Epidemiology, Clinical Characteristics, and Associations for Rome IV Functional Nausea and Vomiting Disorders in Adults

Impact of Opioid and Cannabis Use on Low-Dose Amitriptyline Efficacy in Cyclical Vomiting Syndrome: A Real-World Study in the United Kingdom

BACKGROUND

Central neuromodulators, specifically tricyclic antidepressants (TCAs), are prescribed as prophylactic treatment for cyclical vomiting syndrome (CVS). It is unclear whether opioids and/or cannabis affect the treatment response to neuromodulators. The aims of this study were to assess: (i) the prevalence of opioid and cannabis use among outpatients with CVS, (ii) clinical characteristics associated with opioid/cannabis use and response to a three-tiered neuromodulator treatment algorithm, and (iii) the effect of opioid/cannabis cessation on response to the treatment algorithm.

METHODOLOGY

Data from consecutive patients newly diagnosed with Rome IV CVS at a single tertiary care neurogastroenterology outpatient clinic (January 2016-June 2024) were retrospectively collected. Patients were advised to stop consuming opioids and/or cannabis and commenced a low-dose TCA.

RESULTS

Sixty-one (46/75) percent of outpatients with CVS responded to the three-tiered treatment algorithm. Among responders, 42 (91%) patients responded to TCA alone (1st line therapy), 3 (7%) patients responded to TCA and selective serotonin reuptake inhibitor or serotonin norepinephrine reuptake inhibitor (2nd line therapy), and 1 (2%) patient required topiramate (3rd line therapy). The mean [SD] dosage of TCA among responders was 26.5 [18.3] mg. Twenty-five (33%) patients consumed opioids, 14 (19%) took cannabis, and five (7%) consumed both opioids and cannabis. While opioid cessation was associated with clinical response to the treatment algorithm (p = 0.03), opioid intake at the initial consultation was not (p = 0.2). Irritable bowel syndrome was independently associated with significantly greater odds (OR [95% CI]) of opioid consumption at baseline (6.59 [1.49-29.24], p = 0.01). Heartburn was independently associated with lower odds of response to the treatment algorithm (0.2 [0.05-0.65], p = 0.006).

CONCLUSION

Low-dose neuromodulators, along with opioid and cannabis cessation, may be important strategies in the management of CVS.

Worldwide Prevalence and Description of Cyclic Vomiting Syndrome According to the Results of the Rome Foundation Global Epidemiology Study

INTRODUCTION

Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction of unknown origin. The aim of this study was to evaluate the global prevalence of this disorder and its associated factors.

METHODS

Data were collected from nationwide Internet surveys in 26 countries, with subjects evenly distributed by age, sex, and country. The survey included the Rome IV questionnaire and an extensive supplemental questionnaire to evaluate additional factors.

RESULTS

A total of 54,127 participants completed the questionnaire (51% male, mean age 44.3 years). The pooled prevalence of CVS was 0.3% (95% confidence interval [CI] 0.3%-0.4%; n = 187), highest in Brazil (1%, 95% CI 0.6-1.5), and lowest in Japan and Germany (with no subject who fulfilled the criteria for CVS). The mean age of participants with CVS was 36.7 years (SD 13.5), and it was more common in women (56.7% vs 43.5%). Factors independently associated with this syndrome were female sex (odds ratio [OR] 1.52, 95% CI 1.13-2.03), young age (OR 2.57, 95% CI 1.34-4.94, for people between the ages of 18 and 39 years, compared with those older than 65 years), depression (OR 3.14, 95% CI 2.05-4.82, P < 0.001), and anxiety (OR 1.79, 95% CI 1.15-2.78, P < 0.001). Individuals with CVS had impaired quality of life (QoL) (Patient-Reported Outcomes Measurement and Information System 10-item score: physical QoL mean, 12.9 vs 15.5, P < 0.001; mental QoL mean 12.3 vs 14.4, P < 0.001) compared with others.

DISCUSSION

CVS is a relatively common disorder that has a negative impact on QoL. It is important to raise awareness on this syndrome to avoid underdiagnosis and improve clinical practice.

Serotonin Receptors Polymorphisms Are Associated With Cyclic Vomiting Syndrome

BACKGROUND

Cyclic vomiting syndrome (CVS) is a disorder characterized by sudden, recurrent episodes of severe nausea and vomiting. The pathophysiology of CVS is not known but genetic factors that regulate emetic neurocircuitry have been proposed. The aim of this study was to investigate whether different variations in genes encoding serotonin receptors (HTRs) are associated with susceptibility to CVS and/or CVS symptoms.

METHODS

This case-control study included 70 patients with CVS:16 male and 54 female, and 2504 healthy controls from the 1000 Genomes Project database. Single-nucleotide polymorphisms (SNPs) in genes encoding serotonin receptors (HTR1B, HTR1D, HTR3B and HTR3C) and correlations between SNPs and the symptoms of CVS were determined.

KEY RESULTS

Our study discovered that patients with GG, AA and GG genotypes of HTR1B/D rs6296, rs6298 and rs6300, respectively, as well as the CC genotype of HTR3B rs176744 are associated with an increased risk (p < 0.001), whereas allele C in rs3788987 (HTR3B, p < 0.01) and allele A in rs6766410 (HTR3C, p < 0.05) were associated with a decreased risk of CVS. In addition, statistical analysis indicated that CVS patients with GA or AA genotypes of HTR1D rs676643 gene have a seven-fold increase in risk of depression compared to patients with GG genotype (p < 0.01).

CONCLUSIONS AND INFERENCES

Our study revealed for the first time that variations in 5-HTR genes may contribute to CVS susceptibility and CVS-related symptoms.

European Guideline on Chronic Nausea and Vomiting-A UEG and ESNM Consensus for Clinical Management

INTRODUCTION

Chronic nausea and vomiting are symptoms of a wide range of gastrointestinal and non-gastrointestinal conditions. Diagnosis can be challenging and requires a systematic and well-structured approach. If the initial investigation for structural, toxic and metabolic disorders is negative, digestive motility and gut-brain interaction disorders should be assessed. United European Gastroenterology (UEG) and the European Society for Neurogastroenterology and Motility (ESNM) identified the need for an updated, evidence-based clinical guideline for the management of chronic nausea and vomiting.

METHODS

A multidisciplinary team of experts in the field, including European specialists and national societies, participated in the development of the guideline. Relevant questions were addressed through a literature review and statements were developed and voted on according to a Delphi process.

RESULTS

Ninety-eight statements were identified and voted following the Delphi process. Overall agreement was high, although the grade of scientific evidence was low in many areas. Disagreement was more evident for some pharmacological treatment options. A diagnostic algorithm was developed, focussing on the differentiating features between gastrointestinal motility and gut-brain interaction disorders with predominant nausea and vomiting.

CONCLUSION

These guidelines provide an evidence-based framework for the evaluation and treatment of patients with chronic nausea and vomiting.

Rome Foundation Working Team Report on overlap in disorders of gut-brain interaction

In patients with disorders of gut-brain interaction (DGBI), overlapping non-gastrointestinal conditions such as fibromyalgia, headaches, gynaecological and urological conditions, sleep disturbances and fatigue are common, as is overlap among DGBI in different regions of the gastrointestinal tract. These overlaps strongly influence patient management and outcome. Shared pathophysiology could explain this scenario, but details are not fully understood. This overlap has been shown to be of great relevance for DGBI. In addition, symptoms considered to be caused by a DGBI could have a detectable organic cause, and in patients with a diagnosed organic gastrointestinal disease, symptoms not clearly explained by the pathology defining this organic disease are common. Thus, the aims of this Rome Foundation Working Team Report were to review the literature on overlapping conditions among patients with paediatric and adult DGBI and, based on the available epidemiological and clinical evidence, make recommendations for the current diagnostic and therapeutic approach, and for future research. Specifically, we focused on other DGBI in the same or different gastrointestinal anatomical region(s), DGBI overlap with organic bowel diseases in remission, and DGBI overlap with non-gastrointestinal, non-structural conditions.

Cannabis use patterns and association with hyperemesis: A comprehensive review

BACKGROUND

Cannabis use in the general population is prevalent and is rising because of increased acceptance of its use, legalization in most US states, and perceived health benefits. Cannabis product potency has dramatically increased with higher delta-9-tetrahydrocannabinol content. Cannabis has documented antiemetic properties and cannabinoid pharmaceuticals are used in disorders like chemotherapy-induced nausea and vomiting.

PURPOSE

Forty to eighty percent of cyclic vomiting syndrome (CVS) patients use cannabis products, which reportedly reduce stress as well as nausea and vomiting. Cannabinoid hyperemesis syndrome (CHS) has a presentation similar to CVS, but is associated with longstanding, high dose cannabis use, and is thought to be relieved by sustained cannabis abstinence. Most CHS patients have used cannabis on a daily or near-daily basis for more than 2 years. Compulsive hot-water bathing behaviors are reported by most CHS patients, but are not specific for this disorder as they are also noted by about half of CVS patients. Episodic vomiting associated with cannabis use contributes to extensive health resource use, including emergency department visits and inpatient hospitalizations, and impacts patients and their families negatively. Treatment for CHS overlaps with CVS although cannabis abstinence remains the cornerstone of its management. Challenges associated with cannabis use cessation in CHS include patient skepticism of the role of cannabis as a cause of symptoms, perceived benefits of cannabis, and a lack of other effective therapies. In this review, we highlight cannabis use patterns in the US and discuss diagnosis and management of CHS and gaps in knowledge about this disorder.

