Diagnosis of Cyclic Vomiting Syndrome

How do doctors diagnose cyclic vomiting syndrome?

Doctors diagnose cyclic vomiting syndrome based on family and medical history, a physical exam, pattern of symptoms, and medical tests. Your doctor may perform medical tests to rule out other diseases and conditions that may cause nausea and vomiting.

Family and medical history

Your doctor will ask about your family and medical history. He or she may ask for details about your history of health problems such as migraines, irritable bowel syndrome, and gastroparesis. Your doctor may also ask about your history of mental health problems, use of substances such as marijuana, and cigarette smoking.

Your doctor will ask about your family and medical history.

Physical exam

During a physical exam, your doctor will

• examine your body
• check your abdomen for unusual sounds, tenderness, or pain
• check your nerves, muscle strength, reflexes, and balance

Pattern or cycle of symptoms in children

A doctor will often suspect cyclic vomiting syndrome in a child when all of the following are present³:

• at least five episodes over any time period, or a minimum of three episodes over a 6-month period
• episodes lasting 1 hour to 10 days and happening at least 1 week apart
• episodes similar to previous ones, tending to start at the same time of day, lasting the same length of time, and happening with the same symptoms and intensity
• vomiting during episodes happening at least four times an hour for at least 1 hour
• episodes are separated by weeks to months, usually with no symptoms between episodes
• after appropriate medical evaluation, symptoms cannot be attributed to another medical condition

Pattern or cycle of symptoms in adults

A doctor will often suspect cyclic vomiting syndrome in adults when all of the following are present⁴:

• three or more separate episodes in the past year and two episodes in the past 6 months, happening at least 1 week apart
• episodes that are usually similar to previous ones, meaning that episodes tend to start at the same time of day and last the same length of time—less than 1 week
• no nausea or vomiting between episodes, but other, milder symptoms can be present between episodes
• no metabolic, gastrointestinal, central nervous system, structural, or biochemical disorders

A personal or family history of migraines supports the doctor’s diagnosis of cyclic vomiting syndrome.

Your doctor may diagnose cyclic vomiting syndrome even if your pattern of symptoms or your child’s pattern of symptoms do not fit the patterns described here. Talk to your doctor if your symptoms or your child’s symptoms are like the symptoms of cyclic vomiting syndrome.

What medical tests do doctors use to diagnose cyclic vomiting syndrome?

Doctors use lab tests, upper GI endoscopy, and imaging tests to rule out other diseases and conditions that cause nausea and vomiting. Once other diseases and conditions have been ruled out, a doctor will diagnose cyclic vomiting syndrome based on the pattern or cycle of symptoms.

Lab tests

Your doctor may use the following lab tests:

• Blood tests can show signs of anemia, dehydration, inflammation, infection, and liver problems.
• Urine tests can show signs of dehydration, infection, and kidney problems.

Blood and urine tests can also show signs of mitochondrial diseases.

Upper GI endoscopy

Your doctor may perform an upper GI endoscopy to look for problems in your upper digestive tract that may be causing nausea and vomiting.

Imaging tests

A doctor may perform one of more of the following imaging tests:

• Ultrasound of the abdomen.
• Gastric emptying test, also called gastric emptying scintigraphy. This test involves eating a bland meal, such as eggs or an egg substitute, that contains a small amount of radioactive material. An external camera scans the abdomen to show where the radioactive material is located. A radiologist can then measure how quickly the stomach empties after the meal. Health care professionals perform gastric emptying tests only between episodes.
• Upper GI series.
• MRI scan or CT scan of the brain.

References

Vomiting blood Information | Mount Sinai

Hematemesis; Blood in the vomit

Vomiting blood is regurgitating (throwing up) contents of the stomach that contains blood.

Vomited blood may appear bright red, dark red, or look like coffee grounds. The vomited material may be mixed with food or it may be blood only.

Considerations

It may be hard to tell the difference between vomiting blood and coughing up blood (from the lung) or a nosebleed.

Conditions that cause vomiting blood can also cause blood to appear in the stool.

Causes

The upper GI (gastrointestinal) tract includes the mouth, throat, esophagus (swallowing tube), stomach and the duodenum (first part of the small intestine). Blood that is vomited may come from any of these places.

Vomiting that is very forceful or continues for a very long time may cause a tear in the small blood vessels of the throat. This may produce streaks of blood in the vomit.

Swollen veins in the walls of the lower part of the esophagus, and sometimes the stomach, may begin to bleed. These veins (called varices) may be present in people with severe liver damage.

