Re: odd case-cyclical vomiting syndrome?

[Guest guest]

Monika and Barbara,

Just another consideration I'd like to share. There is a disease called "Cyclical Vomiting Syndrome" or CVS. It is rare, but real, and often not properly recognized. It may cause vomiting for hours or days, and then the vomiting stops and the patient can be well for days or weeks. (Even as an RD, I never learned of it until met some people on a medical bulletin board with it a couple years ago, and did a bit of personal research--though I'm surely no expert.)

We are finding it can be related to food sensitivities. Often associated with IBS, abdominal pain and/or migraines and other problems often related to food sensitivities.

Just to become aware of this disorder, since it's often not known my medial docs, since many think it's only a pediatric illness, but it can start anytime in life. (I wouldn't call this form of vomiting 'bulemia' really.

http://www.cvsaonline.org/cvsadultscodev.htm is the link where I found the article I pasted below for your convenience and reference.

Who knows, maybe you'll see one of these patients in your career!

Jan Patenaude, RDDirector, Medical NutritionSignet Diagnostic Corp.www.nowleap.com (toll free)Disease Management Programs for Irritable Bowel Syndrome and Migraine

Barbara,

Albumin typically does not drop in eating disorders, even with extreme low weight.

Bulimics can be normal even slightly overweight.

There is another measure called C3 complement that some practitioners use though I have never used it myself. I typically use MAMC as a long-term protein indicator as it is one measure that (1) cannot be manipulated by the client and (2) is not changed by dehydration, be it due to client behaviors or otherwise.

Just a note, if you do pursue the psychological end, do not assume the vomiting is being induced. Some of these individuals have nervous stomachs that spontaneously purge. Either kind is bulimia, but the reasons for each can differ.

Regards,

Monika M. Woolsey, MS, RD

http://www.afterthediet.com

odd case

Hi all:Have an odd case I just discussed w/MD. Have a young pt., overweight femalehere having vomiting past 2 weeks. MD said he did work up for a lot & hasnot found anything. Starting to think its psychological. She is eating 75 to100% of meals, but told MD she vomits everything.Odd thing is her albumin,total protein labs are perfect & have been sinceshe's been here. MD was asking me if there are any other labs, indicatorsthat would gauge her protein status. (She is not dehydrated)Any guidance or insight would be appreciated.Thanks,Barbara M. , MS, RD, LDClinical Nutrition ManagerFort Walton Beach Medical Center1000 Mar-Walt DriveFor t Walton Beach, FL 32547phone number: 850.863-7523Fax: 850.862-9149Email: Barbara.@...

