Cyclic Vomiting (CV)

Timothy C. Hain, MD Page last modified: December 30, 2007

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Introduction:

Cyclic vomiting consists of spells of uncontrollable vomiting, typically every two or three months (Fleisher et al, 1993). The vomiting can occasionally be so severe as to be lethal. The cause of this syndrome is not entirely certain, but may be migraine. Treatment with migraine prevention medications is sometimes useful as well as with general antiemetics.

Epidemiology:

CV is infrequent but not rare. In the author's practice, which largely includes adults with dizziness, it is encountered about 1/month (about 2% of caseload). It occurs both in adults and children (Aanpreung et al, 2002). It may occur in as many as 1.9% of school age children (Li et al, 2000). It's characteristics in adults and children are simlar (Prakash, 2001).

Pathophysiology/differential diagnosis:

• Migraine
• abnormal gastrointestinal motility
• "slit ventricle" syndrome in shunted children.
• gastrointestinal obstructions
• pancreatic disease
• metabolic disorders such as aminoacidopathies and organic aciduries
• acute intermittent porphyrea
• renal disease
• epilepsy
• psychiatric disorder

The cause of this syndrome is most commonly attributed to migraine. However there are many other theories (Forbes et al, 1995). Abnormal gastrointestional motility (low motility) can be found in persons with this syndrome even between vomiting spells (Abell et al, 1988). Higher than normal motility is found after eating ( Chong et al, 1999). Cyclic vomiting can also occur in overshunted children (Coker et al, 1987). Occasional reports suggest a mitochondrial abnormality or a hypothalamic syndrome (similar to Klein Levin).

Approach:

• Gastroenterology evaluation with Upper GI/Small bowel follow-through
• MRI of brain (?)
• General medical workup

Cyclic vomiting is a diagnosis of exclusion. Most patients initially see a gastroenterologist where disorders such as reflux, gastric malrotation (volvulus) are excluded. In general, in about 40% of patients an underlying etiology is found ( Li et al, 1998), and in the majority of children, migraine is the presumed cause (Li et al, 1999)

According to Olson (2002), a upper GI/Small bowel follow-through followed by a trial of migraine prophylactic therapy is the most effective approach in children. The purpose of the UGSBF is to diagnose volvulus (gastrointestinal obstruction).

Treatment:

Treatment with migraine prevention medications is sometimes useful, as well as antiemetics. Typically patients are put on a migraine suppression medication (such as Verapamil), an antimetic (such as Phenergan), with supplementation during acute flareups.

Particularly useful migraine medications are:

1. verapamil
2. amitriptyline
3. cyproheptadine (used in children)
4. Propranolol
5. sumatriptan and other triptans
6. topiramate (but this one can cause some stomach upset by itself)

(Aanpreung et al, 2003; Anderson et al, 1997; Benson et al, 1995; Forbes et al, 1995)

Many of these medications decrease gastrointestional motility, which would seem to contradict the idea that this condition is due to decrased motility. The author has not attempted treatment with topiramate, depakote or similar medications. Treatment with other triptans than sumatriptan seems reasonable.

Particularly useful antiemetics are:

1. Phenergan
2. Benzodiazepines such as Diazepam
3. Ondansetron and similar medications
4. Domperidone (Motilium)

A general review of anti-emetic treatment can be found here.

The author has had no success at all using medications that increase gastrointestional motility (e.g. metoclopramide) , but erythromycin is advocated by some( Vanderhoof et al, 1993).

Van Calcar et al (2002) reported that L-Carnitine (50 mg/kg) is an effective treatment. We have had no experience.

Anticonvulsants are not helpful in CV.

References:

1. Aanpreung, P. and C. Vajaradul (2002). "Cyclic vomiting syndrome in Thai children." J Med Assoc Thai. 85 Suppl 2: S743-8.
2. Abell, T. L., C. H. Kim, et al. (1988). "Idiopathic cyclic nausea and vomiting--a disorder of gastrointestinal motility?" Mayo Clin Proc63(12): 1169-75.
3. Andersen, J. M., K. S. Sugerman, et al. (1997). "Effective prophylactic therapy for cyclic vomiting syndrome in children using amitriptyline or cyproheptadine." Pediatrics100(6): 977-81.
4. Benson, J. M., S. L. Zorn, et al. (1995). "Sumatriptan in the treatment of cyclic vomiting." Ann Pharmacother29(10): 997-9.
5. Chong, S. K. (1999). "Electrogastrography in cyclic vomiting syndrome." Dig Dis Sci44(8 Suppl): 64S-73S.
6. Coker, S. B. (1987). "Cyclic vomiting and the slit ventricle syndrome." Pediatr Neurol3(5): 297-9
7. Fleisher, D. R. and M. Matar (1993). "The cyclic vomiting syndrome: a report of 71 cases and literature review." J Pediatr Gastroenterol Nutr17(4): 361-9.
8. Forbes, D. (1995). "Differential diagnosis of cyclic vomiting syndrome." J Pediatr Gastroenterol Nutr21 Suppl 1: S11-4.
9. Forbes, D. and G. Withers (1995). "Prophylactic therapy in cyclic vomiting syndrome." J Pediatr Gastroenterol Nutr21 Suppl 1: S57-9.
10. Li, B. U. and J. P. Balint (2000). "Cyclic vomiting syndrome: evolution in our understanding of a brain-gut disorder." Adv Pediatr47: 117-60.
11. Li, B. U., R. D. Murray, et al. (1998). "Heterogeneity of diagnoses presenting as cyclic vomiting." Pediatrics102(3 Pt 1): 583-7.
12. Li, B. U., R. D. Murray, et al. (1999). "Is cyclic vomiting syndrome related to migraine?" J Pediatr134(5): 567-72.
13. Olson, A. D. and B. U. Li (2002). "The diagnostic evaluation of children with cyclic vomiting: a cost-effectiveness assessment." J Pediatr141(5): 724-8.
14. Prakash, C., A. Staiano, et al. (2001). "Similarities in cyclic vomiting syndrome across age groups." Am J Gastroenterol96(3): 684-8.
15. Van Calcar, S. C., C. O. Harding, et al. (2002). "L-carnitine administration reduces number of episodes in cyclic vomiting syndrome." Clin Pediatr (Phila)41(3): 171-4.
16. Vanderhoof, J. A., R. Young, et al. (1993). "Treatment of cyclic vomiting in childhood with erythromycin." J Pediatr Gastroenterol Nutr17(4): 387-91.