Diagnostic Considerations
In addition to the conditions listed in the differential diagnosis, a number of other disorders should be considered in suspected cases of cyclic vomiting syndrome (CVS).
Gastrointestinal (GI) disorders to be considered include the following:
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Gastroesophageal reflux disease (peptic esophagitis)
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Peptic disorders (gastritis, duodenitis, and Helicobacter pylori infection)
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Inflammatory bowel disease (Crohn disease and ulcerative colitis)
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Anatomic obstruction (malrotation with intermittent volvulus)
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Intestinal pseudo-obstruction
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Cholelithiasis (gallbladder dyskinesia)
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Chronic appendicitis
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Recurrent pancreatitis
Neurologic disorders to be considered include the following:
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Abdominal migraine with vomiting
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Migraine headaches with vomiting
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Chronic sinusitis
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Subtentorial neoplasm (cerebellar medulloblastoma or brainstem glioma)
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Chiari malformation
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Familial dysautonomia (Riley-Day syndrome)
Renal disorders to be considered include the following:
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Acute hydronephrosis secondary to uteropelvic junction obstruction
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Nephrolithiasis
Metabolic disorders to be considered include the following:
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Disorders of fatty acid oxidation
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Urea cycle defects
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Mitochondriopathy
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Acute intermittent porphyria
Endocrine disorders to be considered include the following:
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Addison disease
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Diabetes mellitus with ketoacidosis
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Hyperemesis gravidarum
Psychological disorders to be considered include the following:
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Bulimia
Other conditions to be considered include the following:
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Cannabinoid hyperemesis
Allen et al reported 19 CVS cases associated with chronic cannabis use; 10 of the 19 were not included in follow-up, but most of the remaining 9 who abstained from marijuana experienced symptomatic relief. [41] Other cases of cannabinoid hyperemesis have been published, though no long-term follow-up is reported for most of them. [42]
Evidence implicating marijuana use as the actual cause of vomiting is insufficient; no clear temporal relation between the onset of vomiting and the actual initiation of marijuana use has been established. It is possible that these patients already have CVS and are using marijuana for its antiemetic properties.
Although the role of marijuana in CVS has not been well established, a report by McCallum et al found chronic marijuana use to be a risk factor for lack of response to the tricyclic antidepressants used to treat this disorder. Thus, complete abstinence from marijuana may be recommended in patients with CVS. [43]
In a study comparing patients with CVS and those with functional vomiting, patients with CVS were more likely to be younger and male and used marijuana more frequently. [44] In a retrospective review of 31 published case reports and a case series of 98 patients with CVS, cyclic vomiting was associated with chronic daily marijuana use. [45, 46] However, the long duration (2-10 years) of marijuana use before the onset of symptoms and the short follow-up (< 3 months) argued against marijuana as a cause of the vomiting.
Differential Diagnoses
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Appendicitis
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Munchausen Syndrome by Proxy
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Volvulus
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Cyclic versus chronic temporal patterns of recurrent vomiting. Number of emeses is plotted over 2-month period. Chronic pattern, represented by thin dashed line, has low grade on nearly daily basis (eg, gastroesophageal reflux). Cyclic pattern, represented by heavy solid line, involves high-intensity episodes intermittently once every several weeks (eg, cyclic vomiting syndrome).
Tables
Characteristic |
Adults (n = 104) |
Children (n = 147) |
Number of ED visits per patient with CVS (median) |
15 (range, 1-200) |
10 (range, 1-175) |
Number of ED visits before diagnosis of CVS (median) |
7 (range, 1-150) |
5 (range, 0-65) |
Diagnosis not made in ED |
89 (93%) |
119 (93%) |
Diagnosis not recognized in ED in patients with established diagnosis of CVS |
84 (88%) |
97 (80%) |
Number of different EDs visited (mean ± SD) |
4.69 ± 4.72 |
2.6 ± 2.42 |
CVS = cyclic vomiting syndrome; ED = emergency department; SD = standard deviation. |
||
Feature |
Children |
Adults |
Age of onset |
4.8 years (earliest, 6 days) |
35 years (latest, 73 years) |
Delay in diagnosis |
2.6 years |
8 years |
Female-to-male ratio |
57:43 |
17:24 |
Frequency |
Every 2-4 weeks |
Every 3 months |
Duration (mean) |
1-2 days (range, 1-10 days) |
6 days (range, 1-21 days) |
Periodicity |
49% |
Not reported |
Early morning onset |
42% |
50% |
Stereotypical episodes |
99% |
85% |
Prodrome |
72%, 1.5 hours |
93% |
Symptoms |
Nausea, anorexia, pallor |
Nausea, epigastric pain |
Recovery to oral feeding |
6 hours |
24 hours |
Relieving factors |
Deep sleep |
Hot bath or shower (56%) |
Precipitating factors |
Stress (47%), infection (31%) |
Menses (57%), anxiety |
Comorbid conditions |
Anxiety |
Not reported |
Inter episodic nausea |
< 6% |
63% |
Coalescence of episodes |
Few |
50% |
Vomiting |
6 episodes/hr at peak, bile (81%) |
8.5 episodes/hr |
Systemic symptoms |
Pallor, salivation, listlessness |
Intense thirst (33%) |
GI symptoms |
Anorexia, nausea, diarrhea, abdominal pain |
Abdominal pain, diarrhea |
Neurologic symptoms |
Headache, photophobia, phonophobia, abdominal pain |
Irritability, confusion |
Natural history |
=28% progress to migraine |
Not reported |
Family history |
82% |
57% |
Complications |
Dehydration, esophagitis |
Dehydration, esophagitis, laparotomy (18%) |
Morbidity |
14-25 days of missed school per year |
32% completely disabled |