Treatment principles in adults and development of patient-reported outcomes in cyclic vomiting syndrome

BACKGROUND

Cyclic vomiting syndrome is a chronic disorder of gut-brain interaction that is present in both adults and children. It is characterized by severe nausea, vomiting, abdominal pain, and several non-GI symptoms. It is also associated with several comorbid conditions such as anxiety and depression, which affect overall health care outcomes.

METHODS

This article delineates treatment principles, encompassing both abortive interventions and prophylactic regimens currently recommended for CVS. However, it underscores a critical concern: the absence of FDA-approved medications for CVS treatment, with existing therapies relying on retrospective and open-labeled trials.

KEY RESULTS

This article emphasizes the pressing need for the development of CVS-specific outcome assessment tools to facilitate more accurate evaluation and robust data collection for the future studies. In exploring this deficiency, the manuscript also presents the up-to-date data and development that enhances our comprehension of patient-centric concepts, and the challenges faced in creating CVS-specific tools, and presents a roadmap for their development. Addressing this gap is crucial for advancing our understanding of CVS and optimizing patient care.

CONCLUSIONS AND INFERENCES

This elucidates the current state of CVS management but also advocates for a future where tailored tools enhance our ability to measure and improve the outcomes for individuals with this debilitating disorder.

Cyclic vomiting syndrome: Future clinical and research priorities for: Special supplement/proceedings of 3rd international symposium

BACKGROUND

An increasing number of studies have explored the clinical features, epidemiology, pathophysiology, and management of cyclic vomiting syndrome (CVS). CVS is common in adults and children and negatively impacts patients, families, and the healthcare system. A related condition, cannabinoid hyperemesis syndrome (CHS), has been a focus of interest in the lay press and published literature.

PURPOSE

Clinical presentations of CVS have been defined by small series and expert opinion, but recent prospective studies are refining our understanding of the spectrum of emetic episodes and the breadth of comorbid conditions. Large cross-sectional population analyses are clarifying CVS prevalence and factors related to age, ethnicity, and geographic region. CVS pathophysiology is multifactorial with contributions from migraines, dysautonomia, endogenous cannabinoids, mitochondrial dysfunction, genetic abnormalities, and rapid gastric emptying. CVS treatment relies on antiemetics and antimigraine therapies to abort acute episodes coupled with prophylactic regimens employing neuromodulators and antiepileptics. CHS represents a challenge partly because of difficulties in achieving sustained cannabis abstinence. Benefits of other therapies in CHS remain poorly defined. Several areas warrant further scrutiny including better identification of CVS triggers and characterization of different CVS subsets including those with frequent severe episodes, refined description of epidemiology to allow targeting of populations predisposed to CVS development, rigorous definition of pathogenic factors to provide a foundation for exploratory studies of novel therapies, and conduct of controlled trials by multicenter collaborations to confirm benefits of existing and new therapies in development. Progress in these areas will be facilitated by generous governmental and industry support.

Exploring cyclic vomiting syndrome (CVS) worldwide: Current epidemiological insights and recent developments

BACKGROUND

Cyclic vomiting syndrome (CVS), a disorder of gut-brain interaction, presents with recurrent episodes of severe nausea and vomiting. It is often associated with missed or delayed diagnoses and substantial healthcare utilization. Despite historical recognition dating back to the 19th century, epidemiological insights remain limited, with research predominantly originating from specific regions, such as the US. CVS prevalence and incidence rates vary widely and are hindered by inconsistent methodologies and disease recognition.

PURPOSE

This review aims to provide a comprehensive overview of CVS prevalence and incidence rates. It reviews the currently available data and identifies gaps in knowledge. Understanding the global epidemiology of CVS, increasing awareness of the disease, and fostering global collaboration are crucial. Other pertinent issues include disparities in outcomes, particularly among African Americans and Hispanics in the United States, underscoring the need to understand the social determinants of health that drive disease outcomes. This understanding can inform targeted interventions to address these barriers and achieve equitable healthcare both in the United States and globally.

Understanding the adult and adolescent patient experience with cyclic vomiting syndrome: a concept elicitation study

BACKGROUND

Cyclic vomiting syndrome (CVS) is a phasic disorder of gut-brain interaction characterized by episodes of severe nausea and vomiting. In-depth qualitative research on phase-specific CVS symptoms and impacts is lacking. The study objectives were to explore the experience of patients with CVS in the United States and to identify CVS symptoms and impacts on adults, adolescents, and caregivers.

METHODS

Qualitative, cross-sectional, semi-structured concept elicitation interviews were conducted with adults and adolescents with CVS and with adolescents' caregivers. Adolescents either participated alone or in a dyad format with their caregiver. Interview data were analyzed using an open coding approach.

RESULTS

Concept elicitation interviews were conducted with 13 adults (mean age 45.3 years [standard deviation (SD) 13.1]) and 15 adolescents (mean age 14.6 years [SD 1.8]). The most frequently reported prodrome phase symptoms were nausea (n = 12, 92.3%), anxiety (n = 10, 76.9%), and abdominal pain (n = 9, 69.2%) in adults, and nausea (n = 15, 100%), abdominal pain (n = 11, 73.3%), and headache (n = 11, 73.3%) in adolescents. All adults reported nausea, tiredness, and dry heaves in the emetic phase, and 12 (92.3%) reported vomiting and retching. The remaining patient said they no longer vomited due to abortive medications. All adolescents reported nausea and vomiting in the emetic phase; other common emetic phase symptoms were abdominal pain (n = 14, 93.3%), dehydration (n = 13, 86.7%), and tiredness (n = 13, 86.7%). The leading most bothersome impact reported by adults was anxiety associated with impending vomiting (n = 5, 38.5%). Among adolescents, the leading most bothersome impact was on school (n = 7/13 asked, 53.8%), and among their caregivers, it was seeing their child suffer (n = 6/11 asked, 54.5%).

CONCLUSIONS

Patients with CVS experience considerable gastrointestinal and extra-intestinal symptoms. CVS impacts the activities of daily life of patients and their caregivers, with patients reporting negative effects of CVS on their emotional status and their ability to maintain a normal school or work routine.

Cannabinoid Hyperemesis Syndrome: A Rising Complication

Cannabis, commonly known as marijuana, is a psychoactive plant that has been used for both medicinal and recreational purposes for centuries. It contains over 100 biologically active compounds known as cannabinoids, the most notable of which are tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is responsible for the euphoric and hallucinogenic effects associated with cannabis use, while CBD is often utilized for its potential therapeutic benefits, such as pain relief and anti-inflammatory properties. Despite its widespread reputation for alleviating nausea and stimulating appetite, chronic cannabis use has been linked to a paradoxical condition known as cannabinoid hyperemesis syndrome (CHS). CHS is a disorder that paradoxically causes abdominal pain, nausea, and uncontrollable vomiting in long-term cannabis users rather than alleviating pain and reducing nausea. Misdiagnosis of this condition is extremely common, and it is often confused with cyclic vomiting syndrome (CVS). The underlying pathogenesis of CHS is not completely understood, though several mechanisms have been proposed. Although considered rare, there has been a steady increase in CHS diagnoses in the Emergency Department (ED). This article summarizes the symptoms, pathogenesis, treatments for CHS, and differential diagnoses to further increase our understanding of this condition.

Symptom Patterns in Adults With Cyclic Vomiting Syndrome: A 6-Month Prospective Observational Study

BACKGROUND

Data are limited on the natural history and symptom patterns of cyclic vomiting syndrome (CVS), a disorder of gut-brain interaction characterized by recurrent stereotypical vomiting, retching, and nausea episodes.

METHODS

A 6-month, observational, remote study prospectively assessed symptom patterns in adults with CVS using an electronic daily diary. Patients recorded their disease experience, including CVS symptoms and associated severity, in the daily diary. The study defined a CVS episode start as the first day of 5 or more vomiting and/or retching (V + R) events. Episode end was defined as the first day of ≥ 7 (prespecified main analysis) or ≥ 4 (sensitivity analysis) days without any diary V + R events.

KEY RESULTS

Eighty-eight of 93 (94.6%) enrolled patients (62 female; mean age, 37.7 years) had daily diary data recorded during the study; 61 (69.3%) patients had at least one episode. In the prespecified main analysis, 191 episodes (median, 0.6 per 30 diary days) were reported (median duration, 3.0 days); 17.8% of the episodes lasted > 10 days. In the sensitivity analysis, 248 episodes (median, 0.7 per 30 diary days) were reported (median duration, 2.0 days). Thirteen of 88 (14.8%) patients with diary data had interepisodic V + R (reported V + R events without meeting the threshold for study-defined episode). Other CVS-related (non-V + R) symptoms (most frequently nausea, abdominal pain, and sweating) were reported more frequently during the episode versus the interepisodic period.

