Cyclical Vomiting: The missed diagnosis

Dr John P Wright

Updated: 22 May 2007

The classical case is a 15 year old girl who repeatedly vomits unexpectedly and without significant warning of nausea. Everyone including the patient is perplexed. Anorexia nervosa and old-fashioned manipulation are suspected but not proven by the rest of the evidence. Gastroscopies and empirical treatment with proton pump inhibitors follow but the vomiting continues. Psychological assessment confirms the impenetrability of youth and the vomiting continues.

What is cyclical vomiting? It is a syndrome of repeated attacks of nausea and vomiting without obvious organic cause. In its classical form is simply a variant of migraine headaches without the headache. The clinical problem is that many patients present in an atypical way and some are simply due to idiopathic vomiting without an adequate explanation.

Cyclical vomiting tends to occur at almost predictable times. Attacks are often monthly and start at night. The patient wakes with the attack which seems to be precipitated by triggering factors such as personal stress, lack of sleep, menses, chocolate and motion sickness. Onset in the family car is a common situation which brings all the factors together. The interplay of mother, daughter, school and the family complicate the issue and staying home from school adds further stress and uncertainty.

Table 1. Rome III Diagnostic Criteria for Cyclical Vomiting Syndrome

At least 3 months, with onset at least 6 months previously of:

1. Stereotypical episodes of vomiting regarding onset (acute) and duration (< 1 wk).
2. Three or more discrete episodes in the prior year.
3. Absence of nausea and vomiting in between the episodes.
4. There are no metabolic, gastrointestinal, or central nervous system structural or biochemical disorders.
5. Supportive criteria: personal or family history of migraine headaches.

Cyclical vomiting has 4 phases.

The first is the prodrome which consists to a varying degree of nausea, lethargy and anorexia. Less common are increased salivation and a desire to be left alone. Thus the diagnosis of psychological factors is confirmed.

The second phase is vomiting which may last for 24 hours or more but is characterized by incapacitating vomiting. Investigation by gastroscopy may show oesophagitis or haemorrhagic gastric lesions. These are secondary effects of the vomiting. Abdominal pain confuses the diagnosis but symptoms of stress are usually associated as evidenced by tachycardia, sweating and an increased frequency of defaecation. The patient is restless and drinks fluids only to continue vomiting shortly afterwards. An extraordinary association is a leukocytosis which is interpreted as indicating an inflammatory response. This may tempt surgical intervention.

The third phase is the recovery during which the patient may feel exhausted and sleep.

The fourth phase is the period in between attacks when the patient is well with no gastrointestinal symptoms.

There is a relationship between migranous headaches, abdominal migraine and cyclical vomiting. Treatment with anti-migraine therapy is appropriate particularly in patients with more typical migraine patterns of prodrome, attack and recovery.

Other patients may simply have chronic vomiting which is a variant of functional dyspepsia. These patients do not have the cyclic pattern and they have no family history of migraine related problems and less autonomic symptoms.

Table 2. Rome III Diagnostic Criteria for Functional Dyspepsia

At least 3 months of:

1. Post prandial fullness
2. Early satiety
3. Epigastric pain
   1. Epigastric burning sensation.

and

No evidence of structural disease

Treatment of cyclical vomiting is empirical as the diagnosis is usually not definitive. Preventative therapy as for migraine suffers may work in some patients. In others a simple explanation may suffice but as in all functional problems reassurance that serious organic disease is not present goes a long way in symptom relief. Clear evidence based data is not available for the management of these patients so common sense and simple support go a long way.

In summary cyclic vomiting is a frequently missed diagnosis. Conversely chronic vomiting is also common and may respond to standard therapy for the functional dyspepsia such as high dose proton pump therapy. In the end of the day a careful history and minimal investigation will usually resolve the dilemma.