The management of cyclic vomiting syndrome

Abstract

Cyclic vomiting syndrome (CVS) is a rare abnormality of the neuroendocrine system that affects 2% of children. It is a frequently missed diagnosis in the emergency department and may require a number of emergency department visits before the diagnosis is made. The objectives of this review are to identify the clinical features that suggest a diagnosis of CVS and to review the literature on its management. The MEDLINE and EMBASE databases were searched from January 1948 to October 2011 using the keywords 'Cyclic' or 'Vomiting'. Papers were excluded if they did not follow the consensus guidelines or if they were case reports. This review analysed 1093 cases of cyclic vomiting in 25 papers that fulfilled the inclusion criteria. All except one paper were retrospective studies. The size of these cohort studies ranged from three to 181 patients, with a mean patient size of 29. This review found that over 40% of patients have headaches/migraines, with associated anxiety and depression in ≈ 30% of cases. There is a family history of headaches/migraines in 38.9%, and this association was much stronger in the adult CVS cohort compared with the paediatric cohort. Compared with paediatric CVS, adults have a longer duration of attacks and they occur more frequently (5.9 vs. 3.4 days, 14.4 vs. 9.6 episodes/year). Limited data are available on the treatment of the acute phase of CVS, but in adults, sumatriptan has been shown to be effective. For prophylactic treatment, tricyclics are effective in both adult and paediatric CVS, with a clinical response in 75.5 and 67.6% of patients, respectively, in nonplacebo-controlled cohort studies. Furthermore, propranolol has been shown to be useful in children. CVS is an intractable illness with a major impact on the patient's quality of life. There is a long duration between the onset of symptoms and the diagnosis of the condition. There is a high association with headaches/migraines and anxiety/depression. The symptoms are more severe in adult-onset CVS. Tricyclic antidepressants have good efficacy in reducing the frequency/duration or the intensity of attacks. There is limited evidence on the acute management of CVS.

Cyclic vomiting syndrome: a case series and review of the literature

“…In our small case series, 6 of 14 patients achieved full remission with amitriptyline, and a further 2 showed a substantial improvement in symptoms. The findings are in keeping with a meta-analysis of previous studies,12 and thus support the use of TCADs as an efficacious prophylactic treatment option for CVS.…”

“…A recent systematic review and meta-analysis of 25 separate cohorts of patients with CVS reported a higher proportion of patients with headaches or migraines (40%) than seen in our case series 12. There was also a family history of headaches or migraines in 40% in this meta-analysis.…”

“…Treatment should be initiated at the earliest signs of nausea. Sumatriptan (a 5-hydroxytryptamine (HT)- 1 receptor antagonist) has been shown to have some efficacy in aborting the attacks during the prodromal phase,12 when administered, intranasally, subcutaneously or even orally, particularly in patients with a family history of migraine 34 35 49…”

13-Year-Old Girl With Recurrent, Episodic, Persistent Vomiting: Out of the Pot and Into the Fire

“…Prophylaxis with tricyclic antidepressants in the asymptomatic phase has been shown to be helpful in 75.5% of adult patients and 67.6% of pediatric patients, in a non-placebo-controlled cohort study. 15 Propranolol has also been shown to be effective as prophylactic treatment in children. 16 Patients presenting with symptoms of CVS often undergo extensive evaluation for alternative causes of their symptoms.…”

Cannabinoid Hyperemesis

“…The patient could be discharged 4 h later and was counseled to stop smoking marijuana [118]. Propranolol is a nonspecific, lipophilic beta-1/beta-2-blocker that has been used to treat CVS, particularly in pediatric patients [119]. Its use in CHS has to date been very limited.…”