From the Guidelines
Cyclical vomiting syndrome (CVS) should be managed with a two-pronged approach, including preventive medications and abortive therapy during acute episodes, with the goal of reducing symptoms, healthcare utilization, and improving patients' quality of life 1.
Key Considerations
- The condition remains underdiagnosed and undertreated, with most patients experiencing years of diagnostic delays and unnecessary investigations 1.
- Early recognition and appropriate treatment can significantly improve outcomes, reducing the frequency and severity of episodes, and enhancing overall well-being 1.
- A thorough understanding of the various CVS phases, including prodromal, interepisodic, emetic, and recovery phases, is essential for optimal care 1.
Treatment Approach
- Preventive medications, such as tricyclic antidepressants (e.g., amitriptyline) or anticonvulsants (e.g., topiramate), can help reduce episode frequency and severity 1.
- Abortive therapies, including antiemetics like ondansetron or promethazine, can be effective in managing symptoms during acute episodes 1.
- Patient education on recognizing and responding to the prodromal phase is crucial for successful episode abortion and overall management 1.
Additional Considerations
- Identifying and avoiding personal triggers, such as stress, lack of sleep, or specific foods, can help reduce episode frequency 1.
- Maintaining a regular sleep schedule and eating pattern may also contribute to improved outcomes 1.
- Supplementation with L-carnitine or coenzyme Q10 may be beneficial in certain cases, particularly when mitochondrial dysfunction is suspected 1.
From the Research
Definition and Characteristics of Cyclical Vomiting Syndrome
- Cyclical vomiting syndrome (CVS) is a disorder characterized by recurrent and unpredictable episodes of intense vomiting, interspersed with periods of apparent wellbeing 2.
- CVS primarily affects children and adolescents but can persist into adulthood 2, 3.
- The exact etiology of CVS remains unknown, but genetic factors, nervous system alterations, autonomic dysregulation, and environmental factors are postulated as possible triggers 2.
Diagnosis of Cyclical Vomiting Syndrome
- There is no specific test for confirming the presence of CVS, and diagnosis is based on the Rome criteria 3.
- Thorough evaluation of symptoms and the ruling out of other possible causes of recurrent vomiting are required 2.
- Minimal recommended testing includes an upper endoscopy and imaging studies of the abdomen 3.
- Diagnostic tests of exclusion, such as an upper gastrointestinal (GI) contrast study and basic laboratory screening, are essential 4.
Management and Treatment of Cyclical Vomiting Syndrome
- Management of CVS typically involves a multidisciplinary approach, including pharmacologic options, behavioral, and psychologic support therapies 2.
- Prophylactic therapy consists of tricyclic antidepressants (amitriptyline), antiepileptics (topiramate), and aprepitant in refractory patients 5, 3.
- Abortive therapy consists of triptans, antiemetics (ondansetron), and sedation 5, 3.
- Treatment of comorbid conditions, such as anxiety, depression, migraine headache, autonomic dysfunction, and sleep disorders, is extremely important to improve overall patient outcomes 5, 3.
- Lifestyle and non-pharmacological interventions, such as meditation, relaxation, and biofeedback, play a pivotal role in successful management 5, 4.
Impact and Future Research
- CVS has a significant negative impact on patients, families, and the healthcare system 2, 3.
- Future research to understand the pathophysiology of CVS and develop targeted therapies is needed 2, 3, 4.
- The development of novel therapies, such as those targeting the endocannabinoid system, may offer the potential to transform the care of patients with CVS 6.