As Reprinted from Code “V†The Official Newsletter of the CVSA-USA/CanadaVol, No 11, No. 1 Spring 2003CYCLIC VOMITING SYNDROME IN ADULTS R. Fleisher, M.D.Associate Professor of Pediatrics - GI, University of Missouri, Columbia,Co-founder, CVSA-USA/CanadaThe first description of CVS in the English language was written by Dr. Gee in 1882. He reported a series of patients, all of whom were children ranging in age from infancy to nine years. Thereafter, CVS was considered a pediatric disorder and, to this day, most internists and gastroenterologists whose practices are limited to adults continue to be unaware of it. Making a diagnosis of CVS is difficult because it is a " functional" disorder. The simplest example of a functional disorder is a runner's leg cramp; the cramped muscle is not diseased, no blood tests or x-rays would show abnormalities and the pain certainly is not "all in the head." It is real even though medical tests designed to detect disease don't find any. In functional disorders, suffering is caused by healthy organs which function in ways that cause symptoms, but that are not diseased. Therefore, CVS cannot be diagnosed by blood tests, x-rays, or other technologic means. The diagnosis is made by a knowledgeable physician who elicits a history from the patient typical of CVS. The past decade has seen a resurgence of interest in CVS, largely as a result of the work of CVSA and it's members. Unfortunately, the fact that CVS affects adults as well as children is still largely unknown. The fourteenth addition of on's "Principles of Internal Medicine" (1998) is a textbook with more than 2500 pages; it mentions the vomiting that accompanies migraine headaches and motion sickness, but does not mention CVS. Over the past 35 years, I've provided care to 233 patients with CVS, 43 of whom were adults. My oldest patient is 69 years old and had her first episode in her early 40's. The histories related by most of my adult patients are characterized by years or decades of either insufficient treatment (such as being given IV fluids in emergency rooms and then sent home still sick) or ill-advised surgeries that did not help (such as fundoplication, gallbladder removal, or operations to facilitate emptying of the stomach). Most CVS patients can identify circumstances that tend to trigger the onset of some or many of their episodes. In children, common triggers include colds, flu, sinusitis, fatigue, motion sickness, asthma attacks and menstrual periods. But the commonest triggers in children are heightened emotional states, either stressful or exciting. Discerning triggering factors is useful because, if the identified triggers can be removed or ameliorated, the CVS episodes may be prevented or aborted more easily. I have been struck by the fact that the majority of adult CVS patients are prone to anxiety. Many of them have anxiety or panic attacks. Ordinarily, such attacks usually come and go within minutes or hours. But with many adult CVS patients, anxiety attacks set off CVS episodes that then go on for 2 to 4 days. Panic attacks come on suddenly, "out of the blue," night or day. A diagnosis of panic attack can be made if 4 or more of the following 13 symptoms occur and reach peak intensity within ten minutes: heartbeats that are fast, irregular or "pounding;" profuse sweating; chills and/or hot flashes; trembling or shivering; nausea and/or abdominal pain; chest pain or discomfort; dizziness or light headedness; feeling as though one can't get a good breath; a choking sensation; numbness or "pins-and-needles" feelings; a feeling of unreality or detachment; a fear of losing control; and a fear of dying. During panic attacks, the autonomic nervous system becomes very over-active.The autonomic nervous system is that part of our nervous system that controls bodily functions that we ordinarily have no voluntary control over, such as our heart beat, sweat gland activity, and the actions of our stomach. It would be a mistake to think about CVS as either a mental or physical disorder. The whole person is affected. We can conceptualize human beings as being separable into a mental/psychological part and a physical part, but in reality, each of us is an indivisible being. No disturbance in our emotional lives occurs without physical changes and no physical distress can reach our awareness without accompanying emotional changes. Some of the typical coping measures that CVS patients employ not only seem to help with nausea, but also counteract the intense anxiety that underlies and is caused by nausea. Examples of these measures include "hydrotherapy" in the form of prolonged baths or showers, pacing about, attempting to smoke, and the use of marijuana.When individuals feel anxious, they may be aware of their physical discomfort, but entirely unaware of what is setting it off. The patient and the physician may then embark on a fruitless search for diseases that might be causing the physical symptoms. The stress of further diagnostic testing may even make the underlying, unrecognized anxiety worse. An important part of management in anxiety-prone CVS patients is helping them recognize mounting anxiety when it occurs so that they might combat it and keep it from triggering a CVS episode. My clinical impression is that Zofran, an otherwise excellent anti-nausea medication, may not work well in some patients with nausea that is principally driven by intense anxiousness. There is another kind of nausea and vomiting that affects many adults with CVS. I call it "dyspeptic nausea." It consists of brief bouts of nausea, with or without vomiting, that come and go during the day. For example, an individual may wake up at the usual time, feel nauseated, vomit, and after an hour or less feel well enough to go to work or school. Or, one might develop nausea while at a dinner party, excuse oneself, vomit in the bathroom or just walk about outside "for some fresh air," and then feel better. Bouts of dyspeptic nausea are not CVS episodes, although, they may sometimes trigger episodes. Dyspeptic nausea is also anxiety driven, although the individual may be entirely unaware of being tense or anxious. It's occurrence points to a possibly effective method of treatment, such as anti-anxiety medications and/or therapy.Treatment of CVS in patients who are anxiety prone isn't easy; there is no sure-fire method that works for everyone. Treatment within a doctor-patient relationship that is collaborative, dedicated and not defeated by failure is infinitely better than no treatment at all or mistreatment. I am very encouraged by the work of Yvette Taché and other scientists who are working on the biology of the autonomic link between our emotions and our gastrointestinal functions. The day is coming when CVS will be easily recognized because it will be easily cured. w

