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Vomiting, Cyclic, Emergency Medicine

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Vomiting, Cyclic, Emergency Medicine

Basics

Description

Commonly present to ED with unexplained onset of nausea/vomiting and abdominal pain.

May have benign physical exam or various findings based on degree of dehydration:

May present with above in addition to refusal to eat/drink, reduced or lack of tear production, sunken fontanels, reduced or absent urine output (reduced wet diapers)

Must rule out other potentially serious conditions (see Differential Diagnosis)

Atypical severity or atypical episodes should raise suspicion of underlying disorder not due to cyclic vomiting:

Outpatient gastric emptying study should be done to r/o gastroparesis or other gut motility disorders as cause of frequent emesis.

  • A chronic, idiopathic disorder characterized by recurrent, discrete episodes of disabling nausea and vomiting separated by symptom-free intervals lasting a few days to months
  • Adult population " “ average age of diagnosis is 31:Average age of onset is 21
  • Pediatric population " “ average age of diagnosis is 5
  • General characteristics:Phase 1: Interepisodic phase:Symptom freePhase 2: Prodrome:Varying intensity of nausea and diaphoresisPhase 3: Emetic phase:Intense nausea/vomiting/retching/dry heaving up to 7 daysPhase 4: Recovery phase:Improvement of nausea and tolerance of PO intake
  • Average age of onset is 21
  • Phase 1: Interepisodic phase:Symptom free
  • Phase 2: Prodrome:Varying intensity of nausea and diaphoresis
  • Phase 3: Emetic phase:Intense nausea/vomiting/retching/dry heaving up to 7 days
  • Phase 4: Recovery phase:Improvement of nausea and tolerance of PO intake
  • Symptom free
  • Varying intensity of nausea and diaphoresis
  • Intense nausea/vomiting/retching/dry heaving up to 7 days
  • Improvement of nausea and tolerance of PO intake

Epidemiology

  • True incidence and prevalence in adult general population unknown due to limited data and research, increasing recognition in syndrome
  • In pediatric population, cyclic vomiting syndrome affects 0.04 " “2% of population with estimated new cases 3/100,000 annually

Etiology

  • Etiology unknown
  • Pathophysiology is also unknown and is under research:Limited research suggests multifactorial factors such as autonomic, central, and environmental to be involved
  • Limited research suggests multifactorial factors such as autonomic, central, and environmental to be involved

Diagnosis

Signs and Symptoms

  • History of similar prior episodes
  • No preceding trigger identified at times but typically when asked specifically may identify
  • Will complain of abdominal pain, usually epigastric
  • Normal vital signs or abnormal vital signs demonstrating:TachycardiaHypotension (including orthostatic hypotension)Tachypnea
  • Cool extremities and/or delayed (>2 s) capillary refill indicating shock
  • Varying degrees of consciousness:Alert, lethargic, or obtunded
  • Dry mucous membranes:Sunken eyesDry/sticky or cracked mouth
  • Poor skin turgor
  • Oliguria or anuria
  • Tachycardia
  • Hypotension (including orthostatic hypotension)
  • Tachypnea
  • Alert, lethargic, or obtunded
  • Sunken eyes
  • Dry/sticky or cracked mouth

Essential Workup

Diagnosis Tests & Interpretation

  • Perform necessary exam and lab or radiographic tests necessary to rule out other conditions with similar presenting signs and symptoms
  • Cyclic vomiting has no specific diagnostic feature nor specific biochemical marker
  • Extensive list of other diagnostic possibilities
  • Diagnosis of adult cyclic vomiting is based on Rome III criteria:Stereotypical episodes of vomiting regarding onset (acute) and duration (<1 wk)At least 3 episodes in the past yearAbsence of nausea/vomiting between episodes
  • Stereotypical episodes of vomiting regarding onset (acute) and duration (<1 wk)
  • At least 3 episodes in the past year
  • Absence of nausea/vomiting between episodes
  • CBC
  • Electrolytes, BUN/Cr, glucose
  • Liver enzyme, liver profile
  • Lipase
  • Lactate
  • Urinalysis
  • Pregnancy test
  • Toxicology screen/drug levels:AcetaminophenSalicylic acidAlcohols:Ethanol, isopropanol, methanol, ethylene glycolDigoxin
  • Acetaminophen
  • Salicylic acid
  • Alcohols:Ethanol, isopropanol, methanol, ethylene glycol
  • Digoxin
  • Ethanol, isopropanol, methanol, ethylene glycol
  • Tailor imaging to individual patient presentation

