Clinical, Psychiatric, and Manometric Profile of Cyclic Vomiting Syndrome in Adults and Response to Tricyclic Therapy

Abstract

Purpose: Our goal was to prospectively investigate 31 adult patients (mean age 29 years, range 18–62) meeting Rome II criteria for cyclic vomiting syndrome (CVS). Methods: All subjects completed a clinical questionnaire, Hamilton Rating Scale for Anxiety (HAM-A) and Zung Depression inventory. Gastric emptying time (GET) was assessed in 30 subjects and electrogastrogram (EGG) in 11 between acute attacks. 27 patients treated with Amitriptyline at a goal dose of 1 mg/kg per day completed a follow up questionnaire, which included global assessment of symptom status and quality of life score. Results: The mean age of onset of CVS was 29, range 14–53 years and cycles of nausea and vomiting were accompanied by severe epigastric and diffuse abdominal pain. A typical attack ranged from 1 to 14 days with majority being 4–6 days. The HAM-A revealed that 84% had an anxiety disorder and based on Zung Depression inventory 78% suffered from mild to severe depression. Only 4 (13%) patients reported migraine, but 14 had a family history of migraine. GET was rapid in 23 (77%), normal in 4 and delayed in 3. The EGG was abnormal in 7 of 11 patients with 4 having tachygastria. Of 13 patients using marijuana, 7 believed it was therapeutic while 2 had resolution of CVS after stopping use. For acute attacks IV lorazepam was the most effective in our clinical experience. For long-term prevention patients were treated with Amitriptyline with a target dose of 1 mg/kg and 15 patients achieved 75 mg/day (range: 50–150 mg) for 16.8 months (range: 12–24 months). The average number of ER visits and hospitalizations were significantly diminished from 27 to 6 when annually adjusted. 26% achieved full remission and 93% had a favorable response. The major side effect of amitriptyline was hypersomnia and dizziness that caused two subjects to stop the treatment. Conclusions: This large single center experience of CVS in adults has the following hallmarks: 1) Prominence of abdominal pain and increased prevalence of anxiety and depression. 2) Rapid gastric emptying and tachygastric EGG findings. 3) Successful suppression of attacks can be achieved by long-term high dose amitriptyline therapy.