All information copyright 1998-2003 CVSA-USA/Canada3585 Cedar Hill Rd. N.W., Canal Winchester, OH 43110Telephone: E-mail: waitesd@...

[Guest guest]

Jan,

How interesting. That is why I put that disclaimer in my post re: finding out how the vomiting is occurring. I see too many people jump to the conclusion that if someone is vomiting it is intentional.

If IBS and migraines are associated, sounds like there may be either a serotonin-mediated or CCK-mediated mechanism.

Always something to learn out there, eh? :-)

Monika

odd case

Hi all:Have an odd case I just discussed w/MD. Have a young pt., overweight femalehere having vomiting past 2 weeks. MD said he did work up for a lot & hasnot found anything. Starting to think its psychological. She is eating 75 to100% of meals, but told MD she vomits everything.Odd thing is her albumin,total protein labs are perfect & have been sinceshe's been here. MD was asking me if there are any other labs, indicatorsthat would gauge her protein status. (She is not dehydrated)Any guidance or insight would be appreciated.Thanks,Barbara M. , MS, RD, LDClinical Nutrition ManagerFort Walton Beach Medical Center1000 Mar-Walt DriveFor t Walton Beach, FL 32547phone number: 850.863-7523Fax: 850.862-9149Email: Barbara.@...

As Reprinted from Code “V†The Official Newsletter of the CVSA-USA/CanadaVol, No 11, No. 1 Spring 2003CYCLIC VOMITING SYNDROME IN ADULTS R. Fleisher, M.D.Associate Professor of Pediatrics - GI, University of Missouri, Columbia,Co-founder, CVSA-USA/CanadaThe first description of CVS in the English language was written by Dr. Gee in 1882. He reported a series of patients, all of whom were children ranging in age from infancy to nine years. Thereafter, CVS was considered a pediatric disorder and, to this day, most internists and gastroenterologists whose practices are limited to adults continue to be unaware of it. Making a diagnosis of CVS is difficult because it is a " functional" disorder. The simplest example of a functional disorder is a runner's leg cramp; the cramped muscle is not diseased, no blood tests or x-rays would show abnormalities and the pain certainly is not "all in the head." It is real even though medical tests designed to detect disease don't find any. In functional disorders, suffering is caused by healthy organs which function in ways that cause symptoms, but that are not diseased. Therefore, CVS cannot be diagnosed by blood tests, x-rays, or other technologic means. The diagnosis is made by a knowledgeable physician who elicits a history from the patient typical of CVS. The past decade has seen a resurgence of interest in CVS, largely as a result of the work of CVSA and it's members. Unfortunately, the fact that CVS affects adults as well as children is still largely unknown. The fourteenth addition of on's "Principles of Internal Medicine" (1998) is a textbook with more than 2500 pages; it mentions the vomiting that accompanies migraine headaches and motion sickness, but does not mention CVS. Over the past 35 years, I've provided care to 233 patients with CVS, 43 of whom were adults. My oldest patient is 69 years old and had her first episode in her early 40's. The histories related by most of my adult patients are characterized by years or decades of either insufficient treatment (such as being given IV fluids in emergency rooms and then sent home still sick) or ill-advised surgeries that did not help (such as fundoplication, gallbladder removal, or operations to facilitate emptying of the stomach). Most CVS patients can identify circumstances that tend to trigger the onset of some or many of their episodes. In children, common triggers include colds, flu, sinusitis, fatigue, motion sickness, asthma attacks and menstrual periods. But the commonest triggers in children are heightened emotional states, either stressful or exciting. Discerning triggering factors is useful because, if the identified triggers can be removed or ameliorated, the CVS episodes may be prevented or aborted more easily. I have been struck by the fact that the majority of adult CVS patients are prone to anxiety. Many of