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PED-EM-L  September 2000

PED-EM-L September 2000

Subject:

Re: abdominal pain mystery

From:

cvsadwaites <[log in to unmask]>

Reply-To:

cvsadwaites <[log in to unmask]>

Date:

Tue, 12 Sep 2000 07:10:17 -0400

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (231 lines)

Dr. Fisher,
your email was forwarded on to me to give you some possible info on an
illness that may be what you are looking at.
Cyclic Vomiting Syndrome is an unexplained disorder of children and some
adults that was first described in 1882 by Dr S Gee.  The condition is
characterized by recurrent, prolonged attacks of severe nausea, pain,
vomiting, and prostration with no apparent cause.  Vomiting occurs at
frequent intervals (5-10 times an hour at peak) for hours up to 10 days (1-4
most common).  Some experience little to no vomiting, but have incredible
pain with their episodes.  The episodes tend to be similar to each other in
symptoms and duration.  The person is typically well in between episodes.

Episodes can begin anytime, but typically begin during the night or early
morning.  The person is very pale, and resists talking. The abdominal pain
is extremely intense.  Tests run for all other known causes for the pain and
vomiting come back negative, no other cause or reason for the symptoms can
be found.
You mention abdominal Migraine in your post, it is believed by many of the
specialist dealing with CVS, these two are related, CVS and abdominal
migraine.

I am including some general info on CVS in this post, if you are interested
I can send more detailed info on CVS/abdominal Migraine to you with a
mailing address.

I wish you luck in finding answering for this family and young boy.

Debra Waites
CVSA Administrator
3585 Cedar Hill Rd NW
Canal Winchester, OH 43110
ph. 614-837-2586  fax: 614-837-2586
[log in to unmask]
www.beaker.iupui.edu/cvsa

DIAGNOSTIC GUIDE
 CYCLIC VOMITING SYNDROME (CVS)

RESEARCH DEFINITION:  Cyclic Vomiting Syndrome is a disorder in which a
patient has experienced a minimum of three discrete episodes of vomiting
each usually involving more than four emeses per hour at the peak.  There
are typically no more than two episodes per week.  An average episode lasts
for 24-48 hours (2 hour min.)  but can last for 10 days or more.  There are
varying intervals of normal health between the episodes when the patient is
free from vomiting.  There is no apparent cause for the vomiting found on
testing.

CURRENT DIAGNOSTIC CRITERIA:
Essential Criteria:
* Recurrent severe discrete episodes of nausea & vomiting, minimum of 3
distinct episodes
* More than 4 emeses per hour at the peak
* Episodes last from hours to days, 24-48 hrs (average) - min 2 hours, may
be up to 10 days or more
* Less than 2 episodes per week. On average every 2-4 weeks.
* Varying intervals of normal health between episodes
* No apparent cause of vomiting (found on testing)

Supportive Criteria
* Pattern: For the individual patient, each episode is similar as to time of
onset, intensity, duration, frequency, associated signs and symptoms
* Self-Limited:  Episodes resolve spontaneously if left untreated.
* Family history of migraine or CVS
* Past need for IV fluids during episodes

Associated Symptoms: (Not all exist in every patient):
Bilious vomiting, nausea, abdominal pain, headache, motion sickness,
sensitivity to light,
 sensitivity to noise
Associated Signs:
Fever, pallor, diarrhea, dehydration, excess salivation, social withdrawal,
sweating, high
blood pressure

DIAGNOSTIC STUDIES USED TO EXCLUDE SPECIFIC DIAGNOSES THAT MIMIC CVS
The diagnosis of CVS is made by careful review of the patient's history,
physical examination, and laboratory studies to rule-out other diseases that
may cause vomiting similar to that seen in children with CVS.  Diagnoses
that can cause a cyclic vomiting pattern can include abdominal migraine,
chronic sinus infections, brain tumors, structural abnormalities of the
intestinal tract, kidney blockage, metabolic and endocrine disorders and
psychological disturbances.  Below is a list of studies to help guide the
diagnostic work-up for patients with the cyclic vomiting pattern.

