Pediatric Emergency Update: Cyclic Vomiting Syndrome

Abstract

Vomiting is a common chief complaint in the pediatric ED population. Emergency nurses should develop a systematic approach that is age and developmentally appropriate to evaluate the child with vomiting to identify life-threatening emergencies. Vomiting isasymptomthatcanindicateavastarrayofmedicalproblems from catastrophic to benign. Some children have chronic recurrent vomiting episodes, diagnosed as cyclic vomiting syndrome. Emergency nurses caring for pediatric patients must be objective and open to all differential diagnoses that vomiting could represent. Misdiagnosis of children with the chief complaint of vomiting is not uncommon. It is important to look at each body system of a child brought to the emergency department with recurrent vomiting. The following case report of a 4-month-old infant brought to the pediatric emergency department for frequent vomiting can serve as an example. The child was beautiful, well developed, chubby, awake, and alert, being evaluated in the outpatient setting by both his pediatrician and a gastroenterologist for recurrent vomiting. The child’s primary nurse in the pediatric emergency department noted that a complete workup was ordered, which included blood tests, urine tests, radiographs, and a computed tomography (CT) scan of the head. The child’s mother was concerned that he kept spitting up (vomiting) for no apparent reason. Part of the complete workup for this infant involved obtaining a straight catheter urine specimen. When the diaper was removed to obtain this specimen, abnormal urine flow was noted. The child’s urine stream would start and stop and then repeat this pattern. Documentation of this was placed in his medical record, and the ED pediatrician was notified. A brain tumor was identified on CT scan. Fortunately, during this pediatric emergency visit, this child with a history of recurrent vomiting was evaluated objectively, using a systematic format. The child was admitted with the newly diagnosed brain tumor for further evaluation and treatment. When all differential diagnoses—both life-threatening and benign—that may cause the child’s vomiting are eliminated, cyclic vomiting syndrome can be diagnosed. Cyclic vomiting syndrome is a chronic gastrointestinal condition identified in children as long ago as in the 1800s. The description of cyclic vomiting syndrome includes the following: the child has 3 or more distinct episodes of recurrent severe vomiting, with completely normal health between episodes, and the child’s vomiting occurs with similar timing, symptoms, and duration. The vomiting episodes of children diagnosed with cyclic vomiting syndrome have variable duration from hours to days, with no exact cause identified. The exact pathophysiology of recurrent cyclic vomiting is unknown. Emergency nurses who care for pediatric patients need to ensure that all potential life-threatening differential diagnoses are eliminated before labeling pediatric patients as having cyclic