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September 3, 2019

Image challenge: Gastroparesis mimicry

What caused nausea, vomiting, early satiety and 40 pounds of unintentional weight loss in 37-year-old patient?

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Gastroenterology clinical image challenge: A 37-year-old woman presented to clinic with four months of worsening nausea, vomiting, early satiety and 40 pounds of unintentional weight loss. Initially, her symptoms were worse with solids, resulting in a gnawing abdominal pain, but they progressed to involve both solid and liquid ingestion within a matter of months rendering her completely unable to tolerate oral intake without severe vomiting for the two weeks preceding her presentation to our center. Her past medical, surgical, social and family history were noncontributory. Evaluation elsewhere consisted of an esophagogastroduodenoscopy notable for significant amounts of gastric retained solid food, and a computed tomography (CT) scan of the abdomen and pelvis showing a dilated stomach. After failing antiemetic and prokinetic agents, she was referred for gastric electrical stimulator placement for idiopathic gastroparesis based on a gastric emptying study, revealing 60 percent retention at four hours.

 

On initial presentation to our clinic, the patient was hemodynamically stable. Physical examination revealed a thin woman with body mass index of 17.7 kg/m2, mild temporal wasting, dry mucous membranes, skin tenting, and epigastric tenderness without rebound or guarding. Laboratory testing revealed a mild leukocytosis (12.61 × 10 cells/mm) with a normal differential, and metabolic panel showed a potassium of 2.9 mEq/L, chloride 87 mEq/L, bicarbonate 36 mEq/L, blood urea nitrogen 36 mg/dL, and creatinine 1.4 mEq/L with no prior history of renal dysfunction. Hepatic function panel showed a total bilirubin of 1.5 mg/dL, alanine aminotransferase 591 IU/L, and aspartate aminotransferase 265 IU/L. The patient was admitted to the hospital for intravenous fluid hydration and a repeat CT scan of her abdomen and pelvis was obtained revealing abnormal findings prompting a push enteroscopy the following day. This revealed complete inability to advance the endoscope through an extrinsically compressed distal second/proximal third portion of the duodenum.

 

What is the diagnosis and how should this patient be managed?

 

To find out the diagnosis, read the full case in Gastroenterology.

 

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