CONCLUSIONS AND INFERENCES

This prospective longitudinal study shows marked heterogeneity of CVS episodes and highlights the need to better define and characterize episodes in these patients.

Synergistic defecation effects of Bifidobacterium animalis subsp. lactis BL-99 and fructooligosaccharide by modulating gut microbiota

Introduction

Synbiotics have revealed the possibility of improving constipation through gut microbiota. The synergistic efficacy of Bifidobacterium animalis subsp. lactis BL-99 (BL-99) and fructooligosaccharide (FOS) on constipation have not been investigated.

Methods

Loperamide-induced constipated mice model was established to explore the effect of BL-99, FOS, and BL-99+FOS on changes of defecation-related parameters, gut microbiota and metabolites.

Results and discussion

The results showed that BL-99, FOS, and BL-99+FOS each alleviated constipation, with the synbiotic showing significant efficacy in the first black stool defecation time, fecal number, fecal weight, and the gastrointestinal transit rate (P < 0.05). Additionally, significant increased in serum 5-HT and IL-10 were observed in the BL-99+FOS group, alongside an increased relative abundance of Lachnospiraceae_NK4A136_group, Blautia, and Clostridium sensu stricto 1, while significantly reducing the relative abundance of Alistipes and Bacteroides. These changes facilitated alterations in short-chain fatty acids (SCFAs) metabolism, and were closely associated with the expression of genes related to the 5-HT pathway and the modulation of serum inflammatory factors. This study provides a theoretical basis for BL-99 and FOS synbiotics to improve constipation by regulating the gut microbiota and metabolites.

Whole Gut Motility Patterns in Patients with Chronic Nausea and Vomiting

Background/Objectives: Chronic nausea and vomiting (N/V) disorders are common in clinical practice. Our primary aim was to compare total and segmental gastrointestinal transit times as well as gastric contraction patterns in patients with chronic N/V syndrome to those of healthy volunteers (HVs). In the patient group, our secondary aim was to explore how symptoms and motility patterns were affected by a serotonin HT4 receptor agonist (Prucalopride). Methods: Patients with chronic N/V syndrome and HVs underwent baseline assessment of regional gastrointestinal (GI) motility/transit using the Motilis 3D-Transit system. Patients were then treated with Prucalopride 2 mg daily for 28 days, with the 3D-transit examination repeated within 10-20 days after treatment onset. Two self-administered questionnaires (the Gastrointestinal Symptom Rating Scale [GSRS] and Gastroparesis Cardinal Symptom Index [GCSI]) were used to assess patients' symptoms. Results: A total of 19 patients (13 F; median age 25 years (IQR 22-39) and 55 HVs (25 F; median age 28 (24-35) were included. At baseline, no differences in regional GI transit times were found between groups. However, patients had a significantly lower gastric contraction amplitude than HVs (9 mmHg (IQR 8-11) vs. 12 (10-15: p < 0.001). In response to Prucalopride treatment, gastric emptying time was reduced from a median of 3.1 h to 1.6 h (p < 0.005). Further, the GCSI was significantly reduced from GCSI 3.0 (IQR 2.3-3.7) at baseline to GCSI 1.9 (IQR 1.3-3.2) with Prucalopride. Conclusions: Patients with chronic N/V syndrome have significantly lower gastric contraction amplitude than HVs and may symptomatically benefit from prokinetics. They do not, however, have evidence of panenteric dysmotility.

A Comprehensive Review and Update on Cannabis Hyperemesis Syndrome

Cannabis, derived from Cannabis sativa plants, is a prevalent illicit substance in the United States, containing over 400 chemicals, including 100 cannabinoids, each affecting the body's organs differently upon ingestion. Cannabis hyperemesis syndrome (CHS) is a gut-brain axis disorder characterized by recurring nausea and vomiting intensified by excessive cannabis consumption. CHS often goes undiagnosed due to inconsistent criteria, subjective symptoms, and similarity to cyclical vomiting syndrome (CVS). Understanding the endocannabinoid system (ECS) and its dual response (pro-emetic at higher doses and anti-emetic at lower doses) is crucial in the pathophysiology of CHS. Recent research noted that type 1 cannabinoid receptors in the intestinal nerve plexus exhibit an inhibitory effect on gastrointestinal motility. At the same time, the thermoregulatory function of endocannabinoids might explain compulsive hot bathing in CHS patients. The prevalence of cannabis CHS is expected to rise as legal restrictions on its recreational use decrease in several states. Education and awareness are vital in diagnosing and treating CHS as its prevalence increases. This comprehensive review explores the ECS's involvement, CHS management approaches, and knowledge gaps to enhance understanding of this syndrome.

Contesting Cannabinoid Hyperemesis Syndrome: How Narratives of Cannabis Shape Diagnosis Contestation and Treatment Resistance

Cannabinoid hyperemesis syndrome (CHS) is characterized by the onset of cyclic bouts of severe nausea and vomiting in chronic cannabis users. As the number of CHS diagnoses rises, it is important to understand how people experience the disease. Using a narrative framework, we explore how the symbolic meaning participants associated with cannabis shaped the way they experienced diagnosis and treatment of CHS. To do this, we relied on semi-structured interviews with 24 people who self-reported having CHS. Participants had very positive perceptions of cannabis, which contributed to them contesting the diagnosis and resisting the treatment. They initially contested the diagnosis because they believed that cannabis was beneficial and helped with nausea, that claims about the harms of cannabis were part of a larger medical conspiracy to stigmatize it, and that they had different symptoms than those with CHS. They resisted treatment recommendations of abstinence and sought to continue using cannabis by trying new routes of administration, using only certain types of cannabis, reducing the amount or frequency of use, or substituting other substances. Findings point to the importance of understanding how narratives can shape the way people respond to diagnosis and treatment.

Chronic nausea and vomiting syndrome and impact on quality of life

INTRODUCTION AND AIM

Chronic nausea and vomiting syndrome is a disorder of gut-brain interaction that affects the productive-age population. Our aim was to determine the association of this disorder with quality of life, workplace performance, and socioeconomic impact related to gastrointestinal health.

METHODS

A cross-sectional study on a Mexican population was conducted. The patients were classified as having chronic nausea and vomiting syndrome or other disorders of gut-brain interaction. A comparative analysis of quality of life, workplace productivity, annual medical consultations, and digestive health-related expenses was carried out, applying a logistic regression model.

RESULTS

One thousand patients were included, 79.2% of whom met the criteria for a disorder of gut-brain interaction. Of the 792 patients, 10.3% presented with chronic nausea and vomiting syndrome. Said syndrome was associated with a negative impact on usual activities (OR 4.34, 95% CI 1.90-9.30, p ≤ 0.001), pain/discomfort (OR 2.09, 95% CI 1.31-3.33, p ≤ 0.001), anxiety/depression (OR 2.08, 95% CI 1.30-3.40, p ≤ 0.001), workplace presenteeism (OR 3.96, 95% CI 2.47-6.44, p ≤ 0.001), and workplace absenteeism (OR 2.54, 95% CI 1.52-4.16, p ≤ 0.001). There was also a higher number of annual medical consultations for digestive health (p = 0.013), without generating a greater annual expense due to digestive health (p = 0.08).

CONCLUSIONS

Chronic nausea and vomiting syndrome produces a negative impact on quality of life, which could be secondary to its symptomatology or its association with anxiety and depression.

A Standardized Classification Scheme for Gastroduodenal Disorder Evaluation Using the Gastric Alimetry System: Prospective Cohort Study

Background and Aims

Gastric Alimetry™ (Alimetry, New Zealand) is a new clinical test for gastroduodenal disorders involving simultaneous body surface gastric electrical mapping and validated symptom profiling. Studies have demonstrated a range of distinct pathophysiological profiles, and a classification scheme is now required. We used Gastric Alimetry spectral and symptom profiles to develop a mechanism-based test classification scheme, then assessed correlations with symptom severity, psychometrics, and quality of life.

Methods

We performed a multicenter prospective cohort study of patients meeting the Rome IV criteria for functional dyspepsia and chronic nausea and vomiting syndromes. Patients underwent Gastric Alimetry profiling, and a standardized digital classification framework was devised and applied to separate patients into those with a) abnormal spectral analyses (ie aberrant gastric frequencies, amplitudes, and rhythms); and normal spectral analyses with b) symptoms correlated to gastric amplitude (subgroups: sensorimotor, postgastric, and activity-relieved), and c) symptoms independent of gastric amplitude (subgroups: continuous, meal-relieved, meal-induced).

Results

Two hundred ten patients were included (80% female, median age 37), of whom 169 met the criteria for chronic nausea and vomiting syndromes and 206 met the criteria for functional dyspepsia (79% meeting both criteria). Overall, 83% were phenotyped using the novel scheme, with 79/210 (37.6%) classified as having a spectral abnormality. Of the remainder, the most common phenotypes were "continuous pattern" (37, 17.6%), "meal-induced pattern" (28, 13.3%), and "sensorimotor pattern" (15, 7.1%). Symptom patterns independent of gastric amplitude were more strongly correlated with depression and anxiety (Patient Health Questionnaire 2: exp(β) 2.38, P = .024, State-Trait Anxiety Inventory Short-Form score: exp(β) 1.21, P = .021).

