AGA: ‘Prompt recognition’ is key to diagnosis, management of cyclic vomiting syndrome
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Key takeaways:
- Cyclical vomiting syndrome should be considered in any adult presenting with episodes of repetitive vomiting.
- Treatment includes lifestyle measures, abortive medication, supportive therapy and rehydration.
The AGA has published a clinical practice update highlighting the need for awareness and “prompt recognition” of cyclical vomiting syndrome to effectively diagnosis and treat patients.
“Most patients with cyclic vomiting syndrome (CVS) can benefit substantially from currently available treatments, but this disorder remains poorly recognized by clinicians,” David J. Levinthal, MD, PhD, director of the Neurogastroenterology & Motility Center and assistant professor at University of Pittsburgh School of Medicine, told Healio. “Thus, there remains a very large ‘treatment gap’ for adults who continue to suffer needlessly without access to effective therapy.”
Levinthal and colleagues expanded on existing guidelines from the American Neurogastroenterology and Motility Society-Cyclic Vomiting Syndrome Association and used data from recently published studies, as well as clinical experience, to create the update, which was published in Gastroenterology.
“This practice update is meant to be of high clinical value to physicians across a wide spectrum of disciplines — primary care providers, gastroenterologists, emergency medicine physicians and others — who are on the front lines seeing patients with CVS,” Levinthal said.
Clinical features, diagnosis of CVS
CVS is a chronic disorder of brain-gut interaction characterized by recurrent, acute episodes of nausea, vomiting and retching, separated by periods without symptoms, researchers wrote. The condition has four distinct phases — interepisodic, prodromal, emetic and recovery — and most episodes occur during early morning hours.
Rome IV criteria for CVS includes:
- episodes of acute-onset vomiting lasting less than 7 days;
- at least three discrete episodes in 1 year, two of which occurred in the prior 6 months, with episodes separated by at least 1 week of baseline health; and
- absence of vomiting between episodes, although milder symptoms such as nausea, occasional vomiting and dyspepsia may be present.
However, researchers noted that with a wide range of presentations and clinical severity, other diagnostic clues include:
- prodromal symptoms, lasting a median of 1 hour prior to vomiting;
- prodromal and emetic phases associated with other symptoms such as fatigue, feeling hot or cold, mental fog, restlessness, anxiety, headache, bowel urgency, acute diarrhea or constipation, abdominal pain, diaphoresis, flushing, shakiness or tremulousness; and
- abdominal pain, present in most patients during an episode.
In addition, episodes are often triggered by psychological and physiological factors, the most common of which is stress, which studies show has been confirmed in 70% to 80% of patients. CVS also is associated with mood disorders such as anxiety, depression and panic disorder; migraines; and seizure disorders.
“The key to improving the diagnostic gap for CVS is to recognize the defining episodic nature of the illness,” Levinthal said. “In essence, improving the clinical recognition of CVS will serve to improve health for adults suffering for years without relief.”
While clinical recognition “remains the anchor of the diagnostic approach,” researchers wrote, a basic workup for episodic vomiting should include blood work and urinalysis. A one-time esophagogastroduodenoscopy or other upper GI imaging could exclude obstructive lesions, although repeat procedures should be avoided.
Gastric emptying scans also should not be routinely performed, and other testing should be based on individualized patient history.
Lifestyle, pharmacologic management
Levinthal and colleagues recommend addressing comorbid conditions related to CVS with assistance from referral and allied health services, which may include pharmacologic or nonpharmacologic therapies such as cognitive behavioral therapy or mindfulness meditation. Lifestyle modifications such as regular sleep, avoiding prolonged fasting and stress management are also advised.
“Patients should attempt to identify and mitigate or avoid CVS triggers during the interepisodic phase,” Levinthal and colleagues wrote.
Researchers also recommend prophylactic therapy — aimed at extending the length of the interepisodic phase and/or reducing the length and severity of the emetic phase — for patients with moderate to severe CVS, defined as more than four episodes per year, each of which last at more than 2 days, with ED utilization. Tricyclic antidepressants are strongly recommended as first-line treatment, while topiramate, aprepitant, zonisamide and levetiracetam are second-line agents; however, the choice should be individualized based on the patient.
Abortive therapy is designed to avoid the emetic phase or drastically reduce its severity and is most effective when medication is taken as early into the prodromal phase as possible. This may be a challenge for those who quickly transition to the emetic phase without a prodrome, researchers wrote.
The most common abortive therapy regimen includes sumatriptan, which can be administered via nasal spray, and an antiemetic agent, such as ondansetron, which is available in a sublingual tablet. Other antiemetics are available as rectal suppositories. Sedating agents, such as diphenhydramine or benzodiazepines, may also be used as abortive therapy.
ED management may be necessary for patients presenting with an episode of uncontrolled retching and vomiting and may include control of abdominal pain and IV fluids and antiemetics.
“About half of all adult CVS patients visit the emergency department at least once a year due to lack of access to effective therapy,” Levinthal told Healio. “Improving access to treatment for adults with CVS not only will improve patients’ quality of life, but also substantially reduce the burden on the health care system.”
The recovery phase, which typically lasts approximately 1 to 2 days, includes rest and consumption of electrolyte-rich fluids or nutrient drinks.
“Although CVS is classified as a ‘disorder of gut-brain interaction,’ we truly do not understand the pathophysiologic basis of this disorder,” Levinthal said. “The future for CVS care hinges on research that uncovers disease mechanisms that can be targeted and form basis for personalized medicine approaches. There also are unknowns about some of the epidemiologic features of CVS, including the true prevalence of the disorder, frequency of conditions that are comorbid with CVS and predictors of treatment response.”
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