7-Year-Old Male with Recurrent Early Morning Vomiting: Diagnostic Workup

Case at a Glance

A 7-year-old male with known FPIES (Food Protein-Induced Enterocolitis Syndrome) to egg, peanut, and avocado presented with three episodes of early morning vomiting over an 11-day period. Initial CT scan was negative, with consideration for MRI if symptoms persist.

Patient's Story

The patient experienced his first episode on a Monday morning at 6:30 AM, with 4-5 vomiting episodes over several hours, progressing from food particles to yellow bile-like material. This was accompanied by diarrhea. The patient's mother also developed fatigue and chills the same day without GI symptoms. Seven days later, the patient had early morning vomiting of clear liquid in two small episodes. Four days after that, he had a single morning vomiting episode with visible food particles, again accompanied by diarrhea. All episodes occurred 8-10 hours after the last meal, consistently during sleep or upon waking, without preceding nausea or pain.

Initial Assessment

Physical examination was unremarkable. The patient remained active and well between episodes. Vital signs stable. The concerning pattern of early morning vomiting prompted consideration of increased intracranial pressure, despite the patient's known GI conditions and strong family history of gastroesophageal reflux disease.

The Diagnostic Journey

Given the pattern of early morning vomiting, a CT scan of the head was performed to rule out brain tumor or other intracranial pathology. The CT scan returned normal results. The pediatric team recommended MRI if symptoms recurred, as it could detect smaller masses not visible on CT. A gastroenterology consultation was scheduled to evaluate potential GI causes given the patient's FPIES history and family history of severe GERD.

Final Diagnosis

Pending further evaluation. Differential diagnosis includes cyclic vomiting syndrome, gastroesophageal reflux disease (given strong family history), dietary triggers, or less likely intracranial pathology requiring MRI confirmation.

Treatment Plan

Close monitoring with instructions to seek emergency care if vomiting recurs. Scheduled gastroenterology consultation to evaluate GI causes. Consider MRI if symptoms persist. Dietary modifications may be considered, particularly avoiding high-fat, high-sugar meals close to bedtime. Family education on symptom monitoring and when to seek care.

Outcome and Follow-up

Patient scheduled for GI specialist evaluation. Parents educated on the low likelihood of brain tumor given normal CT and presence of associated diarrhea in most episodes, which is atypical for intracranial causes. Follow-up arranged for symptom monitoring and potential MRI if indicated by specialist or symptom recurrence.