Conclusion

A mechanistic classification scheme for assessing gastroduodenal disorders is presented. Classified phenotypes showed independent relationships with symptom severity, quality of life, and psychological measures. The scheme is now being applied clinically and in research studies.

AGA Clinical Practice Update on Diagnosis and Management of Cyclic Vomiting Syndrome: Commentary

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding the diagnosis and management of cyclic vomiting syndrome.

METHODS

This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are experts in treating patients with cyclic vomiting syndrome.

Psychogastroenterology of cyclic vomiting syndrome: A crucial need to build evidence

Cyclic vomiting is a disorder of gut brain interaction (DGBI) emphasizing the need for treatment of both the brain and the gut. Despite clinical success of psychological therapies for CVS, also called brain-gut treatments, an evidence-base is lacking and these treatments are available in few GI practices. This has resulted in an "all guts no brain" approach to CVS. The current paper is a call to action to develop more evidence and use of brain-gut therapies in CVS.

The aging gastrointestinal tract: Epidemiology and clinical significance of disorders of gut-brain interaction in the older general population

BACKGROUND

Most previous reports on the prevalence of disorders of gut-brain interaction (DGBI) show higher rates in younger individuals. Exceptions are faecal incontinence and functional constipation.

AIM

To compare prevalence rates for 22 DGBI and 24 primary symptoms, by age, using the Rome Foundation Global Epidemiology (RFGES) study dataset.

METHODS

The RFGES dataset enables diagnosis of 22 DGBI among 54,127 participants (≥18 years) in 26 countries. Older age was defined as ≥65 years. We assessed differences between age groups by sex, geographic region, somatisation, abnormal anxiety and depression scores, quality of life (QoL), individual gastrointestinal symptoms and disease severity for irritable bowel syndrome (IBS).

RESULTS

Rates for any DGBI were 41.9% and 31.9% in the <65 and ≥65 age groups, respectively. For all Rome IV diagnoses except faecal incontinence, rates were higher in the younger group. The older group had lower scores for any DGBI by geographic region, non-gastrointestinal somatic symptoms, abnormal anxiety and depression scores, and IBS severity, and better scores for QoL. The mean number of endorsed symptoms and their frequency were higher in the younger group.

CONCLUSIONS

In this large general population study, the prevalence and impact of DGBI, apart from faecal incontinence, were higher in the younger group. Despite this, DGBI rates are still high in absolute terms in the ≥65 age group and necessitate clinical awareness and, perhaps, an age-specific treatment approach.

Acute and Long-Term Effects of App-Delivered Heartfulness Meditation on Psychological Outcomes and the Endocannabinoid Signaling System in Cyclic Vomiting Syndrome

INTRODUCTION

Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction often triggered by stress. Interventions such as meditation may improve psychological outcomes and health-related quality of life (HRQoL), but their efficacy and the underlying mechanism are unknown.

METHODS

We conducted a 6-week single-arm pilot study to assess the effects of heartfulness meditation (HFM) in CVS using a custom-designed meditation app. Primary outcomes included state and trait anxiety and mood state changes pre vs post-meditation, and secondary outcomes were psychological distress, coping, sleep quality, and HRQoL at baseline and at weeks 3 and 6. Serum concentrations of endocannabinoids N -arachidonylethanolamine and 2-arachidonoylglycerol and related lipids were measured pre- and post-HFM at baseline and week 6.

RESULTS

In 30 treatment completers, there was a significant improvement in state anxiety ( P < 0.001), total mood disturbance ( P < 0.001), and other mood states (all P values < 0.05) across the 3 time points. Trait anxiety was also improved at week 6. There was a significant improvement in psychological distress (Global Severity Index), sleep quality (daytime dysfunction), coping (using religion/spirituality), and HRQoL (mental and physical) across the 3 time points (all P < 0.05). Significant increases in N -arachidonylethanolamine and related lipids N -oleoylethanolamine and palmitoylethanolamide post vs pre-HFM were observed at week 6 ( P < 0.001, 0.002, 0.003, respectively). No adverse effects were noted.

DISCUSSION

App-delivered HFM is feasible, safe, and effective and improves psychological outcomes and augments endocannabinoids. This provides insight into the mechanism underlying HFM and has potential for widespread use as a digital therapeutic in CVS and other disorder of gut-brain interaction.

Cyclic vomiting syndrome: From pathophysiology to treatment

Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent and unpredictable episodes of intense vomiting, interspersed with periods of apparent wellbeing. This disorder, which primarily affects children and adolescents but can persist into adulthood, has recently been the subject of extensive study and analysis in the medical literature. The aim of the present review is to examine the most important aspects of the epidemiology, pathophysiology, subtypes, diagnostic criteria, and current management of CVS. Even though the exact etiology remains unknown, genetic factors (polymorphisms), nervous system alterations and autonomic dysregulation, and environmental factors (use and abuse of cannabinoids) are postulated as possible triggers. CVS has significant diagnostic challenges, given that there is no specific test for confirming its presence. Thorough evaluation of symptoms and the ruling out of other possible causes of recurrent vomiting are required. Management of CVS typically involves a multidisciplinary approach. Pharmacologic options are explored, such as antiemetics and preventive medications, as well as behavioral and psychologic support therapies. Treatment personalization is essential, adapting it to the individual needs of each patient. Despite advances in the understanding of CVS, it remains a significant clinical challenge. This disorder impacts the quality of life of those affected and their families, underscoring the ongoing need for research and the development of more effective treatment strategies.

Development of a Digital Patient Assistant for the Management of Cyclic Vomiting Syndrome: Patient-Centric Design Study

BACKGROUND

Cyclic vomiting syndrome (CVS) is an enigmatic and debilitating disorder of gut-brain interaction that is characterized by recurrent episodes of severe vomiting and nausea. It significantly impairs patients' quality of life and can lead to frequent medical visits and substantial health care costs. The diagnosis for CVS is often protracted and complex, primarily due to its exclusionary diagnosis nature and the lack of specific biomarkers. This typically leads to a considerable delay in accurate diagnosis, contributing to increased patient morbidity. Additionally, the absence of approved therapies for CVS worsens patient hardship and reflects the urgent need for innovative, patient-centric solutions to improve CVS management.

OBJECTIVE

We aim to develop a digital patient assistant (DPA) for patients with CVS to address their unique needs, and iteratively enhance the technical features and user experience on the initial DPA versions.

METHODS

The development of the DPA for CVS used a design thinking approach, prioritizing user needs. A literature review and Patient Advisory Board shaped the initial prototype, focusing on diagnostic support and symptom tracking. Iterative development, informed by the design thinking approach and feedback from patients with CVS and caregivers through interviews and smartphone testing, led to significant enhancements in user interaction and artificial intelligence integration. The final DPA's effectiveness was validated using the System Usability Scale and feedback questions, ensuring it met the specific needs of the CVS community.

RESULTS

The DPA developed for CVS integrates an introductory bot, daily and weekly check-in bots, and a knowledge hub, all accessible via a patient dashboard. This multicomponent solution effectively addresses key unmet needs in CVS management: efficient symptom and impacts tracking, access to comprehensive disease information, and a digital health platform for disease management. Significant improvements, based on user feedback, include the implementation of artificial intelligence features like intent recognition and data syncing, enhancing the bot interaction and reducing the burden on patients. The inclusion of the knowledge hub provides educational resources, contributing to better disease understanding and management. The DPA achieved a System Usability Scale score of 80 out of 100, indicating high ease of use and relevance. Patient feedback highlighted the DPA's potential in disease management and suggested further applications, such as integration into health care provider recommendations for patients with suspected or confirmed CVS. This positive response underscores the DPA's role in enhancing patient engagement and disease management through a patient-centered digital solution.

CONCLUSIONS

The development of this DPA for patients with CVS, via an iterative design thinking approach, offers a patient-centric solution for disease management. The DPA development framework may also serve to guide future patient digital support and research scenarios.

Cannabinoid hyperemesis syndrome: Clinical trajectories and patterns of use three months following a visit to the emergency department

OBJECTIVES

Cannabinoid hyperemesis syndrome (CHS) is a clinical condition of cyclic vomiting, nausea, and abdominal pain associated with chronic cannabis use. Despite increased recognition of CHS, there are limited details on cannabis use practices and symptoms over time. Understanding what happens in the period surrounding the emergency department (ED) visit, including any changes in symptoms and cannabis use practices following the visit, can help inform the development of patient-centered interventions around cannabis use disorder for patients with CHS.

METHODS

A prospective observational cohort (n = 39) of patients with suspected CHS recruited from the ED at the time of a symptomatic cyclic vomiting episode was followed for 3 months. Disease progression, cannabis use practices, and health care utilization were monitored.

