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Cyclic Vomiting Should Be Considered in Adults Presenting With Recurrent Vomiting St. Louis- A warning to consider a diagnosis of cyclic vomiting syndrome in adults with recurrent vomiting has been voiced by Dr. Chandra Prakash, a fellow in gastroenterology at Washington University School of Medicine here. The syndrome has been considered rare in adults although it is well recognized in children, he noted. It has distinctive features that differentiate it from functional nausea and vomiting, which is characteristic by continuous, unexplained symptoms lasting three or more months. "Most important is the cyclic nature: symptoms start abruptly, go away just as abruptly, then recur." Dr. Prakash explained in an interview with Gastroenterology & Endoscopy News. "Some patients have a prodome, others don't. Unlike functional nausea and vomiting, the duration of episodes and cycles varies considerably from one person to the next. Adults with this disorder do not have histories extending into childhood." In open-label use, tricyclic antidepressants appear to help control symptoms when given in modest doses for a prolonged period, but response to these agents appears to be less satisfactory in adult cyclic vomiting syndrome than in the childhood disorder or in typical functional nausea and vomiting, he reported. "Although the criteria for diagnosis of cyclic vomiting syndrome in children and adults are identical, the pathogenesis may be different, and treatment should not be empirically extapolated across groups." Dr. Prakash advised. Only a few cases of adult cyclic vomiting syndrome have been reported in the literature, he noted. It is not clear whether the disorder originates in the central nervous system or the GI tract. No uniformly beneficial treatment has been discovered. Dr. Prakash and Dr. Ray E. Clouse, the senior author, reviewed clinical data from 20 adult patients (11 females, nine males; mean age, 41) with cyclic vomiting syndrome, seen over a 10-year period. Of these, 17 patients were treated with tricyclic antidepressants specifically for cyclic vomiting syndrome. All subjects had been seen by many physicians without a diagnosis and underwent repeated investigation before the diagnosis of cyclic vomiting syndrome was made. Ten of these 20 subjects had distal erosive esophagitis, and one had Mallory-Weiss tear on upper endoscopy; both lesions were considered secondary to vigorous vomiting. Three patients underwent surgical exploration without improvement before the correct diagnosis was made. In the St. Louis series, the criteria for diagnosis included discreet, stereotypic episodes of severe vomiting lasting 12 hours or more, seven or more days between episodes, complete resolution of symptoms between episodes, three or more episodes, no organic explanations for the symptoms. The character of the episodes was compared to published data in pediatric patients. Response to low dose tricyclic antidepressants was compared to published preliminary data in pediatric patients with cyclic vomiting syndrome (AM J Gastroenterol 1996; 91;1923). The symptoms in the cyclic vomiting syndrome patients began at an average of 35 years. The average length of episodes was 6.4 days, and cycle interval averaged three months. Age at presentation in cyclic vomiting syndrome and functional nausea and vomiting patients did not differ, but the cyclic vomiting group reported a longer duration of symptoms preceding presentation, and there were more males in the cyclic vomiting group. Pain was a dominant complaint in cyclic vomiting syndrome, occurring in 65% of patients, compared to 35% of patients with functional nausea and vomiting. In the cyclic vomiting series, tricyclic antidepressants, including amitriptyline, doxepin and other agents, were used in 17 patients. Media dosages did not differ from those used in the functional nausea and vomiting group. Use of trycyclic antidepressants decreased the severity of episodes in seven patients and increased cycle interval in three, but was less effective than for functional nausea and vomiting. by Linda Pembrook Based on an interview with Dr. Chandra Prakash |
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