Repeated vomiting and retching may cause bleeding and damage to the lower esophagus called Mallory Weiss tears.

Other causes may include:

• Bleeding ulcer in the stomach, first part of the small intestine, or esophagus
• Blood clotting disorders
• Defects in the blood vessels of the GI tract
• Swelling, irritation, or inflammation of the esophagus lining (esophagitis) or the stomach lining (gastritis)
• Swallowing blood (for example, after a nosebleed)
• Tumors of the mouth, throat, stomach or esophagus

Home Care

Get medical attention right away. Vomiting blood can indicate a serious medical problem.

When to Contact a Medical Professional

Contact your health care provider or go to the emergency room if vomiting of blood occurs. You will need to be examined right away.

What to Expect at Your Office Visit

The provider will examine you and ask questions such as:

• When did the vomiting begin?
• Have you ever vomited blood before?
• How much blood was in the vomit?
• What color was the blood? (Bright or dark red or like coffee grounds?)
• Have you had any recent nosebleeds, surgeries, dental work, vomiting, stomach problems, or severe coughing?
• What other symptoms do you have?
• What medical conditions do you have?
• What medicines do you take?
• Do you drink alcohol, smoke, or use tobacco?

Tests that may be done include:

• Blood work, such as a complete blood count (CBC), blood chemistries, blood clotting tests, and liver function tests
• Esophagogastroduodenoscopy (EGD) (placing a lit tube through the mouth into the esophagus, stomach and duodenum)
• Rectal examination
• Tube through the nose into the stomach and then applying suction to check for blood in the stomach
• X-rays

If you have vomited a lot of blood, you may need emergency treatment. This may include:

• Administration of oxygen
• Blood transfusions
• EGD with application of laser or other treatments to stop the bleeding
• Fluids through a vein
• Medicines to decrease stomach acid
• Possible surgery if bleeding does not stop

DeGeorge LM, Nable JV. Gastrointestinal bleeding. In: Walls RM, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia, PA: Elsevier; 2023:chap 26.

Kovacs TO, Jensen DM. Gastrointestinal hemorrhage. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 126.

Savides TJ, Jensen DM. Gastrointestinal bleeding. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 20.

Last reviewed on: 1/30/2023

Reviewed by: Michael M. Phillips, MD, Emeritus Professor of Medicine, The George Washington University School of Medicine, Washington, DC. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Clinical tests and tasks | “RMJ” No. 13 dated 07/13/2015

Choose one of the answers provided.

1. Which of the signs is not typical for exacerbation of duodenal ulcer:

a) pain on an empty stomach;
b) pain 30 minutes after eating;
c) pain 2.5 hours after eating;
d) pain on the right in the epigastrium;
e) heartburn, sour belching.

2. A patient with a long-term course of gastric ulcer developed almost constant pain radiating to the back. What complication can be expected:

a) pyloric stenosis;
b) penetration;
c) malignancy;
d) perforation;
e) dumping syndrome.

3. Decreased secretory-acid-forming function of the stomach is observed in:

a) chronic antrum-gastritis;
b) chronic atrophic gastritis;
c) chronic hypertrophic gastritis;
d) Zollinger-Ellison syndrome;
e) all the indicated forms.

4. What is the most reliable method to rule out gastric ulcer malignancy:

a) X-ray;
b) endoscopic;
c) feces for occult blood;
d) gastric juice with histamine;
e) endoscopy with biopsy.

5. A patient suffering from gastric ulcer during the period of the next exacerbation complained of belching with a rotten egg, vomiting of the food taken the day before. What complication arose in the patient:

a) penetration;
b) perforation;
c) bleeding;
d) pyloric stenosis;
e) malignancy.

6. A patient complains of pain in the epigastrium, appearing 1.5–2 hours after eating and on an empty stomach. This symptom presumably indicates the presence of:

a) chronic gastritis;
b) gastric ulcer;
c) duodenal ulcer;
d) cholecystitis;
e) pancreatitis.

7. High serum amylase may occur in all conditions except:

a) rupture of a pancreatic cyst;
b) chronic congestive heart failure;
c) ectopic pregnancy;
d) pigs;
e) acute pancreatitis.

8. The most valuable laboratory indicator in the diagnosis of exacerbation of chronic pancreatitis is:

a) leukocytosis;
b) the level of aminotransferases in the blood;
c) blood and urine amylase levels;
d) the level of alkaline phosphatase;
e) hyperglycemia.

9. Hepatomegaly, splenomegaly and melena are suspicious:

a) bleeding duodenal ulcer;
b) bleeding veins of the esophagus with cirrhosis of the liver;
c) mesenteric artery thrombosis;
d) nonspecific ulcerative colitis;
e) bleeding stomach ulcers.

