A Thorough History: Worth a Million‐Dollar Workup and a Trip to the Operating Room

1Emory University School of Medicine, Atlanta, GA

Meeting: Hospital Medicine 2007, May 23-25, Dallas, Texas

Abstract number: 125

Case Presentation:

A 21‐year‐old woman with no significant medical history presented to the emergency room with a 2‐day history of acute‐onset, intractable nausea associated with nonbloody, nonbilious vomiting. Four years earlier she had experienced similar monthly episodes. Her physical exam was remarkable only for orthostatic hypotension. Laboratory studies revealed a urine pregnancy test was negative and blood chemistries and liver and pancreatic enzymes were normal. The differential diagnosis included cholecystitis, gastroeso‐phagitis, and intra‐abdominal orintracranial malignancy. A previous workup had included upper endoscopy, computed tomography studies of the abdomen and brain, gastric emptying study, and barium swallow, all of which were negative. A previous cholecystectomy had provided no relief. On further questioning, the patient's episodes appeared stereotypic: 3‐6 days in duration, acute in onset, temporally related to various physical and mental stresses (eg, menses, urinary tract infections, job loss, etc.), and followed by weeks‐long symptom‐free intervals. A diagnosis of cyclic vomiting syndrome was made. The patient was aggressively fluid‐resuscitated and provided with supportive care (ie, metoclopramide, promethazine, etc.). The nausea and vomiting resolved within 48 hours of admission.

Discussion:

Cyclic vomiting syndrome is a common diagnosis in children, with an estimated prevalence of 1.6%. The prevalence among adults is lower but is being increasingly recognized. Because of a lack of physician awareness, time to diagnosis is prolonged (8 years in adults and 3 years in children). Patients undergo countless unnecessary diagnostic and surgical procedures. The extensive workup our patient endured cost $3000 in imaging and surgery alone. Diagnostic criteria include: a minimum of 3 stereotypic episodes of acute‐onset vomiting within 1 year separated by a symptom‐free interval of at least 1 week and the absence of any organic cause (demonstrated by brain imaging and upper endoscopy or upper‐GI series). Having a personal or family history of migraine headaches is more than twice that of the general population (25% vs. 12%). Although most features of the syndrome are similar among age groups, episode duration is longer in adults (4‐6 days in adults vs. 2 days in children). Treatment involves supportive care during an acute episode and interval prophylactic measures, if warranted based on case severity (ie, tricyclic antidepressents, sumatriptan, etc).

Conclusions:

Cyclic vomiting syndrome is a diagnosis that should be included in every hospitalist's differential of patients presenting with recurrent, episodic vomiting. The key to diagnosis is awareness and early recognition through thorough history taking. Treatment includes supportive and prophylactic care, similar to the management of migraine headaches.

Author Disclosure:

A. Kalokhe, None; B. Quinn, None; S. Fluker, None; J. Stein, Society of Hospital Medicine, consulting fees or other remuneration (payment); sanofi‐aventis, consulting fees or other remuneration (payment); J. Doyle, None.

To cite this abstract:

Kalokhe A, Quinn B, Fluker S, Stein J, Doyle J. A Thorough History: Worth a Million‐Dollar Workup and a Trip to the Operating Room. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 125. Journal of Hospital Medicine. 2007; 2 (suppl 2). https://www.shmabstracts.com/abstract/a-thorough-history-worth-a-milliondollar-workup-and-a-trip-to-the-operating-room/. Accessed September 22, 2019.

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