What is the workup for daily morning vomiting?

From the Guidelines

A workup for daily morning vomiting should begin with a thorough history and physical examination to identify potential causes, with a focus on ruling out pregnancy, gastroesophageal reflux disease (GERD), gastroparesis, medication side effects, and psychological conditions like anxiety, as suggested by 1 and 1. The clinical evaluation should include a detailed history of the vomiting episodes, including the timing, duration, and any associated symptoms, as well as a physical examination to identify any signs of underlying conditions.

• Laboratory tests should include a complete blood count, comprehensive metabolic panel, thyroid function tests, and amylase/lipase levels, as these can help identify potential causes of vomiting, such as infections, metabolic disorders, or pancreatic disorders, as noted in 1.
• Upper endoscopy may be necessary to evaluate for structural abnormalities or inflammation, particularly if GERD is suspected, as suggested by 1.
• For suspected GERD, a trial of proton pump inhibitors like omeprazole 20mg daily before breakfast for 2-4 weeks may be diagnostic and therapeutic, as this can help alleviate symptoms and improve quality of life, as implied by 1.
• If gastroparesis is suspected, a gastric emptying study should be performed, as this can help diagnose delayed gastric emptying and guide treatment, as noted in 1.
• Brain imaging with CT or MRI may be warranted if neurological symptoms are present or if increased intracranial pressure is suspected, as this can help identify potential causes of vomiting, such as tumors or hydrocephalus, as suggested by 1.
• While awaiting diagnosis, symptomatic treatment with antiemetics such as ondansetron 4mg as needed or metoclopramide 10mg before meals may provide relief, as these medications can help alleviate nausea and vomiting, as implied by 1.
• Lifestyle modifications including eating smaller, more frequent meals, avoiding trigger foods, and elevating the head of the bed can help manage symptoms, as these changes can help reduce symptoms of GERD and other conditions, as noted in 1 and 1. The most recent and highest quality study, 1, suggests that cyclic vomiting syndrome (CVS) should also be considered in the differential diagnosis, particularly if the patient experiences prodromal symptoms, abdominal pain, and vomiting episodes that tend to occur in the early morning hours.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Evaluation

The workup for daily morning vomiting involves a thorough initial evaluation, including:

• Assessment of airway, breathing, and circulation 2
• Assessment of hydration status and red flag signs, such as bilious or bloody vomiting, altered sensorium, toxic/septic/apprehensive look, inconsolable cry or excessive irritability, severe dehydration, concern for symptomatic hypoglycemia, severe wasting, and Bent-over posture 2
• Defining what the patient means by nausea and vomiting, determining whether symptoms are acute or chronic, and considering medication or toxin adverse effects 3

History and Physical Examination

The history and physical examination guide the approach in an individual patient, including:

• Associated symptoms, timing of onset and duration of symptoms, exacerbating or relieving factors, alarm symptoms, medication and substance use, relationship with recent food ingestion, and comorbidities 4
• Regular review in the early phases of an undifferentiated vomiting illness to ensure that more fulminant illnesses are not overlooked and that secondary complications of dehydration do not arise 5

Investigations

Investigations, such as serum electrolytes and blood gases, renal and liver functions, and radiological studies, are required in any child with dehydration or red flag signs to diagnose surgical causes 2

• Testing for an underlying cause should be performed when symptoms are chronic or moderate-severe, and medication adverse effects, neurologic causes, gastrointestinal diseases, metabolic or endocrine conditions, and psychogenic disorders should be considered in particular 3

Management

Management priorities include:

• Treatment of dehydration 2
• Stoppage of oral fluids/feeds and decompression of the stomach with nasogastric tube in patients with bilious vomiting 2
• Antiemetic ondansetron for children unable to take orally due to persistent vomiting, post-operative vomiting, chemotherapy-induced vomiting, cyclic vomiting syndrome, and acute mountain sickness 2
• Nonpharmacologic management options, such as fluid and electrolyte replacement, small, frequent meals, and avoidance of trigger foods 4
• Pharmacologic therapy, such as serotonin antagonist or dopamine antagonist, when a specific etiology is not identified 4