10. Cytolysis syndrome is most pronounced at:

a) hereditary spherocytosis;
b) Gilbert’s syndrome;
c) chronic active hepatitis;
d) cholelithiasis;
e) cirrhosis of the liver.

11. Only direct (conjugated) hyperbilirubinemia is typical for:

a) hemolytic jaundice;
b) hepatocellular jaundice;
c) extrahepatic cholestasis;
d) intrahepatic cholestasis;
e) violations of the capture and binding of bilirubin.

12. An increase in the level of direct and indirect bilirubin is observed at:

a) hereditary spherocytosis;
b) Gilbert’s syndrome;
c) choledocholithiasis;
d) active hepatitis;
e) tumors of the pancreas.

13. The most characteristic manifestation of non-specific ulcerative colitis is:

a) diffuse pain in the abdomen;
b) loose stools;
c) frequent bloody bowel movements;
d) nodular erythema;
e) pain in the joints.

14. Chronic recurrent pancreatitis occurs most often in:

a) peptic ulcer;
b) cholelithiasis;
c) post-gastroresection syndrome;
d) chronic colitis;
e) giardiasis.

15. The most prone to metastasis in gastric cancer are:

a) regional lymph nodes;
b) liver;
c) Virchow’s gland;
d) Douglas space;
d) lungs.

Answers

1 – b. 2 – b. 3 – b. 4 – d. 5 – d. 6 – c. 7 – b. 8 – c. 9 – b. 10 – c. 11 – c. 12 – g. 13 – c. 14 – b. 15 – c.

TASKS

Task #1

Patient S., 32 years old, complains of chills, weakness, headache, weakness, nausea, intense pain in the right hypochondrium, which arose last night after eating fatty meat and lasted all night with short breaks. The pain is aggravated by changing the position of the body, turning.

It is known that the older sister was diagnosed with calculous cholecystitis at the age of 44.

At the age of 7 years, the patient suffered hepatitis A, after which for several years she noted episodes of pain in the right hypochondrium after fatty foods, sometimes accompanied by vomiting. At the age of 18, the analysis of bile obtained by duodenal sounding revealed a large number of leukocytes in portions B and C. She was repeatedly treated in sanatoriums, took choleretic drugs. According to the patient, with repeated ultrasound of the biliary tract, “sand was detected.” I felt satisfactorily. The patient has a history of 5 pregnancies that ended in normal term delivery. The patient is currently pregnant at 18 weeks.

Objectively: hypersthenic build, increased nutrition (body mass index – 33 kg/m2), clean skin, scleral icterus, body temperature 39°C. The liver does not protrude from under the costal arch, soft-elastic consistency, palpation is sharply painful. Sharply positive symptoms of Georgievsky – Mussy, Ortner, Murphy, Lepene. The abdomen is slightly swollen. The spleen is not palpable.

In the blood test: leukocytes – 15100 / μl, p / i – 11%, s / i – 53%, lymphocytes – 19%, monocytes – 12%, eosinophils – 5%, erythrocytes – 4200 million / μl, hemoglobin – 121 g / l, platelets – 290,000 / μl, ESR – 17 mm / h. Bilirubin total – 2.6 mg / dl, direct – 0.5 mg / dl. Fibrinogen – 4. 82 g / l. Total protein – 82 g/l, albumin – 5.6 g/l. ALT – 24 IU, AST – 18 IU, g-GT – 160 IU, alkaline phosphatase – 380 IU / l.

Esophagogastroduodenoscopy showed gastroesophageal reflux, no other pathology was detected.

Ultrasound of the abdominal organs: the liver is slightly enlarged (+1 cm), the contours are even, the parenchyma is of normal echogenicity. Intrahepatic bile ducts are dilated, ductus choledochus – 6 mm. The gallbladder is enlarged up to 5 cm in diameter, the walls are thickened, a “double contour” is detected, Mussy’s ultrasound symptom. In the neck of the gallbladder there is an echo-dense shadow 1.5 cm in size. The pancreas is of normal size and shape, echogenicity is normal. The pancreatic duct is not dilated.

Formulate a preliminary diagnosis.

