Department of Gastroenterology, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA; Department of Interventional Gastroenterology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USAUnited States
Department of Gastroenterology, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USAUnited States
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This illustrative case suggests mechanisms that may contribute to disease progression and complications in adults with Cyclical Vomiting Syndrome (CVS). Symptoms initially followed a characteristic pattern in the context of marijuana use and led to repeated hospitalizations. Escalating opioid use for pain control resulted in coalescence of the syndrome with more frequent and severe emetic episodes, ultimately complicated by an esophageal microperforation. While analgesic therapy may play an important role in management of acute exacerbations, ongoing use of narcotics may contribute to the development of refractory CVS. This association of disease progression with opiates suggests that coalescent CVS should be considered a foregut manifestation of narcotic bowel syndrome.
Keywords: Cyclical vomiting syndrome; Coalescing attack; Opioids; Narcotic bowel syndrome; Narcotic bowel syn- drome
This case highlights several key points that are important for patients and physicians who deal with CVS, an unexplained disorder first described in children but now increasingly recognized in adults. The patient’s esophageal perforation was a secondary complication of repetitive vomiting, which more commonly causes esophagitis or gastrointestinal bleeding due to Mallory Weiss tears. Even though the apparent microperforation of the esophagus is an extreme example, it still emphasizes the need to identify an underlying disorder rather than focusing exclusively on the important consequences of repetitive vomiting. While only seen in a subset of patients, the case also illustrates the fact that CVS can undergo a phenotypic switch from its classic, dichotomous patterns of emetic and asymptomatic phases to eventual coalescence of increasingly frequent attacks with chronic nausea and pain complicated by typical exacerbations.1,2 Only a detailed history revealed that the patient clearly met disics, antiemetics and fluids. However, long-term treatment of CVS with preventative strategies is essential to reduce the number of attacks. After recognizing the disease, physicians need to identify potential triggers, such as opioid and cannabinoid use, both of which contributed in the case described. With the emergence of dependence, discontinuation of opioids or cannabinoids will trigger withdrawal symptoms that mirror emetic episodes of CVS. Thus, a slower taper may be required to prevent withdrawal in these individuals. In addition, clonidine and TCAs should be considered to blunt to autonomic response associated with withdrawal. TCAs remain the treatment of choice as preventative therapy for patients with CVS. Should TCAs fail or be contraindicated, coenzyme Q10 or anticonvulsive drugs may be 10-12 acceptable alternatives. Seen in a broader context, our observation suggests that coalescing CVS is a foregut manifestation of the narcotic bowel syndrome and will require a multidisci- 1,2 plinary approach to achieve long-term remission.
Authors have no conflicts of interest or financial disclosure to make.
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