Cyclic Vomiting Syndrome in a 25-Year-Old Postpartum Female

Case at a Glance

A 25-year-old postpartum female presenting with five episodes of severe, sudden-onset vomiting over two years, requiring emergency department visits for IV hydration and antiemetic therapy. Episodes are characterized by inability to tolerate oral intake, profound weakness, and complete resolution within 24-48 hours.

Patient's Story

The patient is a 25-year-old female, gravida 1 para 1, who delivered her first child approximately one year ago. She reports significant weight loss of nearly 100 pounds postpartum through increased physical activity including regular hiking. Over the past two years, she has experienced five distinct episodes of severe, acute-onset vomiting that have required emergency department evaluation. The most recent episode began at 7 AM with gastric discomfort and nausea, rapidly progressing to intractable vomiting with inability to tolerate any oral intake, including water. Associated symptoms included diaphoresis, tremors, weakness, and presyncope. The patient required emergency department treatment with IV fluids and multiple doses of antiemetics before symptom resolution around 10 PM. Post-episode, she experienced chest pain and burning sensation, likely secondary to forceful vomiting, along with persistent fatigue lasting 1-2 days.

Initial Assessment

Physical examination during acute episodes reveals signs of dehydration including tachycardia, orthostatic changes, and poor skin turgor. The patient appears distressed with pallor and diaphoresis. Abdominal examination shows mild epigastric tenderness without rebound or guarding. Vital signs typically normalize following IV hydration. Between episodes, the patient appears well with normal physical examination findings.

The Diagnostic Journey

Initial emergency department workups have focused on acute stabilization with IV hydration and antiemetic medications. Basic laboratory studies including complete blood count, comprehensive metabolic panel, and urinalysis have been unremarkable. The patient has not undergone comprehensive gastrointestinal evaluation despite recurrent presentations. Episodes lack consistent triggers, occurring with varying dietary intake and circumstances, making identification of causative factors challenging.

Final Diagnosis

Working diagnosis of Cyclic Vomiting Syndrome (CVS) based on clinical presentation of recurrent, stereotypical episodes of intense vomiting with symptom-free intervals. Differential diagnosis includes gastroparesis, superior mesenteric artery syndrome (given significant weight loss), gallbladder disease, and cannabinoid hyperemesis syndrome pending further history and diagnostic workup.

Treatment Plan

Immediate management continues with IV hydration and antiemetic therapy during acute episodes. Long-term management plan includes: 1) Primary care physician referral for comprehensive evaluation and care coordination, 2) Gastroenterology consultation for specialized assessment, 3) Diagnostic studies including upper endoscopy, celiac disease serologic testing, gallbladder ultrasonography, and gastric emptying study, 4) Detailed substance use history including marijuana use assessment, 5) Prophylactic antiemetic therapy consideration for frequent episodes, 6) Patient education regarding trigger avoidance and early intervention strategies.

Outcome and Follow-up

Patient requires established primary care relationship for ongoing management and specialist referrals. Emergency action plan needed for future episodes including when to seek immediate medical attention. Close monitoring for complications of recurrent vomiting including dental erosion, electrolyte imbalances, and nutritional deficiencies. Follow-up appointments scheduled to assess response to treatment interventions and adjust management plan accordingly. Patient counseling provided regarding the chronic nature of suspected cyclic vomiting syndrome and importance of comprehensive outpatient evaluation.