Task #2

Patient A., 52 years old, was admitted to the clinic with complaints of pain in the epigastric region, which occurs 20–30 minutes after eating, belching with air, weight loss by 3 kg over the last month. The first signs of the disease appeared in the autumn 3 years ago (pain in the epigastric region began to occur 30–40 minutes after eating, he independently took drotaverine and algeldrate / magnesium hydroxide with a short-term effect), was not examined, drew attention to the seasonality of pain (in spring and autumn) . The last deterioration in well-being – during the last month, the pain was of the same nature, at the height of the pain, irradiation to the back was observed. There was an eructation of air. To clarify the diagnosis and treatment was admitted to the clinic.

On admission: the general condition is satisfactory. The skin and visible mucous membranes are slightly pale. Vesicular breathing in the lungs, no wheezing, rhythmic, clear heart sounds, blood pressure – 140/80 mm Hg. Art. Pulse – 80 bpm. The abdomen is soft, moderate muscle tension in the epigastrium, local pain in the epigastric region. The liver and spleen are not enlarged. In the blood test: erythrocytes – 3750000, hemoglobin – 10. 7 g%, color. pok. – 0.9, ESR – 15 mm / h. When esophagogastroduodenoscopy – the esophagus is not changed, the cardia closes completely. The stomach is well straightened with air. On the lesser curvature, in its middle third, there is a star-shaped whitish scar with a distinct convergence of folds. There is also a fresh ulcer with edematous, inflammatory-modified edges, 6×8 mm in size. There is a blood clot at the bottom of the ulcer. The bulb of the duodenum is not changed. A mucosal biopsy was taken from the edges of the ulcer. Histological examination: a picture of atrophic gastritis with symptoms of intestinal metaplasia of the epithelium, the edge of the ulcer, caught in the cut, with signs of chronic inflammation. NR was detected in a small amount. pH-metry was not performed due to the nature of the localization of the ulcer.

Formulate a clinical diagnosis.

Task no. 3

Patient I., 48 years old, was admitted to the clinic on the 3rd day of illness with complaints of pain in the right hypochondrium, nausea, repeated vomiting of bile, fever up to 38°C. The patient’s condition is moderate, the number of breaths is 28/min, the pulse is 110 beats/min. Tongue dry, covered with white coating. The abdomen is tense and sharply painful in the right hypochondrium, where the bottom of the gallbladder is palpated. The Shchetkin-Blumberg symptom is also determined there, the symptoms of Ortner, Murphy, Mussy are positive. Leukocytosis – 18×109/ l. Against the background of conservative therapy for 12 hours, the patient’s condition did not improve, body temperature increased, leukocytosis increased.

1. Your preliminary diagnosis: a) acute focal pancreatitis; b) acute catarrhal cholecystitis; c) perforated duodenal ulcer; d) acute phlegmonous cholecystitis; e) acute perforated cholecystitis.

2. The most characteristic signs in this disease: a) vomiting of bile; b) pain in the right hypochondrium; c) palpable bottom of the gallbladder; d) muscular defense in the right hypochondrium; e) Ortner’s symptom.

3. The optimal method for diagnosing this disease is: a) computed tomography of the abdominal cavity; b) retrograde cholangiopancreatography; c) ultrasound examination; d) intravenous cholecystocholangiography; e) laparoscopy.

4. Your treatment tactics: a) emergency surgery; b) massive antibiotic therapy; c) percutaneous sanitation of the gallbladder; d) complex infusion therapy; e) antispasmodic therapy.

Answers

Task number 1. Chronic recurrent acalculous cholecystitis in the stage of exacerbation, moderate course.

Task number 2. Stomach ulcer, first detected, with localization on the lesser curvature in the acute phase.

Task No. 3. 1 – d. 2 – b, d, e. 3 – c. 4 – a.

How to stop vomiting in a child: doctors about the dangers of home treatment

Causes of vomiting in children

As Elena Grek, a pediatric gastroenterologist at the SM-Clinic in St. Petersburg, told Gazeta.Ru, children vomit for several reasons:

“Most often this is a manifestation of intestinal infections: enterovirus, adenovirus or bacterial infections. Second place is occupied by food poisoning. And in older children, vomiting can be a symptom of an exacerbation of a disease of the gastrointestinal tract, for example, gastritis. If the child vomits bile, but at the same time he feels fine, it may be a reflux of bile into the stomach.

Usually such episodes recur with a certain frequency: once a week or a month. Another cause of vomiting in children is sunstroke. When overheated, a child usually vomits only once, and there are no other signs of gastrointestinal upset. In this case, it will be enough to let the baby rest in a dark, cool room.

The doctor also noted that vomiting can begin if blood pressure rises sharply, but this is extremely rare in young children.

Most parents are unable to understand what causes vomiting in children. Moreover, sometimes it can be accompanied by loose stools and abdominal pain. It is necessary to seek medical help from a pediatrician or pediatric gastroenterologist, and in some cases, you will need to call an ambulance.