them have anxiety or panic attacks. Ordinarily, such attacks usually come and go within minutes or hours. But with many adult CVS patients, anxiety attacks set off CVS episodes that then go on for 2 to 4 days. Panic attacks come on suddenly, "out of the blue," night or day. A diagnosis of panic attack can be made if 4 or more of the following 13 symptoms occur and reach peak intensity within ten minutes: heartbeats that are fast, irregular or "pounding;" profuse sweating; chills and/or hot flashes; trembling or shivering; nausea and/or abdominal pain; chest pain or discomfort; dizziness or light headedness; feeling as though one can't get a good breath; a choking sensation; numbness or "pins-and-needles" feelings; a feeling of unreality or detachment; a fear of losing control; and a fear of dying. During panic attacks, the autonomic nervous system becomes very over-active.The autonomic nervous system is that part of our nervous system that controls bodily functions that we ordinarily have no voluntary control over, such as our heart beat, sweat gland activity, and the actions of our stomach. It would be a mistake to think about CVS as either a mental or physical disorder. The whole person is affected. We can conceptualize human beings as being separable into a mental/psychological part and a physical part, but in reality, each of us is an indivisible being. No disturbance in our emotional lives occurs without physical changes and no physical distress can reach our awareness without accompanying emotional changes. Some of the typical coping measures that CVS patients employ not only seem to help with nausea, but also counteract the intense anxiety that underlies and is caused by nausea. Examples of these measures include "hydrotherapy" in the form of prolonged baths or showers, pacing about, attempting to smoke, and the use of marijuana.When individuals feel anxious, they may be aware of their physical discomfort, but entirely unaware of what is setting it off. The patient and the physician may then embark on a fruitless search for diseases that might be causing the physical symptoms. The stress of further diagnostic testing may even make the underlying, unrecognized anxiety worse. An important part of management in anxiety-prone CVS patients is helping them recognize mounting anxiety when it occurs so that they might combat it and keep it from triggering a CVS episode. My clinical impression is that Zofran, an otherwise excellent anti-nausea medication, may not work well in some patients with nausea that is principally driven by intense anxiousness. There is another kind of nausea and vomiting that affects many adults with CVS. I call it "dyspeptic nausea." It consists of brief bouts of nausea, with or without vomiting, that come and go during the day. For example, an individual may wake up at the usual time, feel nauseated, vomit, and after an hour or less feel well enough to go to work or school. Or, one might develop nausea while at a dinner party, excuse oneself, vomit in the bathroom or just walk about outside "for some fresh air," and then feel better. Bouts of dyspeptic nausea are not CVS episodes, although, they may sometimes trigger episodes. Dyspeptic nausea is also anxiety driven, although the individual may be entirely unaware of being tense or anxious. It's occurrence points to a possibly effective method of treatment, such as anti-anxiety medications and/or therapy.Treatment of CVS in patients who are anxiety prone isn't easy; there is no sure-fire method that works for everyone. Treatment within a doctor-patient relationship that is collaborative, dedicated and not defeated by failure is infinitely better than no treatment at all or mistreatment. I am very encouraged by the work of Yvette Taché and other scientists who are working on the biology of the autonomic link between our emotions and our gastrointestinal functions. The day is coming when CVS will be easily recognized because it will be easily cured. w

All information copyright 1998-2003 CVSA-USA/Canada3585 Cedar Hill Rd. N.W., Canal Winchester, OH 43110Telephone: E-mail: waitesd@...

