Cyclic Vomiting Syndrome Clinical Practice Update Guides Diagnosis, Management

David Levinthal, MD, PhD

Credit: University of Pittsburgh

The American Gastroenterological Association (AGA) has released new clinical guidance to help clinicians and patients recognize the signs and symptoms of cyclic vomiting syndrome (CVS).¹

The clinical practice update, published on July 16, 2024, in Gastroenterology, reviews the available evidence and provides expert advice regarding the diagnosis and management of CVS, a highly prevalent yet poorly recognized condition that is often underdiagnosed and subsequently undertreated.¹

“Our goal with this Clinical Practice Update is to increase awareness of cyclical vomiting syndrome to reduce the diagnostic delay and increase patients’ access to treatment. We hope to reach primary care, ER and urgent care providers, who are on the frontlines interacting with CVS patients seeking care, especially during an attack,” David Levinthal, MD, PhD, director of the neurogastroenterology and motility center at the University of Pittsburgh Medical Center, said in a press release.²

A disorder causing sudden, repeated attacks of severe nausea and vomiting, CVS is estimated to affect up to 2% of the population. Despite being a common condition, delays in diagnosis and treatment are common due to a lack of recognition and frequent misdiagnosis. There is no single test to diagnose CVS, nor is there a single treatment to prevent or cure it. Thus, the AGA clinical practice update reviews the available evidence and provides expert advice for diagnosing and treating CVS.^2,3

Diagnosing CVS

Guideline authors outline general awareness of CVS and its prompt recognition as being key to effective management, asserting clinicians should consider a CVS diagnosis in any adult patient presenting with episodic bouts of repetitive vomiting. Diagnostic clues important for clinicians to consider include prodromal symptoms, constitutional, cognitive, affective, autonomic, and motor symptoms, stereotypical symptom clusters, and the presence of abdominal pain during episodes.¹

“A diagnosis is a powerful tool. Not only does it help patients make sense of debilitating symptoms, but it allows healthcare providers to create an effective treatment plan,” Levinthal said.²

Like other disorders of the gut-brain interaction, CVS is diagnosed based on Rome IV criteria. The Rome clinical criteria for CVS are:

• Stereotypical episodes of acute-onset vomiting lasting <7 days
• ≥ 3 discrete episodes in a year, of which 2 have occurred in the prior 6 months
• Episodes should be separated by at least 1 week of baseline health
• Absence of vomiting between episodes, but some milder symptoms, such as nausea, occasional vomiting, and dyspepsia may be present.

However, investigators noted considerable heterogeneity in the duration and frequency of CVS episodes that may not align with Rome criteria have necessitated the distinction between mild and moderate-severe forms of CVS:

• Mild: < 4 episodes/year lasting less than 2 days
• Moderate-severe: > 4 episodes/year lasting > 2 days and requiring ≥ 1 emergency department visit or hospitalization

CVS is divided into 4 distinct phases—inter-episodic, prodromal, emetic, and recovery—each associated with a specific treatment approach and management goal. By tailoring treatment approaches to each phase of CVS and addressing management goals, healthcare providers can effectively manage the condition and improve patient outcomes.¹

Recognizing comorbid conditions associated with adult CVS can also help make a diagnosis and guide management. These frequently include mood, migraine, and seizure disorders.¹

To rule out similar or overlapping conditions, limited testing is necessary, including blood work, urinalysis, and one-time esophagogastroduodenoscopy or upper gastrointestinal imaging. The update advises against the regular ordering of gastric emptying scans and further recognizes potential complications posed by the use of cannabis.¹

Managing CVS

Addressing comorbid conditions associated with CVS through pharmacologic and nonpharmacologic therapies can significantly improve CVS symptoms and overall quality of life. Additionally, identifying and avoiding triggers during the inter-episodic phase is beneficial for patients, as is getting regular sleep, avoiding prolonged fasting, and pursuing stress management techniques.¹

Prophylactic therapy is indicated for moderate-severe CVS to extend the length of the inter-episodic phase and/or reduce the length and severity of the emetic phase, while abortive therapy seeks to avoid or reduce the severity of the emetic phase and is most successful when medications are taken as early into the prodromal phase as possible. Often, combinations of ≥ 2 agents are needed to reliably abort CVS attacks.¹

In the recovery phase, typically lasting 1-2 days, consuming electrolyte-rich fluids or nutrient drinks is the priority, after which patients should focus on avoiding triggers, getting quality sleep, and reducing stress to prevent future episodes.¹

Investigators noted major gaps in the understanding of the pathophysiology and natural history of CVS limit the development of more effective treatments, and personalized therapeutic approaches are hindered by an incomplete understanding of the clinical features and comorbidities predicting clinical responses. Still, they conclude CVS is a common and treatable condition.¹

References

1. ^{American Gastroenterological Association. ‘We have treatments’: Doctors urge patients with chronic vomiting to not suffer in silence. July 16, 2024. Accessed July 16, 2024.}
2. ^{Levinthal DJ, Staller K, Venkatesan T, et al. AGA Clinical Practice Update on Diagnosis and Management of Cyclic Vomiting Syndrome: Commentary. Gastroenterology. https://doi.org/10.1053/j.gastro.2024.05.031}
3. ^{Cleveland Clinic. Cyclic Vomiting Syndrome. Diseases & Conditions. November 2, 2023. Accessed July 16, 2024. https://my.clevelandclinic.org/health/diseases/14894-cyclic-vomiting-syndrome}