Endoscopy can be used to diagnose the underlying condition.Empiric therapy with H2 blockers or proton pump inhibitorscan be used but may delay diagnosis of conditions such as H. pylori. For patients with chronic epigastric pain, the possibilities of inflammatory bowel disease, anatomic abnormalitysuch as malrotation, pancreatitis, and biliary disease should beruled out by appropriate testing when suspected (see Chapter126 and Table 128-3 for recommended studies). Testing for H. pylori can be performed by biopsy during endoscopy with useof a urease test or presence histologically on tissue. If endoscopyis not done, noninvasive tests for infection can be done with reasonable accuracy with H. pylori fecal antigen and 13C urea breath tests (urea is metabolized into 13CO2 by the organism).
If H. pylori is present in association with ulcers, it should be treated with a multidrug regimen, such as omeprazole-clarithromycin-metronidazole, omeprazole-amoxicillin-clarithromycin, or omeprazole-amoxicillin-metronidazole, given twice daily for 1 to 2 weeks. Other proton-pump inhibitors may be substituted when necessary. Bismuth compounds are effective against H. pylori and can be considered. In North America, only the subsalicylate salt is available, the use of which raises some concerns about Reye syndrome and potential salicylate toxicity. Tetracycline is useful in adults, but should be avoided in children less than 8 years of age. In the absence of H. pylori, esophagitis and peptic ulcer disease are treated with a pro-ton-pump inhibitor, which yields higher rates of healing than H2 receptor antagonists. Gastric and duodenal ulcers heal in 4 to 8 weeks in at least 80% of patients. Esophagitis requires 4 to 5 months of proton-pump inhibitor treatment for optimal healing.
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Cyclic vomiting syndrome (CVS) presents with intermittentepisodes of prolonged nausea and vomiting with periods ofhealth in between. It can occur at any age but is diagnosedmost frequently in preschool to school-age children. It isthought to be a migraine variant; many patients have a positive family history of migraines, and some with CVS willeventually develop migraine headaches. Triggers to an episode often include viral illnesses, stressful or exciting events(holidays, birthdays, vacations), physical exhaustion, and menses.
Episodes can start at any time, but will often start in theearly morning hours. Episodes are similar to each other in timing and duration. Repetitive vomiting can last hours todays. Patients can also have abdominal pain, diarrhea, andheadaches. Those affected are typically pale, listless, andprefer to be left alone. They may have photoor phonophobia.
There are no specific tests for CVS, which is diagnosedbased on the history and the exclusion of other disorders.Diagnoses that should be considered include malrotationwith intermittent volvulus, UPJ obstruction, eosinophilicesophagitis, and intracranial mass lesions, and metabolic disorders. Rome III criteria for diagnosis are outlined inTable 126-5.
For the acute episode, supportive treatment includes hydration; dark, quiet environment; and antiemetics such as ondansetron. In addition, abortive therapy using antimigraine medications such as NSAIDs and triptans can be used. For those with frequent or prolonged episodes, prophylactic therapy can be used, such as cyproheptadine, tricyclic antidepressants, beta blockers, or topiramate.