BMJ  2006;333:137 (15 July), doi:10.1136/bmj.333.7559.137

Commentary

A clinical challenge

¹ Department of Gastroenterology, King's Mill Hospital, Sutton-in-Ashton NG17 4JL robert.logan{at}nottingham.ac.uk

Several learning points arise from Mr Neville's case.¹ The most important relates to the diagnostic approach when we are challenged with pieces of a clinical puzzle that do not neatly fit together.

Gastro-oesophageal reflux disease usually poses few diagnostic challenges, especially when there is a good symptomatic response to empirical anti-secretory therapy. However, in this case, Mr Neville's poor response to treatment and persistent symptoms led to further investigation and several protracted stays in hospital. The normal oesophageal manometry and lower oesophageal sphincter pressures were an appropriate trigger for further investigations to eliminate underlying organic disease, especially distal obstructing lesions or intermittent torsion of a hiatus hernia (although symptoms are more typically episodic with a hernia).

As with difficult to diagnose diarrhoea, admission to hospital provided the main clue to the final correct functional diagnosis. The importance of the careful clinical observations made while Mr Neville was eating cannot be emphasised enough. It is difficult to judge to what extent the possible underlying psychological components confounded the diagnosis, but seeking a second opinion from a fresh perspective is often very helpful when faced with a diagnostic challenge. More generally, patients and their doctors often mistakenly refer to regurgitation as vomiting, without recognising the importance of differentiating between the effortless nature of the former in contrast to most causes of vomiting.

Managing patients with psychological disorders

The other important learning point illustrated by this case is how to deal with patients who have potentially insoluble problems. One approach is to ask patients about their concerns or thoughts about the diagnosis. Another, not possible in this case, is to offer to review and repeat tests at some future time. Although it is essential always to be sympathetic and understanding, adopting the most appropriate approach to patients in whom underlying psychological problems may be contributing to their symptoms is fraught with difficulties and is a real challenge for the clinician.

A useful approach is to mention the importance of the "brain-gut axis" in functional gastrointestinal disorders at the outset. In this case, sharing the results of the impedance measurements together with getting Mr Neville to place his hand on his abdomen was a neat method of providing the patient with an opportunity to gain immediate insight into his problems. I suspect that the patient's sense of relief as his symptoms resolved and his weight increased was similar to that of his doctors.

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Competing interests: None declared.

References

1. Fox M, Young A, Anggiansah R, Anggiansah A, Sanderson J. A 22 year old man with persistent regurgitation and vomiting: case outcome. BMJ 2006;333: 133.[Free Full Text]

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A 22 year old man with persistent regurgitation and vomiting: case outcome

Mark Fox, Alasdair Young, Roy Anggiansah, Angela Anggiansah, and Jeremy Sanderson
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