*  OBTAIN BETWEEN AND DURING AN ACUTE EPISODE
** IMPORTANT TO BE OBTAINED DURING THE HEIGHT OF ACUTE EPISODE

Blood Studies
* CBC with diff count & ESR
* *electrolytes, BUN, creatinine, glucose
* *AST, ALT,GGTP, bilirubin
* *amylase, *lipase
* **ammonia, **lactate (no tourniquet)
* **carnitine and **quantitative plasma amino acids
* lead level
Urine Studies
* UA w/ microscopic, Ca++/G ratio
* urine culture
* **quantitative organic acids, d-aminolevulinic acid porphobilinogen



11/99 cvsa



Stool Studies
* occult blood
* WBC
Radiologic Studies
* ultrasound or CT scan of **kidneys (hydronephrosis), urinary tract, liver,
biliary tract, pancreas, adrenal glands, ileo-cecal-appendix region
* barium study of upper GI w/ small bowel follow thru
* MRI or CAT scan of the brain
Other Studies - if indicated
* EEG
* urine toxicology screen for drugs of abuse
* pregnancy test


_________________________________________________________________
 MEDICATION POSSIBILITIES FOR TREATMENT OF CVS


This is a list of the most commonly prescribed medications for of CVS
episodes.
1) This is NOT a complete list.

2) Medication and dosage decisions must be made under the careful
supervision of a  physician.  CVSA medical advisors are willing to consult
with physicians.

3) There is no one medication that proves to be the answer for even most
patients  with CVS.  Most patients have multiple medication trials.


ABORTIVE MEDICATIONS (used to stop the episode once it has started)

ondansetron (Zofran)
granisitron (Kytril)
tropisetron ( ? )

sumitriptan (Imitrex)

ketorolac (Toradol)

PROPHYLACTIC MEDICATION  (used daily if warranted to prevent episodes)

cyproheptidine (Periactin)
pizotofen (Sandomigran) - not available in USA but families get it from
Canada
amitriptyline (Elavil)
propranolol (Inderal)

SEDATIVE MEDICATION (used during the episode to allow sleep)

lorazepam (Ativan)
chlorpromazine (Thorazine) in combination with diphenhydramine (Benadryl)

PAIN MEDICATION

ibuprofen (Motrin)
ketorolac (Toradol)

GASTRIC MOTILITY MEDICATION

cisipride (Propulsid)

CONTRACEPTIVE (for episodes associated with menses)

Loestrin                       10/97
??












----- Original Message -----
From: "Jay Fisher" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Sunday, September 10, 2000 2:26 PM
Subject: abdominal pain mystery


> Looking for ideas on the following case:
>
> 5 year old otherwise healthy male with a one and a half year history of
> intermittent severe, colicky, incapacitating abdominal pain.
> Occasionally associated with non-bilious vomiting. Occurs about once a
> month and does not appear food related. Child was found to have
> bilateral hydronephrosis prenatally. PE is normal. Weight is about 10th
> percentile. Patient was admitted with an episode of gross hematuria one
> month ago, without pain, which quickly resolved. Negative workup has
> included the following: Upper GI, Barium Enema; IVP, non-contrast abd
> CT, and renal ultrasound have shown progression of hydronephrosis on the
> right, but no evidence of nephrolithiasis. CBC, electrolytes, lipase,
> hepatic enzymes are normal. Stool studies negative. Urinalysis presently
> notable for a ph of 8, otherwise normal. Peds GI and Peds Urology are on
> the case.
>
> I witnessed one of the episodes and they are quite impressive. The child
> doubles up, grunts in excruciating pain with teeth clenched, hands in
> fists, and extremities trembling, lasting about a minute followed by
> persistent peri-umbilical pain. The child appears pale during the
> episodes. He can communicate with you in between the spasms. The family
> is appropriate and at the end of their rope. Abdominal migraine has been
> suggested by the family and I find this dx lacking.
>
> ? Intermittent UPJ obstruction, SMA syndrome, porphyria ?
>
> Thanks
>
> Jay Fisher MD
>
> For more information, send mail to [log in to unmask] with the
message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>   http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
>

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

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