Author: Peter Kvapil, MDSeries Editor: Richard Goodgame, MD

Disclosures

October 11, 2004

Case Presentation

This 48-year-old woman has epigastric fullness, nausea, and vomiting after eating.

Twelve years ago the patient was told that she had an ulcer. Eight months ago she began having intermittent symptoms of gastrointestinal reflux and regurgitation, especially when supine. Four months ago she had to stop eating solid food because it exacerbated these symptoms and also caused abdominal pain, epigastric fullness, and vomiting. Vomiting was worse 1 hour after meals and the vomitus contained undigested food. For the past week she has been unable to tolerate any intake except sports drinks. She has lost 15 pounds over the past 6 months. Her bowel movements are normal. She has no fever, chills, or night sweats.

Her medical history is positive for migraine headaches and mitral valve prolapse. She takes daily nonsteroidal anti-inflammatory drugs (NSAIDs) of various types, along with a number of H2-blockers and proton-pump inhibitors (PPIs). There is no alcohol, tobacco, or substance abuse, and no significant family history of disease.

Results of physical examination were unremarkable; vital signs were normal. There was no lymph node enlargement. The only abnormalities were a mitral click and murmur (apparently unchanged) and mild epigastric tenderness. There was no mass or succussion splash.

Routine laboratory studies revealed the following:

Hemoglobin: 12.3 g/dL
White blood cell count: 8.4 x 103 cells/mm3
Polymorphonuclear leukocytes: 66%
Sodium: 140 meq/L
Potassium: 4.3 meq/L
Chloride: 104 meq/L
Bicarbonate: 21 meq/L
Blood urea nitrogen: 13 mg/dL
Creatinine: 0.9 mg/dL
Total protein: 7.2 g/dL
Albumin: 4.3 g/dL
Total bilirubin: 0.4 mg/dL
Direct bilirubin: 0.1 mg/dL
Alkaline phosphatase: 100 U/L
Alanine aminotransferase: 23 U/L
Aspartate aminotransferase: 18 U/L
Amylase: 40 U/L
Lipase: 33 U/L

The patient presented with a recent upper gastrointestinal x-ray that had been reported as normal (Figures 1-3).

Which of the diagnostic tests listed below would you favor ordering at this time and why?

  • Radionucleotide gastric emptying study

  • Upper gastrointestinal endoscopy

  • Computed tomography (CT) scan of the abdomen with oral and intravenous contrast

  1. Radionucleotide gastric emptying study. The patient presented with symptoms that suggested poor gastric filling or emptying. The causes of such symptoms are numerous, but can generally be divided into primary motility disturbances of the stomach (gastroparesis) vs mechanical processes (such as masses, strictures, and infiltrative diseases). The barium x-ray is usually a good test to differentiate between these 2 pathologies. If the barium x-ray is indeed normal, then a gastric emptying study could document gastroparesis and quantify the severity of the motor abnormality.Upper gastrointestinal endoscopy. The justification for performing this study would be the suspicion that the barium x-ray missed some serious pathology. There are many features associated with this case that suggest serious illness. There is a history of ulcer disease. She takes numerous NSAIDs. She has lost weight. At age 48, the patient is approaching "the cancer years." The underlying disease could be a motility disturbance. But one of the most helpful guidelines in evaluating a patient who may have a motility disturbance is to first and foremost absolutely rule out mechanical obstruction.CT scan of the abdomen with oral and intravenous contrast. Following the reasoning outlined above, before performing a study to document and quantify a motility defect, serious anatomic disease of the upper abdomen must be ruled out. The barium study does not give enough information about the other organs/tissues of the upper abdomen: pancreas, lymph nodes, and liver. Diseases in these organs/tissues could induce a secondary motility problem.

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