Idiopathic cyclic vomiting syndrome associated with gastroesophageal reflux and chronic sinusitis

Idiopathic cyclic vomiting syndrome associated with gastroesophageal reflux and chronic sinusitis To the Editor: Olson et al1 compared the cost and benefit of three initial treatment strategies in cyclic vomiting syndrome (CVS) and reported that: (1) when compared with the extensive evaluation strategy, initial antimigraine treatment avoided 65% of the esophagogastroduodenoscopy and small-bowel radiographs, and (2) empiric migraine therapy was the most cost-effective initial strategy. We report a 10-year-old girl who had stereotypical cyclic vomiting attacks occurring every three weeks for the last five years. No family history of migraine but history of motion sickness was noticed. She had dehydration, irritability, and fetal position. No hematologic and biochemical abnormalities were detected. Small-bowel radiographs and brain magnetic resonance imaging were normal, but sinus computerized tomography revealed chronic sinusitis. In 24-hour pH monitoring, she had severe gastroesophageal reflux (GER, total reflux time: 17%). Esophagogastroduodenoscopy and esophageal biopsy revealed esophagitis. Vomiting attack repeated three weeks later despite omeprazole and domperidone treatment. At that time vomiting dramatically responded to intravenous chlorpromazine. After amitriptyline treatment she never had another attack, although she still had GER, necessitating antireflux surgery. In the series by Li et al2 of children with idiopathic CVS, 41% had associated disorders (GER and chronic sinusitis) that could contribute to the vomiting. They stated that once the cyclic vomiting pattern is identified, systematic diagnostic testing is warranted to look for these underlying disorders.2 In their study, in 53% a single diagnosis was determined. They stated that the tests with the highest yield of positive results were endoscopy and radiography of the sinus and small bowels (43%, 38%, and 28%, respectively).2,3 Withers et al4 also reported that patients with CVS were more likely to have GER than controls. It is also known that a triggering factor can be identified in 80% of cases and the infections, particularly chronic sinusitis, are the most common.5 As a conclusion, we emphasize that although CVS is known as an exclusion diagnosis, it is not always the case, and because the probability of association of GER and chronic sinusitis in CVS seems high, the initial evaluation strategy should at least include sinus computed tomography and pH monitoring.

Mukadder Ayse Selimoglu, MD Vildan Ertekin, MD HuseyinTan, MD Erol Selimoglu, MD Departments of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric Neurology, and Otolaryngology Ataturk University Letters

Faculty of Medicine Erzurum, Turkey YMPD372 10.1067/S0022-3476(03)00352-4

REFERENCES 1. Olson AD, Li BU. The diagnostic evaluation of children with cyclic vomiting: a cost-effectiveness assessment. J Pediatr 2002;141:724-8. 2. Li BU, Murray RD, Heitlinger LA, Robbins JL, Hayes JR. Heterogeneity of diagnoses presenting as cyclic vomiting. Pediatrics 1998; 102(3 Pt 1):583-7. 3. Huffman GB. Differential diagnosis of cyclic vomiting in children. Am Fam Physician 1999;59:675. 4. Withers GD, Silburn SR, Forbes DA. Precipitants and aetiology of cyclic vomiting syndrome. Acta Paediatr 1998;87:272-7. 5. Rasquin-Weber A, Hyman PE, Cucchiara S, Fleisher DR, Hyams JS, Milla PJ, et al. Childhood functional gastrointestinal disorders. Gut 1999; 45(Suppl 2):II60-8.

Reply To the Editor: Selimogu et al present a case of a patient who apparently responded to prophylactic medication used to prevent cyclic vomiting syndrome (CVS) who also had esophagitis (endoscopy) and sinusitis (sinus films). As we have seen in a number of cases, the child may have had three separate diagnoses. Although each of the diagnoses may be distinct, we have found that chronic sinusitis can trigger bouts of vomiting and, conversely, these bouts cause secondary esophagitis. Our costeffectiveness analysis suggests that the most effective use of medical resources in the patient with CVS would have been an initial trial of antimigraine medication before further testing. The patient described would likely have responded to this initial therapy and, if no other symptoms remained, no further workup would have been undertaken. The diagnoses of esophagitis and sinusitis would likely have been missed if these conditions were asymptomatic. For the purpose of this cost-effectiveness analysis, the potential benefit gained (ie, costs avoided by recognizing silent sinusitis or esophagitis) must exceed $25,000 per patient for a test to become part of the initial diagnostic strategy. This case report is very instructive because it illustrates the possibility of missing significant concomitant diagnoses and underscores the critical need for pediatricians to carry a high index of suspicion for underlying disorders as they continue to manage patients with cyclic vomiting. Recurrent headaches, unexplained fever, or maxillary and frontal tenderness would indicate the need for sinus computed tomography. Similarly, epigastric or substernal pain worsened by eating, or hematemesis would indicate the need for endoscopy. Allan D. Olson, MD Centocor, Inc Malvern, PA 19355-1307 B. Li, MD Children’s Memorial Hospital Chicago, IL 60614 YMPD373 10.1067/S0022-3476(03)00353-6

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