Differential Diagnosis

  • Infectious:AppendicitisPyelonephritisPneumoniaCholecystitis
  • Metabolic/endocrine:Renal failure/uremiaElectrolyte disorderDiabetic ketoacidosisThyroid disorderAdrenal insufficiencyPheochromocytomaPregnancy or hyperemesis gravidarum
  • Renal:NephroureterolithiasisUVJ obstruction/hydronephrosis
  • GI:GastroparesisBowel obstructionPeptic ulcer diseaseCholelithiasisPancreatitisMalrotation with volvulusInflammatory bowel disease
  • CNS:Intracranial hemorrhageBrain tumorHydrocephalusCVA
  • Cardiovascular:Anginal equivalentSTEMI/NSTEMI
  • Toxicology (examples):Cannabinoid hyperemesisMushroom toxicity:>100 speciesAcute alcohol/toxic alcohol ingestion:Ethanol, isopropanol, methanol, ethylene glycolAlcohol withdrawalHeroin withdrawalAny acute/subacute ingestion; consider:AcetaminophenSalicylic acidDigoxin
  • Psychiatric:Self inducedBulimiaAnorexiaAnxiety
  • Appendicitis
  • Pyelonephritis
  • Pneumonia
  • Cholecystitis
  • Renal failure/uremia
  • Electrolyte disorder
  • Diabetic ketoacidosis
  • Thyroid disorder
  • Adrenal insufficiency
  • Pheochromocytoma
  • Pregnancy or hyperemesis gravidarum
  • Nephroureterolithiasis
  • UVJ obstruction/hydronephrosis
  • Gastroparesis
  • Bowel obstruction
  • Peptic ulcer disease
  • Cholelithiasis
  • Pancreatitis
  • Malrotation with volvulus
  • Inflammatory bowel disease
  • Intracranial hemorrhage
  • Brain tumor
  • Hydrocephalus
  • CVA
  • Anginal equivalent
  • STEMI/NSTEMI
  • Cannabinoid hyperemesis
  • Mushroom toxicity:>100 species
  • Acute alcohol/toxic alcohol ingestion:Ethanol, isopropanol, methanol, ethylene glycol
  • Alcohol withdrawal
  • Heroin withdrawal
  • Any acute/subacute ingestion; consider:AcetaminophenSalicylic acidDigoxin
  • >100 species
  • Ethanol, isopropanol, methanol, ethylene glycol
  • Acetaminophen
  • Salicylic acid
  • Digoxin
  • Self induced
  • Bulimia
  • Anorexia
  • Anxiety

Treatment

Pre-Hospital

  • Address airway/breathing/circulation
  • Initiate IV, oxygen (if indicated), place on cardiac monitor
  • Start IV fluids if presenting with vomiting and/or abnormal vital signs

Initial Stabilization/Therapy

  • Address airway/breathing/circulation
  • Continue IV/O2 (as indicated), cardiac monitor
  • Address abnormal vital signs specifically hypotension and tachycardia:Adults: 500 to 1000 mL bolus 0.9% NSPediatric: 20 mL/kg bolus 0.9% NS
  • Adults: 500 to 1000 mL bolus 0.9% NS
  • Pediatric: 20 mL/kg bolus 0.9% NS

Ed Treatment/Procedures

  • Supportive care in acute phase
  • Abort emetic phase of nausea/vomiting with antiemetics
  • IV 0.9 normal saline:Add dextrose after initial boluses
  • Correct electrolyte abnormalities
  • Treat pain with analgesics
  • Provide light sedation for very symptomatic patients
  • Administer gastric acid suppressants:H2 receptor antagonistProton pump inhibitors
  • Consider antimigraine triptans
  • Add dextrose after initial boluses
  • H2 receptor antagonist
  • Proton pump inhibitors