RESULTS

Participants reported high rates of persistent CHS symptoms (abdominal pain, nausea, or cyclic vomiting) in the 2-week period immediately following an ED visit with a median duration of 7 days. Cannabis use frequency and quantity were reduced immediately after the ED visit, but most participants returned to pre-ED visit cannabis use patterns within a few days. Recurrent ED visits for cyclic vomiting were reported by 25% of participants who completed follow-up during the 3-month follow-up period.

CONCLUSIONS

Participants continued to have ongoing symptoms after the ED visit, but most managed symptoms on their own and did not return to the ED. Longitudinal studies beyond 3 months are needed to better understand the clinical course of patients with suspected CHS.

Epidemiology, Comorbidities, and Treatment of Cyclic Vomiting Syndrome in the United States

INTRODUCTION

Cyclic vomiting syndrome (CVS) imposes a substantial burden, but epidemiological data are scarce. This study aimed to estimate the incidence and prevalence of CVS, comorbid conditions, and treatment patterns, using administrative databases in the United States.

METHODS

This cross-sectional study used claims data from Merative MarketScan Commercial/Medicare Supplemental and Medicaid databases in all health care settings. Incidence and prevalence rates for 2019 were calculated and stratified by age, sex, region, and race/ethnicity. Patient characteristics were reported among newly diagnosed patients with CVS (i.e., no documented claims for CVS before 2019). CVS was defined as having 1+ inpatient and/or 2+ outpatient CVS claims that were 7+ days apart.

RESULTS

The estimated prevalence of CVS was 16.7 (Commercial/Medicare) and 42.9 (Medicaid) per 100,000 individuals. The incidence of CVS was estimated to be 10.6 (Commercial/Medicare) and 26.6 (Medicaid) per 100,000 individuals. Both prevalence and incidence rates were higher among female individuals (for both Commercial/Medicare and Medicaid). Comorbid conditions were common and included abdominal pain (56%-64%), anxiety (32%-39%), depression (26%-34%), cardiac conditions (39%-42%), and gastroesophageal reflux disease (30%-40%). Despite a diagnosis of CVS, only 32%-35% had prescriptions for prophylactic treatment and 47%-55% for acute treatment within the first 30-day period following diagnosis.

DISCUSSION

This study provides the first population-level estimates of CVS incidence and prevalence in the United States. Comorbid conditions are common, and most patients with CVS do not receive adequate treatment. These findings underscore the need for improving disease awareness and developing better screening strategies and effective treatments.

AGA Clinical Practice Update on Diagnosis and Management of Cannabinoid Hyperemesis Syndrome: Commentary

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding diagnosis and management of cannabinoid hyperemesis syndrome.

METHODS

This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors.

Cannabis use in the United States and its impact on gastrointestinal health

In recent years, the legalization and social acceptability of cannabis use have increased in the United States. Concurrently, the prevalence of cannabis use has continued to rise, and cannabis products have diversified. There are growing concerns regarding the health effects of regular and high-potency cannabis use, and new research has shed light on its potentially negative effects. Here, we review evidence of the gastrointestinal (GI) effects of cannabis and cannabinoids. Dysregulation of the endocannabinoid system might contribute to various GI disorders, including irritable bowel syndrome and cyclic vomiting syndrome, and endocannabinoids have been found to regulate visceral sensation, nausea, vomiting, and the gut microbiome. Cannabis has been shown to have antiemetic properties, and the US Food and Drug Administration has approved cannabis-based medications for treating chemotherapy-induced nausea and vomiting. Yet, chronic heavy cannabis use has been linked to recurrent episodes of severe nausea and intractable vomiting (cannabinoid hyperemesis syndrome). Given the considerable heterogeneity in the scientific literature, it is unclear if cannabinoid hyperemesis syndrome is truly a distinct entity or a subtype of cyclic vomiting that is unmasked by heavy cannabis use and the associated dysregulation of the endocannabinoid system. The changes in cannabis legalization, availability, and public risk perceptions have outpaced research in this area and there is a need for robust, prospective, large-scale studies to understand the effects of cannabis use on GI health.

Rising Inpatient Utilization and Costs of Cannabis Hyperemesis Syndrome Hospitalizations in Massachusetts After Cannabis Legalization

GOALS

We described the demographics, inpatient utilization, and cost of services among patients hospitalized for putative cannabinoid hyperemesis syndrome (CHS) predating and postdating cannabis legalization in Massachusetts.

BACKGROUND

As the recreational use of cannabis has been widely legalized nationally, the resulting shifts in clinical presentation, health care utilization, and estimated costs of CHS hospitalizations remain unclear in the postlegalization era.

STUDY

We performed a retrospective cohort study among patients admitted to a large urban hospital between 2012 and 2021, before and after the date of cannabis legalization in Massachusetts (Dec 15, 2016). We examined the demographic and clinical characteristics of patients admitted for putative CHS, the utilization of hospital services, and estimated inpatient costs pre and postlegalization.

RESULTS

We identified a significant increase in putative CHS hospitalizations pre and post-cannabis legalization in Massachusetts (0.1% vs 0.02% of total admissions per time period, P < 0.05). Across 72 CHS hospitalizations, patient demographics were similar pre and postlegalization. Hospital resource utilization increased postlegalization, with increased length of stay (3 d vs 1 d, P < 0.005), and need for antiemetics ( P < 0.05). Multivariate linear regression confirmed that postlegalization admissions were independently associated with increased length of stay ( Β = 5.35, P < 0.05). The mean cost of hospitalization was significantly higher postlegalization ($18,714 vs $7460, P < 0.0005), even after adjusting for medical inflation ($18,714 vs $8520, P < 0.001) with intravenous fluid administration and endoscopy costs increased ( P < 0.05). On multivariate linear regression, hospitalization for putative CHS during postlegalization predicted increased costs ( Β = 10,131.25, P < 0.05).

CONCLUSIONS

In the postlegalization era of cannabis in Massachusetts, we found increased putative CHS hospitalizations, with a concomitant increased length of hospital stay and total cost per hospitalization. As cannabis use increases, the recognition and costs of its deleterious effects are necessary to incorporate into future clinical practice strategies and health policy.

Perspectives, experiences, and concerns with cyclical vomiting syndrome: Insights from online targeted-disease forums

INTRODUCTION

There is limited research examining the biopsychosocial impact of cyclic vomiting syndrome (CVS) on patients. This study aims to assess individuals' experiences, fears, and concerns associated with CVS and the impact of CVS on their daily lives.

METHODS

We employed social netnography to analyze publicly available posts related to CVS that were identified from six US online forums and Twitter. A randomly selected sub-cohort of posts per pre-defined criteria was first qualitatively analyzed using an inductive thematic approach. Then, machine learning topic modeling was applied to explore themes in an unsupervised manner for the entire corpus of posts. Afterward, findings from the qualitative and quantitative approaches were integrated to generate a thematic network.

RESULTS

Based on the 39,179 collected posts, seven domain themes were identified. Overall, 41.4% of the posts were related to "biopsychosocial burden" of CVS, including physical impact, psychological impact, and social impact. In 22.3% of posts, individuals shared their experience of "interactions with the healthcare system", and 14.2% of posts were related to "perceived CVS triggers." Individuals also shared "solutions to alleviate their symptoms" and "mental health needs" in 10.2% and 8.8% of posts, respectively. Finally, 6.1% of the posts were about "seeking/sharing support" with others.

DISCUSSION

This is the first social netnography study to describe the in-depth experiences of individuals living with CVS and the marked impact on their physical, mental, and social health. The study also highlights the unmet need for effective therapies, both pharmacological and non-pharmacological, to alleviate the biopsychosocial impact of CVS.

Cannabis use and cyclical vomiting syndrome: An open debate

INTRODUCTION

Cyclical vomiting syndrome (CVS) carries a significant financial burden on the U.S. healthcare system due to the recurrent emergency department visits and inpatient hospitalizations. We aimed to update the literature on the predictors of hospital utilization and readmission among individuals admitted with CVS.

METHODS

This is a retrospective nationwide study of patients hospitalized with a primary diagnosis of CVS. Using weighted data from the National Inpatient Sample (NIS) and the National Readmission Database (NRD), we conducted a multivariate regression analysis to assess predictors of length of stay (LOS), and 30-day readmission.

RESULTS

Primary admissions for CVS totaled 35,055 in the NIS, and 31,240 in the NRD. 2012 patients (6.4%) were readmitted within 30 days. On multivariate regression, cannabis use was associated with reduced LOS (adjusted Mean Difference (aMD) = -0.53 days, 95% CI: -0.68 to -0.38), and 30-day readmissions (adjusted Hazard Ratio (aHR) = 0.63, 95% CI: 0.54-0.73).

DISCUSSION

Cannabis use among CVS admissions was associated with reduced LOS and 30-day readmissions; these results could be in fact driven by Cannabis Hyperemesis Syndrome (CHS)-related hospitalizations and the effect of cannabis cessation on decreased symptomatology. ICD-10 coding for CHS should be transitioned to specific codes to improve the differentiation between CVS and CHS-related hospitalizations.

