1. The boy has been experiencing recurrent episodes of intense nausea and vomiting for over 3 years, with stereotypical cyclical pattern consistent with cyclic vomiting syndrome. 2. Diagnostic workup found no underlying cause and the boy is otherwise healthy between episodes. Management includes lifestyle modifications and abortive/prophylactic medications like ondansetron and amitriptyline which have reduced severity and frequency of episodes. 3. Cyclic vomiting syndrome is an important consideration for children presenting with stereotypical episodes of vomiting, and further workup is only needed if alarm symptoms are present that suggest an alternative underlying cause.

1. Recurrent vomiting
Anshu Srivastava
Department of Paediatric Gastroenterology
SGPGIMS, Lucknow

2. Regurgitation and vomiting often confused in children
APT 2011;34:263-73/ GCNA 32 (2003) 997–1019
Cyclic
↑intensity, ↓frequency
Chronic
↓Intensity, ↑frequency
Recent years: Increase in cases with nausea and vomiting and gastroparesis
Regurgitation: Effortless return of food from stomach, no nausea/retching
Vomiting: forceful expulsion of gastric/intestinal contents, often associated with
nausea & retching
 Rumination: effortless regurgitation of recently ingested food with
subsequent re-mastication/ re-swallowing or spitting
Vomiting: acute vs recurrent ( chronic vs cyclic)

3. triggers of vomiting in the blood or CSF
input from the GI tract
motion sickness and labyrinthine disorders
stress-induced, behavioural or
psychiatric disorders

4. Chronic/ recurrent
Chronic
Gastrointestinal
•Gastroesophageal reflux disease
•Food allergy
•Eosinophilic esophagitis
•Achalasia cardia*
•Gastritis
•Gastroparesis
•GOO: hypertrophic pyloric stenosis,
peptic ulcer, pancreatitis, mass lesion
•Small bowel obstruction: duodenal
stenosis, annular pancreas, superior
mesenteric artery syndrome
•Rumination syndrome
Non Gastrointestinal
•Raised intracranial tension: SOL
•Chronic sinusitis
•Uraemia
•Overfeeding
Recurrent
Gastrointestinal
•Cyclic vomiting syndrome
•Abdominal migraine
•Malrotation with volvulus
Non Gastrointestinal
•Metabolic:
Mitochondrial cytopathy (FAOD
respiratory chain disorders etc)
Urea cycle defects
•DKA
•Addison’s disease
•Acute hydronephrosis due
to PUJ obstruction (Dietl’s
crisis)

5. Clues in history
Nature of vomitus
Non bilious
• esophageal, gastric, D1
• pseudo vomiting in achalasia cardia, ± dysphagia
• stale food and large volume: GOO/ gastroparesis
associated with epigastric fullness, early satiety, succussion splash
and visible distension
Bilious vomiting
• obstruction distal to second part of duodneum,
• after repeated episodes of vomiting,
• patients with gastro jejunostomy
Feculent ( distal intestinal obstruction, gastro-colic fistula):
abdominal pain, distension, gola formation

6. Clues in history
Pattern of vomiting; cyclical or chronic
Associated symptoms: pain, jaundice, fever, urinary
symptoms, headache etc
Drug intake especially chemotherapeutics, radiation
Precipitants: specific food, stress, menstrual cycles,
febrile illness etc
Previous surgery
Family history: migraine, CVS
Vomiting: acute or chronic

7. Clues on examination
Complete general and systemic examination
Growth failure
Recent significant weight loss (SMA syndrome)
Signs of nutrient deficiency (malabsorption)
Hypertension
Oral cavity; dental erosions, halitosis (GERD/ rumination)
Eczema, reactive airway disease; (food allergy)
Fundus/ neurologic abn (CNS)
Abdominal: lumps, visible peristalsis, abdominal tenderness,
surgical scar (SAIO/ pseudoobstruction)
Hypotonia, developmental delay, cardiomyopathy;
(mitochondrial cytopathy)

