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ANSWER: C
Critique
The patient in this clinical presentation has symptoms most consistent with cyclic vomiting syndrome (CVS) and has undergone additional testing to exclude luminal pathology. His gastric emptying study is consistent with rapid gastric emptying, which can be seen in 60% of patients with CVS. There is increasing recognition of hyperemesis in the setting of cannabis use, and this may be contributing to this patient’s symptoms. However, prior to recommending that patients stop using cannabis, appropriate treatment for CVS should be instituted. There are several reports that suggest long-term tricyclic antidepressant (TCA) therapy significantly reduces the frequency and duration of CVS episodes, ED visits, and hospitalizations. Although psychiatric disorders are associated with nonresponse to TCA therapy, an appropriate trial of a TCA is warranted prior to referral to psychiatry in the absence of a clear psychological diagnosis. The clinical picture does not suggest small intestinal bacterial overgrowth.
Reference
1. Hejazi R.A., Reddymasu S.C., Namin F., Lavenbarg T., Foran P., McCallum R.W. Efficacy of tricyclic antidepressant therapy in adults with cyclic vomiting syndrome: a two-year follow-up study. J. Clin. Gastroenterol. 2010;44:18-21.
ANSWER: C
Critique
The patient in this clinical presentation has symptoms most consistent with cyclic vomiting syndrome (CVS) and has undergone additional testing to exclude luminal pathology. His gastric emptying study is consistent with rapid gastric emptying, which can be seen in 60% of patients with CVS. There is increasing recognition of hyperemesis in the setting of cannabis use, and this may be contributing to this patient’s symptoms. However, prior to recommending that patients stop using cannabis, appropriate treatment for CVS should be instituted. There are several reports that suggest long-term tricyclic antidepressant (TCA) therapy significantly reduces the frequency and duration of CVS episodes, ED visits, and hospitalizations. Although psychiatric disorders are associated with nonresponse to TCA therapy, an appropriate trial of a TCA is warranted prior to referral to psychiatry in the absence of a clear psychological diagnosis. The clinical picture does not suggest small intestinal bacterial overgrowth.
Reference
1. Hejazi R.A., Reddymasu S.C., Namin F., Lavenbarg T., Foran P., McCallum R.W. Efficacy of tricyclic antidepressant therapy in adults with cyclic vomiting syndrome: a two-year follow-up study. J. Clin. Gastroenterol. 2010;44:18-21.
ANSWER: C
Critique
The patient in this clinical presentation has symptoms most consistent with cyclic vomiting syndrome (CVS) and has undergone additional testing to exclude luminal pathology. His gastric emptying study is consistent with rapid gastric emptying, which can be seen in 60% of patients with CVS. There is increasing recognition of hyperemesis in the setting of cannabis use, and this may be contributing to this patient’s symptoms. However, prior to recommending that patients stop using cannabis, appropriate treatment for CVS should be instituted. There are several reports that suggest long-term tricyclic antidepressant (TCA) therapy significantly reduces the frequency and duration of CVS episodes, ED visits, and hospitalizations. Although psychiatric disorders are associated with nonresponse to TCA therapy, an appropriate trial of a TCA is warranted prior to referral to psychiatry in the absence of a clear psychological diagnosis. The clinical picture does not suggest small intestinal bacterial overgrowth.
Reference
1. Hejazi R.A., Reddymasu S.C., Namin F., Lavenbarg T., Foran P., McCallum R.W. Efficacy of tricyclic antidepressant therapy in adults with cyclic vomiting syndrome: a two-year follow-up study. J. Clin. Gastroenterol. 2010;44:18-21.