Age Differences in Upper Gastrointestinal Symptoms and Vagal Modulation in Women With Irritable Bowel Syndrome

BACKGROUND/AIMS

Patients with irritable bowel syndrome (IBS) often report upper gastrointestinal (GI) (e.g., nausea and heartburn), somatic, and emotional symptoms. This study seeks to examine the relationships among younger and older women with IBS and indicators of autonomic nervous system (ANS) function and daily nausea and heartburn symptoms.

METHODS

Women were recruited through clinics and the community. Nocturnal heart rate variability (HRV) was obtained using ambulatory electrocardiogram Holter monitors. Individual symptom severity and frequency were collected using 28-day diaries. All variables were stratified by younger (<46 years) and older (≥46 years) age groups.

RESULTS

Eighty-nine women with IBS were included in this descriptive correlation study (n = 57 younger; n = 32 older). Older women had reduced indices of vagal activity when compared to younger women. In older women, there was an inverse correlation between nausea and vagal measures (Ln RMSSD, r = -.41, p = .026; Ln pNN50, r = -.39, p = .034). Heartburn in older women was associated with sleepiness (r = .59, p < .001) and anger (r = .48, p = .006). Nausea was significantly correlated with anger in the younger group (r = .41, p = .001). There were no significant relationships between HRV indicators and nausea and heartburn in younger women.

CONCLUSIONS

Age-related differences in ANS function that are associated with nausea may portend unique opportunities to better understand the vagal dysregulation in women with IBS.

Cannabinoids and the Gastrointestinal Tract

The synthesis and degradation of endocannabinoids, location of cannabinoid (CB) receptors, and cannabinoid mechanisms of action on immune/inflammatory, neuromuscular, and sensory functions in digestive organs are well documented. CB2 mechanisms are particularly relevant in immune and sensory functions. Increasing use of cannabinoids in the United States is impacted by social determinants of health including racial discrimination, which is associated with tobacco and cannabis co-use, and combined use disorders. Several conditions associated with emesis are related to cannabinoid use, including cannabinoid hyperemesis or withdrawal, cyclic vomiting syndrome, and nausea and vomiting of pregnancy. Cannabinoids generally inhibit gastrointestinal motor function; yet they relieve symptoms in patients with gastroparesis and diverse nausea syndromes. Cannabinoid effects on inflammatory mechanisms have shown promise in relatively small placebo-controlled studies in reducing disease activity and abdominal pain in patients with inflammatory bowel disease. Cannabinoids have been studied in disorders of motility, pain, and disorders of gut-brain interaction. The CB2-receptor agonist, cannabidiol, reduced the total Gastroparesis Cardinal Symptom Index and increases the ability to tolerate a meal in patients with gastroparesis appraised over 4 weeks of treatment. In contrast, predominant-pain end points in functional dyspepsia with normal gastric emptying were not improved significantly with cannabidiol. The CB2 agonist, olorinab, reduced abdominal pain in inflammatory bowel disease in an open-label trial and in constipation-predominant irritable bowel syndrome in a placebo-controlled trial. Cannabinoid mechanisms alter inflammation in pancreatic and liver diseases. In conclusion, cannabinoids, particularly agents affecting CB2 mechanisms, have potential for inflammatory, gastroparesis, and pain disorders; however, the trials require replication and further understanding of risk-benefit to enhance use of cannabinoids in gastrointestinal diseases.

Plasma endocannabinoids and cannabimimetic fatty acid derivatives are altered in cyclic vomiting syndrome: The effects of sham feeding

Cyclic vomiting syndrome (CVS) is an underdiagnosed disorder of the gut-brain interaction. Our understanding of the pathophysiology of CVS is evolving. Here, we tested the hypotheses that: (1) the levels of endocannabinoids and related lipids are altered in CVS, and (2) cephalic-vagal stimulation drive changes in endolipid levels. Ten adult patients with CVS and eight healthy controls were included. Indirect measurements of parasympathetic (RFa) functions were performed with spectral analysis of heart rate variability and respiratory activity. Plasma levels of endocannabinoids and related lipids were measured at baseline and during a sham feeding. Values are reported as mean ± standard error of the mean and compared using t-test or ANOVA. CVS patients had a lower parasympathetic tone and response to the Valsalva maneuver and deep breathing than the controls. The baseline 2-Arachidonoylglycerol (2-AG) had a significantly higher concentration in CVS (5.9e-008 ± 3.7e-008 mol/L) than control (3.7e-008 ± 1.3e-008 mol/; p < 0.05). Sham feeding did not change the concentration of 2-AG. 2-oleoylglycerol (2-OG) was significantly higher in CVS than control and did not change with sham feeding. Levels of N-acylethanolamines, including anandamide (AEA), were not different in CVS vs control. After sham feeding, AEA showed a trend toward increasing (p = 0.08) in CVS, but not in control. With sham feeding, palmitoyl ethanolamine significantly increased in both CVS and control groups; oleoyl ethanolamine in CVS only, and stearoyl ethanolamine in the control group. Levels of endocannabinoids and related lipids are altered in CVS patients. Sham feeding affects endogenous signaling lipids in a disease and time-dependent manner.

Intrapyloric Botulinum Toxin Injection for Refractory Nausea and Vomiting in Pediatric Patients

OBJECTIVES

Chronic nausea and vomiting may be associated with gastroparesis or other conditions. Poor mechanistic understanding of symptoms often precludes targeted therapy. Numerous case series suggest that intrapyloric botulinum toxin injection (IPBI) may be beneficial in treating gastroparesis and dyspepsia in children. We hypothesized that nausea, vomiting, and other symptoms, independent of gastroparesis, may improve with IPBI. We sought to identify gastric emptying (GE) and manometric patterns in IPBI responders versus nonresponders.

METHODS

Electronic records of 25 pediatric patients who received IPBI for refractory nausea, vomiting, or both were retrospectively reviewed. We assessed symptom improvement post-IPBI and compared symptoms, GE, and antroduodenal manometry (ADM) findings between IPBI responders and nonresponders.

RESULTS

At least one major symptom improved in 19 patients (76%) after IPBI. Of 22 patients completing a GE study, 14 had delayed GE with no significant difference between IPBI responders and nonresponders. Of 22 patients who underwent ADM, 18 had normal fasting peristalsis, 5 had postprandial antral hypomotility, 4 had neuropathic findings, and 19 had pylorospasm. IPBI responders, compared to nonresponders, demonstrated higher antral pressures with feeding ( P < 0.0001) and shorter duration of pylorospasm ( P = 0.0036). Antral pressures did not differ significantly with fasting or following motilin agonists.

CONCLUSIONS

Our findings suggest that IPBI may have therapeutic benefit in pediatric patients with chronic nausea and/or vomiting, independent of gastroparesis. ADM findings of intact antral peristalsis and elevated antral pressures, in conjunction with efficacy of IPBI, support pyloric non-relaxation as a potential contributor to nausea and/or vomiting in pediatric patients.

Gastric Alimetry® Test Interpretation in Gastroduodenal Disorders: Review and Recommendations

Chronic gastroduodenal symptoms are prevalent worldwide, and there is a need for new diagnostic and treatment approaches. Several overlapping processes may contribute to these symptoms, including gastric dysmotility, hypersensitivity, gut-brain axis disorders, gastric outflow resistance, and duodenal inflammation. Gastric Alimetry® (Alimetry, New Zealand) is a non-invasive test for evaluating gastric function that combines body surface gastric mapping (high-resolution electrophysiology) with validated symptom profiling. Together, these complementary data streams enable important new clinical insights into gastric disorders and their symptom correlations, with emerging therapeutic implications. A comprehensive database has been established, currently comprising > 2000 Gastric Alimetry tests, including both controls and patients with various gastroduodenal disorders. From studies employing this database, this paper presents a systematic methodology for Gastric Alimetry test interpretation, together with an extensive supporting literature review. Reporting is grouped into four sections: Test Quality, Spectral Analysis, Symptoms, and Conclusions. This review compiles, assesses, and evaluates each of these aspects of test assessment, with discussion of relevant evidence, example cases, limitations, and areas for future work. The resultant interpretation methodology is recommended for use in clinical practice and research to assist clinicians in their use of Gastric Alimetry as a diagnostic aid and is expected to continue to evolve with further development.

Amitriptyline-Induced Insomnia in a Young Lady Diagnosed With Cyclic Vomiting Syndrome: A Case Report

The author reports a 19-year-old woman suffering from repeated episodes of non-bloody vomiting for 18 months. All routine and special investigations were normal. She was labeled as a case of cyclic vomiting syndrome (CVS), and she developed insomnia after the initiation of amitriptyline as a prophylactic treatment. The case was reported to increase awareness regarding the importance of monitoring medication side effects among clinicians when using different classes of medications to treat CVS.

Normative Values for Body Surface Gastric Mapping Evaluations of Gastric Motility Using Gastric Alimetry: Spectral Analysis

INTRODUCTION

Body surface gastric mapping (BSGM) is a new noninvasive test of gastric function. BSGM offers several novel and improved biomarkers of gastric function capable of differentiating patients with overlapping symptom profiles. The aim of this study was to define normative reference intervals for BSGM spectral metrics in a population of healthy controls.