8. Investigations
Blood
• CBC with differential, ESR
• Electrolytes, glucose, renal
functions
• Liver and pancreatic enzymes
• Lactate, pyruvate, ammonia,
carnitine
Urine
• Urine analysis
• Organic acids, amino acids
• Porphyrin screen
Stool
• Occult blood
Imaging
• UGI and SBFT
• Ultrasound/ CT abdomen
abdomen
• MRI brain
Endoscopy and motility studies
• Upper gastrointestinal endoscopy
with biopsies
• 24 hours esophageal pH and
impedance
• Esophageal manometry
• Antroduodenal manometry
• Gastric emptying study
• Small bowel transit and colonic
transit
Current Gastroenterology Reports 2001, 3:248–256

9. Case 1 - 6 year old boy
 Vomiting daily (not large volume/ non bilious,
never contains stale food)
 Occurs at any time
 No relationship to meals
 Sometimes wakes up at night with symptoms
 Once had small amount of blood in vomitus
Symptomatic for past 10 months
No weight loss, hematemesis, dysphagia, abdominal pain,
respiratory symptoms
No history of drug intake like NSAID
Examination: normal growth, no positive finding

10. Investigations
• Outside: normal UGI endoscopy, no erosions,
no hiatus hernia
• Diagnosis?
• Was esophageal biopsy taken? no
• What next??

11. GER Eosinophilic
esophagitis
Normal esophagus
Esophageal Histology: useful
Small number of intraepithelial eosinophils
Basal cell thickening
Lengthening of stromal papillae

12. 24 hour pH metry
Criteria measured Test result “normal” ranges
Reflux index 11% 6 %
Number of episodes >30s 38 25
Episodes >5 min 1 3
Longest epsiode 27 min 9.2min
Abnormal pH study
Diagnosis : GERD

13. Onset of symptoms
Omeprazole 20 mg OD
Lifestyle changes
Treatment and follow up
Asymptomatic
Symptoms resolved after 3 weeks
Ongoing therapy

14. Clinical Presentation
• Infant
–Regurgitation
–Irritability
–Feeding problem
–FTT
–Apnoea
• Child
– Regurgitation/vomiting
– Heartburn
– Epigastric pain
– Retro-sternal pain
– Dysphagia
– Extra-esophageal
• Pulmonary
• ENT

15. Who is at risk for severe GERD
• Esophageal atresia
• Neurologic impairment
• Obesity
• Hiatus hernia
• Cystic fibrosis
• Family history GERD/ GERD complications
Scand J Gastroenterol. 2010;45(2):139-46/ Can J Gastroenterol. 2010;24(5):312-6.
J Pediatr Gastroenterol Nutr. 2010;50(2):161-6/ C ochrane Database Syst. 2007;Rev(1):
CD006151.

16. Pyloric stenosis Malrotation
Diagnosis : Barium contrast radiography
Detection of anatomic abnormalities
Neither sensitive nor specific for diagnosing GERD
-Brief duration produces false-negatives
-Frequent occurrence of non-pathological reflux
during the examination produces false-positives

17. 11 year old boy with chest pain
24 hours pH study
Reflux index: % time pH<4, GOLD standard
Symptom correlation
pH 7
pH 4
pH 0
Chest
pain
Symptom correlation
Period of 2 minutes before event is considered
Association: acidic reflux and chest pain
Time
Two minutes time period

18. Combined pH and impedance
Advantages:
 Ability to detect all GER episodes and with a pH sensor
classify them as acid and non-acid GER
 Differentiate between liquid, gas or mixed GER
 Differentiate swallows (antegrade flow) from GER
(retrograde flow). No dietary restrictions required
 Measure accurately the height of the refluxate and the
proximal extent of the GER episode
 The mechanisms of bolus and acid clearance can be studied
JPGN 2009: 48;2–12

19. Different substances
have a different Impedance
Air (high) 5000 .. 10.000
Ohm
Basal oesophageal impedance 1500 .. 2000 Ohm
Liquid (low) 200 .. 500 Ohm
Air
Baseline
Liquid
Ohm
6000
3000
0

