcesComing Soon! CVS.mcw.eduCVSAonline.orgAmerican Neurogastroenterology and American Neurogastroenterology and Motility Society (www.motilitysociety.org)International Foundation for Functional Gastrointestinal Disorders

ReferencesReferences:

Evans, R. W., & Whyte, Chad. (2013). Cyclic vomiting syndrome and abdominal migraine in adults and children. Headache, 6, 984-993.

Lee, L. Y., Abbott, L., Mahlangu, B., Moodie, S. J., & Anderson, S. (2012). The management of cyclic vomiting syndrome: a systematic review. European Journal of Gastroenterology & y g y y p gyHepatology, 24:9, 1001-1006.

Li, B. K., & Williams, S. E. (2012). Cyclic vomiting syndrome: clinical geatures and comorbidities. Contemporary Pediatrics, 9, 34-46.

Talwalkar, J. S., Scholand, S. J., & Doolittle, B. R. (2013). Ginger as an adjunctive treatment for cyclic vomiting syndrome. Alternative and Complementary Therapies, 19(2), 94-97.

Thurler, A. H., & Kuo, B. (2013). From heave to leave: Understanding cyclic vomiting syndrome. Gastroenterology Nursing, 36:6, 407-413.

Tonore, T. B., Spree, D. C., & Abell, T. (2014). Cyclic vomiting syndrome: A common, underrecognized disorder. Journal of the American Association of Nurse Practitioners, 26:340-347.