METHODS

BSGM was performed in healthy controls using Gastric Alimetry (Alimetry, New Zealand) comprising a stretchable high-resolution array (8 × 8 electrodes; 196 cm 2 ), wearable Reader, and validated symptom-logging App. The evaluation encompassed a fasting baseline (30 minutes), 482 kCal meal, and 4-hour postprandial recording. Normative reference intervals were calculated for BSGM metrics including the Principal Gastric Frequency, Gastric Alimetry Rhythm Index (a measure of the concentration of power in the gastric frequency band over time), body mass index (BMI)-adjusted amplitude (μV), and fed:fasted amplitude ratio. Data were reported as median and reference interval (5th and/or 95th percentiles).

RESULTS

A total of 110 subjects (55% female, median age 32 years [interquartile range 24-50], median BMI 23.8 kg/m 2 [interquartile range 21.4-26.9]) were included. The median Principal Gastric Frequency was 3.04 cycles per minute; reference interval: 2.65-3.35 cycles per minute. The median Gastric Alimetry Rhythm Index was 0.50; reference interval: ≥0.25. The median BMI-adjusted amplitude was 37.6 μV; reference interval: 20-70 μV. The median fed:fasted amplitude ratio was 1.85; reference interval ≥1.08. A higher BMI was associated with a shorter meal-response duration ( P = 0.014).

DISCUSSION

This study provides normative reference intervals for BSGM spectral data to inform diagnostic interpretations of abnormal gastric function.

Whole exome/genome sequencing in cyclic vomiting syndrome reveals multiple candidate genes, suggesting a model of elevated intracellular cations and mitochondrial dysfunction

OBJECTIVE

To utilize whole exome or genome sequencing and the scientific literature for identifying candidate genes for cyclic vomiting syndrome (CVS), an idiopathic migraine variant with paroxysmal nausea and vomiting.

METHODS

A retrospective chart review of 80 unrelated participants, ascertained by a quaternary care CVS specialist, was conducted. Genes associated with paroxysmal symptoms were identified querying the literature for genes associated with dominant cases of intermittent vomiting or both discomfort and disability; among which the raw genetic sequence was reviewed. "Qualifying" variants were defined as coding, rare, and conserved. Additionally, "Key Qualifying" variants were Pathogenic/Likely Pathogenic, or "Clinical" based upon the presence of a corresponding diagnosis. Candidate association to CVS was based on a point system.

RESULTS

Thirty-five paroxysmal genes were identified per the literature review. Among these, 12 genes were scored as "Highly likely" (SCN4A, CACNA1A, CACNA1S, RYR2, TRAP1, MEFV) or "Likely" (SCN9A, TNFRSF1A, POLG, SCN10A, POGZ, TRPA1) CVS related. Nine additional genes (OTC, ATP1A3, ATP1A2, GFAP, SLC2A1, TUBB3, PPM1D, CHAMP1, HMBS) had sufficient evidence in the literature but not from our study participants. Candidate status for mitochondrial DNA was confirmed by the literature and our study data. Among the above-listed 22 CVS candidate genes, a Key Qualifying variant was identified in 31/80 (34%), and any Qualifying variant was present in 61/80 (76%) of participants. These findings were highly statistically significant (p < 0.0001, p = 0.004, respectively) compared to an alternative hypothesis/control group regarding brain neurotransmitter receptor genes. Additional, post-analyses, less-intensive review of all genes (exome) outside our paroxysmal genes identified 13 additional genes as "Possibly" CVS related.

CONCLUSION

All 22 CVS candidate genes are associated with either cation transport or energy metabolism (14 directly, 8 indirectly). Our findings suggest a cellular model in which aberrant ion gradients lead to mitochondrial dysfunction, or vice versa, in a pathogenic vicious cycle of cellular hyperexcitability. Among the non-paroxysmal genes identified, 5 are known causes of peripheral neuropathy. Our model is consistent with multiple current hypotheses of CVS.

Cyclic Vomiting Syndrome and Cannabis Hyperemesis Syndrome: The State of the Science

This article provides a narrative review of the state of the science for both cyclic vomiting syndrome and cannabis hyperemesis syndrome along with a discussion of the relationship between these 2 conditions. The scope of this review includes the historical context of these conditions as well as the prevalence, diagnostic criteria, pathogenesis, and treatment strategies for both conditions. A synopsis of the endocannabinoid system provides a basis for the hypothesis that a lack of cannabidiol in modern high-potency Δ 9 -tetrahydrocannabinol cannabis may be contributory to cannabis hyperemesis syndrome and possibly other cannabis use disorders. In concluding assessment, though the publications addressing both adult cyclic vomiting syndrome and cannabis hyperemesis syndrome are steadily increasing overall, the state of the science supporting the treatments, prognosis, etiology, and confounding factors (including cannabis use) is of moderate quality. Much of the literature portrays these conditions separately and as such sometimes fails to account for the confounding of adult cyclic vomiting syndrome with cannabis hyperemesis syndrome. The diagnostic and therapeutic approaches are, at present, based generally on case series publications and expert opinion, with a very limited number of randomized controlled trials and a complete absence of Level 1 evidence within the cyclic vomiting literature overall as well as for cannabis hyperemesis syndrome specifically.

Negative Impact of Disorders of Gut-Brain Interaction on Health-Related Quality of Life: Results From the Rome Foundation Global Epidemiology Survey

BACKGROUND & AIMS

This study used the database from the Rome Foundation Global Epidemiology Survey to assess the differences in quality of life overall, and by age and sex, across individual disorders of gut-brain interaction (DGBI), gastrointestinal anatomical region(s), and number of overlapping DGBI.

METHODS

Data were collected via the Internet in 26 countries, using the Rome IV diagnostic questionnaire and a supplemental questionnaire including the Patient-Reported Outcomes Measurement Information Systems Global-10 quality of life measure. Factorial analyses of variance were used to explore physical and mental quality of life, adjusting for multiple comparisons.

RESULTS

Among the 54,127 respondents, quality of life deteriorated significantly with increasing number of overlapping DGBI, with respondents reporting ≥2 DGBI having significantly poorer quality of life than those with only 1 DGBI or those without any DGBI. Men with DGBI reported better quality of life than women, and those aged ≥65 years reported better quality of life than those <65 years. Age, sex, number of overlapping DGBI, somatization, anxiety, depression, and functional experiences (concern, embarrassment, or stress associated with bowel functioning) relating to DGBI, were significant predictors of poorer physical and mental quality of life.

CONCLUSIONS

This study is the most comprehensive assessment of quality of life to date in adults living with a DGBI. It provides a representative picture of DGBI impact on adults in the global adult population and highlights the significant detrimental impact of living with a DGBI on quality of life.

An analysis of cannabinoid hyperemesis syndrome Reddit posts and themes

INTRODUCTION

Reddit hosts a large active community of members dedicated to the discussion of cannabinoid hyperemesis syndrome. We sought to describe common themes discussed and the most frequently mentioned triggers and therapies for cannabinoid hyperemesis syndrome exacerbations in the Reddit online community.

METHODS

Data collected from six subreddits were filtered using natural language processing to curate posts referencing cannabinoid hyperemesis syndrome. Based on a manual review of posts, common themes were identified. A machine learning model was trained using the manually categorized data to automatically classify the themes for the rest of the posts so that their distributions could be quantified.

RESULTS

From August 2018 to November 2022, 2683 unique posts were collected. Thematic analysis resulted in five overall themes: cannabinoid hyperemesis syndrome-related science; symptom timing; cannabinoid hyperemesis syndrome treatment and prevention; cannabinoid hyperemesis syndrome diagnosis and education; and health impacts. Additionally, 447 trigger and 664 therapy-related posts were identified. The most commonly mentioned triggers for cannabinoid hyperemesis syndrome episodes included: food and drink (n = 62), cannabinoids (n = 45), mental health (e.g., stress, anxiety) (n = 27), and alcohol (n = 22). Most commonly mentioned cannabinoid hyperemesis syndrome therapies included: hot water/bathing (n = 62), hydration (n = 60), antiemetics (n = 42), food and drink (n = 38), gastrointestinal medications (n = 38), behavioral therapies (e.g., meditation, yoga) (n = 35), and capsaicin (n = 29).

DISCUSSION

Reddit posts for cannabinoid hyperemesis syndrome provide a valuable source of community discussion and individual reports of people experiencing cannabinoid hyperemesis syndrome. Mental health and alcohol were frequently reported triggers within the posts but are not often identified in the literature. While many of the therapies mentioned are well documented, behavioral responses such as meditation and yoga have not been explored by the scientific literature.

CONCLUSIONS

Knowledge shared via online social media platforms contains detailed information on self-reported cannabinoid hyperemesis syndrome disease and management experiences, which could serve as valuable data for the development of treatment strategies. Further longitudinal studies in patients with cannabinoid hyperemesis syndrome are needed to corroborate these findings.