20. Gastric reflux
/ shaped waveform
Liquid swallow
shaped waveform

21. Case 2- 13 year old girl
Symptomatic for the past 6 months
 Vomits 2 to 4 hours after a meal
 Large volume, non bilious
 Stale food vomiting
 Early satiety
 Feeling of upper abdominal fullness and distension
 Has lost 3 kgs in the last 6 months
No pain abdomen, systemic symptoms
no corrosive/ drug intake

22. Examination and Investigation
Examination
• O/E 37 kg ht 155 cm
• BP 110/76 , PR 94/m RR 24
• Afebrile
• General physical – normal
• Systemic exam – normal
• Body image –normal
• No abnormal feeding habits
Investigations
• Blood sugar 96 mg/dl
• Thyroid function normal
• ABG pH 7.43 HCO3 23, Lactate < 2
mmol/L,
• Urine ketones – negative
• Hemogram, LFT, KFT, serum
electrolytes normal
• TTG negative
• Fundus exam – no papilledema
• BMFT, USG abd – normal
• UGIE – normal, Biopsy no GERD
Diagnosis??

23. Gastric emptying: methodology
Tc99mStandard meal
• 237 Kcal
• 75% carbohydrate
• 16% protein
• 8% fat
25g rice
25g pulses
25g flour
6 hours fasting
Meal consumed in 10-15min
Dynamic acquisition
60 sec frames first 60 min
Static acquisition
2, 3 and 4 hours

24. Gastric emptying study: Percent gastric retention
1 h: 100% 2 h: 80%
3 h: 60%
4 h: 40%
1h : normal < 96%
2h : normal < 71%
3h : normal < 44%
4h : normal < 22%

25. Diagnosis:
Gastroparesis (idiopathic)

26. No difference between girls and boys
Same across 5-18years of age
Emptying slower in children as compared to adults.
Assessment of gastric emptying in children: Establishment of
normative data. Manuscript submitted for publication

27. Treatment and follow up
Started on Itopride 25mg TID 1 hour before
meals.
Small frequent liquid/ semsolid meals
Avoid high fat, high fibre diet
Significant improvement in symptoms
Improved appetite
Weight gain

28. Gastroparesis Workup
Exclude mechanical obstruction
UGIE/ Barium UGI series/ USG/CT scan
Evaluate gastric emptying
Solid phase gastric emptying time- scintigraphy
(GOLD STANDARD)
Determine the etiology:
Blood count, glucose, K, Ca, albumin,TSH, free T4,
HbA1C, ANA, histology, antroduodenal manometry
etc
Gastroenterology 2004;127:1592–1622
Neurogastroenterol Motil (2010) 22, 113–133

29. Antroduodenal Manometry
Fasting state : MMC
Fed state
Gastroenterology 2004;127:1592–1622
Neurogastroenterol Motil (2010) 22, 113–133

30. Case 3:13 yr boy
1y 4y 9 y
Bilious vomiting with ‘gola’ formation,
Pain abdomen and borborygmi, constipation during
that period
Each episode last 2-3 days, multiple episodes,
needs admission and IV fluids
Poor weight gain, normal
appetite
episodic symptoms, once every 2-3 months,
Asymptomatic in between
No fever
or
systemic
symptom
s
Appearing
well

31. Differential diagnosis for
bilious vomiting
Surgical
causes
beyond D2
Malrotation
Duodenal webs, stenosis
Intussusception
Volvulus, adhesions etc

32. Malrotation
DJ not crossed to left side
Jejunal loops on the right
side
Paucity of bowel loops in
left side
Management:
surgery
Suspect:
1. Early symptoms in life
2. Episodic bilious
vomiting
3. Features of
obstruction

33. Case 4 : 6 year old boy
Recurrent vomiting past 3 ½ years
 Episodes: 2-3 times/year and lasts for 2-4 days
 Starts with nausea – retching
 At its peak, he vomits 8-10 times/hour, occ bilious
 Symptoms start at any time, mostly early morning
 No significant abdominal pain, abdominal
distension
 Frequently requires admission and IV fluids
 No triggers could be identified
• In the interim he is a normal playful child, does well in school
• Growth and development normal
• Examination: general and systemic is normal

