Cyclical vomiting syndrome

Specialties Emergency

Published

Anybody encountered a patient with this diagnosis? I had a pt come in the other day, report of vomiting x23 during past 4 hours, severe pain 10/10 in abdomen, letter from GI doctor stating she was diagnosed with cyclical vomiting syndrome and gastroparesis. Pt was begging for phenergen and dilaudid. Pt had previous rx for dilaudid 2mg PO, phenergen 25mg PO, and reglan 10mg PO. I gave her phenergen IV and IM, bentyl IM, protonix IV, tigan IM. Pt seemed to calm down but still begging for pain medication, asking for dilaudid by name. Became irritated when ED doc explained dilaudid may increase n/v and would not be given. (ED doc did not believe report of pain and flagged pt as drug seeker). Pt would only wretch and dry heave when I left the room or when doc was in room talking to pt. She was good enough to walk around and keep asking for pain medication. I witnessed vomiting x3 during 2.5 hour stay, watery undigested food, no bile. Im not sure what to think...........

Any input greatly appreciated.

Specializes in Trauma, Teaching.

{{{Erin}}} being on chemo, I totally understand the constant nausea, but I know mine has an end in sight.

I would strongly suggest you get a letter from your doctor detailing your established diagnosis and the course of treatment you need to receive. I know when we get someone in, with any chronic condition with a letter, they get taken for face value a good deal more rapidly.

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Thanks for reading! I have a follow up with the doctor who suggested the dilaudid, and I plan to discuss with her in detail 1) why she thinks it helped and 2) my concerns related to potentially trying to request this treatment in the future. I currently have an letter from my old GI doctor, but even with that I've even met resistance to giving my ativan before (with the doctor who then refused me care, leading to my second critical lab in my life).

I'm definitely also planning on talking about adjusting my home regimen. I've been able to abort some episodes at home, but was unable to abort this one even though I was doing all the things that normally work, and I had a lot of forewarning that my body was trying to cycle. I've made some adjustments to my daily med (amitriptyline) but I might consider trying a different antidepressant to see if it helps better. Funny how antidepressants help with GI issues, but it all goes back to the enteric nervous system and all those synapses and neurotransmitters in our gut! One of my best friends is also on ami for chronic gut issues- hers being a daily inability to eat/tolerate food issue that isn't quite IBS and isn't quite celiac and gets super fun and annoying to try to figure out what and why it's happening.

Anyway, I feel optimistic that the new GI doc will have some ideas to improve my self-management!

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I've had a couple of patients cyclic vomiting syndrome. Most of the time it was all about management to prevent a flare-up, and fluid administration/diet modifications when it did hit. We usually used Zofran instead of Phenergan though, since Phenergan can make patients loopy.

This. We typically use Zofran for CVS pts. We use Phenergan sparingly. Fluid, Zofran, maybe some Bentyl. Rarely, if ever, pain meds.

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Cyclic vomiting- synonymous with hypohydromorphonemia

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I've encountered this before, because I have been dating this person with cvs for the past year. I hope you're not some nurse from Houston, because I would hate to know that the people I deal with here secretly think these things about my girlfriend. I assure you, she's not a junkie, and it's pretty much her worst nightmare. Yes, the drugs feel good. But they make her sick later if she's on them too long, so no, she does not just go to the hospital pretending to be sick. In fact, it pretty much ruins her life, and she would really prefer to stay OUT of the hospital for as long as possible. The fact that no medical staff is willing to believe her conditions has made her life even worse, when she ended up tearing a hole in her esophagus and had to get surgery for it. Now she has strictures that form from this and imhas to get dilations periodically to just eat. She's also diabetic. It's really serious and very depressing at times for her, to the point where she has contemplated suicide. It would be irresponsible for any one of you to make this sort of judgment call on a person just because they ask for dilaudid by name. It's just that it works really well at stopping the vomiting. The phenergan is there to knock her out. That's the point—to stop the pain and knock her out.

Anybody encountered a patient with this diagnosis? I had a pt come in the other day, report of vomiting x23 during past 4 hours, severe pain 10/10 in abdomen, letter from GI doctor stating she was diagnosed with cyclical vomiting syndrome and gastroparesis. Pt was begging for phenergen and dilaudid. Pt had previous rx for dilaudid 2mg PO, phenergen 25mg PO, and reglan 10mg PO. I gave her phenergen IV and IM, bentyl IM, protonix IV, tigan IM. Pt seemed to calm down but still begging for pain medication, asking for dilaudid by name. Became irritated when ED doc explained dilaudid may increase n/v and would not be given. (ED doc did not believe report of pain and flagged pt as drug seeker). Pt would only wretch and dry heave when I left the room or when doc was in room talking to pt. She was good enough to walk around and keep asking for pain medication. I witnessed vomiting x3 during 2.5 hour stay, watery undigested food, no bile. Im not sure what to think...........

