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home - Miscellaneous - Other - Vomiting Written by Dr Sebastian Zeki

Defines the pathophysiology of fluid and nutrient malabsorption,
including causes, e.g. anatomical and functional short bowel
syndrome, high output stomas, enterocutaneous fistulae and
pancreatic insufficiency

Knows how to investigate patients with malabsorption
Describes the clinical consequences of malabsorption, including
malnutrition, fluid and electrolyte disturbance and micronutrient
deficiency and anaemia and how to manage these

Describes all other causes of anaemia, including bone marrow
disorders and haemolysis

Describes the metabolism, absorption and bioavailability of iron, B12
and folate and clinical conditions and diets associated with their

Identifies and appropriately investigates clinical features suggestive of

Manages fluid, electrolyte and micronutrient disturbances associated
with short bowel syndrome or high output stomas

Uses the appropriate investigations for the different types of anaemia
Takes a careful clinical approach to managing patients with
malabsorption and anaemia. Explains plan of management clearly to
patients and their relatives.



Knows the different causes of enteric dysmotility (myopathy and
neuropathy) and their presenting features

Have a knowledge of scleroderma amyloid and congenital motor
abnormalities of the gut that affect absorption

Knows the principles of investigation pain relief and prokinetic drug

Understands bacterial overgrowth and its treatment
Understands how emotional status can affect gut function
Knows how diabetic complications can affect the gut
Can determine when organic obstruction is occurring TO
Can understand the principles and interpret the results of
gastrointestinal motility investigations (including manometry transit
studies etc) and autonomic function tests
Advises on appropriate prokinetic drugs and analgesics
Can detect and treat bacterial overgrowth
Advises on appropriate surgery including bypass procedures
Can relieve symptoms while not causing/risking harm with other
medications (e g opiates)

Works with the multidisciplinary NST psychiatrists/psychologists
surgeons and the pain management team

Can give careful explanation of the problems to the patient carers
friends and family


Unknown but associations:1. Associated with migraines (headaches and abdominal).2. Metabolic disorders: Mitochondrial disorders of fatty acid oxidation (eg, medium-chain acyl coen-zyme A dehydrogenase deficiency)Respiratory chain defects (eg, MELAS)Mitochondrial DNA deletions.50% of CVS may have maternal inheritance of a mitochondrial DNA sequence variation4. Hypothalamic-pituitary-adrenal axis defects Corticotropin-releasing factor can induce gastric stasis and vomiting by vagal stimulation.5. Food allergy:Sensitivity to cow's milk, soy, and egg white protein is related to CVS in children.Other food triggers include chocolate, cheese, and monosodium glutamate.6. Catamenial CVS CVS can be related to onset of periodCan respond or be exacerbated by OCP7. Chronic cannabis use:CVS can be exacerbated by cannabis cessationCan also relieve the symptoms Natural History75 % of children with CVS will go on to develop migraine head-aches by age 18.In adults, most will respond eventually to antidepressants. Diagnostic Criteria Work Up:Bloods.Urinalysis, and (in children).Evaluation for metabolic disorders (eg, lactate, ammonia, amino acids, urine organic acids) during an acute episode.UGI endoscopy/ SBFT.CT/MRI of the head. TreatmentIf FH of migraines try anti- migraine treatment.Consider amitryptyline if there is no family history of migraines.Empirically (with variable success) in children can try sumatriptan, erythromycin, carnitine, propranolol, cyproheptadine, and TCA’s.Cyproheptadine and propranolol are used as alternatives.Unproven treatments include topiramate and co-enzyme Q10.Sumatriptan, ketorolac, prochlorperazine, and TCA’s anecdotally.Consider OCP in catamenial CVS. Begins in the early morning hours Prodromal pallor, anorexia, nausea, abdo pain 3-6 days 3-6 months of normality Episode is stereotypical for each patient Supportive criteria include:History or family history of migraine headaches. Cyclical Vomiting Syndrome Pathogenesis Written by Dr Sebastian Zeki