34. Diagnosis received elsewhere
• Malrotation of gut
• Appendicitis
• GI tuberculosis: ATT given
• Brain tumor
2y 4 y3 y 5 y 6 y
E E EEE E EE
Last episode
• Taken up for exploratory laparotomy
• Parents refused at the last minute
• Anxious & worried parents
 Upper GI endoscopy
 Barium meal follow through
 CT head
 Hmg, RFT, LFT, ABG, urine
 USG abdomen
All normal S
G
P
G
I
 8 admissions, 3-5 days each
 Iv fluids, antiemetic and antibioticsOnset of symptoms

35. Diagnosis?
NASPGHAN (pediatric)
• Min 5 episodes or 3 attacks in 6mo time
• Episodic intense nausea and vomiting, lasts 1hr to
10days, separated by ≥ 1 week
• Stereotypical
• Vomiting> 4times/hr, for ≥ 1hr
• Return to baseline health b/w episodes
• Not attributed to other etiology
JPGN 2008;47:379-93
Cyclic vomiting syndrome

36. Acute onset
Intense
nausea and
vomiting
Return to
baseline
health
Symptom free
interval
Cyclical
pattern
Stereotypical
“Switch
turned
on-off ” !!
Trigger

37. Management
 Counseling patient and parents
 Lifestyle changes
• Avoid fasting/ over exertion
• Ensure adequate sleep
• Avoid triggers/excitement
 Treatment
Abortive therapy : Dark quiet environment, IV fluids
• Ondansetron 0.3–0.4mg/kg/dose IV q 4–6 h
• Lorazepam 0.05–0.1mg kg/dose IV q6 h
Prophylaxis: Amitryptiline was started at 0.25mg/kg/QHS and
increased to 0.5 mg/kg HS after baseline EKG
Episodes reduced in severity and frequency

38. Child with stereotypical cyclical pattern of vomiting
age 2-18years; 85-90% have CVS, ~10-15% other etiology
Age <2years- high chances of metabolic and GI causes
Do BMFT for malrotation, electrolytes (Na, K, chloride,
bicarbonate), blood glucose, Bun and creatinine, ±USG
abdomen in all cases
Check: Age <2 years or Presence of alarm features
No: manage as CVS yes: investigate further

39. Alarm symptoms: suspect something else…
 Bilious vomiting, abdominal tenderness, severe pain, distension
 Conversion to continuous pattern ...... GI: volvulus, adhesions,
pancreatitis, biliary, UPJ obstruction etiology.
• Amylase, lipase, LFT
• USG/ SBFT/ CT / UGI endoscopy /24h esophageal pH study
• Gastric emptying scan/ Antroduodenal manometry
 Attacks precipitated by fasting, high protein meal, intercurrent illness.....
 Hypoglycemia , high anion gap metabolic acidosis with ketosis, respiratory
alkalosis, persistent Hyponatremia
 Acute encephalopathy (lethargy, severe irritability, confusion, psychosis or
rapidly changing/unstable mental status)
Metabolic :FAOD, urea cycle disorder, organic acidemia, mitochondrial
• ABG, lactate, Urine ketones, Urine for PBG, urine organic acids,
• serum amino acids, blood ammonia, plasma cortisol, carnitine and acyl
carnitine, etc

40. Alarm symptoms: suspect something
else…
Abnormal neurological examination
- altered mentation, abnormal eye movements, ataxia,
- focal neurological signs, papilledema, development regression
or stagnation,
- recent changes in personality
CNS etiology: posterior fossa or hypothalamic tumor, Chiari
malformation, hydrocephalus, or subdural hematoma *(more
often chronic), complex partial seizures (rare)
• MRI head
• Fundus examination
• EEG when indicated

41. Conclusions
• Vomiting may be the presenting symptom of many
diseases, ranging from self-limited to life-threatening and
GI to non GI
• Detailed history along with pattern (cyclic vs chronic)
important to differentiate etiologies
• Bilious emesis at any age is suggestive of intestinal
obstruction and needs immediate attention.
• Disorders like GERD, CVS, gastroparesis, rumination are
increasing and awareness with high index of suspicion
helps in making timely diagnosis
• Investigations should be targeted to the likely differential
diagnosis

42. Thanks