A 9-year-old girl is brought to the clinic for evaluation of recurrent vomiting. The patient has no symptoms today but has had nausea, vomiting, and diffuse abdominal pain for several days each month over the last 8 months. When the vomiting occurs, it typically begins early in the morning, recurs 10-15 times a day, and lasts for 2 days. The vomiting is nonbloody and nonbilious. The mother states that the episodes were more frequent around the beginning of the school year and occurred 5 times in a 2-month span. The last 2 times, the mother has taken time off work because the daughter required hospitalization for intravenous hydration. The patient has no fever, headache, or diarrhea during the episodes. Between episodes, she is active and eats well. Height and weight are at the 25th percentile for age, similar to her prior growth curves at her well visit 6 months ago. The patient is in no distress and is well hydrated. Mucous membranes are moist, but the maxillary incisors have erosive dental caries. The abdomen is soft and nontender. Neurologic examination is normal. Which of the following is the most likely cause of this patient's symptoms?
Cyclic vomiting syndrome | |
History |
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Symptoms |
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This child has a recurrent, predictable pattern of acute and frequent vomiting that resolves spontaneously with no symptoms between episodes. Growth, examination, and eating patterns are also normal, findings suggestive of cyclic vomiting syndrome.
Cyclic vomiting syndrome is a diagnosis of exclusion, often requiring laboratory evaluation and imaging during acute episodes to eliminate urgent causes of acute vomiting and abdominal pain. The pathogenesis is unknown, but most patients have a personal/family history of migraines. Vomiting episodes may be triggered by stress or infection and be accompanied by nausea, vague abdominal pain, headache, and lethargy. These symptoms self-resolve after 1 or 2 days. Patients typically have regular, predictable symptom intervals (eg, 2-4 weeks) and are typically asymptomatic between episodes.
Physical examination is nonfocal and nonspecific (eg, evidence of dehydration). Treatment is abortive (eg, triptans) and/or supportive (eg, antiemetics, rehydration), and most children have gradual resolution of symptoms during adolescence.
(Choice A) Bulimia nervosa is characterized by recurrent binge eating followed by inappropriate compensatory behavior to prevent weight gain (eg, self-induced vomiting [purging]). This diagnosis is unlikely with no history of caloric restriction, binge eating, or preoccupation with body weight and shape.
(Choice B) Chronic pancreatitis may present with recurrent bouts of abdominal pain, nausea, and vomiting. Poor growth and diarrhea are common, and examination reveals epigastric tenderness to palpation; none of these findings is seen in this patient.
(Choice D) Factitious disorder imposed on another is a form of child abuse, in which a caregiver intentionally induces illness in a child or reports inconsistent symptoms. In contrast, this patient has a clear pattern of illness surrounding times of stress, as well as examination findings consistent with recurrent vomiting (eg, erosive caries).
(Choice E) Gastroesophageal reflux disease in children is characterized by regurgitation or epigastric or substernal pain. Acute episodes of persistent vomiting would not be expected.
(Choice F) Inflammatory bowel disease typically presents as colitis, or abdominal pain and diarrhea. Fever, weight loss, and abdominal tenderness on examination are common but not seen in this patient with discrete episodes of vomiting.
Educational objective:
In children, recurrent, self-limiting episodes of profuse vomiting and nausea without an apparent cause suggests cyclic vomiting syndrome. Key historical features include a history of identifiable triggers (eg, stress, infection) or a personal/family history of migraines.