A recent retrospective study (CJ Lucia-Casadonte et al. JPGN 2018; 67: 13-17) examined the costs and yield of testing for Cyclic Vomiting Sydrome (CVS).
As a bonus –this is a study with CME available (& ABP MOC): NASPGHAN-JPGN CME The full text can be obtained at CME website.
This study looked at 503 charts from a single center using ICD-9 coding to identify patients. In this group, 165 (33%) had a diagnosis of CVS with 135 of this group (82%) meeting NASPGHAN diagnostic criteria with a mean age of 7.7 years.
- 6 (4%) had a change in management based on CVS evaluation
- The mean cost for screening was $6125.02 per patient
- Atypical symptoms included bilious emesis in 9 (7%), abdominal pain in 67 (50%), attacks precipitated by fasting 1 (0.7%), and neurologic abnormalities in 3 (2%).
- Brain MRI was performed in 68 patients and 10 were considered abnormal; though, only 1 (0.7%) had a change in management related to increased intracranial pressure (this patient had hx/o hydrocephalus). Other findings included Chiari I malformation, cerebral cyst, macrocephaly, and abnormal myelination pattern.
- Other underlying diagnosis: UPJ obstruction (n=1), unspecified metabolic condition with carnitine deficiency (n=1), and eosinophilic esophagitis.
- Given the costs involved, the authors reiterate NASPGHAN recommendations to avoid a ‘shotgun’ approach and note that it has previously been shown that “the most cost effective therapy in the management of CVS to be UGI with small bowel follow through (SBFT) with empiric treatment.” Additional evaluation would be indicated for those with red flags and/or progressive or a changing pattern of vomiting episodes.
- The authors indicate that endoscopy was the most costly evaluation tool at their institution ($11,500) and only used in 36 patients and was considered to have a low yield.
My take: This study underscores the low yield and expense involved in the evaluation of pediatric CVS; yet, it remains difficult to balance this with the concern of overlooking some anatomic and metabolic problems which can benefit from a timely diagnosis.
Related blog post:
- Diet of drugs for CVS -this is probably the most popular post over the many years of this blog