Any input greatly appreciated.

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I am a preceptor in a small ED and will be starting a residency in another ED right after graduation. I have been able to participate in the care of a few patients with this diagnosis and was honestly shocked by the stigma that surrounds it. My son was diagnosed with CVS at 4, he is obviously not a seeker. I know exactly what dose of medications will work to help stop an attack. Heck, he could say "ondansetron" with a sweet little lisp when getting triaged at our local children's hospital. We are lucky to have a GI that has found the right preventative medication which keeps him mostly attack free and out of the hospital. But, he also tells us that these medications are less successful the older the person gets. Gosh, I just hope that as an adult he is met with nonjudgmental compassion when he arrives at the ED.

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Specializes in Adult Internal Medicine.
I am a preceptor in a small ED and will be starting a residency in another ED right after graduation. I have been able to participate in the care of a few patients with this diagnosis and was honestly shocked by the stigma that surrounds it. My son was diagnosed with CVS at 4, he is obviously not a seeker. I know exactly what dose of medications will work to help stop an attack. Heck, he could say "ondansetron" with a sweet little lisp when getting triaged at our local children's hospital. We are lucky to have a GI that has found the right preventative medication which keeps him mostly attack free and out of the hospital. But, he also tells us that these medications are less successful the older the person gets. Gosh, I just hope that as an adult he is met with nonjudgmental compassion when he arrives at the ED.

From my professional experience, CVS in children and CVS in adults are different, remember CVS is a constellation of disorders. I have never seen an adult patient with CVS that had onset in childhood. Best of luck with your son.

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I am a preceptor in a small ED and will be starting a residency in another ED right after graduation. I have been able to participate in the care of a few patients with this diagnosis and was honestly shocked by the stigma that surrounds it. My son was diagnosed with CVS at 4, he is obviously not a seeker. I know exactly what dose of medications will work to help stop an attack. Heck, he could say "ondansetron" with a sweet little lisp when getting triaged at our local children's hospital. We are lucky to have a GI that has found the right preventative medication which keeps him mostly attack free and out of the hospital. But, he also tells us that these medications are less successful the older the person gets. Gosh, I just hope that as an adult he is met with nonjudgmental compassion when he arrives at the ED.

Not likely. As a parent of a child whose onset was 7 y/o and an ED nurse, my kid was labeled as a drug seeker and "behavioral" pt by 12.

No such luck here with a good gi doc, and I spend most of my kids admissions arguing with "doctors". We have been threatened numerous times to have the states "child safety" called on us. My response is always the same, " if you think I'm neglecting or abusing my child, and you threaten me with reports but never make them, you should lose your license" very very frustrating.

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No mention of concurrent drug use - especially marijuana from the posts. Are any of your departments doing drug screens to assess for a drug related component?

What I'm finding with the patients being seen in the departments I'm working in is all these patients are chronic marijuana users.

We throw every anti-emetic at these patients, including Haldol, yet all that seems to ease the symptoms (other than a threat to use only non-parenteral approaches) is a narcotic - which miraculously works the second it is pushed like a switch has been thrown. Certainly leads one to identify these patients as seekers.

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Specializes in Hospital medicine; NP precepting; staff education.
No mention of concurrent drug use - especially marijuana from the posts. Are any of your departments doing drug screens to assess for a drug related component?

What I'm finding with the patients being seen in the departments I'm working in is all these patients are chronic marijuana users.

We throw every anti-emetic at these patients, including Haldol, yet all that seems to ease the symptoms (other than a threat to use only non-parenteral approaches) is a narcotic - which miraculously works the second it is pushed like a switch has been thrown. Certainly leads one to identify these patients as seekers.

We haven't routinely done drug screens but do educate the patients about the relation between THC and cyclic vomiting syndrome.

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We haven't routinely done drug screens but do educate the patients about the relation between THC and cyclic vomiting syndrome.

I find that the pot smokers just don't believe it. It can't possibly be the weed, it must be a coincidence.

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Specializes in ER.

If 2mg dilaudid does the trick, I don't think we're talking drug seekers. Real seekers will go for repeated doses, and some to take home. I'd happily give a dose of dilaudid to prevent hours of retching, and prevent a dozen doses of ineffective meds.

I'm thanking my lucky stars that I don't have any diseases that require an opiate. Anyone with a problem that can't be verified by lab or Xray is subject to doubt from professionals, especially during horrible stressful shifts. I know I tend to question patients' stories when beds are tight, and I'm starting to feel guilty about not being able to get people treated. I think it's a defense mechanism, if I have to neglect them, I'm more likely to minimize their pain. Sad, but true, and I have to be aware of it.

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