[Guest guest]

I have found it interesting, and have learned a TON of new research in the past couple years working for Signet Diagnostic Corp (as a consultant). They have a test called a Mediator Release test. (Check out our website at www.nowleap.com. If you fill out a 'complimentary prescreen, I'm the one that reviews it.)

I learned of this ONLY because we've had 2 clients with IBS or migraine (and CVS) that did our LEAP program hoping for IBS/migraine relief. To their (and our) surprise, their CVS/vomiting also stopped. (Purely anecdotal, so we don't yet suggest we are effective for CVS. . . if anybody wanted to do a study, we'd welcome it!) So, yes, likely all that mediator release stuff.

I'd be happy to send a TON of reading (journal articles, summaries, monograph) on the topic for your review. Very cutting edge and fascinating stuff. Just maybe it'll be mainstream in another 20 years. :-}

Jan Patenaude

Jan,

How interesting. That is why I put that disclaimer in my post re: finding out how the vomiting is occurring. I see too many people jump to the conclusion that if someone is vomiting it is intentional.

If IBS and migraines are associated, sounds like there may be either a serotonin-mediated or CCK-mediated mechanism.

Always something to learn out there, eh? :-)

Monika

odd case

Hi all:Have an odd case I just discussed w/MD. Have a young pt., overweight femalehere having vomiting past 2 weeks. MD said he did work up for a lot & hasnot found anything. Starting to think its psychological. She is eating 75 to100% of meals, but told MD she vomits everything.Odd thing is her albumin,total protein labs are perfect & have been sinceshe's been here. MD was asking me if there are any other labs, indicatorsthat would gauge her protein status. (She is not dehydrated)Any guidance or insight would be appreciated.Thanks,Barbara M. , MS, RD, LDClinical Nutrition ManagerFort Walton Beach Medical Center1000 Mar-Walt DriveFor t Walton Beach, FL 32547phone number: 850.863-7523Fax: 850.862-9149Email: Barbara.@...

