Stomach

ACG / ANMS Guidelines

Cyclic Vomiting Syndrome (CVS)

Rome IV diagnosis, CVS vs. CHS vs. functional vomiting, biopsychosocial management, TCA prophylaxis, and sumatriptan abortive therapy. Based on Frazier, Li & Venkatesan. AJG 2023.

6 Key Topics5 Clinical CasesCVS · CHS · TCAs · Triptans

Overview & Diagnosis

Rome IV criteria & epidemiology

Cyclic Vomiting Syndrome — What Is It?

CVS is a chronic, episodic disorder characterized by recurrent, stereotypical episodes of severe nausea and vomiting separated by symptom-free intervals. It is a brain-gut disorder — not a gastric disease — and is underdiagnosed in adults.

Rome IV Diagnostic Criteria

All must be fulfilled over the last 6 months:

1Stereotypical episodes of acute-onset vomiting lasting <1 week

2≥3 discrete episodes in the past year

3Absence of vomiting between episodes (though other milder symptoms may be present)

4Not explained by another diagnosis after appropriate evaluation

Supportive Features

Personal or family history of migraine; stereotypy (each episode similar to prior ones); relief with hot showers/baths; nocturnal onset; identifiable triggers (stress, menses, specific foods).

Epidemiology

Prevalence ~2% in US adults (likely underestimated)

Mean age of onset: 25–34 years in adults

Female predominance (60%)

Mean diagnostic delay: 2.7–6 years

Up to 50% comorbid migraine

Co-morbid anxiety/depression in ~70%

Cannabis use common (~50%) — often used for symptom relief

Four Phases of CVS

ProdromeNausea, pallor, sweating — opportunity for abortive treatment

EmeticIntense vomiting/retching — peak phase, often requires IV therapy

RecoveryNausea resolving; fluid/nutrition restoration

InterepisodicSymptom-free (or baseline) — prophylaxis phase

Common Triggers

Psychological

• Emotional stress

• Excitement/anticipation

• Panic attacks

Physical

• Sleep deprivation

• Physical exhaustion

• Menses

• Infections

Dietary

• Cheese, chocolate

• Alcohol

• MSG

• Fasting

Diagnostic Workup — When & What (Frazier 2023)

CVS is a clinical diagnosis based on Rome IV criteria. However, targeted testing is needed to exclude organic causes, especially on first presentation.

All patients (first episode)

• CBC, CMP, lipase, TSH

• Urine HCG (women of childbearing age)

• Upper endoscopy if alarm features present

• Consider brain MRI if headache or neurologic sx

Consider in select patients

• Gastric emptying study (exclude gastroparesis)

• Small bowel follow-through / CT enterography

• Mitochondrial DNA testing (maternal inheritance pattern)

• Urine organic acids (rule out metabolic disorder)

Key Point from Frazier 2023

The diagnosis of CVS should not be one of exclusion by extensive testing — a positive pattern recognition approach using Rome IV criteria and stereotypy is preferred. Overinvestigation contributes to the average 6-year diagnostic delay.

Frazier R, Li BUK, Venkatesan T. Am J Gastroenterol 2023;118(7):1157–67; Venkatesan T et al. Neurogastroenterol Motil 2019; Rome IV 2016.