Cyclic Vomiting Syndrome Differential Diagnoses

  • Author: Thangam Venkatesan, MBBS; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: Apr 23, 2010
 
 

Diagnostic Considerations

Consider the following in suspected cases of cyclic vomiting syndrome (CVS):

  • GI disorders
  • Neurologic disorders
    • Abdominal migraine with vomiting
    • Migraine headaches with vomiting
    • Chronic sinusitis
    • Subtentorial neoplasm (cerebellar medulloblastoma, brainstem glioma)
    • Chiari malformation
    • Familial dysautonomia (Riley-Day syndrome)
  • Renal disorders
    • Acute hydronephrosis secondary to uteropelvic junction obstruction
    • Nephrolithiasis
  • Metabolic disorders
    • Disorders of fatty acid oxidation
    • Urea cycle defects
    • Mitochondriopathy
    • Acute intermittent porphyria
  • Endocrine disorders
    • Addison disease
    • Diabetes mellitus with ketoacidosis
    • Pheochromocytoma
    • Hyperemesis gravidum
  • Psychological disorders
  • Other - Pregnancy
  • Cannabinoid hyperemesis
    • Allen et al reported 19 cyclic vomiting syndrome cases associated with chronic cannibas use. In this study, 10 patients were not included in follow-up; most of the remaining 9 who abstained from marijuana had symptom relief.[40] Other cases of cannabinoid hyperemesis have been reported, although no long-term follow-up is noted in most cases.[41]
    • Evidence implicating marijuana use as the actual cause of vomiting is insufficient; no clear temporal relationship between the onset of vomiting and the actual initiation of marijuana use has been established. These patients may have cyclic vomiting syndrome and are using marijuana for its antiemetic properties.
    • Although the role of marijuana in cyclic vomiting syndrome has not been well established, a recent report by McCallum et al shows chronic marijuana use is a risk factor for lack of response to tricyclic antidepressants used in the treatment of this disorder. Thus, complete abstinence from marijuana may be recommended in patients with cyclic vomiting syndrome.[42]

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Thangam Venkatesan, MBBS  Assistant Professor, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin

Thangam Venkatesan, MBBS is a member of the following medical societies: American Gastroenterological Association and Indian Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

B UK Li, MD  Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Seth Marcus, MD  Fellow, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Memorial Hospital, Northwestern University

Seth Marcus, MD is a member of the following medical societies: American Academy of Pediatrics and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Shikha Sundaram, MD  Fellow, Department of Gastroenterology, Hepatology and Nutrition, Children's Memorial Hospital of Chicago and Northwestern University

Shikha Sundaram, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association

Disclosure: Nothing to disclose.

Abhilasha Pandey, MBBS  Froedtert Hospital, Medical College of Wisconsin

Disclosure: Nothing to disclose.

Specialty Editor Board

Jayant Deodhar, MD  Associate Professor in Pediatrics, BJ Medical College, India; Honorary Consultant, Departments of Pediatrics and Neonatology, King Edward Memorial Hospital, India

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

David A Piccoli, MD  Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine

David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Steven M Schwarz, MD, FAAP, FACN, AGAF  Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center

Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research

Disclosure: Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor; Johnson & Johnson, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

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Cyclic versus chronic temporal patterns of recurrent vomiting. The number of emeses is plotted over a 2-month period. The chronic pattern, represented by a thin dashed line, has low grade on nearly a daily basis (eg, gastroesophageal reflux). The cyclic pattern, represented by a heavy solid line, involves high-intensity episodes intermittently once every several weeks (eg, cyclic vomiting syndrome).
Table 1. Characteristics of Emergency Department Visits in Patients With Cyclic Vomiting Syndrome
CharacteristicAdults



(n = 104)



Children



(n = 147)



Number of ED visits per patient with cyclic vomiting syndrome (Median)15 (range, 1-200)10 (range, 1-175)
Number of ED visits prior to a diagnosis of cyclic vomiting syndrome (Median)7 (Range, 1-150)5 (Range, 0-65)
Diagnosis not made in the ED89 (93%)119 (93%)
Diagnosis not recognized in the ED in patients with an established diagnosis of cyclic vomiting syndrome84 (88%)97 (80%)
Number of different ED visited (Mean ± standard deviation)4.69 ± 4.722.6 ± 2.42
Table 2. Clinical Features in Adults and Children with Cyclic Vomiting Syndrome[39]
Feature ChildrenAdults
Age of Onset4.8 y (Earliest, 6 d)35 y (Latest, 73 y)
Delay in Diagnosis2.6 y8 y
Female-to-Male Ratio57:4317:24
FrequencyEvery 2-4 wkEvery 3 mo
Duration (Mean)1-2 d (range, 1-10 d)6 d (range, 1-21 d)
Periodicity49%Not reported
Early Morning Onset42%50%
Stereotypical Episodes99%85%
Prodrome72%, 1.5 h93%
SymptomsNausea, anorexia, pallorNausea, epigastric pain
Recovery to Oral Feeding6 h24 h
Relieving FactorsDeep sleepHot bath/shower (56%)
Precipitating FactorsStress (47%), infection (31%)Menses (57%), anxiety
Comorbid conditionsAnxietyNot reported
Interepisodic nausea< 6%63%
Coalescence of EpisodesFew50%
Vomiting6/hr at peak, bile (81%)8.5/hr
Systemic SymptomsPallor, salivation, listlessnessIntense thirst (33%)
GI SymptomsAnorexia, nausea, diarrhea, abdominal painAbdominal pain, diarrhea
Neurologic SymptomsHeadache, photophobia, phonophobia, abdominal painIrritable, confused
Natural history≥ 28% progress to migraineNot reported
Family history82%57%
ComplicationsDehydration, esophagitisDehydration, esophagitis, laparotomy (18%)
Morbidity14-25 d of missed school/year32% completely disabled
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