THE AMERICAN Gastroenterological Association (AGA) has reviewed available evidence and provided expert advice regarding the diagnosis and management of cyclic vomiting syndrome (CVS), a treatable but disabling condition marked by recurrent episodes of severe vomiting and nausea.
Diagnosis of CVS relies on clinical criteria established by the Rome Foundation, emphasising recognition of the syndrome’s episodic nature and associated symptoms. Key diagnostic features include stereotypical bouts of vomiting and retching, often preceded by prodromal symptoms such as anxiety, restlessness, abdominal pain, or an impending sense of doom. Clinicians should identify these patterns to distinguish CVS from other conditions.
Triggers, including stress, sleep deprivation, hormonal changes, and physical exertion, play a significant role and vary between patients. Recognising triggers and prodromal cues enables timely intervention, particularly during the prodromal phase, when abortive therapies are most effective.
Management of CVS focuses on both acute and preventive strategies. Lifestyle modifications are foundational, with recommendations for regular sleep, stress management, and avoiding prolonged fasting. Prophylactic therapies are critical for patients with moderate-to-severe CVS, defined as experiencing four or more episodes per year lasting over 2 days and requiring emergency care. Tricyclic antidepressants are first-line options, while medications like topiramate and aprepitant serve as alternatives.
Abortive therapies aim to halt episodes early, often requiring combinations of medications such as sumatriptan and ondansetron. Delivery methods like nasal sprays and sublingual tablets are vital for patients with active vomiting. Sedation, often achieved with agents like benzodiazepines, is another effective approach during acute episodes. Hot bathing or showering during episodes is a common self-soothing behaviour providing temporary relief, though it may lead to complications such as burns.
Addressing comorbid conditions like anxiety, depression, migraines, or postural orthostatic tachycardia syndrome significantly improves outcomes. Diagnostic evaluation includes limited testing to rule out overlapping conditions, with a focus on patient history to avoid unnecessary procedures. Emergency department care prioritises sedation, intravenous fluids, and antiemetics, delivered in a calm, supportive environment.
Research into CVS’s pathophysiology and disparities in care remains crucial for improving treatment outcomes, and collaborative efforts to develop targeted therapies and standardised registries are key steps forward. While CVS can be highly disabling, prompt recognition and effective management can dramatically improve patients’ quality of life.
Ada Enesco, EMJ
Reference
Levinthal DJ et al. AGA clinical practice update on diagnosis and management of cyclic vomiting syndrome: commentary. Gastroenterology. 2024;167(4):804-811.e1.