Medication

  • Ondansetron 4 " “8 mg IV/PO/ODT q4 " “8h prn
  • Metoclopramide 10 mg IV/IM q2 " “3h prn 4 " “8 mg IV/PO/ODT q4 " “8h prn
  • Prochlorperazine 5 " “10 mg IV/PO/IM (peds: 0.1 mg/kg/dose PO/IM/PR) q6 " “8h prn
  • Promethazine 12.5/25 mg PO/IM/PR q4 " “6h (IV use common but not approved) (peds: 0.25 " “1 mg/kg PO/IM/PR q4 " “6h prn if >2 yr)
  • Ketorolac 15 " “30 mg IV
  • Lorazepam 0.5 " “1 mg IV/IM/PO
  • Morphine 0.1 mg/kg IV
  • Sumatriptan 4 " “6 mg SC-repeat in 1 hr prn
  • Cimetidine (H2-blocker): 800 mg PO at bedtime nightly (peds: 20 " “40 mg/kg/24 h)
  • Famotidine 20 mg IV q12h
  • Pantoprazole 40 mg IV q24h
  • Ranitidine 50 mg IV/IM q8h

Follow-Up

Disposition

  • Vital signs/lab or physical exam findings suggestive of moderate to severe dehydration
  • Inability to tolerate PO fluids
  • Stable vital signs
  • Cessation of vomiting and pain control
  • Able to tolerate PO fluids and keep self hydrated
  • GI consult for further outpatient workup when symptom free
  • Consider additional referral to specialist managing this syndrome

Follow-Up Recommendations

  • Prophylaxis:Identification and avoidance of triggers:Emotional stress, poor sleep, fasting, illness, marijuana, specific foods (chocolate, cheeses, etc.)Management of coexisting conditions:Migraine headaches, psychiatric disorders, chronic narcotic, and marijuana useMedications (outpatient-in active research):Tricyclic antidepressants (amitriptyline)PropranololCoenzyme Q-10AntihistaminesAntianxiety medications
  • Identification and avoidance of triggers:Emotional stress, poor sleep, fasting, illness, marijuana, specific foods (chocolate, cheeses, etc.)
  • Management of coexisting conditions:Migraine headaches, psychiatric disorders, chronic narcotic, and marijuana use
  • Medications (outpatient-in active research):Tricyclic antidepressants (amitriptyline)PropranololCoenzyme Q-10AntihistaminesAntianxiety medications
  • Emotional stress, poor sleep, fasting, illness, marijuana, specific foods (chocolate, cheeses, etc.)
  • Migraine headaches, psychiatric disorders, chronic narcotic, and marijuana use
  • Tricyclic antidepressants (amitriptyline)
  • Propranolol
  • Coenzyme Q-10
  • Antihistamines
  • Antianxiety medications

Pearls and Pitfalls

  • Obtain good history about prior cyclic episodes and similarities to prior episodes
  • Manage active coexisting conditions if applicable
  • Exclude other disorders with similar presentations of nausea/vomiting/abdominal pain

Additional Reading

  • Abell ‚ TL, Adams ‚ KA, Boles ‚ RG, et al. Cyclic vomiting syndrome in adults. Neurogastroenterol Motil. 2008;20:269 " “284.
  • Fleisher ‚ DR, Gornowicz ‚ B, Adam ‚ K, et al. Cyclic Vomiting Syndrome in 41 adults: The illness, the patients, and problems of management. BMC Med. 2005;3:20.
  • Hejazi ‚ RA, McCallum ‚ RW. Review article: Cyclic vomiting syndrome in adults " “ rediscovering and redefining an old entity. Aliment Pharmacol Ther. 2011;34:263 " “273.
  • Venkatesan ‚ T, Prieto ‚ T, Barboi ‚ A, et al. Autonomic nerve function in adults with cyclic vomiting syndrome: A prospective study. Neurogastroenterol Motil. 2010;22:1303 " “1307.
  • Venkatesan ‚ T, Tarbell ‚ S, Adams ‚ K, et al. A survey of emergency department use in patients with cyclic vomiting syndrome. BMC Emerg Med. 2010;10:4.

Codes

ICD9

  • 346.20 Variants of migraine, not elsewhere classified, without mention of intractable migraine without mention of status migrainosus
  • 346.21 Variants of migraine, not elsewhere classified, with intractable migraine, so stated, without mention of status migrainosus
  • 536.2 Persistent vomiting

ICD10

  • G43.A Cyclical vomiting
  • G43.A0 Cyclical vomiting, not intractable
  • G43.A1 Cyclical vomiting, intractable

SNOMED

  • 18773000 cyclical vomiting syndrome (disorder)