1. Cyclic Vomiting Syndrome LT Greg Gorman

2. Features Diagnosed 3-6 times a year in tertiary hospitals. 20-30 times a year in Germany after WW2 Boys and girls equally

3. Age of Onset

4. Episodes Episodes are similar 85% have uniform length episodes 1-70 episodes per year (avg. 12) 50% have regular cycle

5. Course in 5 y/o girl 2.5 22 2 222 27.5 2027 29 26.535 2642 In hours; green boxes are episodes

6. Course in 12 y/o girl 1 22 2 1/2 11 wks14 wks 12 wks 10.6 wks In hours; green boxes are episodes 12 th birthday 1 st day of school Parents out of town Parents went to Dineyland without her

7. Course in 8 y/o girl 2.5 22 2 222 27.5 2027 29 26.535 2642 In hours; green boxes are episodes

8. Course in 14 y/o boy 2.5 22 2 222 27.5 2027 29 26.535 2642 In hours; green boxes are episodes

9. Duration of Episodes Fleisher, 1993

10. Timing of Episodes Charateristic timing in 76 % Usually upon awakening or middle of night Fleisher JPGN ‘93

11. Associated Symptoms Epigastric pain Nausea Saliva holding Loose stools (30 %) Headache (27 %) Fever (23 %) Occasional hypertension, tachycardia

12. Associated Symptoms Willingness to drink water “I drink the water because sometimes vomiting helps to relieve the nausea and, as far as I know I’m going to vomit anyway, it is far less unpleasant to bring up a dilute solution than to vomit concentrated hydrochloric acid…”

13. Associated Symptoms Triggers (75 %) Parental conflict (most common) Non-noxious excitement (birthdays etc) URIs Others: Menstruation, hot weather, exhaustion, motion sickness, specific foods, asthma attacks

14. Family History IBS (67 %) (2-6x normal prevalence) Migraine (11%) Motion Sickness (46%) Type A Personality (76%) Epilepsy (6%) (10x normal prevalence)

15. Course Over half symptom free 1 yr later Others last decades ? End at puberty

16. Pathogenesis Migraine equivalent Fits pattern and family history Eipileptic equivalent Case report of 5 seizure patients with CVS pattern

17. Differential Diagnosis Brain Stem Glioma Obstructive Uropathy Others

18. Management Anti-emetics Induction of sleep Resolution with consultation alone Psychosocial support