Efficacy of aprepitant as a prophylactic medication in adults with cyclic vomiting syndrome

BACKGROUND

Aprepitant is a neurokinin-1 receptor antagonist, and recent guidelines by the American Neurogastoenterology and Motility Society recommend its use as prophylaxis in moderate-to severe cyclic vomiting syndrome (CVS). Data are limited to small studies in children. We aimed to determine its efficacy in adults with CVS.

METHODS

A retrospective review of CVS patients diagnosed using Rome criteria at a tertiary referral center was conducted. Drug response was defined as >50% reduction in symptoms and/or healthcare utilization. An intent-to-treat (ITT) analysis was conducted.

KEY RESULTS

Of 96 patients prescribed aprepitant, 26 (27%) were unable to start due to cost/lack of insurance coverage. Of 70 receiving therapy, mean age was 33 ± 11 years; 51 (73%) were female and 56 (80%) Caucasian. The majority (93%) were refractory to other prophylactic medications. Aprepitant was taken thrice weekly in 51 (73%), daily in 16 (23%) and a few times a month in 3 (4%) due to cost. Fifty (71.4%) had a global symptom response to aprepitant. There was significant reduction in the number of CVS episodes (14.5 ± 11.7 to 6.2 ± 8.0, p < 0.0001), emergency department visits (4.2 ± 7.7 to 1.8 ± 3.4, p = 0.006), and hospital admissions (1.6 ± 3.9 to 0.8 ± 2.1, p = 0.02) in patients treated with aprepitant. Seven (10%) discontinued the drug due to minor side effects.

CONCLUSIONS AND INFERENCES

Aprepitant is a safe and effective prophylactic medication in adults with refractory CVS. Adequate insurance coverage is a major barrier preventing its use.

Clinical characteristics and long-term outcomes in patients with cyclic vomiting syndrome: A 15-year experience at a tertiary referral center

BACKGROUND

Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction (DGBI) characterized by recurrent episodes of nausea and vomiting. Most children outgrow their CVS symptoms and develop migraine headaches, but there are limited data in adults. We thus sought to determine the natural history of CVS in adults.

METHODS

We conducted a retrospective analysis of patients at a specialized tertiary care clinic. Frequency of CVS episodes, emergency department (ED) visits, and hospitalizations were recorded at the index visit and at follow-up.

KEY RESULTS

Of 455 CVS patients with complete data, mean age was 33 ± 13 years, 294 (65%) were female, and 392 (86%) were Caucasian. Mean duration of follow-up was 47.4 ± 37.2 months. There was a significant reduction in frequency of CVS episodes/year (18 to 6.8), ED visits (6.1 to 2), and hospitalizations (2.3 to 0.7) (all p-values < 0.001) but only 88 (19%) of patients had complete resolution of episodes at follow-up. On multivariable regression analysis, non-white race [0.33 (0.11-0.98) p = 0.01], comorbidity count [0.77 (0.62-0.95) p = 0.01], cannabis use [0.36 (0.2-0.65) p = 0.0007], and aprepitant use [0.2 (0.08-0.005) p < 0.001] were associated with a reduced odds of complete resolution of CVS episodes. Of note, 19 patients (4%) died.

CONCLUSIONS AND INFERENCES

While most adults with CVS improved with specialized care, in contrast to children, only a small subset (~1 in 5) had complete resolution of symptoms. Reasons for the effects of race, cannabis use, and comorbidity burden on outcomes in CVS are unclear and warrant further investigation.

Diagnosis and Management of Cyclic Vomiting Syndrome: A Critical Review

Cyclic vomiting syndrome (CVS) is a chronic disorder of gut-brain interaction characterized by recurrent disabling episodes of nausea, vomiting, and abdominal pain. CVS affects both children and adults with a prevalence of approximately 2% in the United States. CVS is more common in female individuals and affects all races. The pathophysiology of CVS is unknown and a combination of genetic, environmental, autonomic, and neurohormonal factors is believed to play a role. CVS is also closely associated with migraine headaches and likely have a shared pathophysiology. The diagnosis of CVS is based on the Rome criteria, and minimal recommended testing includes an upper endoscopy and imaging studies of the abdomen. CVS is frequently associated with anxiety, depression, and autonomic dysfunction. Patients with CVS commonly use cannabis therapeutically for symptom relief. By contrast, cannabinoid hyperemesis syndrome is believed to be a subset of CVS with chronic heavy cannabis use leading to hyperemesis. Due to the recalcitrant nature of the illness, patients often visit the emergency department and are hospitalized for acute CVS flares. Guidelines on the management of CVS recommend a biopsychosocial approach. Prophylactic therapy consists of tricyclic antidepressants (amitriptyline), antiepileptics (topiramate), and aprepitant in refractory patients. Abortive therapy consists of triptans, antiemetics (ondansetron), and sedation. Treatment of comorbid conditions is extremely important to improve overall patient outcomes. CVS has a significant negative impact on patients, families, and the healthcare system, and future research to understand its pathophysiology and develop targeted therapies is needed.

The Effect of Acotiamide on Nausea as a Symptom of Chronic Nausea and Vomiting Syndrome after Coronavirus Disease 2019

Chronic nausea and vomiting syndrome (CNVS), one of a functional gastroduodenal disorder, was identified in an 8-year-old girl and a 13-year-old boy who had complained of nausea for more than 4 months following coronavirus disease 2019 (COVID-19) due to normality of their head computed tomography and upper gastrointestinal tract images. The patients' symptoms responded quickly to acotiamide, a medication that is effective for treating functional dyspepsia (FD). Despite being a distinct illness from FD, CNVS is also a functional gastrointestinal disorder, and acotiamide may be just as effective for CNVS following COVID-19 as for FD.

Weight loss outcomes are not compromised in bariatric patients using cannabis

BACKGROUND

The legalization of cannabis in several states has led to increased documented use in the population. Bariatric surgery patients are no exception with estimates of anywhere from 6 to 8%. Cannabis is known to be associated with increased appetite, mood disorders, hyperphagia, and rarely, hyperemesis, which can potentially affect post-surgical weight loss. We aim to study the differences in bariatric surgery outcomes between cannabis users and non-users.

METHODS

A retrospective review identified patients undergoing bariatric surgery. Patients were divided into two groups, cannabis users (CU) and non-cannabis users (non-CU). Cannabis users (defined as using at least once weekly) and a group of non-users were called to obtain additional information. Primary outcome was weight loss. Secondary outcomes included incidence of post-operative nausea and vomiting (PONV), length of stay (LOS), readmission, and need for additional intervention.

RESULTS

A cohort of 364 sleeve gastrectomy patients met inclusion criteria, 31 (8.5%) CU and 333 (91.5%) non-CU. There was no difference in EWL between CU and non-CU at 1 week, 1 month, 3 months, 6 months, 9 months, 1 year, and 2 years. However, the CU group trended towards greater EWL at 3 years (52.9% vs. 38.1%, p = 0.094) and at 5 years (49.8% vs. 32.7%, p = 0.068). There were no significant differences between CU and non-CU with respect to either incidence or severity of PONV at one year after surgery or longer follow-up.

CONCLUSION

Cannabis users did not experience inferior weight loss after bariatric surgery despite common assumptions that appetite stimulation can lead to suboptimal weight loss outcomes. Our findings add to other work challenging this dogma. Larger, long-term, multicenter studies are warranted.

A novel scalable electrode array and system for non-invasively assessing gastric function using flexible electronics

BACKGROUND

Disorders of gastric function are highly prevalent, but diagnosis often remains symptom-based and inconclusive. Body surface gastric mapping is an emerging diagnostic solution, but current approaches lack scalability and are cumbersome and clinically impractical. We present a novel scalable system for non-invasively mapping gastric electrophysiology in high-resolution (HR) at the body surface.

METHODS

The system comprises a custom-designed stretchable high-resolution "peel-and-stick" sensor array (8 × 8 pre-gelled Ag/AgCl electrodes at 2 cm spacing; area 225 cm² ), wearable data logger with custom electronics incorporating bioamplifier chips, accelerometer and Bluetooth synchronized in real-time to an App with cloud connectivity. Automated algorithms filter and extract HR biomarkers including propagation (phase) mapping. The system was tested in a cohort of 24 healthy subjects to define reliability and characterize features of normal gastric activity (30 m fasting, standardized meal, and 4 h postprandial).

KEY RESULTS

Gastric mapping was successfully achieved non-invasively in all cases (16 male; 8 female; aged 20-73 years; BMI 24.2 ± 3.5). In all subjects, gastric electrophysiology and meal responses were successfully captured and quantified non-invasively (mean frequency 2.9 ± 0.3 cycles per minute; peak amplitude at mean 60 m postprandially with return to baseline in <4 h). Spatiotemporal mapping showed regular and consistent wave activity of mean direction 182.7° ± 73 (74.7% antegrade, 7.8% retrograde, 17.5% indeterminate).

CONCLUSIONS AND INFERENCES

BSGM is a new diagnostic tool for assessing gastric function that is scalable and ready for clinical applications, offering several biomarkers that are improved or new to gastroenterology practice.