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Vomiting is a common presenting symptom in general pediatrics. In addition, cyclic vomiting syndrome (CVS) has an estimated prevalence of 2%. Which of the following scenarios is consistent with a child with the diagnosis of CVS?

A. A 5-year-old boy with recurrent episodes of nonbilious vomiting that occur after he sleeps in during the weekend or after a high-protein meal

B. A 6-year-old girl with recurrent episodes of fast-paced vomiting (up to 4 emeses per hour) every 3 weeks that begin in the morning and last about 24 hours

C. A 6-month-old girl with recurrent episodes of bilious vomiting and abdominal pain every 4 to 6 hours

D. A 5-year-old girl with recurrent episodes of nonbilious vomiting every 4 hours, occipital headache, and mild ataxia

E. A 6-week-old girl with recurrent episodes of nonbilious vomiting after every feed

Answer: B

The typical patient with CVS presents with recurrent, stereotypic episodes of frequent emesis every 2 to 4 weeks that begin suddenly and last 24 to 48 hours. There is a return to periods of baseline health between episodes. The vomiting cannot be attributed to another disorder. A thorough history and physical examination is important, as specific conditions and symptoms suggest that the diagnosis is not consistent with CVS. These conditions are (1) presentation at < 2 years of age; (2) bilious vomiting, abdominal tenderness, and/or severe abdominal pain; (3) attacks associated with intercurrent illness, fasting, and/or a high-protein meal; (4) abnormalities on neurologic examination; or (5) progressively worsening episodes or a conversion to a continuous or chronic pattern.

The patient in answer choice A had bilious emesis that occurred after a period of fasting or a high-protein meal. These symptoms suggest a partial urea cycle enzyme deficiency, which can occur after such situations. The patient in answer choice C has bilious emesis and abdominal pain. Although CVS can present with similar symptoms, it is important to rule out a surgical condition, such as volvulus or malrotation, as well as pancreatitis. In addition, this child does not have a 3-week cycle with a return to baseline. The patient in answer choice D has neurologic symptoms, which is concerning for increased intracranial pressure or a metabolic disorder. The patient in answer choice E has symptoms consistent with pyloric stenosis.

A 7-year-old girl presents to the emergency department (ED) after vomiting 15 times over the past 8 hours. The vomiting began suddenly upon awakening that morning. After examining her medical record, you note that she ...

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