As Reprinted from Code “V†The Official Newsletter of the CVSA-USA/CanadaVol, No 11, No. 1 Spring 2003CYCLIC VOMITING SYNDROME IN ADULTS R. Fleisher, M.D.Associate Professor of Pediatrics - GI, University of Missouri, Columbia,Co-founder, CVSA-USA/CanadaThe first description of CVS in the English language was written by Dr. Gee in 1882. He reported a series of patients, all of whom were children ranging in age from infancy to nine years. Thereafter, CVS was considered a pediatric disorder and, to this day, most internists and gastroenterologists whose practices are limited to adults continue to be unaware of it. Making a diagnosis of CVS is difficult because it is a " functional" disorder. The simplest example of a functional disorder is a runner's leg cramp; the cramped muscle is not diseased, no blood tests or x-rays would show abnormalities and the pain certainly is not "all in the head." It is real even though medical tests designed to detect disease don't find any. In functional disorders, suffering is caused by healthy organs which function in ways that cause symptoms, but that are not diseased. Therefore, CVS cannot be diagnosed by blood tests, x-rays, or other technologic means. The diagnosis is made by a knowledgeable physician who elicits a history from the patient typical of CVS. The past decade has seen a resurgence of interest in CVS, largely as a result of the work of CVSA and it's members. Unfortunately, the fact that CVS affects adults as well as children is still largely unknown. The fourteenth addition of on's "Principles of Internal Medicine" (1998) is a textbook with more than 2500 pages; it mentions the vomiting that accompanies migraine headaches and motion sickness, but does not mention CVS. Over the past 35 years, I've provided care to 233 patients with CVS, 43 of whom were adults. My oldest patient is 69 years old and had her first episode in her early 40's. The histories related by most of my adult patients are characterized by years or decades of either insufficient treatment (such as being given IV fluids in emergency rooms and then sent home still sick) or ill-advised surgeries that did not help (such as fundoplication, gallbladder removal, or operations to facilitate emptying of the stomach). Most CVS patients can identify circumstances that tend to trigger the onset of some or many of their episodes. In children, common triggers include colds, flu, sinusitis, fatigue, motion sickness, asthma attacks and menstrual periods. But the commonest triggers in children are heightened emotional states, either stressful or exciting. Discerning triggering factors is useful because, if the identified triggers can be removed or ameliorated, the CVS episodes may be prevented or aborted more easily. I have been struck by the fact that the majority of adult CVS patients are prone to anxiety. Many of them have anxiety or panic attacks. Ordinarily, such attacks usually come and go within minutes or hours. But with many adult CVS patients, anxiety attacks set off CVS episodes that then go on for 2 to 4 days. Panic attacks come on suddenly, "out of the blue," night or day. A diagnosis of panic attack can be made if 4 or more of the following 13 symptoms occur and reach peak intensity within ten minutes: heartbeats that are fast, irregular or "pounding;" profuse sweating; chills and/or hot flashes; trembling or shivering; nausea and/or abdominal pain; chest pain or discomfort; dizziness or light headedness; feeling as though one can't get a good breath; a choking sensation; numbness or "pins-and-needles" feelings; a feeling of unreality or detachment; a fear of losing control; and a fear of dying. During panic attacks, the autonomic nervous system becomes very over-active.The autonomic nervous system is that part of our nervous system that controls bodily functions that we ordinarily have no voluntary control over, such as our heart beat, sweat gland activity, and the actions of our stomach. It would be a mistake to think about CVS as either a mental or physical disorder. The whole person is affected. We can conceptualize human beings as being separable into a mental/psychological part and a physical part, but in reality, each of us is an indivisible being. No disturbance in our emotional lives occurs without physical changes and no physical distress can reach our awareness without accompanying emotional changes. Some of the typical coping measures that CVS patients employ not only seem to help with nausea, but also counteract the intense anxiety that underlies and is caused by nausea. Examples of these measures include "hydrotherapy" in the form of prolonged baths or showers, pacing about, attempting to smoke, and the use of marijuana.When individuals feel anxious, they may be aware of their physical discomfort, but entirely unaware of what is setting it off. The patient and the physician may then embark on a fruitless search for diseases that might be causing the physical symptoms. The stress of further diagnostic testing may even make the underlying, unrecognized anxiety worse. An important part of management in anxiety-prone CVS patients is helping them recognize mounting anxiety when it occurs so that they might combat it and keep it from triggering a CVS episode. My clinical impression is that Zofran, an otherwise excellent anti-nausea medication, may not work well in some patients with nausea that is principally driven by intense anxiousness. There is another kind of nausea and vomiting that affects many adults with CVS. I call it "dyspeptic nausea." It consists of brief bouts of nausea, with or without vomiting, that come and go during the day. For example, an individual may wake up at the usual time, feel nauseated, vomit, and after an hour or less feel well enough to go to work or school. Or, one might develop nausea while at a dinner party, excuse oneself, vomit in the bathroom or just walk about outside "for some fresh air," and then feel better. Bouts of dyspeptic nausea are not CVS episodes, although, they may sometimes trigger episodes. Dyspeptic nausea is also anxiety driven, although the individual may be entirely unaware of being tense or anxious. It's occurrence points to a possibly effective method of treatment, such as anti-anxiety medications and/or therapy.Treatment of CVS in patients who are anxiety prone isn't easy; there is no sure-fire method that works for everyone. Treatment within a doctor-patient relationship that is collaborative, dedicated and not defeated by failure is infinitely better than no treatment at all or mistreatment. I am very encouraged by the work of Yvette Taché and other scientists who are working on the biology of the autonomic link between our emotions and our gastrointestinal functions. The day is coming when CVS will be easily recognized because it will be easily cured. w

All information copyright 1998-2003 CVSA-USA/Canada3585 Cedar Hill Rd. N.W., Canal Winchester, OH 43110Telephone: E-mail: waitesd@...