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Media Gallery

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).

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Table 1. Characteristics of Emergency Department Visits in Patients With Cyclic Vomiting Syndrome

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.

Table 2. Clinical Features in Adults and Children with Cyclic Vomiting Syndrome

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

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Author

Thangam Venkatesan, MD Associate Professor of Medicine, Fellowship Director, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical College of Wisconsin

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

Disclosure: Nothing to disclose.

Coauthor(s)

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin; Attending Gastroenterologist, Director, Cyclic Vomiting Program, Children’s Hospital of Wisconsin

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

Disclosure: Nothing to disclose.

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, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching. for: Abbott Nutritional, Abbvie, speakers' bureau.

Acknowledgements

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