Do not forget that babies have regurgitation, and they have nothing to do with vomiting. About half of newborns under the age of three months spit up at least once a day.

How to quickly stop vomiting at home

Seeing that the child is vomiting, parents ask themselves the question “How to quickly stop vomiting at home?” Many adults hope that there is a universal drug that will immediately solve the problem.

However, Ksenia Batrak, a pediatrician at the SM-Clinic in St. Petersburg, warns that it is practically impossible to stop vomiting quickly, and most often it is not necessary and even dangerous:

“It is no coincidence that doctors do not advise giving children antiemetics. Vomiting is a protective symptom that helps the body rid itself of infection. By stopping it with the help of pills, we harm children ourselves. We also interfere with the correct diagnosis, blurring the clinical picture of the disease. So it’s not worth trying to stop vomiting at home.”

Andrey Kurenkov, pediatrician, expert of the Mama TV channel, also warns against home “treatment” of parents:

“In no case should you stop vomiting on your own, without seeing a doctor. The fact is that vomiting occurs in many diseases, some of which are mild and self-limiting, and some are deadly (intestinal obstruction, diabetic ketoacidosis, acute adrenal insufficiency, non-food poisoning, increased intracranial pressure). If vomiting is caused by these reasons, and you will try to stop it, you risk losing time.

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What can be given to a child for vomiting lemon. But the main task is to provide the child’s body with a sufficient amount of fluid to prevent dehydration.

“If you vomit once, you can give dried fruit compote. But if the child continues to vomit, you need to switch to fractional drinking: take at least a few sips every 10-15 minutes. It is better to drink plain water, but boiled, ”recommends Dr. Batrak.

Does the child have dry mouth, foamy saliva or no saliva, reduced urge to urinate, small urine volume, decreased activity? These are signs of dehydration. Loose stools further accelerate fluid loss.

Vomiting and diarrhea are dangerous for a small child due to a decrease in electrolytes in the body. Together with the liquid, the child also loses biologically significant elements that support important processes in cells. Pediatrician Ksenia Batrak told how they can be replenished: “To compensate for the loss of glucose or acids, you can add a little sugar or lemon juice to ordinary water. You can also buy ready-made solutions with a verified composition of electrolytes, salt and sugar. For example, Regidron Bio. Usually, children do not really like their taste, but such solutions help to replenish the balance of nutrients. If the cause of vomiting in children is food poisoning, sorbent preparations can be taken.

Pediatrician Andrei Kurenkov explains why a drug for adults cannot be used to restore the water-salt balance (rehydration):

salt concentration, and they themselves can provoke vomiting. For children, funds with low osmolarity are needed. For adults – Regidron, for children – Regidron-Bio.

How to stop vomiting if there is nothing to vomit

There are cases when the gag reflex persists even when there is nothing left to vomit. In such a situation, parents try to find a way to stop the child from vomiting.

However, pediatric gastroenterologist Elena Grek warns that the only option is to seek medical help: “All parents can do is move the child to a cool and quiet room, dim the lights, put something cold on the head, pat on the head or tummy. In other words, try to calm down while waiting for the doctor.”

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Doctor or ambulance

How do I know if my child needs an ambulance or is it enough to wait for a doctor?

Andrey Kurenkov advises to focus on your own life experience:

“You have to solve only one question on your own: the child needs emergency or planned medical care. If, in the process of waiting for the doctor, despite your efforts to drink water, the child’s condition worsens and his urination becomes less frequent, you need to call an ambulance.

The doctor emphasizes that no medication should be given until the doctor arrives, all the efforts of the parents should be devoted to feeding the child with low-osmolar oral rehydration agents, which were discussed above. This will help prevent dehydration.

What to do after a child vomits

Doctors say that the universal remedy for vomiting in children is drinking.

Elena Grek tells what to drink and even feed a child after vomiting: “If the body perceives liquid well, then warm weak tea can be added to the water. The drink should not be made too hot. Tea can be sweetened and a little lemon can be added to restore the acid balance. Any food after vomiting should also be liquid and homogeneous in composition. Porridge or chicken broth will do. Fatty and fried foods should be avoided.

But if the vomiting does not stop, the head and stomach begin to hurt, loose stools appear, the temperature rises, and the child himself is lethargic and unable to even drink, the doctor warns: you should immediately seek medical help.

Can I give my child fizzy drinks when dehydrated from vomiting and diarrhea?

“In no case should you give a child soda to drink with vomiting and diarrhea (loose stools).